Economics of Dementia

1. Economics of Dementia Julie Bynum, MD MPH December 7, 2010

3. Disease Specific Costs • Why Discuss them?

4. Alzheimer’s Research Trust, 2010

5. Stella Marr’s postcard Alzheimer’s Research Trust, 2010 To Lobby for More Research Funding

6. Understand what needs to be done for better outcomes in the future (or at least as good)

7. Canary in a coal mine

16. Medicare Part A (Health Insurance) Trust Fund Balance, 2001-2018Under High Cost, Low Cost, and Intermediate Assumptions Fund balance as % of annual expenditures: ActualProjected Low cost Intermediate High cost NOTE: The Medicare Trustees recommend that the HI Trust Fund assets should be maintained at a level of at least 100% of annual expenditures. SOURCE: Kaiser Family Foundation based on 2009 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds.

17. 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 better quality in a different model.

18. How are dementia costs different from other diseases? Alzheimer’s Research Trust, 2010

19. EXAMPLES Health Medical Psychiatric & Behavioral Supervision Social Safe housing Functional Supports (eating, dressing etc) Informal Care Spousal support Unpaid caregiving Productivity loss Reduced hours due to informal care giving “Sandwich Generation”

20. Distribution of costs is different in dementia from other diseases.

21. Direct Costs Who are the stakeholders? Alt. (Who pays the bills?)

22. Community Nursing home HOSPITAL Assisted Living

23.                         Community Local Care System HHA HOSPITAL SNF Nursing home                   Clinic Assisted Living            

24. Community Nursing home Assisted Living Funding Transitions Assisted Living Nursing home HOSPITAL Private Pay Medicare Private Pay Medicaid Medicare SNF Transitions HOSPITAL

25. Expenditures Community vs. Institution in Dementia Bynum, Unadjusted Data MCBS 2004

26. Expenditures Community vs. Institution in Dementia Bynum, Unadjusted Data MCBS 2004

27. Expenditures Compared to Other Diseases Bynum, Unadjusted Data MCBS 2004

28. Expenditures Compared to Other Diseases Bynum, Unadjusted Data MCBS 2004

29. Expenditures Compared to Other Diseases Bynum, Unadjusted Data MCBS 2004

30. Expenditures Compared to Other Diseases Bynum, Unadjusted Data MCBS 2004

31. Difficulty Comparing Costs to Other Diseases • Avg. 4 chronic conditions compared to 1 without dementia. Bynum, Unadjusted Data MCBS 2004

32. Hospitalization In Medicare approximately 50% of costs are for hospital care.

33. Ask ourselves why? • Behavioral issues/psychiatric admissions • Inability to self manage chronic disease • Caregiver stress and burnout • Clinician uncertainties about diagnosis and management

34. Biopsychosocial Model of Health Psychological Social Physical Engel, 1977

35. BiopsychosocialModel of Costs for the Dementia Patient Psychological Social Physical

36. Consider how costs might be different in the future

37. Consider how costs might be different in the future Current

38. How Much Does Social 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 Maker Services: $41,184 Adult Day Care: $15,600 Genworth Report 2010

39. What if we delayed progression of disease? • Delay progression reduces number in late stage of disease with high social and informal care costs • Cost argument current medications

40. Acetyl Cholinesterase Inhibitors and Controversies

41. 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

42. What if we did non-medical care differently?

43. A Family Intervention to Delay Nursing Home Placement of Patients with Alzheimer’s Disease: A Randomized Controlled TrialMittelman MS et al. JAMA 1996;276:1725. Sample: Referred, volunteer 206 spouse-caregivers of AD pts living at home with > 1 relative in area Intervention enrolled over 3.5 yrs: Indiv. & Family counseling: task oriented, teaching techniques for problem solving, improve communication and support of primary caregiver Caregivers joined a support group (any) 24 hr available counselor for crises or questions F/u up to 8 years Funding: NIMH

44. Results: Delay of Institutionalization 329 Days Mittelman MS et al. JAMA 276:1725-1731, 1996

45. Interventions Studied to Delay Nursing Home Placement in People with Alzheimer’s Disease Spouse-Caregiver Intervention Drug Study: Donepezil No Effect on Nursing Home Delay Placement by 329 Days AD2000 Collaborative Group Lancet 2004;363:2105-15. Mittelman MS et al. JAMA 276:1725-1731, 1996

46. Costs of Two Interventions(Estimates since no published data) Caregiver Intervention 2.4 FTE counselor with 85pt caseload Salary 35-45K/yr inflated for benefits $1280-1600/patient/yr Drug Intervention Donepezil $1560/pt/yr Added cost 329 days in Nursing Home = $43,428/pt

47. NH 30% Home/AL 70% Where Do People With Alzheimer’s Disease Live? Source: Alzheimer’s Association, 2004

48. “Not everything that counts can be counted, and not everything that can be counted counts.” Albert Einstein