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Science & the Public

U.S. health system not adequately prepared for the aging sick

The problem can really break down for people with multiple chronic conditions.

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An editorial in tomorrow’s Journal of the American Medical Association offers anything but welcome words for Baby Boomers and their elders. These aging, if not geriatric, individuals constitute a large share of the 75-million-and-growing number of patients annually who must cope with at least two chronic medical conditions — ones that will each require at least a year of ongoing treatment.

Is the U.S. healthcare system prepared to deal with these patients? “Current indications suggest that it is not,” according to physicians Anand Parekh and Mary Barton. And they might be expected know. Parekh is the Deputy Assistant Secretary for Health and Barton works for the Agency for Healthcare Research and Quality.

Two-thirds of U.S. medical spending goes to treat the one-quarter of Americans with multiple chronic health conditions. There’s a good reason that such a disproportionate share of insurance and government spending goes to help these people, Parekh and Barton note: As the number of chronic conditions that any individual has increases, so does the number of unnecessary hospitalizations; adverse drug events; redundant tests; instances of conflicting medical advice — and, most importantly, cases of “poor functional status and death.” Yep, that last one is a killer.

The pair points to diabetes as a good example. One in ten American adults suffers from this metabolic disease — and 90 percent of these individuals have at least one additional chronic condition. Such as cardiovascular disease. Or incipient dementia. Or crippling arthritis. Or an osteoporotic fracture. Or prostate cancer. Or chronic obstructive pulmonary disease.

To maximize their patients’ care and quality of life, physicians in disparate fields should be coordinating the monitoring and treatment of people with multiple, long-term illnesses. But there’s little financial or even social incentive for them to do so, Parekh and Barton say. Under the current “fee-for-service” rubric, each additional medical test or office visit warrants another payment. And overworked docs can find it frustrating to try to touch bases with similarly overworked peers to review cases.

Nor has there been much research investigating the special risks associated with managing comorbidities (although that is starting to change), Parekh and Barton point out. In the past, people with many chronic diseases would have died by middle age, or at least before a second, third (much less a fourth) long-term ailment was diagnosed. So one glass-half-full way to look at the problem is that people are surviving longer with disease. A good thing, right?

A more dismal prospect: Our golden years may be tarnished by having to suffer with more disease — and over far longer periods.

As my 90-something mother-in-law said to me one day after perhaps her seventh doctor’s visit of the month: “You know, Janet, getting old sucks.” Aside from the out-of-character verb that she chose, there was a spare elegance to what she said. She was tired of the chronic pain, of having to remember to take all of those pills, of failing to remember what she’d planned for dinner and of having to hunt once again for her misplaced reading glasses (or shoes, house key, hearing aid, credit card . . . fill in the blank).

I valued every day we had with this sweet woman. And just wished her doctors had been able to manage her myriad symptoms better so that she didn’t come to look forward to the end.

As more — and an increasing proportion — of us approach our geriatric years, we had better hope that medicine learns how to manage multiple chronic ails. Indeed, it’s in our collective vested interests to see that more research dollars get funneled into this understudied area. And soon.

Citations

Parekh, A.K. and M.B. Barton. 2010. The Challenge of Multiple Comorbidity for the US Health Care System. Journal of the American Medical Association 303(April 7):1303.
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