Caring for the Elderly

Older Americans consume more health services and account for a large percent of health spending.  A Dartmouth Atlas report gives statistics and trends in regard to health care for the elderly.  (Dartmouth Report)  As is usually the case with Dartmouth work, this one spends much of its analysis looking at variation in care patterns, primarily using Medicare fee-f0r-service data.  The scale of the problem is seen in the basic population numbers; there were 43 million people over 65 in 2012, there will be 84 million in 2050; 19.2 million were over 75 in 2012, or 6% of the population and 5.8 million were over 85.  About 1.3 million of these Medicare-eligible persons were nursing home residents in 2012, actually down from earlier years, likely because there are more assisted-living and other housing alternatives to nursing homes.  About 10 million are covered by both Medicare and Medicaid, including half of the nursing home residents.

The report uses the concept of “contact days” as one measure to describe health care use by the elderly, with a contact day being any one on which a person had some interaction with the health system.  The average Medicare recipient has 17 contact days, but there is wide geographic variation across hospital referral regions, from 25 days to 10.2.  Primary care is believed to be important in the coordination of care and 57% of Medicare beneficiaries have a primary care doctor as their main provider, but again, the variation is significant, from 43% to 73%.  Beneficiaries see an average of 3.4 clinicians a year and spend an average of 4.6 days in an inpatient setting.  There is also variation in these numbers, but it is important to remember that there also is great variation in the number of older Medicare patients in different regions, especially Florida and Arizona, and these older patients use much more of all services.  One surprising statistic is that only 10.7% of all beneficiaries receive their free annual wellness visit in a year.

The report next details areas, where, according to supposed consensus guidelines, delivery of care to the elderly is and isn’t progressing.  The authors believe there is still too much prostate and breast cancer screening, too much use of feeding tubes in patients with dementia, too many late referrals to hospice, which limit the ability of that setting to improve end-of-life care and too many ICU days near the end-of-life.  Areas of progress include less use of high-risk meds, although opportunities remain to improve management of medication for chronic disease patients with multiple drugs; diabetes testing, preventable hospitalizations and reduction of hospital readmissions.  Finally the report notes that dementia and associated comorbidities is a particular challenge both in terms of spending and delivering effective and efficient care.