Why doesn't America's health system work for older people?

MW Why doesn't America's health system work for older people?

By Richard Eisenberg

Americans die the youngest and live the sickest lives among residents of 10 nations surveyed, new research shows

Since it's Medicare open-enrollment season and I'm 68, I've been thinking and reading a lot about healthcare and health costs in America for people around my age.

I'm sad to report that things are not looking good, according to two new surveys: "Meeting the Growing Demand for Age-Friendly Care: Health Care at the Crossroads," from the Age Wave consulting firm and the John A. Hartford Foundation, and The Commonwealth Fund's "Mirror, Mirror 2024: A Portrait of the Failing U.S. Health System."

Read: Medicare open-enrollment will be a doozy this year. Here's how to make smart choices.

But interviews I had with the authors of those reports and a top Veterans Affairs Department official suggested that Medicare, medical pros and older patients themselves could make the healthcare system work much better and more affordably for retirees.

Older adults' needs are being 'neglected or avoided'

"There are massive forces that are creating an enormous set of needs pertaining to the aging of our population that are simply being neglected or avoided or not talked about," said Age Wave founder and Chief Executive Ken Dychtwald, who's in his 70s. "They're not being talked about in the political debates. They're not being talked about in our medical schools. They're not being talked about around the dinner table."

When Age Wave and the John A. Hartford Foundation, a group working to improve healthcare for older Americans, asked the Harris Poll to survey roughly 2,500 adults ages 65 and older, they learned that:

-- Just 11% give the nation's healthcare system an "A" grade.

-- 16% give an A to their satisfaction with out-of-pocket health costs. The average Medicare beneficiary spends $7,000 in out-of-pocket healthcare costs annually, not including long-term care, according to KFF.

-- Half say their primary care provider doesn't coordinate their treatment with other providers.

-- 56% call navigating the U.S. healthcare system "difficult and stressful."

-- Only 40% say their healthcare providers routinely evaluate their cognitive health and brain functioning.

-- A mere 55% say their providers evaluate their mobility and physical fitness, even though 62% of respondents say they have difficulty walking or climbing stairs and just 23% of people age 65-plus meet the U.S. physical-activity guidelines.

-- Older adults with three or more health limitations are much less satisfied with their care and out-of-pocket health costs than others.

-- Older women are less satisfied with the healthcare system than older men.

-- 68% say one of their greatest concerns is not being able to afford future health and long-term care needs. Today, the average yearly cost for a private room in a nursing home is over $116,000.

Most are dissatisfied with the size of out-of-pocket health costs

Older adults were most dissatisfied with the amount they pay out of pocket to cover healthcare services and insurance costs. "People do not understand that Medicare pays for some things, not all things," said Terry Fulmer, president of the John A. Hartford Foundation. "People still believe that Medicare pays for nursing homes." It generally doesn't.

Many older adults don't see the dentist because of the cost, Fulmer said. Traditional Medicare doesn't cover most dental visits.

How the U.S. health system ranks

The Commonwealth Fund survey comparing the U.S. health system with that of nine other developed nations said ours was "the worst overall," ranking the lowest on health equity, access and outcomes. Yet the U.S. spends more on healthcare than any other country in the survey.

"In this analysis and others we've done looking at the experience of older adults, we know many feel the squeeze as it relates to out-of-pocket costs," said Reginald Williams, the Commonwealth Fund's vice president for international health policy and practice innovations.

Although the U.S. scored well on health prevention and safety measures according to the Commonwealth Fund study, Americans die the youngest and live the sickest lives among residents of all 10 nations surveyed.

"That is not just happenstance," said Williams. "It's because other countries have put in place policies to ensure that people have better access with care that is affordable and [that] out-of-pocket costs are managed. The message we're trying to get across is that it doesn't have to be this way."

A healthcare system that's rarely age-friendly

Fulmer, 70, and formerly a nurse in geriatrics, said many older Americans are unhappy with the U.S. healthcare system because it is often not age-friendly.

Age-friendly healthcare, she said, means focusing on what her foundation calls the "4 Ms": what matters to older adults; their medications; mentation (mental activity - preventing, identifying and treating dementia, depression and delirium) and mobility.

"If you approach people with the 4 Ms, studies have shown, you reduce readmission to the hospital. You reduce medication error. You reduce falls," said Fulmer.

But only 19% of older adults get reliable 4M care, she noted.

Most older Americans don't feel doctors and other health practitioners listen to them, Fulmer added. Just 58% of her survey's respondents said their primary care or regular healthcare provider "routinely asks questions to understand what matters to me in terms of my health and well-being."

The time squeeze on doctors

One explanation for the lack of age-friendly care: Doctors usually don't have much time to talk with patients during appointments.

"They know they've got eight or 10 minutes and they'll say to themselves, 'This person looks like they're walking OK. They seem to be answering my questions. OK, I'm going to move on,'" said Fulmer. "They're looking at a checklist in order to get paid."

Yet when people 65-plus in the survey said they did receive age-friendly care, they reported better healthcare outcomes than those who didn't.

There are roughly 5,000 age-friendly certified care settings, according to the Institute for Healthcare Improvement $(IHI)$ Age-Friendly Collaborative. The IHI says all CVS $(CVS)$ MinuteClinics and several large hospital networks offer age-friendly care.

Our healthcare system generally lacks coordinated healthcare for people 65 and older, however, the Age Wave/John A. Hartford Foundation report said.

Car problems and human-body problems

Dychtwald made a piercing analogy of what happens when our car breaks down versus when our body does.

"If I needed to get my car fixed and they told me, 'Take it over there and get an appointment to get that spark plug fixed,' and then you needed to make another appointment two months later to someone else to check your battery, and then an appointment somewhere else to see if the tires had the proper inflation, we'd say that's absurd," Dychtwald noted. "But for older people trying to navigate their way through different doctors and appointments, that contributes to their low grade for the American healthcare system."

Over half of Medicare beneficiaries see more than three physicians a year, and 30% see five or more.

How the VA is getting it right

One corner of the U.S. healthcare system that seems to be doing things better, especially for older people, is the Veterans Affairs Department's Veterans Health Administration (VHA). It's the largest integrated healthcare system in America, serving 9.1 million vets each year.

Since 2011, the VHA has offered vets the little-known Whole Health System, with coordinated medical care in conjunction with complementary and integrative care such as acupuncture, yoga, tai chi and meditation.

"The concept behind Whole Health is that rather than being strictly disease-oriented, the way typical healthcare settings are, we expand the aperture and really start to think more about the whole person,"said Dr. Benjamin Kligler, executive director of the Office of Patient Centered Care & Cultural Transformation at the VA. "That's what people want and that's the way you can potentially do a better job."

The VA's Whole Health system includes Whole Health Clinical Care. "We're really moving to try to get everybody participating in care to remember how important it is to get to know what matters most to the veteran," said Kligler, a family physician.

"The Whole Health concept is why I went into medicine to begin with," Kligler added.

What the Whole Health approach means

As an example, he said, an older veteran struggling with diabetes and weight might be told by their primary care doctor: "Let's identify a couple of goals to help you get more toward what matters to you." Ideally, Kligler added, "they're going to put it in your chart as well, so other parts of the healthcare team can see it."

Alternatively, the primary care doctor might send the veteran to one of the VA's Whole Health coaches. "They're specifically trained on how to have that conversation with somebody," Kligler said. Then, the coach can begin working to establish achievable, measurable and specific goals.

"So, it's not just saying, 'I need to exercise more and lose 40 pounds.' It's saying, 'I'm going to walk for half an hour, four times a week for the next month,'" said Kligler.

This approach is starting to expand beyond the VA.

In January 2024, the Centers for Medicare & Medicaid Services $(CMS)$ began letting traditional Medicare and private insurers' Medicare Advantage plans cover services delivered by board-certified health and wellness coaches and educators.

But it's only a trial program; the government is watching to see whether the services improve beneficiaries' health and lower costs.

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October 09, 2024 13:21 ET (17:21 GMT)

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