The committee set a target date of 2030 — the year by which all
baby boomers will have turned 65 or older — for the necessary reforms
to take place.
"We face an impending crisis as the growing number of older patients,
who are living longer with more complex health needs, increasingly outpaces
the number of health care providers with the knowledge and skills to care for
them capably," said committee chair John W. Rowe, professor of health policy
and management, Mailman School of Public Health, Columbia University, New York
City. "The sheer number of older patients in the coming years will require
trying new models for delivering health care and the commitment of greater financial
resources," he added. "If our aging family members and friends are
to live as robustly as they can and in the best health possible, we must have
a work force of adequate size and competency to take care of them."
Work Force Shortage Threatens Quality of Care
Several reports show an overall shortage of health care workers in all fields,
but the situation is worse in geriatric care because it attracts fewer specialists
than other disciplines and experiences high turnover rates among direct-care
workers — nurse aides, home health aides, and personal care aides. For
example, there are just over 7,100 physicians certified in geriatrics in the
United States today — one per every 2,500 older Americans. Turnover among
nurse aides averages 71 percent annually, and up to 90 percent of home health
aides leave their jobs within the first two years.
Older adults as a group are healthier and live longer today than previous generations,
the report notes. Even so, individuals over 65 tend to have more complex conditions
and health care needs than younger patients. The average 75-year-old American
has three chronic conditions, such as diabetes or hypertension, and uses four
or more prescription medications, the committee found. Dementia, osteoporosis,
sensory impairment, and other age-related conditions present health care providers
with challenges they do not often encounter when tending to younger patients.
All Providers Should Be Competent in Geriatric Care
Virtually all health care providers treat older patients to some extent during
their careers — and likely will do so even more frequently given that
one in five Americans will be 65 or older by 2030 — so they need a minimal
level of competence in geriatric care, the committee concluded. Health care
workers should be required to demonstrate competence in basic geriatric care
to maintain their licenses and certifications. All health professional schools
and health care training programs should expand coursework and training in the
treatment of older individuals.
To deliver care more efficiently and alleviate the shortage of adequately trained
workers, the report calls on the health care professions and regulators to consider
expanding the roles and responsibilities of health care providers at various
levels of training. For example, if a certified nursing assistant is able to
administer certain medications, a professional nurse would have more time to
concentrate on more complex patient needs. Additional research is needed on
how to prepare health care workers to assume expanded roles, the committee noted.
Because insufficient training can leave direct-care workers unprepared for
the demands of their jobs and lead to high turnover rates, the federally required
minimum number of hours of training for direct-care workers should be raised
from 75 to at least 120. More training is required for dog groomers and manicurists
than direct-care workers in many parts of the country, the report notes.
Higher Salaries, Financial Incentives Needed
While the number of older patients is rapidly increasing, the number of certified
geriatric specialists is declining. Medicare, Medicaid, and other health plans
need to pay more for the services of geriatric specialists and direct-care workers
to attract more health professionals to geriatric careers and to stanch turnover
among care aides, many of whom earn wages below the poverty level.
Salaries of doctors, nurses, pharmacists, social workers, and others who specialize
in geriatric care lag behind those of their counterparts in other fields. A
geriatrician earned $163,000 on average in 2005 compared with $175,000 for a
general internist, despite the extra years of training required for a geriatric
career. Physicians who choose dermatology can earn over $300,000 a year. Registered
nurses who work in nursing homes or other long-term care facilities earn less
on average than their counterparts, despite working longer hours with more overtime.
Medicare's low reimbursement rate for primary care is the foremost reason that
geriatric specialists earn lower salaries, given that so much of their income
comes from the government program. Medicare should increase its reimbursement
rates for services delivered by geriatric specialists, the report urges.
Direct-care workers are more likely to lack health insurance and use food stamps
than workers in other fields. The median wage for direct-care workers in 2005
was $9.56 an hour. To boost wages, states should allocate funds to be added
to the Medicaid payments that cover the majority of services provided by direct-care
workers, the committee stated.
Family Members, Other Informal Caregivers Need Training
The report calls for health care facilities, community organizations, and other
public and private groups to offer training programs to help family members,
friends, and other informal caregivers provide proper assistance to their loved
ones and to alleviate the stress they may feel in coping with an older friend's
or relative's needs. Health professionals should regard patients and informal
caregivers as an integral part of the health care team, the committee added.
Between 29 million and 52 million family members, friends, and others tend
to aging parents or other older individuals. More than 90 percent of older adults
who receive care at home rely in part on informal caregivers and nearly 80 percent
rely solely on family or friends. However, little is done to ensure informal
caregivers have the necessary knowledge and skills.
State attorneys general should recognize training programs for unpaid caregivers
as a way that nonprofit hospitals could meet their requirement to provide benefits
to their local communities in exchange for their tax-exempt status. In addition,
federal agencies should support the advancement of assistive technologies that
can help older patients manage their conditions and handle the basic activities
of daily life and also can help informal caregivers take care of their loved
ones.
Medicare Hinders Delivery of Quality Care
Although a comprehensive examination of Medicare was not the focus of this
study, the committee noted several ways that the program hinders the provision
of quality care to older adults, including Medicare's low reimbursement rates,
its focus on treating short-term health problems rather than managing chronic
conditions or age-related syndromes, and its lack of coverage for preventive
services or for health care providers' time spent collaborating with a patient's
other providers.
Medicare and other public and private insurance plans need to remove disincentives
that prevent health care providers from adopting new models of care delivery
— such as interdisciplinary team care — that could improve patients'
health and lower costs, the report says. The committee acknowledged the complexities
of making changes to Medicare and the financial crisis facing the program, which
is predicted to run out of money by 2019. It was beyond the committee's purview
to recommend a detailed plan for how to re-engineer Medicare.
The study was sponsored by the John A. Hartford Foundation, Atlantic Philanthropies,
Josiah Macy Jr. Foundation, Robert Wood Johnson Foundation, Retirement Research
Foundation, California Endowment, Archstone Foundation, AARP, Fan Fox and Leslie
R. Samuels Foundation, and Commonwealth Fund. Established in 1970 under the
charter of the National Academy of Sciences, the Institute of Medicine provides
independent, objective, evidence-based advice to policymakers, health professionals,
the private sector, and the public. The National Academy of Sciences, National
Academy of Engineering, Institute of Medicine, and National Research Council
make up the National Academies.
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