July 12, 2005 Features

Active and Proactive- Boomers and the Health Care System

Members of the baby boomer generation (1946-1964), currently between 41 and 59 years old, are looking at the prospect of growing older and the potential limitations to their lifestyles resulting from decreased functional health. This group is thought to be approaching aging in a way that is different from previous generations-they are more active participants in their health care, and they remain more physically active than earlier generations, refusing to decrease their activity level just because they are getting older. According to Reinventing Aging: Baby Boomers and Civic Engagement, a 2004 publication of the Harvard School of Public Health-MetLife Foundation Initiative in Retirement and Civic Engagement, the boomer generation has the ability to redefine the meaning and purpose of the older years.

Changing Health Care

How baby boomers approach such life-altering functional health disorders as stroke, dementia, and progressive diseases has not been fully studied because this generation is just entering the years of greatly increased risk. We do know, however, that some in this generation will face results of the significant changes that have occurred in the health care system in the past few decades.

The health care system has moved from provider-controlled (e.g., physician, clinician) to payer-controlled (e.g., managed care) to increasingly patient-controlled. In the patient-controlled system, payers do not dictate what services can or cannot be provided, but limit how much they will pay. Thus, patients must decide how much a service is worth to them because they will be paying for part or most of it themselves. If people pay more out of their own pockets, it follows that they are more demanding of satisfying results.

The health care system has been changing to accommodate this group's view toward health and the fact that the 18-year span of the baby boomer generation represents more than 75 million people who will be entering their older years in the very near future.

The costs of health care involve more than just hospitalizations and prescription drug costs. The high costs and inefficient methods of dealing with long-term disability are highlighted in the Institute of Medicine's 2003 report, Priority Areas for National Action: Transforming the U.S. Health Care System. The report calls for change, stating that dealing with chronic health problems and disability is one of the fundamental challenges to our health care system.

The World Health Organization (WHO) also has tackled the growing concerns of the functional health status of people with chronic conditions such as stroke. After extensive field testing, it published in 2001 the International Classification of Functioning, Disability, and Health (ICF). In the past four years, ASHA has used the ICF framework for communication disorders in both the speech-language pathology and audiology scopes of practice documents. In 2004, ASHA's updated Preferred Practice Patterns for the Profession of Speech-Language Pathology also incorporated the ICF framework. Subsequently, in both our professional journals and in presentations, interest has steadily increased in the ICF components of Body Function, Activity/Participation, and the Contextual Factors of Environmental and Personal Factors.

Proactive Life Views

The baby boomer generation has different lifestyle habits than previous generations. The study of how these components of the ICF are realized in the boomers will be an important area of research and clinical interests in the near future. This generation may not only have a different view of their potential activity level in older age but also may want to more directly interact with their health care providers, including SLPs and audiologists. This generation pursues the concepts of advocating for oneself, determining how fully to follow health care providers' directions, and requesting accommodation for individual beliefs, cultures, and desires.

The more proactive views of this generation are in concert with the crucial ethical guidelines included in the ICF. These guidelines were not developed merely to satisfy, but rather as part of a broader ethical view of what health is and people's rights to influence how the medical system treats them.

A contradiction seems inherent between using classification systems that assign numbers to behaviors and the ethical calling to value the individual's uniqueness. WHO openly acknowledges a tendency toward depersonalization and other unethical behaviors in the following quote from the section entitled, Ethical Guidelines for the Use of the ICF.

"Individuals classed together under ICF may still differ in many ways. Laws and regulations that refer to ICF classifications should not assume more homogeneity than intended and should ensure that those whose levels of functioning are being classified are considered as individuals." (p. 245)

This section discusses respect and confidentiality issues, ethical clinical use, and social use of ICF information. In all three sections, specific themes are repeated. First, the ICF should always be used in a way that respects the inherent value of all persons, and not as a label. Second, the ICF ratings should always be done with full explicit acknowledgment of the persons, or their advocates, whose behavior is being rated. Third, persons or their advocates should be participants in the assignments of codes and thus have the right to challenge or agree on the appropriateness of such codes. A fourth theme is that the ICF should be used to help empower persons to lead the life they wish to live.

ICF Themes

The first theme concerning the dangers of labeling is unfortunately seen too often in our society. Medical systems use names to label whether someone is a good treatment candidate, such as when an insurance program pays for aphasia intervention but not for dementia intervention. It has been pointed out that even the term "baby boomer" can be stereotyped as persons who are all highly educated, in good health, and sipping lattes as they look over their retirement portfolios. Compared to previous generations, many in this group have had more opportunities, education, and varied life experiences. However, it is important to remember many of this generation have known only poverty, illiteracy, and limited upward mobility. Others have lives and outlooks that may not differ significantly from previous generations.

The second and third themes dealing with knowledge of treatment and the right to interact and challenge are part of a larger empowerment movement in this country. Similar expectations are seen in the relationship of educators to parents of children with and without disabilities, which is more of a partnership than an authoritarian relationship. The ICF goes beyond the view that clients should be informed of the perceived functional health status and intervention plan. These ethical guidelines state that the very numbers assigned to persons by health care providers, which are in fact clinical judgments of deviation and severity, should be fully reported and discussed with clients. This process could, by definition, involve conflict and differences of opinion. It would be wrong for the clinician to assume that this conflict is always the result of the client not fully understanding the situation, whereas this exercise would serve only to try to "sell" the client on the codes chosen. Persons with the disability should instead be seen as the true experts with clinicians trying to best fit their needs.

The fourth theme of encouraging empowerment states that the ICF should be used for more than reporting and documenting aspects of health. It should be an advocacy tool to demonstrate the quality of life concerns associated with altered functional health status. If these areas can be systematically recorded, then they can also be systematically addressed and have a method that encourages third-party payers to reimburse for these important components of health. In the ICF view, advocacy for those with disabilities is not an option, but an essential ethical responsibility of all of us in health care.

WHO defines health as "a state of complete physical, mental and social well being, and not merely the absence of disease and infirmity." It speaks of health as a vibrant source, one that everyone is entitled to, and that health systems should have as their goal. This is also the view of many baby boomers when they consider their health in older years. They may acknowledge that there will be things they cannot do as well as in their younger years, but they still expect to approach, as best as possible, the WHO state of functional health.

This expectation of health may also be seen in their reaction to chronic conditions such as stroke. In addition, the trend toward paying more out of pocket for treatment will most likely grow. Thus, this generation may be more assertive in dealing with the health care system, work harder to maintain some activity even after chronic health problems appear, and demand more personally relevant results than we have seen in the past. We in communication disorders should use the ethical guidelines of the ICF for ethical and practical reasons in that our clients will expect that type of collaborative interaction. It is encouraging that something could be both the best ethical model and the best business model. Or perhaps, that is the way it always is.

Travis Threats, chair and associate professor in the Department of Communication Sciences and Disorders at Saint Louis University, has worked on the development of the World Health Organization's International Classification of Functioning, Disability, and Health (ICF) as ASHA's representative liaison. Contact him at threatst@slu.edu.

cite as: Threats, T. (2005, July 12). Active and Proactive- Boomers and the Health Care System. The ASHA Leader.

Special Interest Divisions

For information on making treatment decisions in eldercare, consider joining Division 15, Gerontology; Division 2, Neurophysiology and Neurogenic Speech and Language Disorders; Division 13, Swallowing and Swallowing Disorders; or Division 14, Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations. For more information about individual divisions and their benefits, visit the division pages on the ASHA Web site.

Suggested Readings

American Speech-Language-Hearing Association. (2001). Scope of Practice in Speech-Language Pathology. Rockville, MD: Author.

American Speech-Language-Hearing Association. (2004). Preferred practice patterns for the profession of speech-language pathology. Available in the ASHA Online Desk Reference.

American Speech-Language-Hearing Association. (2004). Scope of Practice in Audiology. Rockville, MD: Author.

Harvard School of Public Health (2004). Reinventing Aging: Baby Boomers and Civic Engagement. Cambridge, MA: Author. Available at: http://www.hsph.harvard.edu/chc/reinventingaging/Report.pdf [PDF].

Institute of Medicine (2003). Priority Areas for National Action: Transforming the U.S. Health Care System. Available at  http://www.nap.edu/openbook/0309085438/html.

National Committee on Vital and Health Statistics (NCVHS) (2001). Classifying and Reporting Functional Health Status. Washington D.C.: Department of Health and Human Services.

Threats, T. & Worrall, L. (2004).  Classifying communication disability using the ICF. Advances in Speech-Language Pathology, 6(1), 53-62.

World Health Organization (2001) International Classification of Functioning, Disability, and Health (ICF). Geneva: Author.

ASHA Resource

Medically Fragile Adults: Issues in Evaluation and Treatment
2-hour audio CD and manual 0.2 ASHA CEUs  Item #0112602 ($74 member, $99 nonmember)


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