HealthcarePapers, 11(1) April 2011: 41-45.doi:10.12927/hcpap.2011.22251
Chappell and Hollander provide support for a set of policy directives formulated for an aging population. An integrated continuum of care model is the fulcrum of the policy prescription, given evidence-based support for its cost-effectiveness; improved quality of care and quality of life; and the success of similar models found in Denmark, Japan and other countries. This commentary addresses the underlying assumptions of these policy recommendations, identifies the major barriers to their implementation and suggests solutions. Improving our understanding of the dynamics of population aging as it relates to health and healthcare use is a necessary requirement to reaching the aims set out by the authors.
Neena Chappell and Marcus Hollander should be applauded for delineating key evidence-based health policy directives that address past and emerging needs in the context of Canada's aging population. The re-establishment, expansion and refining of community care and a continuum of care services for older adults and persons with disabilities is the primary, but not only, policy prescription recommended. The authors begin by dispelling the myth that population aging is the main reason for the rise in healthcare costs. They recommend several legislative and organizational mechanisms that are precursors for policy transformation, including the development of a new continuing care act in consultation with the provinces. Five key policy prescriptions are advanced in the paper: (1) the reduction of ageism in society; (2) building age-friendly healthy communities along the lines recommended by the World Health Organization (2006); (3) investing in health promotion aimed at preventing disease and injury; (4) developing legislation, policy and practice that assists unpaid caregivers; and (5) advancing an integrated system of care delivery based on a seamless continuum of care model (including home care, home support and other programs). Here, I revisit these health policy issues by examining some of the underlying assumptions and by placing them in the context of several population health and healthcare issues.
Dynamics of Population Aging and Population Health
Chappell and Hollander assemble confirmatory evidence demonstrating that the rise in healthcare costs in Canada observed between the late 1970s and the turn of the millennium have been only modestly affected by the aging of the population. Apocalyptic prophesies of population aging have been fuelled by the aging of the baby boomers – roughly 10 million people born between 1946 and 1965 (Wister 2005). These large birth cohorts begin to reach the age of 65 in 2011, and the full "generation" reaches age 65 by 2031. In 2006, 13.7% of Canadians were 65 or older, and this will rise to between 20 and 24% by 2031. The argument is based on the fact that rates of age-specific healthcare use rise appreciably for individuals who reach 65, and rapidly after age 75 and 80 due to age-related cognitive and physical decline.
Because healthcare costs escalated rapidly over the past three and half decades – for example, between 1975 and 2004, inflation-adjusted rates of healthcare spending increased by 179% (Canadian Institute for Health Information [CIHI] 2005) – research has examined the role of population aging. In a demonstrative article, Evans et al. (2001) analyzed administrative data for British Columbia between 1975 and 1992, which showed the following:
- While per capita hospital expenditures rose, there was a long-term reduction in hospital use rates, meaning that it cost more to provide healthcare.
- The number of physicians per capita and their proportion of costs rose.
- Total expenditures on drugs more than tripled between 1985 and 1999 (rising about 9% per year compared with about 5.5% per year for hospital and physician services), mainly due to the cost of ingredients and an increase in prescribing drugs for hypertension and anti-lipemic agents.
- Population aging only accounted for about 10% of the total increase in healthcare costs over that period.
Confirmatory evidence has also been found at the national level (CIHI 2005).
However, there are several reasons why one should be careful to conclude that population aging in the future will not be a significant factor in healthcare resource formulas. First, the above analyses were conducted during the 1970s to 1990s, at which time the rate of population aging was gradual. This is going to reverse as the baby boomer cohort moves into the 65-plus ages. If there is an interaction between the rate at which a population ages and healthcare cost pressures, then the population aging effect could be significantly underestimated in past studies. Second, there may be shifts in the primary drivers of healthcare costs, which could affect the relative weight of population aging. For example, recent data indicate a significant decline in drug expenditures due to a movement toward less expensive generic prescriptions – in 2009, drug expenditures rose by only 5.1% compared with 5.5% for the total healthcare system (CIHI 2010). Third, regardless of the relative effect of population aging, there will be a significant increase in the absolute number of older persons requiring more intense healthcare in the future, especially when these larger cohorts cross the age threshold of 80.
As the boomers age, they will not create a healthcare crisis, because there are many levers in the system susceptible to policy changes in order to curtail costs; albeit, this assumes corrective policy and program reform. However, it is important to understand that the aging of the baby boomers is going to put significant pressures on the system to change, making the policy prescriptions outlined by Chappell and Hollander even more relevant and urgent.
Will Future Generations of Older Adults Be Healthier?
One perspective is that the boomers will be healthier seniors than their generational predecessors because they are better educated, are wealthier, exercise more, smoke less and are more knowledgeable about healthy lifestyles. Others paint a much gloomier picture, stating that the boomers are engaging in poor eating habits and have higher rates of obesity contributing to poorer health trajectories. This issue is important because health behaviours are malleable and are associated with chronic illness prevalence and management and, ultimately, healthcare use.
A full discussion of this complex field is beyond the scope of this response article. My own research (see Wister 2005) suggests that boomer lifestyles show conflicting patterns but that the overall health profile is likely better than that of earlier generations of seniors. Life expectancy has increased, and disability-free life expectancy has increased, but there may not be a full compression of morbidity (Fries 1989) of all chronic illnesses. Evidence suggests that the landscape of chronic illness is becoming more complex. For instance, Menec et al. (2005) found that between 1985–1987 and 1997–1999, Manitobans aged 65 and over experienced fewer myocardial infarctions, strokes, cancer and hip fractures but had higher rates of diabetes, hypertension and dementia. Thus, although people are living longer, modern medicine has weakened the link between disability and morbidity.
Dementia is among the greatest healthcare concerns of the future but is presently one of the least understood. In 2008, a report by the Alzheimer's Society of Canada determined that approximately 400,000 Canadians were living with dementia and that this number would double by 2038 (Smetanin et al. 2008). Given the crude diagnostic methods available at present, these estimates are tenuous. But even if they are overinflated by a factor of two or three, our healthcare system will need to be adapted to address weaknesses in continuing care and long-term care systems.
Some of the increases in the prevalence rates of chronic illnesses are directly linked to shifts in lifestyle behaviours (e.g., obesity leading to diabetes), while others are likely the result of better screening and early diagnoses and, therefore, more effective treatment (e.g., hypertension and breast and prostate cancers). In other words, better health does not always mean lower healthcare costs. Furthermore, individual care expectations are increasing, supported by research demonstrating that healthy seniors have the highest increases in healthcare use. These factors underline the urgency of policy and program shifts since future older adults will not only expect a full spectrum of healthcare but also desire independent living and the resources required to sustain community living in old age.
Inflexibility in the Healthcare System
It is well known that the healthcare system is composed of a large complex set of programs and services that are becoming more reliant on higher-cost technologies – about 70% publicly funded and about 30% privately funded. The federal government contributes about 14% (down from an estimated 40–50% in 1977) of the total cost for healthcare, while the provinces contribute about 86% (CIHI 2010). The federal-provincial transfer of tax dollars, organizational decentralization and budget constraints have forced healthcare to be rationalized and rationed, with little room for long-term strategic planning and innovation. Priorities are placed on more "medically organized" health services, such as surgeries, that are deemed to be necessary rather than "supplementary." Chappell and Hollander's argument that we need to rebuild a home support program (which has been shown to reduce hospital costs) into an integrated continuum care system is undeniable. The problem is that there needs to be flexibility in the system. The mechanisms to achieve this policy prescription are not only to have continuing care policy recognized as a priority at all levels of government (with federal direction), but also to have a significant long-term commitment of healthcare dollars earmarked for system-level reform and innovations. However, in order to have funding flexibility for policy and program shifts, it may be necessary to create more permanent healthcare organizations and trusts that are protected from economic and political instability.
Revisiting Health Policy Prescriptions
Chappell and Hollander are leading the way in supporting integrated models of healthcare delivery and a continuum of care for older adults with functional impairments. A number of models have been proposed (Béland et al. 2006; Gross et al. 2004; Hollander 2007; Tourigny et al. 2004) that would create a more seamless delivery system, blending health, housing and social services. Integrated models of care aim to improve coordination between acute care (hospitals and clinics), continuing care (home care and support services) and long-term care (residential and nursing homes) – that is, the coordinated assessment and management of older patients and clients. Since some patients will be redirected from hospital and institutional care into less expensive community care shelter and services, an integrated model of care would lower costs (Béland et al. 2006). While there are many integrated models of care delivery in Canada and around the world, the primary features include (1) single entry, (2) a case management approach, (3) geriatric assessment by multidisciplinary teams, (4) coordination of hospital and nursing home care, (5) single assessment instruments for care options and (6) simplified payment and financial coordination (Hollander 2007).
As noted by Chappell and Hollander, an integrated model of care delivery has not been widely implemented because healthcare and community care are funded from different provincial envelopes. Future developments in health policy for the elderly in Canada will require a restructuring of funding mechanisms and jurisdictional responsibilities.
Policy and program change must be made with an understanding of their short- and long-term consequences. Therefore, examination of both intended and unintended consequences of policy needs to be an integral part of this process. For instance, expanding supports to allow older individuals to remain in their home (and outside of more expensive institutional and hospital care) may increase the prevalence of injury or falls, thereby requiring concurrent health programming and policies.
Chappell and Hollander recognize that changes must be made both inside and outside of the healthcare system, such as supports for caregivers, fostering communities that promote independent living over the life course and so on. I would also add priority areas such as palliative and end-of-life care, health promotion campaigns, health literacy and drug policies, although these are not exhaustive.
Canada has one of the better healthcare systems in the world. It is largely publicly funded, accessible and efficient. However, there will be mounting pressures on the healthcare system that require a rethinking of the type, funding and proportion of services needed to support an aging population. Without healthcare reform that addresses these core issues, we may be pushed into a multiple-tiered healthcare system that would compromise the fundamental principles of the Canada Health Act. While there is time before the full weight of the baby boomer generation will be realized, we need to begin policy change immediately, given the time (structural lag) that it takes to integrate such changes into a complex, multi-level healthcare system, and the fact that they are needed now. As Chappell and Hollander point out, many countries have experienced high rates of population aging without healthcare crises (e.g., Denmark and Japan); indeed, these countries have undergone successful healthcare and health policy reform led by federal government to meet the needs of an older population. Canada should be added to this list.
During a period of relatively slow population aging, compared with when the baby boom generation will become elderly, we have witnessed increased healthcare costs primarily linked to hospitals, physicians and pharmaceutical treatments and, therefore, an improved system in terms of reacting to illness. We have not made the same progress in promoting health and caring for an older population. Given the fluid and complicated healthcare landscape, we require more policy discussion, research and analysis. However, there is ample evidence to begin the first prescriptive steps, and these require leadership and commitment.
About the Author
Andrew V. Wister, HBA, MA, PhD, Professor and Chair, Department of Gerontology, Simon Fraser University
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Smetanin, P., P. Kobak, C. Briante, D. Stiff, G. Sherman and S. Ahmad. 2008. Rising Tide: The Impact of Dementia on Canadian Society. Toronto, ON: Alzheimer's Society of Canada.
Tourigny, A., P. Durand, L. Bonin, R. Hébert and L. Rochette. 2004. "Quasi-Experimental Study of the Effectiveness of an Integrated Service Delivery Network for the Frail Elderly." Canadian Journal on Aging 23(3): 231–46.
Wister, A.V. 2005. Baby Boomer Health Dynamics: How Are We Aging? Toronto, ON: University of Toronto Press.
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