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

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The Future of Health Care for Older PeopleWill
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

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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

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Epidemiology of Aging
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The Disability Problem
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75 of Medicares funds are expended on 10 of
its beneficiaries

• (those with chronic conditions)

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Chronic conditions lead to

• Functional impairment
• Disrupted roles and relationships
• Discomfort
• Loss of time and money
• Depression
• Poor quality of life
• Premature mortality

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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

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Innovations in Therapy

• 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

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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

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Effectiveness of Self-Management

• Randomized clinical trial
• Function
• General health, energy
• Hospital days
• Costs
• Lorig et al. Med Care 1999

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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 200149(4)351-359

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Effectiveness of ACE Units

• Randomized trial
• Satisfaction
• Function
• LOS ( costs)
• Landefeld et al. NEJM 1995
• Covinski et al. J Am Geriatr Soc 1997

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Effectivenessof Traditional Home Care

• 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 _at_ p lt
  0.05
• Hedrick et al. HSR 1986

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Cost-Effective Home Care

• Sick, disabled older people
• Physician-led interdisciplinary teams
• Regular patient care conferences
• Operational efficiencies

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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

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Effectiveness of CM

• 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

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The available evidence suggests that these
innovations will

• Improve satisfaction
• Improve function
• Possibly reduce some costs for insurers

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

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

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Who Will Pay

• Medicare?
• Employers?
• Individuals?

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Economic Status ofRetiring Baby Boomers

• Greater income and net worth than parents
• Haves and have nots
• Demographic differences

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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

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The Choice

• Two-tiered health care, or
• (Intra-generational) subsidy for the
• have nots