The fastest growing segment of the US population is the elderly over the age of 85.
The fastest growing segment of the older population is the oldest old — that is, those ages 85 and older. They are projected to total 6 million as early as 2010, twice their 1990 level. Beginning in 2031, when the baby boomers will begin reaching 85, the number of oldest old will increase rapidly. The 85-and-over population is expected to grow fivefold, from 4 million in 2000 to 21 million by 2050.
This group is of particular concern to policymakers and planners because people ages 85 and older are more likely to be disabled than “young” elderly, ages 65 to 74.
In fact, I believe that the frail elderly, those over 85, are not the most expensive segment of the elderly to care for. They are the healthy portion of the population since those with poor genetic makeup or with bad habits are gone. They tend to be more fit than those with poor health, dementia and early death.
In 1995, I wrote a grant proposal to study the care of this elderly population by providing on-site care in assisted living facilities within an 8 mile radius of UCI medical center. Here are some basic data about Medicare beneficiaries in 1995. The changes since that time are chiefly a shift to the right in age in all studies.
In the fee for service sector of Medicare only 21% of beneficiaries used Part A services in 1995, although 84% of beneficiaries had Part B claims, indicating some covered medical service use. Median total expenditures per beneficiary were $884 per year in 1995, a modest amount indicating the small size of most claims. High expenditures are concentrated in a small percentile of the population. The top 2% of beneficiaries spend as much as the bottom 90% and the top 1% spend 19% of all Medicare expenditures. It is unusual for beneficiaries to remain in the very high expenditure group for more than one year. Patients in this category either die of an illness or recover after therapy and return to the low expenditure category. 47% of beneficiaries will be in the top quintile of expenditures for one year in a nine year study. 30% will be in the top decile for one year but only 10% are in the top decile for two or more years and only 1.2 % are in the top decile for four or more years. Mortality is high in this group and, for the beneficiaries who are in the top decile for two or more years, it exceeds 50% and is higher than that of the very high cost one year group. Individuals who have persistently high costs, while a very small group, account for a disproportionate share of expenditures. It is possible that multi-year high expenditures represent cases in which improved care could save substantial amounts of money. In addition, it is apparent that high cost Medicare beneficiaries, even in the un-managed fee for service sector, are a very small proportion of the total.
What about the frail elderly ? The group over age 85 ?
The frail elderly, usually described as those over age 85 and those with chronic illness, are estimated to comprise 10% of all Medicare beneficiaries. If all of the multi-year high cost beneficiaries were in this group it would still leave 88% of this group with costs close to the Average Annual Per Capita Cost over a multi-year span. It is unlikely that costs for this group exceed the average for other age groups and studies of end-of-life costs show a decline in costs after age 80 for decedents and after age 90 for survivors.
Remember this was 14 years ago. Our model was a demonstration project in San Francisco.
A program named On Lok began in San Francisco 25 years ago to care for frail elderly with low incomes, initially among the Chinese-American population of that city, and to keep them in their homes and out of nursing homes. It now operates five community service organizations in the city and has been the impetus for a national demonstration project called PACE (Program of All-inclusive Care for the Elderly). In 1983 On Lok became a dual capitation program funded by Medicare and Medicaid as an alternative to long term nursing home care which is covered, for Medicaid eligible individuals, by Medicaid. At present 15 PACE programs exist nationally as Medicare providers, 10 of which were mandated by OBRA in 1986 as a demonstration project (plus the five On Lok sites in San Francisco), and 40 sites are planned to be in operation next year. The program includes a four year demonstration project of up to 10 for-profit entities which, if successful, could qualify as permanent PACE providers. The PACE model includes a day care center which provides nursing care, case management, social activities, a nutrition program and respite for family care givers. Eligibility for the PACE program is income limited with a maximum income of $14,000 for individuals and $17,000 for married couples. It does not include pharmacy benefits but a new enhancement, called PACENET (Pharmaceutical Assistance Contract for the Elderly Needs Enhancement Tier) will cover drugs after a deductible ($500) and copayment ($8 for generic/ $15 for brands).
An independent evaluation by Abt Associates in 1995 was critical of the PACE model in several respects and suggested that the replication sites may be less successful than On Lok for a number of reasons. The catchment area of On Lok was only 2.5 square miles at initial development and is still less than 10 square miles after expansion. The replication sites have, in general, larger catchment areas and are located in communities with less population density than San Francisco. Another problem has been the slow growth of the replication sites’ client volume. Some of the reasons for slow growth include resistance to four or five day per week visits, the need to apply for Medicaid and the loss of choice of physician and other providers. Family support is necessary for this model to succeed and this varies among the replication sites. The report emphasizes that all sites exclude some eligible patients in spite of a need for expansion and this suggests that selection is occurring. This selection process is described as “niche marketing” or “skimming” in the report and the conclusion is that enthusiasm for the model among providers is greater than among clients.
The greatest change since these studies has to do with the growth of assisted living homes and home care. It is much, much easier to care for frail elderly at home than it was in 1986 or even in 1995. A second option was considered as a model.
A similar program, at the University of Pennsylvania, called CARE (Collaborative Assessment and Rehabilitation for Elders), has been established since 1993. It is certified as a CORF (Comprehensive Outpatient Rehabilitation Facility) and functions as a day hospital similar to the British day hospital. This program found that nursing, mental health, social work and care management services are not well reimbursed in a fee for service environment. Certification as a CORF improved reimbursement. Other limitations included relations with other providers who might feel competition, transportation, limitations on the services reimbursed by the CORF structure, cost of the day care facility and time limits of the CORF model. They are dependent on referral from primary care physicians and have no managed care patients. Patients are seen by Advanced Practice Nurses at intake and needs assessment is completed. Typical problems include poly-pharmacy, depression and cognition. Patients are seen in a “day hospital” for four hours per day, two to three times per week for an average of six weeks. Then the patients are returned to primary care physician follow-up and the CARE program has no long term follow-up.
Here again, there is a model for treating frail elderly with intensive short term care, usually correcting medication problems, assessing psychological issues and coaching family members on proper care. A third model was considered.
The Veterans Administration studied the effectiveness and efficiency of an outpatient Geriatric Evaluation and Management (GEM) program with a randomized trial comparing GEM patients and the usual primary care (UPC) population. This program was based on studies of inpatient geriatric units which had shown improved care. Other outpatient GEM studies had shown little evidence of efficacy of the concept, as measured by consumption of medical services. Tulloch and Moore, in Britain, showed increased number of admissions in GEM patients but reduced bed days and an increased use of social and health services with no difference in prevalence of health problems. The VA study showed significant improvement of health status and quality, as measured by the SF 20, and a significant improvement in survival. No significant differences in costs were reported in the original publication of the study although the GEM patients were seen twice as often.
If elderly patients are seen more frequently, and the problems that have affected them are solved, thereafter, they are less expensive to care for.
In a long term follow-up of the study a potential “investment effect” was identified in that, during the first 8 months of the program, GEM patients incurred 35% more health care cost than the UPC group but in the later stages, after one year, the ratio reversed with GEM patients’ costs being 38% less than the UPC group. This suggests the possibility that initial evaluation identified deferred health needs which, once corrected in the early stage of the study, resulted in less health care expenditures later. If this trend continues it may indicate that early correction of health problems results in less cost in the long term and may support the cost effectiveness of the GEM concept.. Both the GEM group and the control group showed improved health perception and functional status. This effect on the control group was attributed to the “study effect” first noted in the 1920s in efficiency measurement. Control patients responded to the increased attention of the study by improved status. The VA GEM study with long term follow-up has not been replicated and their patients were all male.
Due to an uncooperative medical center administrator, we were unable to conduct this study and prove our thesis; that the elderly have specific issues that, once solved, are no more expensive to care for than younger elderly patients and may, in fact, be less expensive. UCLA did a small scale study that was similar:
A similar study of geriatric assessment but this time performed at home was reported in 1995 by a group at UCLA. The patients were selected from voter rolls of the city of Santa Monica for age over 75 and 37% of those contacted by telephone agreed to participate. They were randomized to an intervention group and a Usual Care group. After a three year study period the intervention group were more able to live independently, less likely to require assistance and less likely to be in nursing homes long term. There was no difference in acute care hospital admissions and the intervention group had more hospital days per year and more physician visits per year than the control group. The principle benefit of the program seemed to be in the reduction of long term nursing home admissions.
Why is this important ? The over-85 elderly group is the fastest growing part of our population. There will be enormous resistance to any attempt to deny them care. The studies above mostly focused on “day hospitals” and intensive evaluation upon intake into the program. The evaluation may include a psychologist and a pharmacist, both of whom are concerned with common issues of depression and polypharmacy. Once these issues are dealt with, the elderly are easy to care for and the care will increasingly be delivered at home or in assisted living facilities.
At the moment, Medicare and the Obama administration do not seem to be focusing on these issues. This may mean that private options may become more important. Note that the common theme in all these studies is more frequent physician visits to these patients, whether they are at home or in day hospitals. Medicare is not only refusing to fund these more frequent visits but is threatening to prosecute physicians who see their elderly patents more frequently than the Medicare rules allow. For this reason, some geriatric physicians are dropping out of Medicare and practicing in a cash setting. The patients seem to be willing to pay for this additional care, suggesting that they and their family members perceive value.
This report discusses the future for Medicare without reform. There are several reforms that could be done without overt rationing. Some of them are discussed above.