The Future of Health Care for Older People: Will the Disadvantaged by Left Behind?

1. The Future of Health Care for Older People:Will the Disadvantaged by Left Behind? Chad Boult, MD, MPH, MBA Professor and Director Lipitz Center for Integrated Health Care Department of Health Policy and Management Bloomberg School of Public Health Johns Hopkins University

2. Forces that will shape the future of health care • Growth in the size of the older population • The epidemiology of chronic conditions • The costs and effects of chronic conditions • The demand for high-quality care

3. Epidemiology of Aging

4. The Disability Problem

5. 75% of Medicare’s funds are expended on 10% of its beneficiaries (those with chronic conditions)

6. Chronic conditions lead to: • Functional impairment • Disrupted roles and relationships • Discomfort • Loss of time and money • Depression • Poor quality of life • Premature mortality

7. Compared to seniors of today, many seniors of 2020 will be: • More affluent • More educated • More “entitled” to health and independence • More demanding of high-quality care • More willing to spend for it

8. Health Enhancement Self management Geriatric evaluation and management ACE units Interdisciplinary home care Case management Group care Disease management Home hospital Transitional care Nursing home teams Innovations in Therapy

9. Effectiveness of Health Enhancement Program • Randomized trial of multifaceted intervention • 26% lower disability • 72% fewer hospital days/1000 • Leveille et al. J Am Geriatr Soc 1998

10. Effectiveness of Self-Management • Randomized clinical trial Function • General health, energy • Hospital days • Costs • Lorig et al. Med Care 1999

11. Effectiveness of GEM • Randomized trial • 33% reduction in loss of function • 56% reduction in depression • 57% reduction in caregiver burnout • 9% higher patient satisfaction • highly rated by primary care physicians • no effect on mortality • cost $1,350 per person treated • Boult et al. J Am Geriatr Soc 2001;49(4):351-359

12. Effectiveness of ACE Units • Randomized trial • Satisfaction • Function • LOS (= costs) • Landefeld et al. NEJM 1995 • Covinski et al. J Am Geriatr Soc 1997

13. Functional ability Satisfaction Use of hospitals Use of outpatient care Use of NHs Mortality Total costs none slight increase slight increase slight increase slight increase slight decrease 15% increase No effects are statistically significant @ p < 0.05 Hedrick et al. HSR 1986 Effectivenessof Traditional Home Care

14. Cost-Effective Home Care • Sick, disabled older people • Physician-led interdisciplinary teams • Regular patient care conferences • Operational efficiencies

15. Effectiveness of IHC • Randomized trials • Better IADLs, ability to walk • Greater satisfaction for pts, families • Less use of hospitals/clinics/NHs • Total costs reduced by 20% • Melin et al. Am J Pub Health 1993 • Cummings et al. Arch Intern Med 1990

16. SW oriented No cost savings Boult et al. J Am Geriatr Soc 2000 Nursing oriented No improvement in health, quality of life, functional ability, satisfactions with care or use of health services Gagnon et al. J Am Geriatr Soc 1999 Effectiveness of CM

17. The available evidence suggests that these innovations will: • Improve satisfaction • Improve function • Possibly reduce some costs for insurers

18. Modelof Senior Care Proactive primary care team Activated person, family IHC Self- mgmt GEM ACE HEP Disease Mgmt. Trans. Care Group Care NH Home hosp.

19. Requirements • Information systems • Professional education • Quality improvement systems • Aligned incentives • Investment in innovation

20. Who Will Pay • Medicare? • Employers? • Individuals?

21. Economic Status ofRetiring Baby Boomers • Greater income and net worth than parents • “Haves” and “have nots” • Demographic differences

22. Future Care for Chronic Illness • Will produce better outcomes • Will require out-of-pocket payments by retired baby boomers • Will be available to affluent retirees • Will be unavailable to disadvantaged groups

23. The Choice Two-tiered health care, or (Intra-generational) subsidy for the have nots