Kate Wilber, PhDDavis School of Gerontology

University of Southern California

April 12, 2010

HEALTHY AGING SUMMIT: Government Reform to Support Healthy AgingUS Health Policy for an Aging Population

Topics Discuss problems in the American Health

Care System Describe the needs and unmet needs Discuss research and programs being

developed to address these problems

Research Team Gretchen Alkema, PhD

VP, SCAN Foundation George Shannon, PhD

Consultant and Gerontology Instructor Jessie Yan, PhD

Post-doctoral Fellow, UCLA Department of Neurology Kathryn Thomas, PhD

University of Georgia David Zingmond, MD, PhD

UCLA/RAND Sutep Laohavanich

Consultant Davis School Graduate Students

Zach Gassoumis Adria Navarro

Pop Quiz 1. True or False: Because they have Medicare most people 65 and older

have free health care.2. Medicare targets acute conditions—what percent of Medicare is spent

on chronic conditions?3. What is the likelihood that a 65 year old will spend some time in a

nursing facility in his/her lifetime? 4. True or False: For those who enter a nursing facility, the majority leave

within 3 months.5. True or False: About 1 in 5 older adults discharged from the hospital is

readmitted within 30 days.6. True or False: Currently, there is about 1 geriatrician for every 3,000

older Americans.7. True or False: Wellness programs are effective for people aged 65+

even those who are living with disabilities or are sedentary/obese.

Q1: T/F: Because they have Medicare most people 65 and older have free care. False: Medicare has high deductibles and cost sharing

requirements (Kaiser Family Foundation)

Median out-of-pocket costs are 16.2% of income 20% purchase additional “Medigap” insurance 1 in 4 (mostly low income or those in poor health)

spent 30% percent+ (2006) 1 in 10 beneficiaries spent more than half Total out of pocket spending was $191 billion (2006) Average out-of-pocket expenses per person was

$4,241 in 2006

A Brief Tour: Medicare One of the largest health care programs in the

world Benefits to over 48 million beneficiaries Expenditures were $524 billion in 2010 65 or older (99% are covered) People with permanent disabilities Focus is treatment for illness not chronic care—

cure rather than care

Parts to Medicare Medicare consumer guide: “When considering

your Medicare options, it is easy to get confused and overwhelmed.”

Part A: Hospital Insurance Part B: Supplementary (MD, etc) Part C: “Medicare Advantage Plans”

PPOs, HMOs, PFFS, SNPs, HSAs, etc.

Part D: Drug benefits

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Medicare Does Not Cover… Long-term custodial care

Long Term Care in a Facility Home and Community Based Services

Dentures and dental care Eyeglasses Hearing aids

Who pays for LTC/LTSS? http://www.longtermcare.gov/LTC/Main_Site/Paying_LTC/Costs_Of_Care/Costs_Of_Care.aspx#Who

49%

18%

7%

20%

5%

Medicaid

Out-of-pocket

Insurance

Medicare

Other

Medicaid Health Care for low income people

All ages Qualifying income

Assets <$2000 individual/$3000 couple Monthly income <$673 individual/1,011.00

couple Pays for about one-half of LTSS

The “Duals” 9 million people

19% of Medicare/ One-quarter of Medicare costs 14% of Medicaid/40% of costs

$250 billion annually Compared to other Medicare more likely to:

Have poor health Functional impairment Reside in a NF Have twice as much health care costs

Q2:What proportion of Medicare is spent on care for chronic conditions?

97% (Kane) Health care system focuses on acute care 90% of Americans 65+ have at least 1 chronic

condition; 77% have 2 or more Medicare spending

In 2002, Medicare beneficiaries with five or more chronic conditions accounted for 76% of Medicare expenditures (Bodenheimer & Berry-Millett, 2009 NEJM)

10% of enrollees account for almost 60% of Medicare costs

Key problem areas in health care for older adults: Acute care system for a chronic care

population Difficulty transitioning among settings System fragmentation

Gaps in care Duplication

Most long term care is not covered Manpower issues

What does the American Health Care System look like?

What does the American Health Care System look like?

“Nightmare to Navigate” (IoM, 2001)

Mrs. C, a recent widow whose husband provided much of her care, was diagnosed a year ago with uncontrolled diabetes and congestive heart failure. Since the death of her husband, Mrs. C has been unable to pay her bills, keep her apartment clean, or adequately prepare food.  She has not paid the rent and the landlord is trying to evict her. Mrs. C. does not have a working phone, her refrigerator has been disconnected, there is no food in her house, and she remembers eating little in recent days. She lives with two uncaged birds and a dog.

Meet Mrs. Consumer (Mrs. C)

What Services does Mrs. C need?

Fragmented Funding, Regulations, and Services

“Death by Assessment”

Client Referral Patterns(Yip, J.J., Myrtle, R.C., Wilber, K. H., Grazman, D.M., 2002)

One More Important Piece to the Puzzle: Caregiving (AARP, 2007)

87% of adults who need help/support with functioning receive help from unpaid caregivers (Mr. C)

Avg. 21 hours/week “Typical” caregiver is a 46 year old woman who works

outside the home AARP estimates:$364 billion/yr Contribution in 2005

Similar to total Medicare expenditures Caregivers have higher rates of Illness and mortality

Developing a More Coherent System Requires: Ability to link

information Data driven

decisions

Make effective referrals (transitions)

Aligned incentives Money Follows the

Person

Efforts to Develop Integrated Information Systems

California Community Choices Data Warehouse Study (Zingmond, Laohavanich, and Wilber) Developing an integrated data warehouse in California

Using Linked Data to Measure Cost and Quality (Zingmond, Ettner, Wilber, and Wenger) Evaluated the relationship of process of care and

subsequent function and survival among people 75+

Those who received higher quality medical care in 1999 sustained smaller declines in function during 2000

Shows the potential of these large linked data sets to help track quality outcomes

Lack of Prevention, Coordination, Care for Geriatric Conditions Quality Findings From RAND (ACOVE Study)

Vulnerable elders receive about half of the recommended care

Quality varies widely from one condition and type of care to another

Preventive care suffers the most; diagnostic and treatment procedures are provided most frequently

Care for geriatric conditions (e.g., falls, incontinence) poorer than for general medical conditions such as hypertension that affect adults of all ages

Summary of the Problem

Services are fragmented, disjointed, and duplicative Inefficiencies and gaps Difficulty to negotiate and transition

Multiple/mutually exclusive funding streams Incompatible regulatory requirements Lack of integrated information Multiple duplicative assessments Various provider types/models/philosophies Complex heterogeneous consumer needs

Care Management Interventions: Connecting the Dots Overtreatment/Polypharmacy

26% of dually eligible elders in our study had a confirmed medication management problem (Alkema et al., 2008)

Intervention: Care managers and consultant pharmacists resolved 61% of cases

Monthly telephone CM Reduced mortality (Alkema, 2008) Reduced hospitalization (Shannon, 2007)

Q3: What is the likelihood that a 65 Year old will spend some time in a nursing facility in his/her lifetime?

40-45% About one-half of

women 65+ will spend some time in a NF

Q4: T/F: The majority of those who enter a NF leave within 3 months.

True. The vast majority (70%) will leave within 90 days

Research focus: NF transitions

10 million Americans need some type of LTSS ($264 in 2008)

Policy Background Focus on “Diversion” (1970s-present)

3+ Decades—risk factors for admission Effectiveness of HCBS “alternatives” PAS programs

Focus on Transition (since 2000) 1999 Olmstead Supreme Court Decision

(Olmstead v. L.C. ex rel. Zimring) Institutionalizing disabled persons capable of living

in the community was discrimination based on the ADA

People should have the option to live "in the most integrated setting appropriate to the needs of qualified individuals with disabilities."

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All episodes (n=3,832)

Residents who transition home (n=1,919)

Proportion That Leave (Gassoumis)

Who leaves: 1-90 days (Gassoumis, Thomas, Enguidanos, Wilber)

True 1 in 3 is readmitted w/in

90 days Our research (Thomas,

2010) Strongest predictor

of remaining in the facility is readmission to the hospital

Q5: T/F: About one in five Medicare beneficiaries discharged from the hospital is readmitted within 30 days.

False California 1/4,000

geriatrician/Californians 65+; nationwide 1/5,350

American medical system woefully unprepared for aging baby boomers (IoM, 2008)

California faces shortfall of 30,000 certified nursing assistants

Q6:T/F: Currently, there is about 1 geriatrician for every 3,000 older Americans.

True (Yan et al., 2009) Active Start : 200 adults

60+ Behavior change & exercise Improvement on all

measures (strength, flexibility and balance)

Across all subgroups (Whites, African Americans, and Hispanics)

Q7: T/F: Wellness programs work for people aged 65+ with disabilities or sedentary/obese.

Healthy Moves Program (Yan 2010, 2011)

Targeted NHC frail older adults Offered in their homes Very basic low intensity program Used motivation: what are your goals? Face-to-face “coaches” were more

effective then telephone

Key Points Health care delivery is fragmented, difficult to navigate,

not geared to chronic care The role of NF is changing dramatically Not enough people trained in geriatrics and gerontology A number of innovations offer promise including

Improving information systems Facilitating better transitions among services Focusing on Prevention/Wellness Build on Evidence-Based Health Promotion Programs (meds

management, fall prevention, chronic disease self management) CM can improve care

Next Steps: Health Reform

Health Care Reform: Moving Toward a Chronic Care System

Incentives for primary care doctors Improved coordination

Medical Homes MDT

Eliminating the co-pay for preventative services Addresses the “donut hole” in drug benefits Aligning cost incentives w/outcomes The CLASS Act (Community Living Assistance

Services and Supports) Offers a LTSS benefit