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.
*
Top Related