1st Day-7th Talk: “The Future of Geriatric Medicine” by Stephen Phillips, M.D.

Dr. Steven Phillips is the Director of Geriatric Care of Nevada and Medical Director at Sierra Health Services. He was the Chairman of the American Geriatrics Society Annual Program Committee. He joined us today to discuss the future of healthcare for older Americans.

The population of people over the age of 65 has shown substantial growth in the past 40+ years. Dr. Phillips presented a graph that showed there were approximately 16.6 million Americans over the age of 65 in the year 1960, 34.7 million Americans 65+ in 2000, and a projected 78.9 million Americans 65+ in the year 2050. Life expectancy in the year 1900 was 47 years of age and this grew to 75 years of age by the year 2000. People are usually disabled for 2 years, on average, before death, and most medical expenses are paid by Medicare. Dr. Phillips briefly discussed some of the implications of these changes in the 21st Century. In the year 2000, 4,200,000 Americans were over the age of 85, and it is projected that this number will increase to 9,000,000 by the year 2030. In the year 2000, long term care costs (Medicaid) were approximately $137 billion, and this number is expected to increase to $281 billion by the year 2030. Most of the medical expenditures that a person will spend over the course of their lifetime will occur in the last 2-3 years of life.

Dr. Phillips stated that caring for older Americans is possible, but only if we, as the voice of geriatric health care professionals, are actively engaged in creating the systems that create these solutions. The Institute of Medicine, in 2001, defined the goal of health care in the report Crossing the Quality Chasm: A new Health System for the 21st Century in care that is: safe, effective, patient-centered, timely, efficient, and equitable. This is the challenge for geriatric service delivery. In addition, true excellence in geriatric service will need to include: focus on function (not just “disease management”), cultural and ethic sensitivity, incorporation of health beliefs, values, and person preferences, equity of service access, attention to wellness and successful aging (not just illness), and an integration of care transitions “across time, place and profession”.

Dr. Phillips discussed several requisites for this type of care to be provided. One requisite is person-centered assessment that identifies the needed services and appropriate level of care and recognizes functional needs as well as medical needs. Another requisite is the coordination of care and information across settings and providers of care that supports transitions, as well as improved self-directed health management. We also need an integrated financing structure that is not defined by the site of care, but coordinated benefits for optimum outcome and resource use. In addition, we need a professional work force that is adequately trained and engaged in the care of these patients. Lastly, linkage with home and community-based services (including informational caregivers) to traditional medical systems of physicians and hospitals would be necessary.

What are some of the strategies for overcoming these obstacles? One strategy that Dr. Phillips discussed was financial restructuring (i.e. reimbursement, payment policies, meaningful “pay-for-performance”, and liability reform to ensure access of quality providers). Another important strategy would be comprehensive training and education. We would need geriatric specialist training, geriatric medicine principles in all disciplines and specialties, and end-of-life care across all settings (i.e. hospital, outpatient, home care, etc.) In addition, we need a better system of management, such as electronic medical records that link care between settings and personal health records that patients can have access to (wellness goals with preventative care). New models of chronic care coordination need to be developed, and technology needs to be applied to the senior population (i.e. telemonitoring and information-based self-directed decision making).

Dr. Phillips used the following quote from Julie Louise Gerberding, director of the Centers for Disease Control and Prevention, to illustrate his point: “The aging of the US population is one of the major public health challenges of the 21st Century. With more than 70 million baby boomers in the United States poised to join the ranks of those aged 65 or older, preventing disease ad injury is one of the few tools available to reduce the expected growth of health care and long term costs.”

There are several opportunities to improve older Americans’ health and quality of life. Leading a healthy lifestyle that includes physical activity, a balanced diet, and not smoking is the first step. We also need to make use of tools such as mammography, colorectal screening, serum PSA, and pap smears for early detection of disease. In addition, injury can be prevented by the administration of home safety evaluation & modification, cognitive screening, falls screening and driving intervention. Lastly, patients can use several techniques to self-manage their health care: chronic disease education, preventive screening information, healthy lifestyle education, and advanced care & end-of-life planning. Dr. Phillips wrapped up his discussion with the Institute of Medicine’s six fundamental aims for health care: safe, effective, patient-centered, timely, efficient, and equitable.