health care & the elderly: myths, misperceptions, & dangers

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HEALTH CARE & THE ELDERLY: MYTHS, MISPERCEPTIONS, & DANGERS. U.S. Demographic Trends & Health Care Costs in Perspective Dave Kingsley, PhD. Aging &Health Care Cost: The Issues. Increasing 65+ population Increase in life expectancy Cost increase as a function of age - PowerPoint PPT Presentation

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University of Kansas Medical Center

HEALTH CARE & THE ELDERLY: MYTHS, MISPERCEPTIONS, & DANGERS
U.S. Demographic Trends & Health Care Costs in Perspective Dave Kingsley, PhD

Aging &Health Care Cost: The Issues
Increasing 65+ populationIncrease in life expectancyCost increase as a function of ageEnd of life care: intensive care servicesNatural history of chronic diseaseCritical analysis: logic, statistics, scientific method

To Which Group Are We Devoting Our Health Care Dollars?
Are we favoring one group over another group?

Are we blaming any particular group for health care cost inflation? What is the narrative concerning health care reform and cost containment? Is the predominant narrative framed in such a manner as to divert our attention from real causes?

What is the media saying versus policy and medical research?

Should the narrative be of major concern to bioethicists?


PROPAGANDA & SCIENCE: LYSENKO

WHAT DOES THE DATA & LITERATURE & PROFESSIONALS SAY?
Data: Agency for Healthcare Research & Quality (AHRQ) Health Cost & Utilization Project Database Bureau of the Census: Life tables, 2010 Census Data & Other Sources Lit Review: Medical Journals, Government Reports, Monographs/Books, Working Papers Interviews

HP&M 873: Research Project Medical Colleague
Michael Waxman, MDMedical Director, Medical Surgical ICU, Research Medical Center, Kansas City, MOClinical Assistant Professor, Kansas University Medical CenterClinical Associate Professor of Medicine, University of Missouri, Kansas CityPrivate Practice, Kansas City Pulmonary PracticeMedical Director, Kindred LTAC Hospital

Our World
If all humanity disappeared, would there still be a world?

No.

There would be no one to call it a world.

Our world is socially constructed.


The Narrative
When you accept a particular narrative, you ignore or hide realities that contradict it. George Lakoff (2009), The Political Mind. New York: Penguin Books, p. 37 The narrative is a story about our World. Composed of frames Narratives consist of sub-narratives Include symbols, metaphors, allegories, myths, misinformation, and emotion (think entitlement).

Sunrises, Sunsets, Unicorns, Welfare Queens, & Baby Boomers: The Fallacy of Reification

Reification & Mental Errors
our tendency to convert abstract concepts into entities. Steven J. Gould (1981), The Mismeasure of Man. New York: W.W. Norton & Co.Other related fallacies and mental errors: fallacy of composition fallacy of division failure to disaggregate & control for other variables (e.g., Simpsons Paradox) Over-generalization Salience & failure to consider background info Ascribing the average as a characteristic to all observations Examples of reification: IQ, The Greatest Generation, Baby Boomer, The Dumbest Generation, Millennials, & Teen Drivers

Ageism
systematic stereotyping of and discrimination against people because they are old (Butler, 1969) Microlevel: ageist predispositions shared by a community are likely to be organized into a coherent set of cognitions and practices that are verbalized and reinforced in social contexts. (Braithwaite, Reducing Ageism in Nelson, 2004, p. 311) In the absence of resistance, ageism inevitably frames the ways in which policymakers think and shapes policy design.

Greedy Geezer Sub-Narrative
Ive got mine, good luck getting yours. James Surowiecki Greedy Geezers, New Yorker, November 22, 2010

SILVER TSUNAMI
This metaphor leads the public to believe that Baby Boomers will hit the health care system in one big wave. The implications: Elderly a threat Elderly a burden The shift in population demographics:

65+ will increase from 13% proportion of total population to 21% by 2035, and will stabilize at that level

Stereotyping & Blaming Elderly In the Mainstream Media:
David Brooks, New York Times columnist, regular guest on PBS News Hour, & NPR commentator Far from serving the young, the old are taking from them. First, they are taking money. Second, they are taking freedom. Third, they are taking opportunity. February 2, 2010, NYT column entitled The Geezers Crusade:

INVIDEOUS COMPARISON BETWEEN GENERATIONS
Our parents were the Greatest Generation, and they earned that title by making enormous sacrifices and investments to build us a world of abundance. My generation, The Baby Boomers, turned out to be The Grasshopper Generation. Weve eaten through all that abundance like hungry locusts. *Thomas L. Friedman, Root Canal Politics, The New York Times Op-Ed, October 25, 2010

BLAMING AND FOMENTING INTER-GENERATION CONFLICT
If anyone should be complaining about deficits, it should be the 20-somethings who will have to pay for all those meds-popping boomers moving into the comfort of Medicare and Social Security. Timothy Egan, Save Us, Millennials, The New York Times Op-Ed, June 4, 2010

Letter to The Editor re: Grasshoppers
Thomas L. Friedman is right. The Greatest Generation built the most prosperous society in history with its blood, sweat and tears, giving its children a tremendous head start. How have responded? By consuming our way to insolvency. And now were robbing future taxpayers of wealth that has yet to be produced. The Grasshopper Generation may be too kind a term for us boomers. Even Grasshoppers dont eat their young. Michael Smith, Cynthiana, KY, Letter to the Editor, New York Times, May 10, 2010

Misinformation Supporting Ageism
Ross Douthat, New York Times columnist As the population ages by 2030, there will be more Americans over 65 than under 18 the power of the elderly may become almost absolute. August 17, 2009, NYT column entitled Telling Grandma No:

The Mantra: Typical Opinion in Reporting
After decades of warnings that budgetary profligacy, escalating health care costs and an aging population would lead to a day of fiscal reckoning, economists and the nations foreign creditors say . He [Senator Bayh] is hardly alone in sounding an alarm about the long-term budgetary outlook, which has Medicare, Medicaid, and Social Security Costs growing at unsustainable rates . NYT, February 10, 2010 front page, above the fold: Party Gridlock Feeds New Fear of a Debt Crisis

Even Health Care Experts Inadvertently Oversimplify & Distort the Picture
Utilization of services increases with age, as physical and mental health deteriorates and chronic conditions progress.

P. L. Barton (2010) Understanding the U.S. Health Services System. Chicago, IL: Foundation of the American College of Health Care Executives:

WHAT HEALTH CARE PROFESSIONALS & STUDENTS BELIEVE

The Elderly As A Threat & Burden

Today, Focus Will be Primarily on Age as It Impacts Acute Care Costs
Demographics of Age in Perspective a. Current configuration of U.S. population b. Trends: 1946 2050 Diseases: Treatment & Costs in Hospitals a. Diagnoses & procedures & cost by 5-year age categories

Health Care Costs & Demographics: Objectivity In the Conversation
Demography The study of populations Epidemiology The study of diseases in populations Health Care Finance Research The Study of Costs in various facets of the Health Care System

Why Is This Discussion Important?
Stereotyping age groups: Ageism Blaming & Scapegoating: A result of ageism Discrimination: A result of ageism & scapegoating We need a reasonable rational discussion to address the real issues in health care

Pig Through A Python Metaphor: Is This Baby Boomer Reality?

POPULATION GROWTH
The 65+ population currently accounts for 13% of the total U.S. population The 65+ population will gradually increase to 21% of the U.S. population by 2035 this is a gradual 25 year increase, not a tsunami This growth is manageable while other health cost drivers, as they are now, will not be.

U.S. POPULATION TREND 1950 - 2050

WILL MOST OF THE ABSOLUTE GROWTH BE IN THE 65+ AGE GROUP?
NO AN AGING POPULATION IS A CRISIS FOR A CAPITALIST ECONOMIC SYSTEM THE U.S. WILL NOT HAVE AN AGING CRISIS (Japan, Germany, & Italy have an aging crisis) THE CHILD (0 18) POPULATION HAS BEEN GROWING STEADILY SINCE 1986

AGE & POPULATION GROWTH

20102050GROWTH (MILLIONS)% GROWTH% OF TOTAL GROWTHAGE CATEGORYPOP (MILLIONS)%POP%0 TO 187524.510123.1426.33520.418 TO 6519462.824956.6954.12842.065+4013.08820.1748.312037.585+62.0194.0013.223110.0TOTAL310100.043912842%

The Children
The baby boom commenced in 1946The child population was 47 million in 1950The baby boom peaked in 1964 at 70 millionA baby dip (not bust) occurred between 1968 and 1986 (bottomed at 64 million)A baby resurgence (not echo or boomlet) began in 1986Reached 70 million in 1996Currently 75 millionWill reach 101 million in 2050

GROWTH BELIES AGING POPULATION PERCEPTIONS
U.S. POPULATION 2010312,000,000 2020341,000,000 2030373,000,000 2040405,000,000 2050439,000,000

Acute Care Costs & Aging
This portion of the presentation focuses on hospital charges as they relate to age categories. The question is: Is aging the cause of past and future escalation in the cost of treating disease? What is the significance of the demeaning phrase (metaphor if you will) unplugging granny?

Primary Sources for Cost & Aging
NIH: Agency for Health Quality & Research (AHRQ or ARK) Analysis of HCUP (Health Cost & Utilization Project) databases 20% sample of hospital admissions & discharges in U.S. Approximately 8 million cases in 2007 (latest year) Triangulation of Statistical Analysis Medical Journals Scholarly Monographs & Textbooks Investigative Journalism Media in general Government Agencies: Bureau of Census, CDC, etc.

ANALYZING HEALTH CARE DATA CAN BE TRICKY
Flaw of Averages: Cost data is highly skewed Geometric Mean (logarithmic transform) The largest group of patients are maternity cases most of which have no complications but many of which have the most expensive complications

Distribution: Length of Stay

DISTRIBUTION: TOTAL CHARGES

THE FLAW OF AVERAGES
Average Hospital Charge for 65+ = $23,400 Average Hospital Charge for under age 65 = $17,335 Is it fallacious to dichotomize average hospital charges in this manner?

Exposing Aggregation Fallacies
AVERAGE CHARGES BY 10 YR AGE CAT: 40 TO 49: $19,706 50 TO 59: $23,372 60 TO 69: $25,581 70 TO 79: $24,470 80 TO 89: $22,024 90+ :$18,516

Admissions & Discharges By Age Categories (5 Year Categories)

Hospital Charges And Age Are Not Linear: 2003

AGE & CHARGES - 2009

Age 67 & +2 SD: Primary Diagnoses & Procedures
Heart Disease: 25%Septicemia: 10%Respiratory Failure: 6%Back Disorders: 5%Complication of Device, Implant, Graft, Surgery: 8%Diabetes: 2%Lung Cancer: 1%Pneumonia: 3%
Heart Surgery: 30%Spinal Fusion: 7%Intubation & Ventilation: 10%Tracheostomy: 4%Other OR Procedures on Vessels Other than Head & Neck: 4%Colorectal Resection: 3%Blood Transfusion: 2%

PERCENT OF CHARGES ABOVE $200,000 BY 5 YEAR AGE CATEGORIES

PERCENT OF CHARGES ABOVE $500,000 BY FIVE YEAR AGE CATEGORIES

PERCENT OF CHARGES ABOVE $1 MILLION BY FIVE YEAR AGE CATEGORIES

PAYOR FOR $500,000+ & AGE LESS THAN 5

PAYOR FOR $1,000,000+ & AGE LESS THAN 5

HEAD & NECK CANCER AGE

Where Health Care Dollars Go**P. L. Barton (2010) Understanding the U.S. Health Services System. Chicago, IL: Foundation of the American College of Health Care Executives

Ignoring Gorillas In Our Midst (Metaphorically Speaking)

Medical Technology: The 2000 pound Gorilla in the Room
Health Affairs, Vol 27(5):Special Issue, November/December 2008:GenomicsPharmaceuticalsMedical Devices Implants/Transplants Medical Imaging A CBO Paper, January 2008: Technological Change and the Growth of Health Care Spending. Revascularization Renal Replacement Therapy Bone Marrow Transpl NICU Joint Replacement Diagnostic Imaging

The Impact of Aging on Health Care Costs (CBO Report On Technology, 2008)
Aging of the Population: the contribution of the an aging population to the growth over the long term is smaller than is commonly perceived. The elderly fraction of the population grew during the past four decades, but the growth was too gradual and insubstantial to account for much of the increase in per capita spending. Page 8

HEALTH CARE COST DRIVERS
Studies Estimating Contributions of Selected Drivers Drivers of Cost TrendSmith, Heffler, & Cutler Newhouse Freedland (2000) (1995) (1992) % % % Aging of the population 2 2 2 Changes in 3rd Party Pay 10 13 10 Personal Income Growth 11 18 5 65

Factors Explaining the Trends in Health Expenditures*
Major influence Technological Change_______________________________________________________Important Influence Growth of health insurance and decline in cost sharing Income Growth________________________________________________________Minor Influence Lagging productivity in health services

Aging of the population

Administrative ExpensesZukerman & McFeeters, page 4


U.S. FEDERAL BUDGET

U.S. FEDERAL SPENDING

Intubation & Ventilation (PRCCS1 216)
Unplugging Granny?
Are elderly patients more likely to be on life support than younger patients? Death panels President Obama: This is not about pulling the plug on granny.

WHO IS PLUGGED IN?

NEONATAL INTENSIVE CARE UNIT

Why Are Our Babies Dying?
Childbirth & Neonatal Care
Only twenty years ago babies weighing under 750 grams less than two pounds rarely survived. In Syracuse during 2000-2001, among babies of twenty-three weeks or greater gestation and less than 750 grams, nearly three quarters left the NICU . Sandra Lane (2010), Why Our Babies Are Dying. Boulder, CO: Paradigm Publishers, page 65.

Medical Imaging
Imaging costs among Medicare beneficiaries with cancer increased from 1999 through 2006, outpacing the rate of increase in total costs among Medicare beneficiaries. Dinan, et al. (2010), Changes in the Use and Costs of Diagnostic Imaging Among Medicare Beneficiaries With Cancer, 1999-2006, JAMA, 303(16), pp. 1625-1631 Entrepreneurial Activity Among PhysiciansDefensive MedicinePower of Patients to Demand More Tests Inglehart, J. (2006), The New Era of Medical Imaging Progress & Pitfalls, NEJM, 354(26), pp. 2822-2828

Transplants & Implants
Bone Marrow Transplant: Average Age = 45 Average Charge =$151,206

Kidney Transplant: Average Age = 48 Average Charge=$133,039 Heart Transplant: Upper Age Limit=55 Average Charge=$330,000 Overall Average Hospital Charge 2007 = $13,545

Medical Industrial Complex: 4000 lb Gorilla
Hospital Chains

HMOs

Insurance Industry

Pharmaceutical Industry

Medical Device & Equipment Manufacturers American Medical Association Financial Services Sector U.S. Congress

The Corporate Transformation of Medicine
This new medical-industrial complex may be more efficient than its nonprofit competition, but it creates the problems of overuse and fragmentation of technology, and cream-skimming, and it may also exercise undue influence on national health policy. Relman, A. (1980), The new medical-industrial complex. New England Journal of Medicine, 303: pp. 963-70.

COMMODITY OR PATIENT
Commodity: 1. a: CONVENIENCE, ADVANTAGE b: something valuable or useful, 2: an economic good: as a: a product of agriculture or mining b: an article of commerce Websters New Collegiate Dictionary commodity (k-md-t) n. pl. commodities 1. Something useful that can be turned to commercial or other advantage: "Left-handed, power-hitting third basemen are a rare commodity in the big leagues" (Steve Guiremand).2. An article of trade or commerce, especially an agricultural or mining product that can be processed and resold.3. Advantage; benefit.4. Obsolete A quantity of goods. http://www.thefreedictionary.com/commodity

Providers, The Free Market & Congress
Need for Congressional Oversight (Some Examples): Drug Prices Relationship Between Medical Device Companies & Physicians Secret Prices: Politics of Physician Preference Items (Lerner, et al. (2008), Health Affairs, 26(6), p. 1560) Senate Bill 2222 (Grassley & Specter, 2006)

Per Capita Cost: U.S. Privatized HC Vs. Govt. Funded, Single Payer HC (2005)*

COUNTRYPER CAPITAPERCENT OF GDPUnited States6,40115.3France3,37411.1Canada3,326 9.8Germany3,28710.7Denmark3,108 9.1Sweden2,918 9.1United Kingdom2,724 8.3Italy2,532 8.9Japan2,426 8.0*Source: CBO & OECD

Last Year of Life Expenditures
Research: Expenditures decrease with increasing age. Levinsky, Wei, Ash, et al (2001) Influence of Age on Medicare Expenditures and Medicare in the Last Year of Life. JAMA, 286, No 11, page 1354 Riley, et al, using 1979 data, made comparable observations (1987) The Use and Costs of Medicare Services by Cause of Death. Inquiry. 24: 233 244

AGGRESSIVE CARE & THE ELDERLY
It appears that both the decreased frequency of hospital admissions and reduced use of aggressive therapy account for most of the decrease in expenditures with age. Levinsky, Wei, Ash, et al (2001) Influence of Age on Medicare Expenditures and Medicare in the Last Year of Life. JAMA, 286, No 11, page 1354

SUPPORT STUDY*
Evaluated the care of seriously ill patients at 5 medical centers (Median age 65) Finding: Older age was associated with higher rates of decisions to withhold aggressive care (after adjusting for prognosis, patient preferences, severity of illness, and prior functional status.) *Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatment. Hamel, M., Teno, J. Goldman, L., et al (1999) Patient Age and Decisions to Withhold Life-Sustaining Treatments from Seriously Ill, Hospitalized Adults. Annals of Internal Medicine, 130: 116 125.

Research Questions (Areas if you will)
How does the quality of life for older persons impact the cost of health care? How can the quality of life be improved for older individuals? How can we reduce infant mortality, pre-term births, and low birth weight?

SUMMARY
The mainstream narrative about health care costs has been reduced to an aging society.The narrative has inflamed ageism, in the form of stereotyping, scapegoating, and discriminating.Aging is not a dominant or even a major factor in health care cost inflation.The narrative should be challenged with an objective debate about the cost factors in a privatized, corporatized, fianancialized health care system.

*