What's Wrong with Healthcare?

Thinking inside and outside of the healthcare box. After 41 years of family practice, what's happened to Canada's healthcare system?

Saturday, May 06, 2006

We Need Courage To Grow Old

You’ve got to be brave to get old! I bet I’ve been told that hundreds of times by my geriatric patients over the years. A close second in advice given to me would be: “Getting old isn’t for cowards” and a third choice would be “If these are the golden years, they can have them”! One eighty five year old fellow would routinely start off every visit with: “Doc, I’ve got a bit of advice for you, don’t get old”.
So getting old isn’t all that delightful, it would seem, and the problems associated with aging certainly aren’t new. But for some reason there seems to be a lot more media attention to the plight of our elderly citizens, and groups speaking out on their behalf. There seems to be continual discontent with various facilities to house our seniors, the lack of entertainment for them in these facilities, and the paucity of staff to care for them. Many of these complaints are justified, but rarely does the person or group complaining come up with suggestions, other than their “wants” for their loved one. Obviously, there is a general lack of understanding of what is happening in our health care system, and how it impacts on the care given to our elderly in our nursing homes.
I think that thirty or forty years ago one could honestly say that nursing homes were truly a “warehousing of the aged”. Many of my patients in those days regarded nursing homes as a place to go to die. As geriatrics became a recognized field of medicine, and as we found more and more evidence that this group of patients responded extremely well to various medical and social interventions, pressure was brought to bear on enhanced medical approaches to our elderly and to our long term care facilities. As this was acted upon, some studies showed that spending on seniors increased by as much as 20% in some years. To curtail costs in Alberta, the Alberta government put a moratorium on the building of new long term care facilities. From a medical perspective, the previously used “you’re too old for this procedure, or this drug doesn’t work in this age group” simply was found to be wrong. Accordingly, renal dialysis and other technological interventions were offered to an ever aging group of patients. Statins, a medication group for lowering cholesterol, initially were not used in people over 65 years of age because it was suggested that this group already had established cardiovascular disease. Interestingly, more and more recent evidence suggests that this group benefits as much or more than the younger age group since the elderly are the group MOST AT RISK. It would seem that as time goes by, the more we learn about the elderly and their treatment, the more effectively we can treat them; they live longer and have a better quality life.
From a payers perspective (the government), it is not money well spent. Because these elderly people are at the sunset of their lives, interventions do not provide a sustainability of cost savings. Interventions in the young can provide good outcomes and low health care costs for fifty or sixty years. In the elderly, costly interventions will provide good outcomes for relatively short periods of time, but ongoing costs, for the remainder of their lives. This is the conundrum the taxpayers of Canada and its administrators (governments) face. The Canada Health Act was brought in to protect the poor, the chronically ill, and the frail elderly, but from a cost perspective, this group is the very group that invested money creates the worst long term results from a cost perspective, but very good short term outcomes from a medical perspective.
The irony is the objectors to private insurers and a private parallel health care system say the insurers won’t cover this group with high health care needs. Of course not! Insurance is for unforeseen events, not ongoing care of the poor, chronically ill, and frail elderly. Medicare was brought in specifically for that group.
Lynda Jonson, a strong advocate for improved care for our seniors, is concerned about the lack of adequate staffing in our long term care facilities. Previously, advocacy groups insisted on more private facilities for our institutionalized seniors. With the new larger private rooms, the nursing staff has twice the area to cover to see the same number of patients as when there were two patients in one room. Consequently, the need for more staff has become even more of a problem in the newer facilities. Adding staff for recreational therapy, physiotherapy, etc, has improved staff ratios without addressing day to day bsic care needs. I recall one dear elderly soul who, because of physical incapacity (but still having perfect mental capacity) was unable to address her toileting without help. “Do you know how humiliating it is to ring for assistance and finally after an hour pee the bed and lie in it for a further half hour” she would ask me? The nurses were unhappy with me, but I wrote an order for this lady to be bed-panned every three hours whether she rang for a nurse or not.
In an effort to contain cost, governments and regional health authorities have set up an elaborate system of classifying patients, and then designating them to an “appropriate” care facility. Lynda Johnson mentions reclassifying an area of an existing facility to the designation of “assisted living” instead of “continuous care” facility, and how the change in designation enables a lower staff ratio. It also changes the amount of government money available to the facility.
The truth is, a continuous downloading and reclassification has been going on for many years to enable cost savings. Certain criteria need to be met to access our hospitals because of limited space, transitional care is a step down from hospital care, home care is using the patient’s “home” bed as a hospital bed, and loved ones as care givers, assisted living is using more of the patients money to provide their needs, and continuous care facilities now are filled with people who once were more appropriately housed in a community hospital. The thrust is to steadily decrease spending on the frail elderly and chronically ill and downloading the responsibility on the patient and their loved ones-----the very thing Medicare was meant to prevent. So cheers to Lynda Jonson and other senior’s advocates, we need you. As the baby boomer generation has its impact something will have to give. Hopefully it won’t be the casting aside of your mother, father, grandma or grandpa, in an age that is prone to “disposables”.


Blogger Lanny said...

And here's another thing you can count on. The rich elderly will be okay because they can pay for home care etc. All the whining about keeping healthcare public only to avoid the rich getting better treatment is actually even more prevalent in this system.

8/5/06 12:03 PM  

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