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Richard W. Besdine, M.D. Headshot

What Would Really Improve Health Care

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As the new Congress threatens to repeal health care reform and Republicans and deficit reduction panels eye major entitlement cuts, Medicare has become their central battleground, just as the first of 78 million Boomers turn 65 and begin joining the program.

The deficit hawks have a point. Even Medicare's most ardent defenders admit that, without changes in organization and financing, government health care expenditures will double in the next seven years. If Medicare is to survive, we must "bend the cost curve," particularly for its greatest consumers: high-need, high-cost older patients.

The question is, how? As a health services researcher and professor of medicine, and recalling the classic movie The Graduate, my advice to America's policymakers, to present and future Medicare beneficiaries, as well as present and future physicians is one word: geriatrics.

Caring for our fast-aging population has become the central health care challenge of our time, making geriatrics a discipline whose time has come. A sub-specialty of internal medicine, geriatrics encompasses the scientific study of aging, the teaching of excellent care, and the provision of that excellent hands-on clinical care to older people, especially the most vulnerable. Now is the time to pay greater attention to all three agendas, and to recognize that repeal would undermine all three.

The first challenge -- delivering the care seniors need -- demands a strategic re-balancing of our health care workforce. We desperately need more primary care physicians, including geriatricians (there are only about 7,000 in America today), as well as biomedical researchers and academics with expertise in geriatrics who can conduct research, develop and implement better models of care delivery, and train the next generation of doctors.

Recruiting them will require inspiring medical students and even mid-career doctors to give geriatrics a second look. The bad news is that geriatrics is a relatively young field that is not always promoted during medical education as energetically as it should be.

The good news is that geriatrics is fascinating. From stem cells to gene sequencing, pursuing cures for Type 2 diabetes, cancer, and Alzheimer's disease, or the emerging studies of frailty, geriatrics researchers grapple with medicine's most essential questions. This work can be so exciting that medical students who gain exposure to bench research through programs such as the American Federation for Aging Research-sponsored Medical Student Training in Aging Research (MSTAR), often find themselves hooked for life.

Encouraging more medical students to pursue geriatrics research careers, supporting that research, and translating it promptly into practice for the benefit of patients everywhere must be among our highest funding priorities.

How can geriatrics help reduce health care spending? One of the most valuable (but least publicized) parts of the Affordable Care Act is its support for innovative ways of delivering care. Backed by $10 billion from the new Center for Medicare and Medicaid Innovation, the ACA promotes practices that improve clinical outcomes, and emphasizes quality over quantity of care. These include patient-centered medical homes; encouraging doctors to work in teams with nurses, social workers, and pharmacists; better coordination and less duplication of care for people who see multiple specialists; smoother transitions from hospital to home; more education about self-care for chronic disease; and more thoughtful and anticipatory palliative and end-of-life care.

These innovations are among the pillars of modern geriatric practice. By expanding their use throughout the system, we can help all health care professionals provide better geriatric care, more cost-effectively.

Most middle-aged Americans can now expect to live into their 80's and even 90's. Good news, but with that longevity often comes a proliferation of chronic diseases -- from heart disease to diabetes to depression -- the number one driver of health care costs. The management of complex chronic disease is at the heart of geriatricians' expertise. Geriatrics is sometimes compared to a long game of chess because we embrace complexity and treat the whole person in ways our colleagues in other fields often cannot, making us natural leaders in this all-important fight.

A candid doctor will admit that the satisfaction of feeling needed and useful is a powerful motivator. Perhaps this is why geriatricians, while at the lower end of the physician compensation scale, consistently report some of the highest levels of professional satisfaction and the lowest burn-out.

Geriatrics is not just important to the health of millions of older patients; it is increasingly essential to the well-being of health care in the United States. For anyone who cares about the practice of medicine, what could be more compelling than that?