Baby Boomers on Brink of Health Care Crisis

US Pharm. 2008;33(6):20-26.

Almost all health care providers care for seniors to some extent at one point or another during their professional career.¹ As the nation's baby boomers begin to reach age 65 in 2011, or by 2030 when one in five Americans will be 65, the likelihood that a provider will treat a senior is even higher. On April 14, 2008, a long-awaited report was released by the Institute of Medicine (IOM), an arm of the National Academy of Sciences, an independent organization chartered by Congress to advise the government on scientific matters.^2-4 The report addresses the readiness of the nation's health care workforce to meet the needs of our aging society.^2,3

The IOM study aimed to include an evaluation of the geriatrics and gerontology workforce and a blueprint for geriatrics care for the 21st century. The American Geriatrics Society (AGS), in its seminal 2005 report (Caring for Older Americans: The Future of Geriatric Medicine) proposed a study along these lines and advocated for the IOM initiative.⁵

The IOM report, entitled Retooling for an Aging America: Building the Health Care Workforce, was released by the 15-member IOM committee headed by AGS member John W. Rowe, MD, a professor of health policy and management at Columbia University in New York City. The report addressed the outlook regarding health care for baby boomers on the brink of entering the health care system for seniors.⁴ A severe shortage of geriatrics health care professionals was noted, and an urgent recommendation was made for a spectrum of initiatives to increase recruitment into geriatrics and ensure that all health care providers who care for seniors are adequately trained to meet the unique health care needs of this population.³ Additionally, the committee expressed a concern that the senior-care health care system is not only unprepared for the surge of seniors about to enter the system but might even discourage seniors from obtaining quality care.⁴ Further, the report concluded that the future workforce "will be woefully inadequate in its capacity to meet the large demand for health services for older adults if current patterns of care and of the training of providers continue."³ This conclusion is especially troubling in light of the fact that when the youngest of the baby boomers reach retirement age in 2030, the number of older Americans will reach 70 million, nearly double the number today.^2,3

The executive summary of the IOM report states that one prediction is certain: "The future elderly population will have a greater collective need for health care services than those who have come before it," regardless of whether the current patterns of health status and utilization continue.⁶ Furthermore, according to the IOM study, due to low reimbursement rates, Medicare may even hinder seniors from getting the best care.^2-4 Since the majority of care of older patients takes place outside the hospital, the committee concluded that preparation for the comprehensive care of older patients should include training in nonhospital settings.⁶ The committee proposed a three-part approach to improve the ability of the health care workforce to care for American seniors (TABLE 1).

Care Model Includes Pharmacists
While the IOM was examining the nation's health care workforce with regard to readiness to meet the needs of our aging population, the AGS sent a letter outlining strategies for meeting these needs.⁷ The letter responded to three related questions: "What is the best use of the health care workforce?" "What models of health care delivery hold promise to provide high quality and cost-effective care for older persons?" and "What new roles or new types of providers would be required under these models?"⁷

The main recommendation proposed was the adoption of a medical home model, an interdisciplinary, collaborative team model in which a primary care physician leads a team of health care professionals who provide senior patients with coordinated care.⁷ The team may include the following professionals: nurses, nurse practitioners, certified nursing assistants, physicians' assistants, pharmacists, social workers, therapists, and informal caregivers.⁷ The organizational and educational leader for the team is the geriatrician.⁷ The letter indicates that while "all persons should have a ëmedical home,' target populations (e.g., frail elderly, those 85 and older, and low income and terminally ill patients), target conditions (e.g., falls, hip fracture, dementia, depression, congestive heart failure, stroke, and delirium), and target settings (e.g., nursing homes, hospice, community, and hospital) require "selective use of more intensely interdisciplinary and collaborative care."⁷

Funding Issues
The IOM report recommends that private insurers, Medicare, and Medicaid provide higher compensation to health care providers who care for seniors and also compensate for specific services currently not covered, such as care coordination. ^2-4 Reimbursement should be enhanced and offered by both pubic and private payers for health care services delivered to seniors by practitioners with expertise in geriatrics designated by certification.^2-4

In an attempt to better prepare providers to care for seniors, Congress should authorize and fund additional training programs for all health care professionals.^2-4 Loan forgiveness, scholarships, and incentives for financing education should be available to professionals who specialize in geriatrics and should be offered by state and federal governments.^2-4

There should be a considerable increase in support by Congress and foundations for research and demonstration programs leading to the development of new models of care including preventive, long-term, and palliative care.^2-4 New models of care for seniors should be shown to be effective and efficient and promote the productive uses of the workforce.^2-4 Individual states and the federal government should increase minimum training standards for all direct-care workers.^2-4 A comprehensive approach for the provision of adequate training for family and other informal caregivers should include funding from public, private, and community organizations.^2-4

AGS President Addresses Congress
The day after the IOM released its report, AGS President Todd Semla, MS, PharmD, testified before the Senate Special Committee on Aging that focused on educational and training initiatives.⁸ He proposed steps the federal government must take to prepare the health care workforce for the coming age boom. The steps that were outlined parallel many in the IOM report and have been advocated for some time by the AGS.⁸

To address the increasing shortage of geriatrics health care professionals trained to care for seniors, Dr. Semla urged the federal government to, among other things,

• Establish programs for loan forgiveness for geriatrics health care professionals

• Expand and fund Title VII Health Professions Programs and support Title VII Nursing Workforce Development Programs

• Expand and enhance support for the nation's Geriatric Research, Education and Clinical Centers

• Increase the number of Medicare graduate medical education slots, particularly in geriatrics

• Collaborate with foundations and other organizations to train direct-care workers and family and other informal caregivers who assist geriatric individuals.⁸

In addition to training, Dr. Semla recommended that Congress reform Medicare and other national health care systems to address reimbursement and provide adequate coverage for necessary and cost-effective services.⁸

Are Pharmacists Prepared?
Are pharmacists prepared to serve the baby boomer seniors of the 21st century (TABLE 1 )? Do enough pharmacists have the required knowledge and skills to provide the services necessary to care for our nation's seniors? While this column has focused on issues in geriatric pharmacy for the past eight years to raise awareness, provide guidelines, and discuss approaches to pharmacotherapy for seniors, more is required to serve this population effectively. Individual practitioners need to seek out supplementary education and training to raise their level of competence to practice effectively within this specialty. Why? Because while considered a specialty, geriatric pharmacy will be necessary to effectively serve a significant portion of the U.S. population. Local, state, and national health care organizations need to continue their efforts to provide continuing education and credentialing to meet these needs (see Resources for the Pharmacist).

Conclusion
As the nation's baby boomers begin to reach age 65 in 2011, or by 2030 when 20% of Americans will be 65, treating a senior will be commonplace for most health care providers. Given the reported impending crisis that, according to the IOM report, the health care workforce is unprepared to adequately respond in size and ability to the average needs of this population and given the huge numbers on the verge of entering the senior care health care system, action must be taken. While bold initiatives are discussed and implemented, pharmacists should take responsibility for honing the skills necessary to perform effectively in serving and advocating for our American seniors.

REFERENCES

1. Health care work force too small, unprepared for aging baby boomers; higher pay, more training, and changes in care delivery needed to avert crisis. Press release, National Academies. April 14, 2008. www8.nationalacademies.org/
onpinews/newsitem.aspx?RecordID=12089. Accessed May 4, 2008.

2. Retooling for an Aging America: Building the Health Care Workforce. Institute of Medicine.
www.iom.edu/CMS/3809/40113/53452.aspx. Accessed May 4, 2008.

3. IOM releases report addressing growing shortage of healthcare providers trained to care for older patients; AGS president to testify at Senate hearing on workforce issues tomorrow. www.americangeriatrics.org/policy/iom_report040907.shtml. Accessed May 1, 2008.

4. Study: boomers to flood medical system. Associated Press. http://my.att.net/s/editorial.dll?pnum=1&bfromind=
7406&eeid=5814656&_sitecat=1522&dcatid=0&eetype=article&render=y&ac=0&ck=&ch=ne&rg=blsadstrgt&_lid=332&_lnm=tg+ne+topnews&ck=. Accessed May 1, 2008.

5. As Institute of Medicine readies report on geriatrics workforce for release, AGS explores avenues to help disseminate and advance key recommendations. American Geriatrics Society Newsletter. www.americangeriatrics.org/newsletter/2008Q1/ags_explores.asp. Accessed May 1, 2008.

6. Retooling for an Aging America: Building the Health Care Workforce: Executive Summary. www.nap.edu/catalog.php?record_id=12089. Accessed May 1, 2008.

7. AGS comments on questions IOM is investigating in study of healthcare workforce for older Americans.www.americangeriatrics.org/policy/iom_report040907.shtml. Accessed May 1, 2008.

8. AGS president advises Congress on steps nation must take to address growing shortage of healthcare professionals trained to care for aging Americans. American Geriatrics Society. www.americangeriatrics.org/policy/iom_report040907.shtml. Accessed May 1, 2008.

9. IOM calls for measures to deal with looming baby boomer health care crisis. American Pharmacists Association. www.pharmacist.com/AM/Template.cfm?Section=Search1&template=/CM/HTMLDisplay.cfm&ContentID=15914. Accessed May 4, 2008.

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