1. 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

2. 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

3. Epidemiology of Aging

4. The Disability Problem

5. 75% of Medicare’s funds are expended on 10% of its beneficiaries (those with chronic conditions)

6. Chronic conditions lead to: Functional impairment Disrupted roles and relationships Discomfort Loss of time and money Depression Poor quality of life Premature mortality

7. 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

8. 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

9. 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

10. Effectiveness of Self-Management Randomized clinical trial Function General health, energy Hospital days Costs –Lorig et al. Med Care 1999

11. 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

12. Effectiveness of ACE Units Randomized trial Satisfaction Function LOS (= costs) –Landefeld et al. NEJM 1995 –Covinski et al. J Am Geriatr Soc 1997

13. Effectiveness of Traditional Home Care Functional ability Satisfaction Use of hospitals Use of outpatient care Use of NHs Mortality Total costs none slight increase slight decrease 15% increase –No effects are statistically significant @ p < 0.05 –Hedrick et al. HSR 1986

14. Cost-Effective Home Care Sick, disabled older people Physician-led interdisciplinary teams Regular patient care conferences Operational efficiencies

15. 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

16. 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

17. The available evidence suggests that these innovations will: Improve satisfaction Improve function Possibly reduce some costs for insurers

18. Model of Senior Care Proactive primary care team Activated person, family IHC ACE Group Care GEM Disease Mgmt. NH Self- mgmt Trans. Care Home hosp. HEP

19. Requirements Information systems Professional education Quality improvement systems Aligned incentives Investment in innovation

20. Who Will Pay Medicare? Employers? Individuals?

21. Economic Status of Retiring Baby Boomers Greater income and net worth than parents “Haves” and “have nots” Demographic differences

22. 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

23. The Choice Two-tiered health care, or (Intra-generational) subsidy for the have nots