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The Right Cure For Ailing Elder Care?


At the end of our lives, we can only hope to see the face of someone like Renee Roberts. She is a 42-year-old geriatric nurse practitioner employed by Evercare, a division of UnitedHealth Group Inc. (UNH) that coordinates care for elderly clients. She also represents a possible solution to the worsening shortage of doctors trained to treat the elderly. A health-care model that relied heavily on nurse practitioners for senior citizens rather than physicians could save the nation money--a lot of money--arguably without compromising quality. "We know that investing in an NP up front leads to better care and a lower cost at the back end," says Evercare Chief Executive Dr. John Mach, himself a geriatrician. "We've achieved a 45% reduction in hospitalizations with no negative impact."

Roberts has a caseload of 80 to 100 very old patients around Augusta, Ga. Most of them live in nursing homes, although she tries to keep patients out of institutions as long as possible. Her mission is to see that her patients get the best medical attention possible, the kind of care nursing-home staff and primary-care doctors might be too busy to provide. She visits up to 10 patients each day, five days a week, spending some 45 minutes to an hour per visit--three or more times the length of a typical doctor visit. She deals with a multiplicity of chronic illnesses, and because many of her patients are suffering from dementia, she can't count on their input to guide her. "I look for the geriatric symptoms they can't tell me about," says Roberts. "If they are leaning to one side, for example, that might mean they have a urinary tract infection."

Roberts also meets frequently with the families of her clients, discussing such uncomfortable issues as end-of-life directives, frequently left unaddressed until the patient is in crisis. "I'm more than a nurse practitioner," she says. "I'm a clinician, I'm a counselor, coach, communicator, manager, collaborator. For me, geriatrics is a very, very rewarding field."

Those last few words are rarely heard from physicians. Each year, U.S. medical schools graduate about 16,000 students, and only 2% seek careers in geriatrics. In a 2006 survey, only 49% of medical school graduates said they received any geriatrics training as part of their medical education. Those numbers translate into a looming health-care crisis as the Baby Boom generation starts hitting old age. Based on Census Bureau projections, the number of Americans aged 65 and older will double in size, from 35 million in 2000 to 70 million in 2030, while those 85 and older, already the fastest-growing age group, are expected to increase from 4.2 million to almost 9.6 million.

As a result, the Alliance for Aging Research estimates there will be a need for 36,000 geriatricians by 2030. In 2005 there were only 6,615 of these certified specialists for the aged--one for every 2,500 people over 75. By 2030 there will likely be only one per 3,600. "Geriatrics is a lost cause," says Dr. Robert L. Kane, director of the University of Minnesota's Center on Aging. "There are just too few [geriatricians] now, and no sign that there is any growing interest" among medical students.

WELL-PREPARED

Nurse practitioners, already used to serving poor and rural populations where doctors are scarce, may be more inclined to take on the aged. "They are filling in the gaps and are pretty much on the front lines in taking care of elders," says Dr. Wayne S. Saltsman, chairman of geriatric medicine at the Lahey Clinic in Burlington, Mass. This class of highly trained nurses, who usually hold master's degrees, are meant to work in collaboration with a doctor, although in 16 states they are allowed to practice independently. They can diagnose and manage acute and chronic illnesses and can write prescriptions in all 50 states. They can also specialize in geriatrics.

Doctors, however, are not keen on the idea of turning elder care over to NPs. "I love nurse practitioners, but that's like saying old people should get less-trained caregivers," says Dr. Robert N. Butler, president of the non-profit International Longevity Center in New York, and founder in 1982 of the first geriatrics department in a medical school, New York's Mount Sinai Medical Center.

Even Evercare insists the 500 NPs it employs in 38 states are not meant to replace doctors but to work with them. Yet study after study has found the primary care provided by NPs is as good as that of a doctor. The federal Office of Technology Assessment determined back in 1987 that NPs can effectively treat 80% of all adult patients, and "outcomes are equal to or better than care by physicians."

Some of the most persuasive arguments for boosting reliance on NPs are economic in nature. A 2003 study by the University of Minnesota, performed for the federal agency that administers Medicare, found that Evercare's greater use of NPs reduced hospitalizations by half when compared with an equivalent population of nursing home patients not enrolled. "On average, using an NP is estimated to save about $103,000 a year in hospital costs per [nurse]," concluded the study, led by Kane. Plus, the nurses themselves are compensated by Medicare at only 85% of the rate of doctors.

Cutting the cost of elder care is no small matter because, while some American hospitals have top-notch geriatric programs, they usually lose money.Mount Sinai's Brookdale Geriatrics Dept., considered one of the best in the nation, has 24 doctors, 14 medical students, and two NPs to handle 12,000 visits per year from 1,500 patients with a mean age of 84. These are not in-and-out checkups; 80% of senior citizens have one chronic disease and 50% have at least two. Visits usually last at least 30 minutes, and an initial visit is always at least an hour. "This clinic is not economically viable," acknowledges Brookdale Chairman Dr. Albert L. Siu. "It's almost impossible to practice geriatric care under Medicare and make money."

GIVEN THAT A THIRD of all hospital patients are on Medicare, and count for almost half of all hospital charges, any inpatient reduction in this population could represent a huge savings. The problem is, there's a shortage of nurses as well as doctors. There are currently about 145,000 nurse practitioners in the U.S., and only some 4,000 have a specialization in geriatrics.

'SYMPTOM MANAGEMENT'

The John A. Hartford Foundation, a New York-based nonprofit focused on improving elder care, is trying to reduce this deficit, with some success. For the past seven years, the foundation has been funding geriatric nurse training centers and scholarships. "There's been a huge increase in graduates as a result," says Kathleen Dracup, dean of the University of California at San Francisco's nursing school. These NPs are not being trained as almost-doctors, she says. "Medical school curricula are still focused on making the diagnosis. But nurses don't come from that. Their training is focused on symptom management."

As it happens, symptom management is just what aging patients with a multitude of ailments often require. And NPs are often better prepared, logistically and mentally, to provide it. "The whole history of nurse practitioners is that we go where doctors don't want to go. We go where we're most needed," says Carolyn Auerhahn, director of the geriatric nurse practitioner program at New York University's College of Nursing. Her own institution is doing its bit. Last October, NYU opened an NP-managed health-care center primarily for older adults without primary care doctors, on the theory that regular preventive care would keep them out of hospitals and nursing homes.

Whether there will ultimately be enough NPs to staff such clinics, and doctors to back them up, is still a question. A handful of states are increasing funding for geriatric training, but the federal government has done little to nothing. Laments Kane: "My guess is we'll push things to the precipice, panic, and then come up with a draconian solution and pump a lot of money into something that we could have solved much more cheaply years earlier."

By Catherine Arnst


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