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

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

Epidemiology of Aging

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Age

Bad things

The Disability Problem

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1993 2000 2010 2020 2030 2040 2050

Disabled Americans(millions)

75% of Medicare’s funds are expended on 10% of its

beneficiaries (those with chronic conditions)

Chronic conditions lead to:

• Functional impairment

• Disrupted roles and relationships

• Discomfort

• Loss of time and money

• Depression

• Poor quality of life

• Premature mortality

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

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

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

Effectiveness of Self-Management

• Randomized clinical trial

Function

• General health, energy

• Hospital days

• Costs– Lorig et al. Med Care 1999

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

Effectiveness of ACE Units

• Randomized trial

• Satisfaction• Function• LOS (= costs)

– Landefeld et al. NEJM 1995– Covinski et al. J Am Geriatr Soc 1997

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 @ p < 0.05

– Hedrick et al. HSR 1986

Cost-Effective Home Care

• Sick, disabled older people

• Physician-led interdisciplinary teams

• Regular patient care conferences

• Operational efficiencies

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

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

The available evidence suggests that these innovations will:

• Improve satisfaction

• Improve function

• Possibly reduce some costs for insurers

Model of Senior Care

Proactive primary care team

Activated person, family

IHC ACE

GroupCare

GEM

DiseaseMgmt.

NH

Self-mgmt

Trans.Care

Home hosp.

HEP

Requirements

• Information systems

• Professional education

• Quality improvement systems

• Aligned incentives

• Investment in innovation

Who Will Pay

• Medicare?

• Employers?

• Individuals?

Economic Status ofRetiring Baby Boomers

• Greater income and net worth than parents

• “Haves” and “have nots”

• Demographic differences

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

The Choice

Two-tiered health care, or

(Intra-generational) subsidy for the

have nots