By Kimberlyn McGrail
September 21, 2011
You’ve heard it before: the boomers are aging and jeopardizing our health care system by the sheer number of them swanning into their golden years. Sounds right – except it isn’t true.
Let’s check the evidence: the older you are, the more likely you are to use health care services. This is a fact, but it does not necessarily follow that the coming bulge of boomers will bankrupt the health care system. Study after study in Canada over the last 30 years shows that aging is an issue, but it exerts only a small and predictable pressure on health care spending (less than one per cent annually from 2010 to 2036).
More recent research shows that increases in utilization – how many and how often Canadians use health services – are twice as important as aging in increasing costs year by year. In other words, while population aging does increase costs, the kinds and amount of services provided to people in every age group are a far more important factor. How and why are these changes occurring?
Increased visits to medical specialists, lab tests increasing costs
The “how” is easier to answer. In a recent study published in the journal, Healthcare Policy, my colleagues and I looked at spending on physician services over a decade and found two major trends. One is that people are seeing a larger number of doctors overall. In particular, they are being referred to specialists more often.
Even more significant is the increased use of diagnostic testing: people are being sent for far more lab tests, CAT scans and other imaging services. For example, about 6 per cent more of the population in B.C. had lab tests in 2006 compared to 1997; that is an additional 260,000 people being referred for laboratory services – a hefty additional cost to the health system. There is no reason to think BC is different from other provinces in this or any other trend.
The second trend we found is that these increases themselves increase with age. That is, the percentage increase in doctor visits, specialist referrals and laboratory testing are all higher at older and older ages.
By 2006 nearly half of people aged 65 and over saw at least one medical specialist during the year, saw at least one surgical specialist, had at least one imaging service, and three-quarters had at least one lab test. This is why the topic of aging and its impact on the system is so complex. The fact that populations are aging exerts only a small pressure on the system, but the fact that the system keeps changing so that more services are directed to everyone, particularly older people, compounds the problem.
More care is not always better care
The questions of “why” the system is changing in this way, and even more importantly, whether these changes are actually improving health and quality of life, are far more difficult to answer. Did more diagnostic procedures detect new conditions, increase the accuracy of diagnosis, alter care management, keep chronic conditions in check and improve patient outcomes? That is, do more tests keep us healthier and living longer?
Or is all this testing simply a response to the wider availability of the technology itself, a kind of defensive medicine, “standard practice” – or even the outcome of seeing many different doctors (who may all feel they need to ‘do’ something)?
Further, were increased referrals to medical specialists necessary, or the predictable outcome of a poorly organized and overly-burdened system of primary care?
Unfortunately, we don’t routinely collect information on diagnostic outcomes and quality of life in health care so these questions are sometimes difficult to answer. But there are some important general cultural facts at play.
We like new things and we seem to have a general assumption that if something is good, then more of it is better. New tests, screening devices and procedures are invented and we expect that they will be adopted immediately into the system.
But we too often forget that care itself comes with certain risks – all drugs have side-effects, many forms of imaging expose us to radiation, surgeries may have complications, even the fact of being diagnosed with a chronic condition can have a negative effect on people’s outlook on life.
There is plenty of research to show that more use of specialist services, tests and imaging do not necessarily create better outcomes. More care is not always better care.
Matching innovation with improved health outcomes
People who need care should absolutely receive what they need. The trick is in defining and understanding that need.
There is a lively ongoing debate about whether earlier and earlier screening, detection and labeling actually improves quality of life and outcomes for patients. The fact is, we don’t often know. We need better ways of measuring the outcomes of increased diagnostic testing beyond our now somewhat crude measurements of morbidity (the number of people with a specific disease) and mortality (the number who die of the disease).
In other words, we need to put our efforts toward tracking more subtle changes in health and quality of life over time, particularly given that much of our health dollars are now spent in addressing chronic health issues.
It is time to shift the conversation from finger pointing at boomers to a much broader discussion about technology , the value and potential dangers of increased diagnostic testing, and whether we are getting value for money from our ever increasing utilization of health services.
Kimberlyn McGrail is Expert Advisor with EvidenceNetwork.ca and an assistant professor at the University of British Columbia and associate director of the UBC Centre for Health Services and Policy Research. EvidenceNetwork.ca is a comprehensive and non-partisan online resource designed to help journalists covering health policy issues in Canada.