Opinion Column

Who Will Care for the Elderly and Disabled?

Advocates of including long-term care services in health reform usually focus on two issues: How many Medicaid dollars should be spent on home care and whether to create a national long-term care insurance program, such as Sen. Edward Kennedy, D-Mass., has proposed in his CLASS Act. But neither of those reforms would mean much without more and better-qualified health care workers and medical professionals to deliver care.

Both long-term assistance and chronic care management often require specially trained doctors, nurses, nurses’ and physicians’ assistants, social workers, or health aides. Yet, we already face desperate shortages of qualified medical professionals and para-professionals who can meet the highly specialized needs of the frail elderly and other disabled adults. As 77 million baby boomers age, this shortage threatens to become a major public health crisis.

We actually are facing two separate, though related, problems. The first is the need for medical practitioners who are trained in geriatric care. You might think that treating aging boomers would be a growth industry. Yet, physician specialists in geriatric medicine are retiring faster than their replacements are being trained. In 2008, there were barely 7,000 geriatricians to treat 38 million seniors. And, according to an eye-opening study by the Institute of Medicine, in 2006-2007 just 253 physicians were enrolled in geriatric medicine fellowships. Oddly, while the opportunities for specialty geriatric training are increasing, the number of doctorss enrolled in these programs has been shrinking. The story is the same for geriatric psychiatry fellowships-more opportunities but fewer takers.

The consequences of this lack of training are potentially deadly because the needs of the frail elderly are very different from those of other patients. They often suffer from multiple diseases-20 percent of those 75 and older have five or more chronic illnesses. They take many more medications, and they often react to those drugs in unpredictable ways. Surveys show that many doctors feel ill-prepared to care for these patients.

Why don’t medical students want to study geriatrics? When I was researching my recent book, Caring for Our Parents, I had the chance to ask Dr. David Greer, the retired dean of the Brown University Medical School and a former geriatrician himself. Greer pointed to three reasons: Low pay, low status among other docs and, perhaps most important, “physicians don’t like to treat patients who don’t get better.”

Medicare and private insurers can address the first, perhaps as part of the push in health reform to create “medical homes”-practices that, for an extra fee, will manage a patient’s overall care. It will, sadly, be much harder to change physician attitudes towards elderly and disabled patients.

The second problem is with those front-line workers who provide the day-to-day physical care for long-term patients. It is tough work for low pay, and it is no surprise that few are willing to do it.

According to the Labor Department, the average wage for a home health worker is just $9.50 an hour, about what we pay the guy who works at the local car wash.

Consumers who hire aides through agencies may pay twice that, but those staffing firms may take half to handle paperwork, training, pay worker’s compensation, and for overhead.

Many home aides have no health insurance, sick days, vacation pay, or retirement benefits. The Labor Department reports they are more likely to be injured on the job than coal miners. Nursing home aides may get some benefits, but they have little opportunity for advancement and often work in a stifling, top-down, highly structured environment. It is no wonder that in many facilities up to 80 percent of workers quit each year.

What can be done to attract more people to these essential jobs? To start, aides could be paid more. But long-term care is already prohibitively expensive for many and higher wages will drive costs beyond the reach of still-more families. Better training and more opportunities for advancement will help. And some nursing homes, in the vanguard of what’s become known as the “culture change movement” are giving aides more autonomy and responsibility. Not surprisingly, they report higher morale and lower turnover.

Both the House leadership health reform bill and the Senate Health, Education, Labor and Pensions Committee measure include modest provisions to encourage better training for elder care workers and medical professionals. It is at least a start. But the growing demand for more home care will mean nothing if there are not enough workers to provide that assistance.

Howard Gleckman, a senior research associate at the Urban Institute, is author of Caring For Our Parents and a frequent writer and speaker on long-term care issues.