Medical Device Daily Washington Editor
As administrators at the Centers for Medicare & Medicaid Services work to rein in spending, various stakeholders continue to offer evidence that while there is no free lunch, the budget lunch sometimes is a worse deal than going with something pricier than the blue plate special. A recent report on the functioning of Medicare enrollees by the Center for Demographic Studies at Duke University (Durham, North Carolina) suggests that investments in long-term care eventually save the taxpayer a dollar or two, a notion that echoes an earlier, privately funded study on power wheelchair use (Medical Device Daily, Nov. 9, 2006).
On the other hand, the growing numbers of the “older old“ — and the impact that 79 million Baby Boomers will have on this population — demand that improvements in the status of the disabled be sustained to keep the federal ledger in balance.
Kenneth Manton, PhD, director of research at the Center for Demographic Studies, and the rest of the team reviewed data obtained in the National Long-Term Care Survey (NLTCS) documented that the percentage of Medicare eligibles who were disabled fell to 19% in 2004/05 from 22.5% in 1982, the first year of data available for the analysis. Those with one disability only dropped from 5.7% in that first year to 2.4% in the final year, and those who were institutionalized due to their disabilities fell from 7.5% to 4% during that same time span.
The definition of disability is based on “the difficulty of performing both activities of daily living,“ which includes basic personal care such as eating, grooming and bathing, and so-called instrumental activities of daily living, a list that includes meal preparation and budget maintenance.
When broken down by age, the ratio of the disabled between the ages of 65 and 74 fell from 14.2% in 1982 to 8.1% in 2004/05. For those aged 75-84, those numbers went from 20.7% to 11.9% and for those older than 85, the disability drop was from 62.1% to 49.7%.
The authors noted, however, that if federal healthcare expenditures are to “decline at the projected rate because of a per annum decline of 1.5% in chronic disability, future disability declines will have to occur at increasingly older ages.“ This improvement in those above the age of 85 “must occur to maintain the current rate of improvement in the fiscal status of Medicare and Medicaid to 2050, the year by which the last of the post-World War II“ cohort has reached that age.
The article noted that the “rate of decline in chronic disability prevalence accelerates from 1982 to 2004/2005, starting at 0.6% per annum in 1982-1984 and increasing to almost four times that level (2.2%) by 1999-2004/2005.“ The authors stated a correlation with “a change in the management of severely disabled persons, especially in long-term institutional care.“ Prior to the 1980s, institutional long-term care was “primarily conceived of as residential and housing services and maintenance care, which was not well developed medically or for rehabilitation.“ Among subsequent institutional changes were the push from acute-care hospitals to skilled nursing facilities (SNFs) and the increased use of post-acute care due to the 100-day limit on Medicare payment for SNFs.
While the authors are reluctant to project the impact of the recent increases to the NIH budget, from slightly more than $10 billion in 2003 to a projected $28 billion in 2007, on disabilities in those aged 65 and older, they nonetheless comment that “investments in biomedical research and the production of innovative and more effective therapeutic and preventive medical care are possible explanations,“ as are “behavioral risk factor changes such as smoking cessation and moderation of alcohol consumption.“
The impact of all this on the budget for Medicare and Medicaid is of no small consequence. The article put the potential savings at $73 billion, “or 17% of all Medicare expenditures expected for the elderly ... if declines in chronic disability prevalence continue at their 1982-1999 rate.“
Manto told Medical Device Daily that cardiovascular and cerebrovascular diseases are most closely tied to the observed drop in disability. “The biggest source of the decline in cardiovascular disease is reductions in disease risk and treatment after the event occurs,“ he stated. On the other side of the coin sits a series of neurological disorders, such as Alzheimer's disease. However, the prevalence of Alzheimer's and other neurological condions is somewhat linked to other elements of health status.
Alzheimer's has “a lot of circulatory disease underlying it,“ Manto remarked, and by some projections, the prevalence numbers “get huge.“ However, he insisted that “[t]he numbers are not as overwhelming as they're sometimes portrayed,“ adding that some Americans are fearful that they will inevitably succumb to Alzheimer's. He said such fears are somewhat overblown.
Getting after disabilities in the extremely elderly sounds particularly difficult, a notion Manto did not refute. On the other hand, early intervention makes a difference here, too. “If you reduce disability in the “young old, it cuts down on disability in the older old,“ Manto said.
“The relative rate of improvement has been higher in those 80 and older,“ he observed, but Manto said that the link between disease and age-related decline is blurry. “A lot of what we see is identifiable as disease syndromes that are separate from the other thing that we call senescence,“ but there is some interplay, often leading to a chicken-or-egg dilemma where differential diagnoses are concerned.
As for the Woodstock crowd that partied heartily with substances that were much less popular or even unavailable prior to the Sixties, Manto said that the effects of drug abuse on the prevalence of cognitive disability are difficult to pin down. “I don't know that it comes through in the numbers, but I'm sure that's a factor in a small percentage of people,“ he said.
“I have a feeling that recreational drug use is a bit like alcohol consumption in that other problems go along with it, and it's not clear that your life expectancy will be as high.“