June 27, 2013
by Donald Sjoerdsma / The Medicare NewsGroup
On television, older Americans look healthy. We see them in commercials riding bicycles, jogging and playing basketball with their grandchildren. Sometimes they’re even surfing.
The doctor’s office tells a different story.
Dana E. King, MD, a family physician at the Sleeth Family Medicine Center, said he’s seeing an increasing burden of chronic illnesses such as diabetes obesity and hypertension in younger, baby boom-aged patients.
King, who is also chair of the Department of Family Medicine at West Virginia School of Medicine, and his colleagues put his observation to the test: Were baby boomers sicker than previous generations? After all, medical technology has advanced, more medications are available, and Americans, on average, are living about 4 years longer than they were in 1980. One might think they’d be healthier.
Turns out that baby boomers, the 78 million Americans born from 1946 through 1964, were more chronically ill, more disabled and had lower self-rated health than the previous generation did at the same age, according to their study, published in JAMA Internal Medicine. More than half of baby boomers reported no regular physical activity.
As King put it, “You are living longer, but you are living longer with disability. You are walking with a cane or living with stents in your chest.”
The new procedures and medications, King said, are helping baby boomers live longer but sicker lives.
In 2011, Medicare spending on patients with two or more chronic conditions made up 93 percent of all program costs, and nearly all of the growth in spending since the late 1980s can be tied to patients with five or more chronic conditions. Managing chronic illness and reducing the rise of preventable chronic disease will be crucial to the federal government curbing Medicare’s cost.
From 1999 to 2008, the percentage of Americans who took at least one prescription drug in the month before being surveyed increased from 44 percent to 48 percent, according to a Centers for Disease Control and Prevention briefing. In that time, the use of two or more drugs increased from 25 percent to 31 percent, while U.S. spending for prescription drugs was $234.1 billion, double what it was in 1999.
Baby boomers are also sicker than their parents because of poor lifestyle choices, according to a National Bureau of Economic Research report.
“Behavioral factors, such as physical activity, weight management, and avoidance of smoking, are key to reducing population disability, often related to musculoskeletal impairments,” the report reads. “Unfortunately, these factors, notably physical activity and obesity, are showing hazardous trends, especially among baby boomers.”
King said there needs to be a cultural shift in the public’s attitude toward living a healthy lifestyle.
“Causing that to happen is no small feat, but I think that people that do what actually physicians would recommend are sort of termed ‘health nuts.’ You know? If you jog or walk everyday with your girlfriends, if you’re on a walking club, or if you do water walking three times a week – people makes comments like ‘Well, she’s kind of ehhhh’—No, that’s normal. That should be the norm,” he said.
Baby boomers began reaching Medicare age in 2011, and there are tens of thousands more on the way.
“It stands to reason,” King said, “that there is going to be a tremendous pressure on Medicare spending.”
Medicare Policy Progresses Slowly
The Centers for Medicare & Medicaid Services has begun adopting policies to manage chronic care, but some experts believe it could go faster and further.
The Affordable Care Act (ACA), President Obama’s still controversial health care law, established a prevention and public health trust fund of $15 billion. In September 2010, the federal government extended a host of preventive measures, like screening for cholesterol and diabetes, to Medicare beneficiaries without any co-payment, and it required private insurers to do the same.
The ACA also offered incentives to get providers to participate in several pilot projects that focus on care coordination and better management of chronic illness, including the Independence at Home demonstration project, Accountable Care Organizations (ACOs) and a transitional care program.
Although the results aren’t in, the federal government has said the new projects, all of which are housed under the Center for Medicare & Medicaid Innovation, will reduce health care costs and increase quality.
Providers who participate in the programs must meet certain guidelines. The ACO shared savings program, for example, requires the 259 participating ACOs to meet 33 measures in four domains of care (patient/caregiver experience, care coordination/patient safety, preventive health and at-risk population). If they meet their goals and keep costs low, they share in the profits.
Kenneth E. Thorpe, PhD, professor and chair of the Department of Health Policy and Management at Emory University, said that the ACA-mandated pilot projects are a small step in the right direction, but there are many proven successes in the Medicare Advantage (MA) program that Traditional Medicare has yet to adopt.
“In short, we need to scale and replicate interventions where the evidence demonstrates improved quality and reduced costs throughout the Medicare program,” he wrote in a December 2012 research paper.
In part, MA insurers, many of whom are heavyweights in the health care insurance industry, are able to try new programs because the federal government pays additional sums so that the plans can offer more comprehensive benefits. The subsidies have been reduced and will continue to be for several years, but MA enrollment, despite the predictions of many experts, has continued to grow. More than 27 percent of Medicare beneficiaries are enrolled in MA plans.
One successful MA program, Thorpe said, is the Comprehensive Medication Therapy Management program. Here, a pharmacist makes sure patients are taking the right dose, filling prescriptions on time and taking it on a prescribed basis.
The Diabetes Prevention Program, another cost-effective measure to come out of MA plans, is aimed at preventing diabetes in overweight, pre-diabetic adults on a one-on-one basis. This is what experts call a “lifestyle intervention,” and it is not covered by Traditional Medicare.
And it’s been proven successful: A large-scale randomized trial of the program found that it reduced the prevalence of diabetes, the fifth leading cause of death in America, by 58 percent as compared to a placebo. It also led to weight loss. The biggest improvements for both were found in participants age 60 and older.
When the Y (formerly the YMCA) implemented the program in a group setting, it resulted in a major reduction in health care costs. If Medicare enrolled a cohort of overweight, non-diabetic seniors, it could generate a net savings of $2 billion over 10 years, Thorpe said.
Provider Tries to Make Health Care Affordable, Accountable
Christopher Chen, MD, a cardiologist, has a theory about hospital admissions for heart failure: They don’t need to happen.
“If I could get my patients to take their medications and not load up with tons of salt and also, to call and access us when they feel short of breath or feel fluid overload, so we can start to adjust the medications, we think, theoretically, we should be able to prevent every single non-acute heart failure admission,” he said.
Chen is the CEO of Chen Medical, an integrated primary care medical practice originally launched in Miami, Fla., more than 25 years ago. The company, which serves low-to-moderate-income seniors, now operates more than 13 medical centers across the southeast United States.
The company’s health care delivery model resulted in hospital stays that are 38 percent shorter than the national average, according to a Chen Medical-authored study published in Health Affairs in early June.
The Chen medical model of care has five major focuses. They:
Chen Medical primarily see patients who have MA for insurance, mainly because MA plans offer benefits, such as transportation and many coordinated care services, that aren’t available in Traditional Medicare, Chen said. Also, MA’s capitated payment model, in which physicians are paid a set amount for each patient they see, eliminates the need to negotiate reimbursement amounts for changes to the delivery system.
When Marva Duhart, 71, a former Miami-Dade County school teacher, started going to Chen Medical in 2010, she had high blood pressure and high cholesterol. Her blood pressure was 210 over 110, which the American Heart Association labels hypertensive crisis, the most severe category. Both are now controlled.
“It’s so normal that sometimes I read it and say, ‘Is this working right?’” she said, laughing. “I feel I should go take it again to make sure it’s right.”
Duhart said she felt that her physician, Dr. Jessica Chen, the daughter-in-law of the company’s founder, took the time to develop a relationship with her.
“I think it’s about looking at the whole patient,” Duhart said. “You’re not just your [blood] pressure. You are the other conditions in your body and you are your exercise.”
The older Chen said scaling down Chen Medical’s culture will be very difficult if Medicare’s current fee-for-service payment system doesn’t change. Chen said he views many providers who participate in ACOs have a schizophrenic mentality. They are trying to become an ACO while keeping a fee-for-service mentality.
“They just don’t mix,” he said. “There’s an expectation they’re trying to change their philosophy of care and change the future, and that’s something that has been very deep.”
“[Our system] ends up paying significant dividends, in the form of better outcomes,” he said.
“You significantly can reduce catastrophic admissions or catastrophic events, and those catastrophic events are oftentimes extraordinarily expensive, so we now have created a situation in that everybody is aligned. Our patients want to do better, and our doctors want to do better. That’s how we save money.”
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