Speaker 1: The way that we approach caring for older adults in this country is not yet right. I won't say it's broken, but it's not perfect. And I think we can all go a long way in thinking about what's everyone's role in making this a little bit better. Because at the end of the day, we're all going to be a part of this. It's the thing we cannot escape,
Speaker 2: Welcome back to until it's fixed, where we have deep conversations about making healthcare simpler and more effective for everyone. I'm your co-host, Dr. Kenny Poole, [00:00:30] United Health Group's Chief Medical Officer of Clinician and Provider Experience, and a board certified internal medicine physician. I'm flying solo today, but we're excited to have Callie back with us next week. So let's dive into today's topic.
Speaker 2: Today's episode is a multifaceted discussion of the ways in which aging Americans are underestimated in terms of their numbers, the economic power, the digital savvy, the resilience, [00:01:00] and the care that they received in our healthcare system. More specifically, we'll focus on the dangers and the injustice of overlooking even the most basic facts about our 65 and older population. I spent years practicing internal medicine as a primary care physician at the Mayo Clinic in Arizona, and a large proportion of our patients are classified as geriatrics or a senior age. Even now, on occasion, I'll [00:01:30] see patients at the Mayo Clinic in Rochester, Minnesota and the division of community internal medicine, geriatrics, and palliative care, where a good proportion of those patients are older. So I've gotten the opportunity to really engage in detail into the lives of older Americans, particularly in matters related to their health. So I had the chance to meet with some colleagues across the field today for some eye-opening conversations. And we'll start with Dr. Charlotte. Yay. Who's the Chief Medical Officer for A A R P [00:02:00] or the American Association of Retired Persons. All right, well, Dr. Yay. First off, thank you for taking the time to talk with us today. Can you share a little bit about yourself and how you came to start working with A A R P?
Speaker 3: Thank you so much. I'm delighted to be here, uh, to have a conversation with you like Yom, a physician, but, uh, my, by way of background, I'm an emergency physician [00:02:30] and to me it's an extraordinary privilege because it is the one place in healthcare where you get to see what works in healthcare and doesn't work. And the same for the community. It is an incredible nexus between healthcare and the community. So from there, I, um, after 20, almost 30 years, I went on to work for the government as a Medicare contractor where I began to understand payment issues and then for the Centers for Medicare and Medicaid Services as a regional [00:03:00] administrator during the standup of the Medicare part benefit. And for the last, uh, 10 plus years, I've been at A A R P services, the business arm of A A R P, with our entire goal of can we actually improve the healthcare outcomes, the affordability, and the experience of care for the consumers. And I feel like I've come back to my roots as an emergency physician because it's really about how [00:03:30] do we make sure that your everyday person, your everyday Jane and Joe can get the access and the care and the empathy and compassion that we all deserve.
Speaker 2: Great. Now thank you for that. So, as I mentioned to you before, you know, we're gonna talk about the aging population today, and that term evokes a lot of different reactions and emotions from people depending upon who you're talking to. And you [00:04:00] know, what, what do we mean when we say that? I wanted to get your perspective on that.
Speaker 3: Right. So I think it is actually time to really change the narrative of aging and all these old perceptions and common perspectives. It's time to change because they're no longer as true as they once were. So first of all, we're living a lot longer than ever before. Right now, 85 and older is the fastest growing population. [00:04:30] A hundred and older is the second fastest growing population. Now, it's not equally distributed across the races, but do you realize that a baby born in 2007 has a 50 50 chance of living to be a hundred?
Speaker 2: Oh, wow.
Speaker 3: So are we really thinking about our hundred year lifespan? I think it's also fascinating that a r p did a survey looking at older adults in the second half of life, and it's true, [00:05:00] over 80% of people 70 and 80 years old have serious chronic conditions. There's no question. But what's really fascinating is 49%, nearly half said their health was excellent to very good. So we have failed to take into account that even as we age, there is still a level of optimism. But the other piece is how many of us realize that we probably are gonna be working longer than ever. [00:05:30] Now, part of it might be economy because we haven't actually planned for a hundred year life and for the economics, but it's also having a sense of purpose. So we are gonna be working, but it's also because we're living longer mm-hmm. , and we're living healthier than ever. So it's time to start changing that narrative.
Speaker 2: Yeah. And I, and I'm glad you called those things out. So I recall, like when I was practicing, particularly in my last practice environment, we cared for [00:06:00] a large geriatric population. I used to always remark to our various patients that there were also a lot of people that really kind of took off at that age, right? Like they really started living their life and became somewhat invigorated. And so my question to you is this, what does good health look like for an older person now?
Speaker 3: Well, first of all, I think we're living longer and healthier than ever. A lot more optimism [00:06:30] than ever. And that attitude really makes a difference. So we have some studies to show that perception of aging really matters. Did you know if you have a positive perception of aging, you live seven and a half years longer. Hmm. And in fact, women with optimism have a 15% longer lifespan than those who don't have that sense of optimism.
Speaker 2: Yeah, and I'm glad you said that because I used [00:07:00] to talk, tell the patients all the time, and, and my intent was not to oversimplify things, but I would tell people, you need to decide. Are you gonna be a 80, 60 year old or are you going to be a 50, 60 year old? And so it's really refreshing hearing you talk about the attitude part of things. My next question is a follow up to that, what about the effects that the outside have in as opposed to the inside out? And so the, the specific question is, what about the societal effects that people have [00:07:30] to deal with as we age? And what sort of biases or additional obstacles would you say that seniors face by and large?
Speaker 3: Oh, absolutely. This sense of negativity about aging is a surround sound. So that begins to color how you feel. And then a r p did a media survey, and I think it's fascinating that older adults, you know, are anticipated to spend 84 billion in technology. Over 90% have devices. [00:08:00] You know, contrary to popular belief, we actually do do technology. 72% of 70 year olds actually have a smartphone, and yet only 5% of imagery show an older adult using technology. Hmm. One out of three images show you to be alone, maybe with a partner and definitely dependent, right? Yeah. You're sitting in a doctor's office with a professional or someone younger showing you to use technology. Yeah. And well over a third of the [00:08:30] 50 plus are actually in the workforce, but only 13% of images actually show an older adult working. So we are climbing up against a real hill of, you know, how we are perceived. But as you just said, it's not inevitable. It's a matter of how you view the world. And remember, okay, maybe I can't do as much as I used to, but that doesn't mean I can't read to a child. It doesn't mean [00:09:00] that I can't learn a new language. And in fact, over a third of older adults, according to a r p surveys, actually use technology and videos to pursue a new passion in life.
Speaker 2: So we talked about bias and the effect that society has on persons as we age, and even the effect that we ourselves can have on ourselves as it relates to our attitudes and whatnot. Can you speak to bias within the [00:09:30] healthcare system towards persons as we age and you know, what kind of effect that has or can have on the health of an aging population?
Speaker 3: Yeah. So we think of us in healthcare as being above bias. You know, we're really treating everybody equally, but it turns out we bring that same age bias into everyday practice. So there was a study that was done in, uh, the [00:10:00] UK actually looking at clinicians prescribing digital health apps. And in the UK they actually have approved digital health apps. Well, if you're under 35, you get prescribed a digital health app, one in 10 patients. If you are 55 and older, only one in 25 patients are ever prescribed digital health apps. And if you're 65 and older, only one in 50 are ever prescribed a digital health app. [00:10:30] In spite of the fact that 80 some percent of 65 and older who have actually used digital health apps thought they were really useful. And as I said, you know, older adults are using technology, 97%, you know, have devices at home. So it is striking that even as clinicians, we think, oh, you're too old. You probably don't know how to use a smartphone. So if we don't begin to tackle, especially as I said, [00:11:00] a baby born in 2007 has a 50 50 chance of living to 104, we need to start changing our view.
Speaker 2: Yeah, no, i, i I, I think that really sum things up in your words. Give us something to take from this interview. You know, a lot of times you, you go through these type of interviews and you don't know what you can do and what's next. And so for me, the follow up and the take home was not only is it important to have that positive attitude and that positive outlook as we [00:11:30] age, but those of us, if you will, from a societal standpoint who are not yet there, need to ensure that there are images and messages that encourage our aging population to age with grace and with fun and with invigoration and with excitement. So I thank you. I think I, I really enjoyed, uh, talking to you and I learned some things as well.
Speaker 2: [00:12:00] Studies consistently find that older persons are healthier, more tech savvy, and more engaged and people give them credit for. And this plays out in bias that even our healthcare system and its workers are not above. And we've got to acknowledge and address that bias if we want to continue improving health outcomes for older folks. So now we've gotten a better understanding of that situation. We can look at how we're set up to care for this aging population moving forward. Miriam Snitcher Top, [00:12:30] who is the managing director of aging research, a advisory board, had amazing insights to share. So Miriam, first off, thank you for taking the time to talk with us. Can you share a little bit about yourself and what got you involved in this work?
Speaker 1: Yeah, absolutely. I'm currently the managing director of aging population research at Advisory Board, which is a sort of complicated title, which means that I lead our research around [00:13:00] senior care. So looking at how the industry can better support the aging population. I've worked at Advisory Board for about seven years on a number of different research areas ranging from imaging to, um, architecture and design for healthcare facilities to home-based care. So it worked on a lot of different things, but for about the last year, I've been focused all around this topic of senior care.
Speaker 2: Got it. When we talk about societal bias and how that affects how we view older [00:13:30] people, how can that impact our ability to reach and support older people in need of care?
Speaker 1: Yeah, one of the things that we've found in our research that has been really interesting is that aging in this country is incredibly stigmatized. It also really personal. And so what I mean by that is, you know, we've spoken with people across the industry. So as I said, I've spoken with Medicare Advantage plans, digital health firms, pharmaceutical companies, hospital leaders, physicians, [00:14:00] and everyone, as they've talked about caring for seniors, they end up telling a personal story. They end up talking about how they cared for a loved one as that person grew older and how they were, or you know, sometimes sadly, were not able to get that person the care that they needed. And so it's obviously this incredibly personal thing, right? Every one of us is getting older, every one of us is going to have loved ones who are getting older. But it's really juxtaposed with this idea that we don't really value [00:14:30] aging in this country.
Speaker 1: We have a really hard time talking about aging. We have a hard time talking with people who are getting older about how to make some of the really hard decisions that come towards the end of someone's life. And we don't really value the workforce that cares for seniors. We don't really consider those jobs to be prestigious. They don't often pay well. And so as a result, that workforce often turns over and leaves for other industries. And that means that older adults are often cared [00:15:00] for a shadow workforce that is either the gig economy or mostly adult children. You know, it's often women who are balancing their careers, their own children, and now caring for, you know, their older relatives. It's that classic sandwich generation. And so it's become this really interesting cycle where we all know that this is going to happen. And yet as a society, we haven't put the focus on caring for this population in [00:15:30] the way that we really need to.
Speaker 2: Great. Thank you for that. So that, that's a perfect segue to my next question. How do we know how effective we are at meeting everyone's needs? And the reason I'm asking this question, the way I'm asking it is I'm sure that through your research you've found out that diversity within an aging population, and not just demographic diversity, but functional diversity. So how do we know who we're reaching [00:16:00] and who we may be missing, who could be falling through the cracks as it relates to caring for an aging population?
Speaker 1: It's really hard because quite frankly, the data isn't there. Seniors, anyone, again, we're talking about anyone over the age of 65. So that's a really big group of people. It is people that live on their own, people who live in assisted living, people who live in nursing homes, people who live with family members who live with friends. It is, you know, [00:16:30] people who are relatively healthy to those that have very, very severe chronic conditions or conditions that get worse as they age. And it's really hard to capture the data around those different groups and those individuals. The other concept that came up a lot in our research was this idea of a forgotten middle when it comes to seniors, and it's related to income, mostly. You know, you have seniors who are wealthy who can afford the care that they need. [00:17:00] If something's not covered by Medicare, like, you know, a long-term care aid, they have the financial means they can afford it.
Speaker 1: You have low income seniors who qualify for Medicaid in addition to Medicare. Um, you know, obviously that's different in each state, but these kind of dual eligibles get access to services paid for by Medicaid. And there's often community services for seniors that are often means tested. And then there's this population in the middle. So these are people who have Medicare coverage, they don't qualify [00:17:30] for Medicaid, they probably cannot afford and full-time in-home care provider. They may not be able to afford a nursing home or assisted living. It's a really hard group to measure. These are the people that are living their lives trying to get to the physicians and the clinicians they need, but we don't necessarily have a ton of data on what additional services they could benefit from. And there's even some data out there that says that for this population, they actually qualify for a lot of services and they just don't even [00:18:00] know how to access them.
Speaker 2: Got it. So that's a segue to my next follow up. So outside of the income piece, which you articulated extremely well, how do things like gender, sexual orientation, race, other demographic factors affect health as we get older? Um, do we see, uh, convergence or a divergence? Do these things become more powerful, less powerful? What's the effect? As we get older,
Speaker 1: I'd say they become more [00:18:30] powerful, right? I mean, we carry with us as we age. The same things that affect us in the earlier parts of our lives. You know, certainly folks who have chronic conditions in their forties, fifties bring them into their sixties and seventies with them. And then those often get more complex as they get older. We also know that there are real inequities when it comes to care in the senior population. There is a huge difference in life expectancy between the richest and the poorest. 1% in this [00:19:00] country, I think it's almost 15 years for men, there are life expectancy differences by race, and this plays out when it comes to access to care. So one example, you know, there are studies that show that for black and Hispanic patients, they're less likely than white patients to receive a home health visit, you know, even if all of them are discharged from the hospital to a home health program. And so these inequities really play out in access to care in ways that then have pretty severe effects [00:19:30] on people's health as they age.
Speaker 2: Got it. So now kind of turning to you as a researcher, what needs to be done to make this data work better, if you will, for us to improve outcomes? Like what can enhance the work that you do so that then the outcomes follow? In terms of improvement, I
Speaker 1: Think for one, we need better data on race and ethnicity. In the senior population, [00:20:00] there's been a lot of studies that have shown that the way that Medicare has coded race isn't accurate, whether it was inputted by a clinician or whether it was self-reported, that that data honestly can't really be trusted. You know, we tried to do some analysis and look at healthcare utilization by race, but found that the data just didn't work very well. And so we had to kind of go about it in a different way. This is gonna become more important as we see the, you [00:20:30] know, rest of the baby boomer generation aging into Medicare and kind of growing into the senior population because the senior population is rapidly becoming less white. The population of non-white seniors is going to double over this decade. And so it's going to become increasingly important that we have data that reflects the diversity of the senior population, and we don't continue to kind of use the same kind of muddied data set that we have.
Speaker 1: The other big [00:21:00] challenge around data is thinking about how access to data on the senior population changes as we see the growth of Medicare Advantage. You know, as more and more seniors choose Medicare Advantage plans over traditional Medicare, that means that the publicly accessible Medicare dataset that many people rely on for analysis, for thoughts to publish research on the senior population, that dataset is not [00:21:30] as accurate anymore because it's reflecting a smaller portion of the Medicare population. So we're really gonna have to think about how do we get access to good data when the majority of seniors are in a Medicare Advantage plan, I think we are seeing some successes. So there are huge challenges, but I think what we're seeing is in some of these more promising models that are looking at care coordination for seniors, they're look, they're using data effectively. So if [00:22:00] you look at some of the senior focused primary care organizations that are growing, they are really able to use data to make sure that seniors are getting the care that they need, that they're sent, you know, that they can see the specialists that they need.
Speaker 1: And they're also making sure that, you know, they're staying out of the hospital and staying out of the emergency department by really prioritizing primary care. Same thing with some of the special needs plans that are coming out of Medicare Advantage. They also are really leveraging data, [00:22:30] you know, trying to identify who are the patients that would benefit from in-home care versus, you know, asking them to go to a facility. So I think there's a lot of work being done. I think the challenge is the senior population is growing and growing rapidly, and we don't always have the resources of available to support some of these models to help them scale and grow so that we're reaching a larger part of the senior population.
Speaker 2: So Miriam, you've given really good answers, and I can tell that you're passionate about this [00:23:00] work. Where does that passion or that interest in this topic, where, where, where does that come from?
Speaker 1: Well, I shared that everyone shares a personal story when I talk to them for this research. So, you know, I, you know, I have one as well and that I, I watched my father really care for my grandfather as he was approaching the end of his life just a few years ago. And watching them try and navigate the healthcare system, understanding Medicare versus Medicaid, [00:23:30] you know, assisted living nursing homes, end of life care was really challenging. My family has a lot of physicians in them we're very well educated, and yet it was hard to understand what the right path was for him. And I think it shows that the system, the way that we approach caring for older adults in this country is not yet, right. I won't say it's broken, but it's not perfect. And I think we can all go a long way [00:24:00] in thinking about what's everyone's role in making this a little bit better. Because at the end of the day, we're all going to be a part of this. It's the thing we cannot escape. We're all going to care for someone as they get older, and then eventually we're all going to get older. Um, and I think it's important that we create a system that really works for everyone.
Speaker 2: Great. Thank you. Yeah. And I, I like that phrase not yet, right? I'm gonna use that and, uh, I mean, so I'll be like, oh, okay, look at him. So ,
Speaker 1: It's all right. You can use it. I don't, I don't need attribution. I [00:24:30] think that it's all yours. You take it.
Speaker 2: Thanks. So people tend to think of people at the extremes of both health and wealth, but there's this huge proportion of the population that's somewhere in the middle, and we need to figure out how we can better support them and find that balance, because as Miriam points out, the system is not yet right as it pertains to providing them what they need. The good news though, is that there are already people thinking about what we [00:25:00] need to do to support that shift, like Optum's own. Dr. Amy, we, how Dr. Wyn Howell, thank you for joining us. Can you share a bit about yourself and what your connection is to the senior population and population health in general?
Speaker 4: Sure. Thank you. And thank you for having me. It's very exciting to be here. So I'm a family physician and I think one thing you should know [00:25:30] about me and this kind of population and why my interest is that it is within the scope of family medicine. And, uh, as we take care of the entire continuum of care from babies delivering babies to the pediatric population, to OB and then the adult and then elderly population, it's very near and dear to my heart as a family physician. And then personally, I'm in the sandwich generation, so I take care of [00:26:00] my parents as well. I'm the main caregivers for them. And we've gone through several medical challenges with my mom pre covid, and then my dad, well, both of them really during covid. So this is a, a very near and dear topic, especially as, as it relates to elderly and elderly women, you know, taking care of my mom. So it's, it's quite challenging.
Speaker 2: So we know that people a 65 and up are going to make a bigger portion of the population than before. [00:26:30] What could that mean in terms of our ability as a system to provide care?
Speaker 4: Yeah, that's a, a really great question and really should have the listeners and policy makers and everyone within our American healthcare system pause because we have over 30 million seniors, uh, 125 women for every a hundred men at the age of 85. This increases to 178 women for every a hundred men. Life expectancy [00:27:00] is longer for women. However, for black women, it's three years less than for white women. So there's clear health disparities, racial disparities as it relates to aging. This presents a clear concern for our American healthcare system to provide equitable care at the right time and the right place to really serve our patients appropriately and justly.
Speaker 2: So in illustrating the dangers or [00:27:30] the consequences if we fail to meet that need or close those gaps, if you will, that brings to mind another question that I have. And that's like, where are we falling short as a system as it pertains to caring for older adults in our country?
Speaker 4: We're falling short on many, many fronts. And then specifically with elderly women, because they tend to live longer. They're the caretakers, but yet they earn 79 cents to the dollar compared to men, right? So when you look at social security [00:28:00] retirement and survivor benefits for men in 2019, for men it was $1,612. For women, it was $1,283. So that's equating to 79 cents to the dollar when compared to men. So we're falling short on social support for all of our seniors, really, right? Fewer social supports, lower standard of living, having more complications as you age, and then adding on to that, you know, microaggressions, racism, [00:28:30] anxiety, all the inequities add up to unjust health vulnerabilities. So I think as we, as a system, as a country move forward, we really should identify these extra burdens, these extra burdens that the elderly carry. Uh, so really the greater risk of health issues combined with the lack of economic opportunity combined with having to pay out of pocket, making less money. [00:29:00] These pressures, I think, are forcing some patients, some elderly patients, some of those who are economically disproportion to really forego healthcare altogether.
Speaker 2: So when you step back and look at the job that we're currently doing, the gaps that are there, and what needs to be done next, and you know, again, you give full assessment, what gives you hope about the future [00:29:30] in terms of caring for an aging population?
Speaker 4: Well, a lot does, right? That's why we're, we're still in it, right? And fighting the good fight. So I think hope with a plan versus hope without, and so hope, optimism, data, knowing what's behind us and knowing how this aging population feels about themselves is very hopeful. So it's not a population that is completely depressed or [00:30:00] is completely outta touch and is completely not engaged within the digital community, right? They are, they're so, they're so engaged, and I think hope with the plan. And what I would say to folks listening is be creative use, especially if you work at Optum, right? Use the data, use the data to seek innovative ways in order for us to care for this population even better. So, you know, if it means having more innovative [00:30:30] care teams and care plans that address the, the full set of challenges that this aging population faces, I think that's critical, right?
Speaker 4: So raising awareness removes blind spots, you know, makes way for screening and history taking and being able to collect the race, ethnicity, language, culture, gender, sexual orientation, all those questions, all those data pieces. I think they're all very, very relevant as we address social drivers for chronic conditions in this population. [00:31:00] So it's really to fully close the unjust health disparities that currently exist. So that's, that's number one. Care teams. I think another way to look at it is truly earning the tru not not earning, but truly providing that space for trust. So professionals, healthcare professionals must gain an understanding, right, of what does it really mean to age right now in our country, quote unquote post pandemic. What does it [00:31:30] really mean to them? And then how do you connect with that? They've lived a really long life, they don't need to have any more unclear, complicated instructions, directions, do this, take this or whatever.
Speaker 4: Just make it very simple for them. But above all, I think trust and having a sense of a warm and welcoming approach when it comes to having them come into the office and making it really feel like their second home, their, their medical home. In the whole spirit of that, I think those are some things, you know, [00:32:00] that we can plan for in addition to hope. And I think the one last thing, and I I always say this at every opportunity that I can get because I think it's so important within our healthcare system that is to help connect the dots. It's that care coordination piece. So it's not care management, it's not case management, it's true care coordination.
Speaker 2: Dr. Wyn Howell, thank you for that. And thank you for your answers. I really appreciated hearing you speak and talking to you, and your passion around this topic is [00:32:30] infectious and palpable.
Speaker 4: Thank you for the opportunity, Dr. Paul.
Speaker 2: So as I reflect on the conversations we had today, it should be called out that this issue of aging is not just an economic issue, it's also a social issue, it's a moral issue and it's a personal issue because we all get older and as more Americans live longer, we need to [00:33:00] continue to make sure that we are prepared as a healthcare system to adequately provide for them. And in order to do this, we know that data is the key, right? Because data can help us fight our inaccurate views of aging, highlight potential solution areas, and keep us working and moving in the right direction towards better healthcare for all of us. And that's it for today. Thanks for listening. Join me next week as we continue the conversation around one thing, you can start today to take [00:33:30] care of your body as you age, and be sure to subscribe or follow wherever you listen so that you can be notified of a new episode. Catch you next time.