Caring for chronically ill elderly patients represents one of the biggest challenges in health care, a challenge that's likely to intensify as the baby boom generation grows older and, inevitably, sicker.

Though boomers may benefit in many ways from maintaining a more active lifestyle than their parents did, they're also likely to enter their senior years a little more banged up. Moreover, boomers tend to indulge themselves when it comes to food and alcohol consumption, which can lead to long-term ailments.

One study found that baby boomers are more likely to have hypertension, high cholesterol, diabetes and obesity than their parents' generation did, according to JAMA Internal Medicine.

Boomers already are driving increases in certain chronic care treatments. The number of knee replacements has increased dramatically as the baby boom generation moves from middle to old age. Knee-replacement procedures rose 218 percent from 1999 to 2008 among those ages 45 to 64, and the reasons go beyond population growth, according to a 2012 study published in the Journal of Bone and Joint Surgery. Obesity and conditions tied to a more active lifestyle, such as sports injuries, were among the big reasons for the increase, according to the study, whose lead author was Elena Losina, co-director of Orthopaedic and Arthritis Center for Outcomes Research at Brigham and Women's Hospital, Boston.

"We baby boomers are not going to age gracefully," says Margherita Labson, R.N., executive director of the home care program at the Joint Commission. Boomers want to remain active in their senior years and Americans in general are living longer, she adds.

When I'm 75

This means demand for chronic care likely will expand sharply as the 76 million baby boomers continue to reach retirement age. And, if nothing changes by the time this generation hits 75 and older, that's when the health care system will become particularly stressed.

"It's certainly a substantial issue going forward," says Mike Kern, M.D., senior vice president and medical director of John Muir Health's Physician Network based in Walnut Creek, Calif. "Consider the fact that [because] Medicare is growing so quickly, we're going to have twice as many Medicare recipients in 2030 as we do now."


Framing the issue:

• Caring for the chronically ill elderly is a poorly coordinated and costly endeavor under most existing care models.
• With millions of baby boomers getting older and acquiring one or more chronic conditions, the problem will get worse.
• Medicare beneficiaries with three or more chronic conditions are the most expensive to treat, yet there is relatively little that is known about how to integrate care for those patients.
• The fast-growing demographic of 75 and older is where chronic illnesses become the most serious, and baby boomers will start turning that age in 2021.
• Practitioners of team-based chronic care say the model could solve many problems, but most reimbursement approaches don't adequately support it.


Kern notes that roughly 90 percent of serious, complex cases are among patients in the Medicare age group, and primarily in patients older than 75. The number of people in that key category is expected to double by 2033 to about 38 million from its current 19 million, according to the U.S. Census Bureau.

The members of the gray-haired set also are more likely to have one or more chronic conditions; as a result, they account for a bigger chunk of Medicare spending, particularly as they near death.

"The nature of chronic disease is that it disproportionately affects patients who are advancing in age," says Kori Krueger, M.D., medical director of the Marshfield (Wis.) Clinic's Institute of Quality, Innovation and Patient Safety.

Multiplicity

Roughly 90 percent of deaths among Medicare participants are associated with nine chronic illnesses: congestive heart failure, chronic lung disease, cancer, coronary artery disease, renal failure, peripheral vascular disease, diabetes, chronic liver disease and dementia, according tothe Dartmouth Atlas of Health Care. And Dartmouth researchers found that people with chronic illness and in the last two years of life account for about 32 percent of total Medicare spending.

The percentage of Medicare patients with specific chronic conditions can be startlingly high. Fifty-eight percent have high blood pressure, 31 percent have ischemic heart disease and 28 percent have diabetes, according to the Centers for Medicare & Medicaid Services chartbook "Chronic Conditions among Medicare Beneficiaries," 2012 edition.

"If you have a doubling of the size of the older population, then even things that have the same prevalence, the number of people with [the disease] doubles," says Marcel Salive, M.D., a researcher in the Division of Geriatrics and Clinical Gerontology at National Institute on Aging, which is part of the National Institutes of Health. "The burden on the system is going to go up, no doubt."

That burden grows greater for patients with multiple chronic conditions, and the majority of Medicare beneficiaries are in that position. Medicare calculated that 32 percent of these patients have two or three chronic conditions, 23 percent have four or five and 14 percent have six or more chronic conditions.

The National Institute on Aging began an effort to boost clinical research specifically for patients with multiple chronic conditions, in part because there has been a lack of studies of patients with more than two conditions. The NIA awarded four grants last August looking at such areas as multimorbidity in heart failure and the effects of common medications among the elderly with multiple conditions.

"A lot of heart failure patients, of course, have heart disease," Salive says. "A lot of them also have diabetes, kidney disease, things like that. The patients tend to be on a lot of different drugs."

Clinical trials usually focus on patients with a single chronic disease or involve early-stage participants who have not acquired the multiple conditions that are likely to show up later. "In the initial part of their diagnosis, they may not have any complications or they may not have any other diseases. But as they age, they may develop those other diseases," Salive says.

The NIA also will try to expand multiple chronic-condition research infrastructure by potentially funding a grant that pays for one. If the concept gets approved and funded, a grant announcement would be made in the summer, he says.

Patients with multiple chronic conditions cost more money for care. "In the Medicare program, about 80 percent of the growth in spending is due to the increase in the share of Medicare patients who have chronic illness," says Kenneth Thorpe, professor and chairman in the Department of Health Policy and Management at Emory University's Rollins School of Public Health.

Moreover, "roughly 80 percent of the spending is associated with patients who have five or more chronic health care conditions," says Thorpe, who also is the executive director of Emory's Institute of Advanced Policy Solutions and director of the Institute's Center for Entitlement Reform.

Medicare beneficiaries who have two to three chronic conditions cost an average of $5,698 in 2010 — which is below the average cost of $9,738 that year. However, beneficiaries with four to five conditions cost $12,174 and those with six or more cost $32,658. "That's where all the money is, and the challenge we face is that a little more than 70 percent of the Medicare population is in a fee-for-service program that doesn't really do effective, comprehensive care coordination," Thorpe says.

Widening support

Thorpe notes that Medicare is moving slowly toward a care coordination model, primarily through selected Medicare Advantage plans. But things may speed up with the appointment expected this month of Sen. Ron Wyden (D-Ore.) to the position of chairman of the Senate Finance Committee, which has oversight of much of Medicare's funding. Wyden, who has made improving chronic care one of his main causes, last month announced he would co-sponsor a bill that, among other things, would create specially designated Medicare plans that would have incentives to respond to the needs of the chronically ill.

The bill aims to encourage care that revolves around teams of providers, uses telemedicine and makes it easier for such clinicians as nurse practitioners and physician assistants to operate at the top of their license.

A number of efforts are under way across the country to boost chronic care, including the type of care coordination that Wyden desires.

John Muir Health has focused on improving care transitions as part of its broader chronic care improvement efforts, which began more than six years ago, Kern says. "At the time, there was, from today's perspective, the strange notion that readmissions weren't really a problem," he says. But studies found otherwise. When a patient is readmitted, the secondary admission generally is worse.

"Readmissions are deadly, readmissions are really ugly," Kern says.

John Muir implemented a program called Care Transitions that sends health coaches to the homes of high-risk patients to educate them on their care and medications. Readmissions have dropped 20 to 30 percent among these high-risk and often chronically ill patients, he says.

Evolving innovation

Researchers at Group Health in Seattle were the primary developers of a well-known approach called the Chronic Care Model in the mid-1990s. Now, the organization is adding a medical home-based structure to the mix, says Eric Larson, M.D., vice president for research for Group Health and executive director and senior investigator for Group Health Research Institute.

The Chronic Care Model aims to be more efficient and effective by reorganizing how providers care for and monitor patients and by trying to get patients and their families more involved in care. The model is based on a more proactive approach to working with the patient that is explicit and evidence-based, according to Rand Corp., which has evaluated it in several papers. A patient registry is used to create reminders and for scheduling, as well as data collection and performance reporting. "Instead of reacting to the next crisis, you try to care for people, and have people care for themselves in a way that's more mindful," Larson says.

The use of a medical home approach has been a part of Group Health's research since 2006. Teams have been set up to enhance access, with a secure portal for Group Health's medical home patients to reach physicians and for clinical staff to reach out to patients. In some cases, the portal provides health monitoring data such as blood pressure or glucose levels.

The portal has proved popular with all ages of patients. "We thought the secure portal would be a place where just young techies are more likely to go to, and older people, people who are really 'sick,' are not going to go there," Larson says. "But in fact, what we found is that the use paralleled the use of services. The people who need more services actually use the secure portal more than anybody, even though they may be in the age demographic you wouldn't expect."

User-friendly

That may bode well for the boomer generation, which eagerly embraces technology and wants to be a more active participant in its health care processes. An Accenture survey of Internet users found that members of the pre-boomer generation are surprisingly active fans of information technology. Boomers ages 55 to 64 have "even higher digital use rates" and are "poised to drive adoption as they age in" to the Medicare program, according to the survey report, "Silver Surfers Are Catching the eHealth Wave."

Many experts also anticipate that the boomers' success at getting what they demand may be a boon to efforts to better engage patients in their care. "I think that baby boomers are going to be more informed and more engaged in their health care than generations before," Marshfield's' Krueger says. Marshfield tries to boost patient access and interaction, using such things as telehealth.

Smaller physician groups are finding ways to create chronic care teams as well. MedNet-One Health Solutions, which assists physician groups with wellness activities and chronic care models using the approach developed by Group Health, has found success working closely with various partners in southeast Michigan, says CEO Ewa Matuszewski. A large payer, Blue Cross Blue Shield of Michigan, in particular, has been very helpful, she says, but MedNetOne also works with partners as varied as hospitalist groups and community organizations to revamp and improve chronic care.

She believes that big changes are needed in primary care, and that they will come. "Once you reach a point where a patient has a chronic condition, you need to do everything you can to make sure they're healthy," Matuszewski says.


Executive Corner

Treating patients with multiple chronic conditions is one of the tougher jobs facing health care providers, and will become even tougher as millions of baby boomers get older. Health & Human Services' strategic framework for tackling multiple chronic conditions includes a number of recommendations, including:

Identify evidence-supported models of care that improve care coordination.

New care models should include the core principles of making care person-centered — empowering the patient, using team-based care and aligning payment incentives accordingly.

Develop payment reforms and incentives.

Because health care professionals currently have few incentives to coordinate care, outcomes are hurt and are reflected in higher hospitalization and rehospitalization rates.

Define appropriate health care outcomes for people with multiple chronic conditions.

HHS officials say the outcomes for those with multiple chronic conditions are not dramatically different from those of other patients, but some are more important because they have increased risk of negative outcomes.

Implement and use health information technology.

Proper use of health IT with chronically ill patients facilitates care coordination and provides for uniform information-sharing among members of a care team.


About the series

This is the second installment in Hospitals & Health Networks' yearlong series examining the many ways the nation's roughly 75 million baby boomers will affect the U.S. health care system as they grow into old age. One of the areas that will be affected is chronic care, a segment of health care already under stress by the challenges of treating multiple chronic conditions. Team-based coordinated care models are being tested by some providers, and may offer a good solution nationwide if an affordable reimbursement approach can be established. The series will include articles in the magazine and in our e-newsletter, H&HN Daily. Here's the complete lineup:

JANUARY
The boomer challenge

FEBRUARY
Chronic conditions

APRIL
The financial impact

JUNE
New care models

OCTOBER
Staffing and management

DECEMBER
Innovation in facilities and care design