Healthy Aging Sumiit - Wilber Health Reform Presentation

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  • Kaye, HS, LaPlante, MP, Harrington, C. Do non-institutional long-term care services reduce Medicaid spending? Health Aff . 2009; 28(1): 262–272. Gaugler JE, Duval S, Anderson KA, Kane, RL. Predicting nursing home admission in the U.S: a meta-analysis. BMC Geriatr . 2007;7:13 interpreted Title II of the Americans with Disabilities Act (ADA), which gives civil rights and protections to individuals with disabilities and guarantees equal opportunity for individuals with disabilities in public accommodations, employment, transportation Miller and Weissart
  • Common Outcomes: Residents transition out in their stay, they remain in the facility long-stay and never leave
  • Healthy Aging Sumiit - Wilber Health Reform Presentation

    1. 1. Kate Wilber, PhD Davis School of Gerontology University of Southern California April 12, 2010 HEALTHY AGING SUMMIT: Government Reform to Support Healthy Aging US Health Policy for an Aging Population
    2. 2. Topics <ul><li>Discuss problems in the American Health Care System </li></ul><ul><li>Describe the needs and unmet needs </li></ul><ul><li>Discuss research and programs being developed to address these problems </li></ul>
    3. 3. Research Team <ul><li>Gretchen Alkema, PhD </li></ul><ul><ul><li>VP, SCAN Foundation </li></ul></ul><ul><li>George Shannon, PhD </li></ul><ul><ul><li>Consultant and Gerontology Instructor </li></ul></ul><ul><li>Jessie Yan, PhD </li></ul><ul><ul><li>Post-doctoral Fellow, UCLA Department of Neurology </li></ul></ul><ul><li>Kathryn Thomas, PhD </li></ul><ul><ul><li>University of Georgia </li></ul></ul><ul><li>David Zingmond, MD, PhD </li></ul><ul><ul><li>UCLA/RAND </li></ul></ul><ul><li>Sutep Laohavanich </li></ul><ul><ul><li>Consultant </li></ul></ul><ul><li>Davis School Graduate Students </li></ul><ul><ul><li>Zach Gassoumis </li></ul></ul><ul><ul><li>Adria Navarro </li></ul></ul>
    4. 4. Pop Quiz <ul><li>True or False: Because they have Medicare most people 65 and older have free health care. </li></ul><ul><li>Medicare targets acute conditions—what percent of Medicare is spent on chronic conditions? </li></ul><ul><li>What is the likelihood that a 65 year old will spend some time in a nursing facility in his/her lifetime? </li></ul><ul><li>True or False: For those who enter a nursing facility, the majority leave within 3 months. </li></ul><ul><li>True or False: About 1 in 5 older adults discharged from the hospital is readmitted within 30 days. </li></ul><ul><li>True or False: Currently, there is about 1 geriatrician for every 3,000 older Americans. </li></ul><ul><li>True or False: Wellness programs are effective for people aged 65+ even those who are living with disabilities or are sedentary/obese. </li></ul>
    5. 5. Q1: T/F: Because they have Medicare most people 65 and older have free care. <ul><li>False: Medicare has high deductibles and cost sharing requirements (Kaiser Family Foundation) </li></ul><ul><ul><li>Median out-of-pocket costs are 16.2% of income </li></ul></ul><ul><ul><li>20% purchase additional “Medigap” insurance </li></ul></ul><ul><ul><li>1 in 4 (mostly low income or those in poor health) spent 30% percent+ (2006) </li></ul></ul><ul><ul><li>1 in 10 beneficiaries spent more than half </li></ul></ul><ul><ul><li>Total out of pocket spending was $191 billion (2006) </li></ul></ul><ul><ul><li>Average out-of-pocket expenses per person was $4,241 in 2006 </li></ul></ul>
    6. 6. A Brief Tour: Medicare <ul><li>One of the largest health care programs in the world </li></ul><ul><li>Benefits to over 48 million beneficiaries </li></ul><ul><li>Expenditures were $524 billion in 2010 </li></ul><ul><li>65 or older (99% are covered) </li></ul><ul><li>People with permanent disabilities </li></ul><ul><li>Focus is treatment for illness not chronic care—cure rather than care </li></ul>
    7. 7. Parts to Medicare <ul><li>Medicare consumer guide: “When considering your Medicare options, it is easy to get confused and overwhelmed.” </li></ul><ul><li>Part A: Hospital Insurance </li></ul><ul><li>Part B: Supplementary (MD, etc) </li></ul><ul><li>Part C: “Medicare Advantage Plans” </li></ul><ul><ul><li>PPOs, HMOs, PFFS, SNPs, HSAs, etc. </li></ul></ul><ul><li>Part D: Drug benefits </li></ul>
    8. 8. Medicare Does Not Cover… <ul><li>Long-term custodial care </li></ul><ul><ul><li>Long Term Care in a Facility </li></ul></ul><ul><ul><li>Home and Community Based Services </li></ul></ul><ul><li>Dentures and dental care </li></ul><ul><li>Eyeglasses </li></ul><ul><li>Hearing aids </li></ul>
    9. 9. Who pays for LTC/LTSS? http://www.longtermcare.gov/LTC/Main_Site/Paying_LTC/Costs_Of_Care/Costs_Of_Care.aspx#Who
    10. 10. Medicaid <ul><li>Health Care for low income people </li></ul><ul><ul><li>All ages </li></ul></ul><ul><li>Qualifying income </li></ul><ul><ul><li>Assets <$2000 individual/$3000 couple </li></ul></ul><ul><ul><li>Monthly income <$673 individual/1,011.00 couple </li></ul></ul><ul><li>Pays for about one-half of LTSS </li></ul>
    11. 11. The “Duals” <ul><li>9 million people </li></ul><ul><ul><ul><li>19% of Medicare/ One-quarter of Medicare costs </li></ul></ul></ul><ul><ul><ul><li>14% of Medicaid/40% of costs </li></ul></ul></ul><ul><ul><li>$250 billion annually </li></ul></ul><ul><ul><li>Compared to other Medicare more likely to: </li></ul></ul><ul><ul><ul><li>Have poor health </li></ul></ul></ul><ul><ul><ul><li>Functional impairment </li></ul></ul></ul><ul><ul><ul><li>Reside in a NF </li></ul></ul></ul><ul><ul><ul><li>Have twice as much health care costs </li></ul></ul></ul>
    12. 12. Q2:What proportion of Medicare is spent on care for chronic conditions? <ul><li>97% (Kane) </li></ul><ul><li>Health care system focuses on acute care </li></ul><ul><li>90% of Americans 65+ have at least 1 chronic condition; 77% have 2 or more </li></ul><ul><li>Medicare spending </li></ul><ul><ul><li>In 2002, Medicare beneficiaries with five or more chronic conditions accounted for 76% of Medicare expenditures (Bodenheimer & Berry-Millett, 2009 NEJM) </li></ul></ul><ul><ul><li>10% of enrollees account for almost 60% of Medicare costs </li></ul></ul>
    13. 13. Key problem areas in health care for older adults: <ul><li>Acute care system for a chronic care population </li></ul><ul><ul><li>Difficulty transitioning among settings </li></ul></ul><ul><ul><li>System fragmentation </li></ul></ul><ul><ul><ul><li>Gaps in care </li></ul></ul></ul><ul><ul><ul><li>Duplication </li></ul></ul></ul><ul><ul><li>Most long term care is not covered </li></ul></ul><ul><ul><li>Manpower issues </li></ul></ul>
    14. 14. What does the American Health Care System look like?
    15. 15. What does the American Health Care System look like?
    16. 16. “ Nightmare to Navigate” (IoM, 2001)
    17. 17. Meet Mrs. Consumer (Mrs. C) Mrs. C, a recent widow whose husband provided much of her care, was diagnosed a year ago with uncontrolled diabetes and congestive heart failure . Since the death of her husband, Mrs. C has been unable to pay her bills , keep her apartment clean, or adequately prepare food .  She has not paid the rent and the landlord is trying to evict her. Mrs. C. does not have a working phone, her refrigerator has been disconnected, there is no food in her house, and she remembers eating little in recent days. She lives with two uncaged birds and a dog .
    18. 18. What Services does Mrs. C need?
    19. 20. Fragmented Funding, Regulations, and Services
    20. 21. “ Death by Assessment”
    21. 22. Client Referral Patterns ( Yip, J.J., Myrtle, R.C., Wilber, K. H., Grazman, D.M., 2002)
    22. 23. One More Important Piece to the Puzzle: Caregiving (AARP, 2007) <ul><li>87% of adults who need help/support with functioning receive help from unpaid caregivers (Mr. C) </li></ul><ul><li>Avg. 21 hours/week </li></ul><ul><li>“ Typical” caregiver is a 46 year old woman who works outside the home </li></ul><ul><li>AARP estimates:$364 billion/yr </li></ul><ul><li>Contribution in 2005 </li></ul><ul><ul><li>Similar to total Medicare expenditures </li></ul></ul><ul><li>Caregivers have higher rates of </li></ul><ul><li>Illness and mortality </li></ul>
    23. 24. Developing a More Coherent System Requires: <ul><li>Ability to link information </li></ul><ul><ul><li>Data driven decisions </li></ul></ul><ul><li>Make effective referrals (transitions) </li></ul><ul><li>Aligned incentives </li></ul><ul><ul><li>Money Follows the Person </li></ul></ul>
    24. 25. Efforts to Develop Integrated Information Systems <ul><li>California Community Choices Data Warehouse Study (Zingmond, Laohavanich, and Wilber) Developing an integrated data warehouse in California </li></ul>
    25. 26. Using Linked Data to Measure Cost and Quality (Zingmond, Ettner, Wilber, and Wenger) <ul><li>Evaluated the relationship of process of care and subsequent function and survival among people 75+ </li></ul><ul><li>Those who received higher quality medical care in 1999 sustained smaller declines in function during 2000 </li></ul><ul><li>Shows the potential of these large linked data sets to help track quality outcomes </li></ul>
    26. 27. Lack of Prevention, Coordination, Care for Geriatric Conditions <ul><li>Quality Findings From RAND (ACOVE Study) </li></ul><ul><ul><li>Vulnerable elders receive about half of the recommended care </li></ul></ul><ul><ul><li>Quality varies widely from one condition and type of care to another </li></ul></ul><ul><ul><li>Preventive care suffers the most; diagnostic and treatment procedures are provided most frequently </li></ul></ul><ul><ul><li>Care for geriatric conditions (e.g., falls, incontinence) poorer than for general medical conditions such as hypertension that affect adults of all ages </li></ul></ul>
    27. 28. Summary of the Problem <ul><li>Services are fragmented, disjointed, and duplicative </li></ul><ul><ul><li>Inefficiencies and gaps </li></ul></ul><ul><ul><li>Difficulty to negotiate and transition </li></ul></ul><ul><li>Multiple/mutually exclusive funding streams </li></ul><ul><li>Incompatible regulatory requirements </li></ul><ul><li>Lack of integrated information </li></ul><ul><li>Multiple duplicative assessments </li></ul><ul><li>Various provider types/models/philosophies </li></ul><ul><li>Complex heterogeneous consumer needs </li></ul>
    28. 29. Care Management Interventions: Connecting the Dots <ul><li>Overtreatment/Polypharmacy </li></ul><ul><ul><li>26% of dually eligible elders in our study had a confirmed medication management problem (Alkema et al., 2008) </li></ul></ul><ul><ul><li>Intervention: Care managers and consultant pharmacists resolved 61% of cases </li></ul></ul><ul><li>Monthly telephone CM </li></ul><ul><ul><li>Reduced mortality (Alkema, 2008) </li></ul></ul><ul><ul><li>Reduced hospitalization (Shannon, 2007) </li></ul></ul>
    29. 30. Q3: What is the likelihood that a 65 Year old will spend some time in a nursing facility in his/her lifetime? <ul><li>40-45% </li></ul><ul><li>About one-half of women 65+ will spend some time in a NF </li></ul>
    30. 31. Q4: T/F: The majority of those who enter a NF leave within 3 months. <ul><li>True. The vast majority (70%) will leave within 90 days </li></ul><ul><li>Research focus: NF transitions </li></ul><ul><li>10 million Americans need some type of LTSS ($264 in 2008) </li></ul>
    31. 32. Policy Background <ul><li>Focus on “Diversion” (1970s-present) </li></ul><ul><ul><li>3+ Decades—risk factors for admission </li></ul></ul><ul><ul><li>Effectiveness of HCBS “alternatives” </li></ul></ul><ul><ul><li>PAS programs </li></ul></ul><ul><li>Focus on Transition (since 2000) </li></ul><ul><li>1999 Olmstead Supreme Court Decision ( Olmstead v. L.C. ex rel. Zimring) </li></ul><ul><ul><li>Institutionalizing disabled persons capable of living in the community was discrimination based on the ADA </li></ul></ul><ul><ul><li>People should have the option to live &quot;in the most integrated setting appropriate to the needs of qualified individuals with disabilities.&quot; </li></ul></ul>
    32. 33. Proportion That Leave (Gassoumis)
    33. 34. Who leaves: 1-90 days (Gassoumis, Thomas, Enguidanos, Wilber)
    34. 35. <ul><li>True </li></ul><ul><li>1 in 3 is readmitted w/in 90 days </li></ul><ul><li>Our research (Thomas, 2010) </li></ul><ul><ul><li>Strongest predictor of remaining in the facility is readmission to the hospital </li></ul></ul>Q5: T/F: About one in five Medicare beneficiaries discharged from the hospital is readmitted within 30 days.
    35. 36. <ul><li>False </li></ul><ul><li>California 1/4,000 geriatrician/Californians 65+; nationwide 1/5,350 </li></ul><ul><li>American medical system woefully unprepared for aging baby boomers (IoM, 2008) </li></ul><ul><li>California faces shortfall of 30,000 certified nursing assistants </li></ul>Q6:T/F: Currently, there is about 1 geriatrician for every 3,000 older Americans.
    36. 37. <ul><li>True (Yan et al., 2009) </li></ul><ul><li>Active Start : 200 adults 60+ </li></ul><ul><li>Behavior change & exercise </li></ul><ul><li>Improvement on all measures (strength, flexibility and balance) </li></ul><ul><li>Across all subgroups (Whites, African Americans, and Hispanics) </li></ul>Q7: T/F: Wellness programs work for people aged 65+ with disabilities or sedentary/obese.
    37. 38. Healthy Moves Program (Yan 2010, 2011) <ul><li>Targeted NHC frail older adults </li></ul><ul><li>Offered in their homes </li></ul><ul><li>Very basic low intensity program </li></ul><ul><li>Used motivation: what are your goals? </li></ul><ul><li>Face-to-face “coaches” were more effective then telephone </li></ul>
    38. 39. Key Points <ul><li>Health care delivery is fragmented, difficult to navigate, not geared to chronic care </li></ul><ul><li>The role of NF is changing dramatically </li></ul><ul><li>Not enough people trained in geriatrics and gerontology </li></ul><ul><li>A number of innovations offer promise including </li></ul><ul><ul><li>Improving information systems </li></ul></ul><ul><ul><li>Facilitating better transitions among services </li></ul></ul><ul><ul><li>Focusing on Prevention/Wellness </li></ul></ul><ul><ul><li>Build on Evidence-Based Health Promotion Programs (meds management, fall prevention, chronic disease self management) </li></ul></ul><ul><ul><li>CM can improve care </li></ul></ul>
    39. 40. Next Steps: Health Reform
    40. 41. Health Care Reform: Moving Toward a Chronic Care System <ul><ul><li>Incentives for primary care doctors </li></ul></ul><ul><ul><li>Improved coordination </li></ul></ul><ul><ul><ul><li>Medical Homes </li></ul></ul></ul><ul><ul><ul><li>MDT </li></ul></ul></ul><ul><ul><li>Eliminating the co-pay for preventative services </li></ul></ul><ul><ul><li>Addresses the “donut hole” in drug benefits </li></ul></ul><ul><ul><li>Aligning cost incentives w/outcomes </li></ul></ul><ul><ul><li>The CLASS Act (Community Living Assistance Services and Supports) </li></ul></ul><ul><ul><ul><li>Offers a LTSS benefit </li></ul></ul></ul>

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