the economics of dementia (julie p.w. bynum)

8/7/2019 The Economics of Dementia (Julie P.W. Bynum)

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Economics of Dementia

Julie Bynum, MD MPH

December 7, 2010


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Disease Specific Costs

Why Discuss them?


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Stella Marrs postcard

To Lobby for More Research Funding

Alzheimers Research Trust, 2010


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Understand what needs to be done forbetter outcomes in the future

(or at least as good)


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Canary in a coal mine


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Fund balance as % ofannual expenditures:

NOTE: The Medicare Trustees recommend that the HI Trust Fund assets should be maintained at a level of at least 100% of annualexpenditures.SOURCE: Kaiser Family Foundation based on 2009 Annual Report of the Boards of Trustees of the Federal Hospital Insuranceand Federal Supplementary Medical Insurance Trust Funds.

Actual Projected

Low cost

Intermediate

High cost

Medicare Part A (Health Insurance)

Trust Fund Balance, 2001-2018

Under High Cost, Low Cost, and Intermediate Assumptions


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Bottom Line

Direct Dementia Care Costs are three times

the Cost of Other Chronic Illnesses.

We currently deliver care in an expensive

way that might be less costly and betterquality in a different model.


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How are dementiacosts different fromother diseases?

Alzheimers Research Trust, 2010


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Health

Social

Informal

Care

Productivityloss

Medical

Psychiatric & Behavioral

Supervision

Safe housing

Functional Supports (eating, dressing etc)

EXAMPLES

Spousal support

Unpaid caregiving

Reduced hours due to informal care giving

Sandwich Generation


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Distribution of costsis different indementia from

other diseases.


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Direct Costs

Who are the stakeholders?

Alt. (Who pays the bills?)


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Community

Nursing home

Assisted Living

HOSPITAL

Local Care System


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Local Care System

Community

Nursing home

Assisted Living

HOSPITAL

HHA

SNF

Clinic


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TransitionsCommunity

Nursing home

Assisted Living

Funding Transitions

Assisted Living HOSPITAL Nursing home

MedicarePrivate Pay MedicaidMedicare SNF Private Pay

HOSPITAL


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ExpendituresCommunity vs. Institution in Dementia

Bynum, Unadjusted Data MCBS 2004


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Expenditures Compared to Other Diseases



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Difficulty Comparing Costs to Other Diseases

Avg. 4 chronic conditions compared to 1 without dementia.


Bynum JAGS 2004


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HospitalizationIn Medicare approximately 50% of costs are for hospital care.

Bynum JAGS 2004


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Biopsychosocial Model of Health

Engel, 1977

Physical

SocialPsychological


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BiopsychosocialM

odel of Costs forthe Dementia Patient

Physical

SocialPsychological


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Consider how costs might be different

in the future

Current


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H

ow Much DoesS

ocial Care Cost?2010 Median Annual Rate for the US

Nursing home (private rm): $75,190

Nursing home (semi-private rm): $67,525

Assisted Living (1Br-single): $38,220

Home Health Aide: $43,472

Home MakerServices: $41,184

Adult Day Care: $15,600

Genworth Report 2010


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What if we delayed progression of disease?

Delay progression reduces number in late

stage of disease with high social andinformal care costs

Cost argument current medications


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Acetyl Cholinesterase Inhibitors and

Controversies


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What if we delayed onset of disease?

By 2050, estimates number of cases 4x

higher based on current incidence rates If disease onset could be delayed, how

much would be saved after 10 yrs?

1-yr: save $10 Billion annually 6-mo: save $4.7 Billion annually

Brookmeyer, AJPH 1998


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What if we did non-medical caredifferently?


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A Family Intervention to Delay Nursing HomePlacement of Patients with Alzheimers Disease: A

Randomized Controlled TrialMittelmanMS et al. JAMA 1996;276:1725.

Sample: Referred, volunteer 206 spouse-caregivers of AD pts livingat home with > 1 relative in area

Intervention enrolled over 3.5 yrs:

1. Indiv. & Family counseling: task oriented, teaching techniquesfor problem solving, improve communication and support ofprimary caregiver

2. Caregivers joined a support group (any)3. 24 hr available counselor for crises or questions

F/u up to 8 years

Funding: NIMH


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Results: Delay of Institutionalization329 Days

Mittelman MS et al. JAMA 276:1725-1731,1996


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Spouse-Caregiver Intervention Drug Study: Donepezil

Interventions Studied to Delay Nursing Home

Placement in People with Alzheimers Disease

Delay Placement by 329 Days No Effect on Nursing Home

Mittelman MS et al. JAMA 276:1725-1731, 1996 AD2000 Collaborative Group Lancet 2004;363:2105-15.


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Costs of Two Interventions(Estimates since no published data)

Caregiver Intervention

2.4 FTE counselor with

85pt caseload

Salary 35-45K/yr inflatedfor benefits

$1280-1600/patient/yr

Drug Intervention

Donepezil $1560/pt/yr

Added cost

329 days in NursingHome = $43,428/pt


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Not everything that counts can be counted, andnot everything that can be counted counts.

Albert Einstein

the economics of dementia (julie p.w. bynum)

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