Fundamental shifts in the American medical system to get ready for aging baby boomers will require a reaction similar in magnitude to the response to HIV/AIDS almost three decades ago, according to one of the authors of a report calling for the shift to begin now.
“I think the response to AIDS early on was on the same level of changing business-as-usual that we’re talking about here,” said David Reuben, one of the authors of “Retooling for an Aging America: Building the Health Care Workforce,” released this week by the Institute of Medicine.
Reuben, director of geriatric medicine and gerontology at the David Geffen School of Medicine at UCLA, said circumstances are different but the threat is real.
“Now we’re playing catch-up ball a bit — not as much as if we started in 2020 — but we’re playing catch-up in the sense that we haven’t really started yet, and we don’t have the galvanizing immediate threat that AIDS presented,” Reuben said.
“The threat is there, though, and we have to acknowledge that and deal with it in a big way,” Reuben added.
Calling for widespread changes in how health care professionals are trained and compensated, the report warns of crisis-level problems if changes aren’t under way before the system is overwhelmed by the largest generation this country has ever produced.
By comparing it to HIV/AIDS, Reuben sets the crisis bar high.
HIV/AIDS reshaped many aspects of our society. It changed attitudes toward sexuality and end-of-life issues. It gave birth to patient activism and medical privacy. And it changed many established practices and procedures in medicine.
A California hospital in pre-HIV/AIDS 1978 looked vastly different than it does now, and not just because of newer, shinier machinery. The treatment and threat of HIV/AIDS has fundamentally changed the way hospitals and health care providers do their jobs. From patient intake to infectious disease protocol, the scope of change caused by HIV/AIDS is enormous.
Although the report was national in scope and intentionally avoided state-by-state analysis, the findings and recommendations are of special interest to California, having the largest number of seniors in the country and a more pronounced shortage of health care specialists than other states.
California was home to about four million people age 65 and older in 2006, according to the Census Bureau. That number is expected to more than double by 2030, the report’s target year to complete the overhaul of the country’s health system.
The ratio of geriatric specialists to seniors in the United States is about one to 2,500, according to the report. In California, there’s one geriatrician for every 4,000 seniors, according to a state legislative report.
Susan Chapman, director of the Allied Health Workforce Program at UC-San Francisco and a contributor to the report, said California is also lacking in nurses, nursing aides and home health aides trained in caring for seniors.
“We need more of everybody, not just geriatricians,” Chapman said. “We need to train everybody to be competent in dealing with seniors. We need education, training and testing for nurses, social workers, physical therapists, speech therapists and home care aides.
“California’s going to look a lot different in the years to come, and we better get ready to deal with it,” Chapman said.
California’s size, diverse population and well-developed educational systems make the state a particularly important place to put the report’s recommendations into action, according to Joseph Scherger, medical director of AmeriChoice, a clinical professor at UC-San Diego and one of the report’s authors.
“We’re about the most diverse state in the country, and that’s an important consideration in treating seniors,” Scherger said. “Cultural competence in dealing with different senior groups can make an enormous difference in how effective the care is.”
“I don’t think we have nearly enough minorities in the health care work force in general, let alone those who work with seniors,” Scherger said.
Moira Fordyce — a professor at the Stanford University School of Medicine and one of California’s moving forces in geriatric advocacy — echoed the calls for a more diverse health care work force.
“Culture and ethnicity has a huge impact on older adults, how they regard themselves, how the family and societal group regards them, how they expect to age and if they should seek help,” she said.
The growing diversity of the population in California “adds an extra dimension to this important topic,” Fordyce said. “There are too few minority health professionals in all medical, nursing and other health-related specialties, not just geriatrics.”
Two of the IOM report’s authors said dealing with aged parents helped inform their work on the project.
“Many of us are dealing right now with aged parents, and we can see how ill-equipped our system is to deal with today’s elderly. Imagine what it will be like in a few years when the senior population doubles,” said Paul Tang, chief medical information officer of the Palo Alto Medical Foundation and a contributor to the report.
“I think this is going to take a cultural realignment,” Tang said. “Our culture right now is just not set up to handle elderly very well.
“We certainly have the resources — what do we spend, $4 trillion a year on health care? But we haven’t aligned the resources very well. We have to rethink things,” Tang said.
Chapman said care for her 87-year-old mother is marked by lack of coordination and communication.
“My mother is trying to live at home independently with four or five chronic conditions, taking probably a dozen medications, and she has five or six providers,” Chapman said. “No one’s in charge, no one talks to each other, and some of them don’t talk to her.”
“It’s a very fragile situation and I think that’s probably the norm rather than the exception,” Chapman said.
The Institute of Medicine’s report could pump vigor into at least two bills winding their way through Sacramento and Congress.
Assembly member Ed Hernandez (D-El Puente) authored a bill to deal with the growing shortage of specific health care professionals in California, and Assembly member Patty Berg (D-Eureka) introduced a bill in February that would forgive some loans to physicians, nurses and social workers who agree to work in geriatrics for at least three years.
Hernandez’ AB 2375 would require the Office of Statewide Health Planning and Development, in collaboration with the Workforce Investment Board, to form a statewide task force to identify the health care fields in which California will experience a shortfall and align those needs with enhanced educational programs at all levels.
Hernandez called the Institute of Medicine recommendations “another reminder that as California’s population grows and ages, the pressures on our health care system will only increase. That’s why my bill to create a health care work force master plan is so important,” Hernandez said.
Berg’s bill, AB 2543, was approved 12-4 by the Assembly Health Committee last week and now moves on to the appropriations committee.
Last month, Sen. Barbara Boxer (D-Calif.) introduced a similar bill in Congress. The Caring for an Aging America Act would provide $130 million in federal funding over five years to attract and retain health care professionals and direct care workers trained in geriatric medicine by providing them with loan forgiveness and career advancement opportunities.
For longtime advocates of improved eldercare, the IOM report and legislative efforts are welcome, if not overdue.
“I have been involved with the American Geriatrics Society and the American Society on Aging for close to 30 years, and we have had concern about the shortage of health professionals skilled in geriatrics and gerontology for a long time,” Fordyce said.