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Avalanche or Glacier?: Health Care and the Demographic Rhetoric

Published online by Cambridge University Press:  29 November 2010

Morris L. Barer ,
Robert G. Evans  and
Clyde Hertzman
Morris L. Barer
Affiliation:
The University of British Columbia
Robert G. Evans
Affiliation:
The University of British Columbia
Clyde Hertzman
Affiliation:
The University of British Columbia
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Abstract

Claims that the health care system is about to be engulfed in a “wave of grey” have become commonplace. Recent cost escalation is commonly attributed to the aging of the population, and there is no shortage of dire warnings about the cost implications of the even more dramatic aging, and costs, still to come. These claims have been largely unsubstantiated. Yet they persist for a number of reasons. First, over long periods of time, the effects of demographic trends can be (and probably will be) quite substantial. But these effects move like glaciers, not avalanches. Second, the effects of aging populations on some types of services which cater differentially to seniors will be much more dramatic; observers of those sub-sectors (such as long-term care) tend to extrapolate that sector-specific experience to health care generally. Third, at the “coal-face,” health care providers are seeing their practices become ever more dominated by seniors. They mistake this increased “presence” of patients aged 65 and over in their practices as evidence of the effects of demographic changes. In this paper we discuss each of these sources of error about the effects of aging population on health care costs. We focus primarily on the confusion between changes in patterns of care for particular age groups, and changes in overall levels of care. Quite extensive empirical evidence has been collected over the past decade from analyses of British Columbia data bases, and these findings are not unique, in Canada, or beyond. The common finding of this body of research is that population aging has accounted for very little of the increase in health care costs over the past three decades, in Canada or elsewhere. Health care utilization has increased dramatically among seniors. But this has had less to do with the fact that there are more of them, than with the fact that the health care system is doing much more to (and for) them than was the case even a decade ago. This suggests that the appropriate care of elderly people should be a central issue for health care policy and management, but that demographic issues are, in the short run at least, largely a red herring.

Résumé

Les déclarations à l'effet que le système de soins de santé canadien est sur le point de s'enliser sont devenues chose courante. La montée en flèche des coûts est communément attribuée au vieillissement de la population, et les mises en garde sinistres quant aux conséquences sur le plan financier de la hausse importante du taux de vieillissement et des coûts à venir viennent de toute part. La majorité de ces déclarations sont sans fondement, mais celles-ci persistent pour un certain nombre de raisons. Premièrement, les répercussions des changements démographiques peuvent être, à la longue (et le seront probablement), très importantes. Toutefois, ces effets se font sentir très lentement (comme un glacier) plutôt que subitement (comme une avalanche). Deuxièmement, l'impact du vieillissement de la population sera encore plus évident sur certains types de services offerts uniquement aux personnes âgées. Les observateurs de ces sous-secteurs (comme celui des soins de longue durée) ont tendance à extrapoler ce phénomène touchant un secteur particulier à l'ensemble des soins de santé. Troisièmement, en étant «au front,» les prestateurs de soins de santé constatent qu'ils desservent un nombre croissant d'aînés. Ils croient, à tort, que cette «présence» accrue de patients de 65 ans et plus dans leur bureau reflète les effets des changements démographiques. Dans le cadre de cet article, nous discutons de chacune de ces erreurs quant aux effets du vieillissement de la population sur le coût des soins de santé. Nous nous concentrons principalement sur la confusion entre les changements au niveau des modèles de soins destinés à un groupe d'âge particulier et les changements survenant dans l'ensemble du système de soins de santé. Au cours des 10 dernières années, de nombreuses conclusions empiriques ont été tirées d'analyses de bases de données de la Colombie-Britannique, et ces résultats ne sont pas uniques, ni au Canada, ni à l'étranger. Cet ensemble de recherches a permis de conclure que le vieillissement de la population n'a causé qu'une faible augmentation du coût des soins de santé au cours des 30 dernières années, au Canada comme ailleurs. L'utilisation des services de soins de santé a connu une hausse importante chez les personnes âgées. Pourtant, ce phénomène est moins attribuable à la croissance du nombre de personnes âgées qu'au fait que le système de soins de santé offre à cette clientèle davantage de services que par le passé. Cette constatation suggère donc que les services de soins appropriés destinés aux personnes âgées devraient être au centre de toutes discussions en matière de politiques et de gestion de soins de santé, et que les questions démographiques, à court terme à tout le moins, ne font que brouiller les pistes.

Keywords

Cost EscalationDemographic TrendsPatterns of CareAppropriate Care.Hausse de coûtstendances démographiquesconfiguration de servicessoins appropriés.
Type
Articles
Information
Canadian Journal on Aging / La Revue canadienne du vieillissement , Volume 14 , Issue 2 , Été/Summer 1995 , pp. 193 - 224
Copyright
Copyright © Canadian Association on Gerontology 1995

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References

Anderson, G.M., Kerluke, K.J., Pulcins, I.R., Hertzman, C., & Barer, M.L. (1993). Trends and Determinants of Prescription Drug Expenditures in the Elderly: Data from the British Columbia Pharmacare Program. Inquiry, 30, 199–207.Google Scholar
Anderson, G.M., & Lomas., J. (1988). Monitoring the Diffusion of a Technology: Coronary Artery Bypass Surgery in Ontario. American Journal of Public Health, 78(3), 251–254.CrossRefGoogle ScholarPubMed
Anderson, G.M., Newhouse, J.P., & Roos, L.L. (1989). Hospital Care for Elderly Patients with Diseases of the Circulatory System, New England Journal of Medicine, 321, 1443–1448.CrossRefGoogle ScholarPubMed
Anderson, G.M., Pulcins, I.R., Barer, M.L., Evans, R.G., & Hertzman, C. (1990). Acute Care Hospital Utilization under Canadian National Health Insurance: The British Columbia Experience from 1969 to 1988. Inquiry, 27, 352–358.Google Scholar
Barer, M.L., Brownell, M., & Sheps, S. (1994). Adult Surgical Utilization in Manitoba: 1981–1991. Report prepared for Capital Planning, Manitoba Health.Google Scholar
Barer, M.L., Evans, R.G., Hertzman, C., & Lomas, J. (1987). Aging and Health Care Utilization: New Evidence on Old Fallacies. Social Science and Medicine, 24(10), 851–862.CrossRefGoogle ScholarPubMed
Barer, M.L., Hertzman, C., Miller, R., & Pascali, M. (1992). On Being Old and Sick: The Burden of Health Care for the Elderly in Canada and the United States. Journal of Health Politics, Policy and Law, 17(4), 763–782.Google Scholar
Barer, M.L., Nicoll, M., Diesendorf, M., & Harvey, R. (1990). From Medibank to Medicare: Trends in Australian Medical Care Costs and Use, 1976–1986. Community Health Studies (Australia), XIV(1), 8–18Google Scholar
Barer, M.L., Pulcins, I.R., Evans, R.G., Hertzman, C., Lomas, J., & Anderson, G.M. (1989). Trends in use of medical services by the elderly in British Columbia. Canadian Medical Association Journal, 141, 39–45.Google Scholar
Black, C., Roos, N.P., Havens, B., & MacWilliam, L. (1995). Rising Use of Physician Services by the Elderly: The Contribution of Morbidity. Canadian Journal on Aging, 14(2), 225–244.Google Scholar
Boulet, J.-A., & Grenier, G. (1978). Health Expenditures in Canada and the Impact of Demographic Changes on Future Government Health Insurance Program Expenditures. Economic Council of Canada Discussion Paper #123. Ottawa: ECC (October).Google Scholar
Canada, Department of Finance. (1993). Economic and Fiscal Reference Tables, August 1993. Ottawa: Department of Finance.Google Scholar
Canadian Study of Health and Aging. (1994). Risk Factors for Alzheimer's Disease in Canada. (Submitted to Neurology.)Google Scholar
Cobb, L.A., Thomas, G.I., Dillard, D.H., Merendino, K.A., & Bruce, R.A. 1959. An Evaluation of Internal Mammary Artery Ligation by a Double-blind Technic. New England Journal of Medicine, 260(22), 1115–1118.Google Scholar
Davidson, W., Molloy, W., Somers, G., & Bédard, M. (1994). Relation between Physician Characteristics and Prescribing for Elderly People in New Brunswick. Canadian Medical Association Journal, 150(6), 917–921.Google ScholarPubMed
Denton, F.T., Li, S.N., & Spencer, B.G. (1987). How Will Population Aging Affect the Future Costs of Maintaining Health-care Standards? In Marshall, V.W. (Ed.), Aging in Canada: Social Perspectives. Markham, ON: Fitzhenry and Whiteside.Google Scholar
Dimond, E.G., Kittle, C.F., & Crockett, J.E. (1960). Comparison of Internal Mammary Artery Ligation and Sham Operation for Angina Pectoris. The American Journal of Cardiology, April, 483–486.Google Scholar
Evans, R.G. (1985). Illusions of Necessity: Evading Responsibility for Choice in Health Care. Journal of Health Politics, Policy and Law, 10(3), 439–467.Google Scholar
Evans, R.G. (1991). Reflections on the Revolution in Sweden. In International Review of the Swedish Health Care System [Den Svenska Sjukvården]. Occasional Paper no. 34 (pp. 118–157). SNS Sweden, Stockholm: SNS.Google Scholar
Evans, R.G., Barer, M.L., Hertzman, C, Anderson, G.M., Pulcins, I.R., & Lomas, J. (1989). The Long Goodbye: The Great Transformation of the British Columbia Hospital System. Health Services Research, 24(4), 435–459.Google Scholar
Fox, P. (1989). From senility to Alzheimer's Disease: the rise of the Alzheimer's Disease movement. The Milbank Quarterly, 67(1), 58–102.Google Scholar
Getzen, T.E. (1992). Population Aging and the Growth of Health Expenditures. Journals of Gerontology (Social Sciences), 47(3), S98–S104.Google Scholar
Gormley, M., Barer, M.L., Melia, P., & Helston, D. (1990). The Growth in Use of Health Services 1977/78 to 1985/86. Regina: Saskatchewan Health.Google Scholar
Greenspan, A.M., Kay, H.R., Berger, B.C., et al. (1988). Incidence of Unwarranted Implantation of Permanent Cardiac Pacemakers in a Large Medical Population. New England Journal of Medicine, 318(3), 158–163.Google Scholar
Henripin, J. (1994). The Financial Consequences of Population Aging. Canadian Public Poicy — Analyse de Politiques, XX(1), 78–94.Google Scholar
Hertzman, C., Pulcins, I.R., Barer, M.L., Evans, R.G., Anderson, G.M., & Lomas, J. (1990). Flat on your Back, or Back to your Flat? Sources of Increased Hospital Services Utilization Among the Elderly in British Columbia. Social Science and Medicine, 30(7), 819–828.Google Scholar
Kanigan, M., & Mix, P. (1989). Surgical Procedures and Treatments — Historical Trends and Recent Data Characteristics. Health Reports, 1(1), 1–96. (SC 82–003) Ottawa: Statistics Canada.Google Scholar
Katzman, R. (1993). Education and the prevalence of dementia and Alzheimer's disease. Neurology, 43, 13–20.CrossRefGoogle ScholarPubMed
Manton, K.G., Corder, L.S., & Stallard, E. (1993). Estimates of Changes in Chronic Disability Incidence and Prevalence Rates in the U.S. Elderly Population from the 1982, 1984, and 1989 National Long Term Care Survey. Journals of Gerontology (Social Science), 48(4), S153–S166.Google Scholar
McDaniel, S.A. (1987). Demographic Aging as a Guiding Paradigm in Canada's Welfare State. Canadian Public Policy — Analyse de Politiques, XIII(3), 330–336.CrossRefGoogle Scholar
Mendelson, D.N., & Schwartz, W.B. (1993). Effects of Aging and Population Growth on Health Costs. Health Affairs, 12(1), 119–125.Google Scholar
Nair, Cyril. (1991). Trends in Hospital Inpatient Utilization, 1961–1988/89. Health Reports 3(2), 189–197. Catalogue #82–003Q. Ottawa: Statistics Canada.Google Scholar
Northcott, H.C. (1994). Public Perceptions of the Population Aging “Crisis”. Canadian Public Policy — Analyse de Politiques, XX(1), 66–77.CrossRefGoogle Scholar
Poterba, J.M., & Summers, L.H. (1987). Public Policy Implications of Declining Old-Age Mortality. In Burtless, G. (Ed.), Work, Health and Income Among the Elderly (pp. 19–51). Washington, DC: Brookings.Google Scholar
Preston, T.A. (1977). Coronary Artery Surgery: A Critical Review. New York: Raven Press.Google Scholar
Quinn, K., Baker, M.J., & Evans, B. (1992). A Population-Wide Profile of Prescription Drug Use in Saskatchewan, 1989. Canadian Medical Association Journal, 146(12), 2177–2186.Google Scholar
Riley, R., & Kanigan, M. (1989). Surgical Procedures and Treatments, 1985–86. Health Reports, 1(2), 253–254. (SC 82–003). Ottawa: Statistics Canada.Google Scholar
Roch, D.J., Evans, R.G., & Pascoe, D.W. (1985). Manitoba and Medicare: 1971 to the Present. Winnipeg: Manitoba Health.Google Scholar
Roos, N.P., Havens, B., & Black, C. (1993). Living Longer but Doing Worse: Assessing Health Status in Elderly Persons at Two Points in Time in Manitoba, Canada, 1971 and 1983. Social Science and Medicine, 36(3), 273–282.Google Scholar
Verbrugge, L.M. (1989). Recent, present, and future health of American adults. Annual Review of Public Health, 10, 333–361.CrossRefGoogle ScholarPubMed
Walker, A. (1987). Meeting the Needs of Canada's Elderly with Limited Health Resources: Some Observations Based on British Experience. In Economic Council of Canada. Aging With Limited Resources. Proceedings of a Colloquium on Health Care, May 1986. Ottawa: Minister of Supply and Services Canada.Google Scholar
Wilkins, R., & Adams, O. (1992). Health Expectancy Trends in Canada, 1951–86. In Robine, J.-H., Blanchet, M., & Dowd, J.E. (Eds.), Health Expectancy (pp. 109–112). London: HMSO (Studies in Medical and Population Subjects #54).Google Scholar
Winslow, C.M., Solomon, D.H., Chassin, M.R., Kosecoff, J., Merrick, N.J., & Brook, R.H. (1988). The Appropriateness of Carotid Endarterectomy. New England Journal of Medicine, 318, 721–727.Google Scholar
Woods Gordon Management Consultants. (1984). Investigation of the Impact of Demographic Change on the Health Care System in Canada — Final Report. (Prepared for the Task Force on the Allocation of Health Care Resources (Joan Watson, chairman).) Toronto: Woods Gordon.Google Scholar