Retooling for an Aging America Building the Health Care Workforce (2008) / Chapter Skim
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2 Health Status and Health Care Service Utilization
2 Health Status and Health Care Service Utilization
Pages 39-74
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From page 39... ...
Older adults also vary in their demographic characteristics, which leads to differences in their demand for and utilization of health services. Projections of the uti lization of health and long-term care services often suffer from important methodological limitations, but all projections indicate that the demand for services for older adults will rise substantially in the coming decades, which will put increasing pressure on Medicare and Medicaid budgets and on the capacity of the health care workforce to deliver those services.
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From page 40... ...
Although it is difficult to predict with accuracy the number and types of health services that will be demanded by older adults, it is clear that the total volume of health and long-term care services needed in the future will be much greater than the volume provided today. The chapter concludes with a brief discussion of the implications of these projections.
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From page 41... ...
Her course has been punctuated by recurrent complications of immobility including pressure sores, contractures, and recurrent pneumonias. She sees her primary care physician every 2 months but also has several emergency department visits per year, occasional hospitaliza tions, and periodic care from home health for wound care.
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From page 42... ...
. An analysis of Medicare expenditures shows that the 20 percent of Medicare beneficiaries with five or more chronic conditions account for two-thirds of Medicare spending (Partnership for Solutions National Program Office, 2004)
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From page 43... ...
Approximately 6.5 percent of older adults live in a long-term care facility. The majority, approximately 1.45 million, live in nursing homes, and approximately 750,000 live in other residential-care settings that provide some long-term care services (Spillman and Black, 2006)
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From page 44... ...
. On average, older adults living in nursing homes and residential care facilities tend to have more severe disabilities than older adults living in their own private homes, although more disabled older adults live in the community than in long-term care settings.
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From page 45... ...
People with depressive symptoms often experience higher rates of physical illness, health care utilization, disability, and an increased need for long-term care services (Federal Interagency Forum on Aging Related Statistics, 2006; Ormel et al., 2002)
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From page 46... ...
Older adults also receive a considerable amount of ambulatory care at hospital outpatient departments. Older adults accounted for more than 13 million visits to hospital outpatient departments in 2004, not including visits to emergency departments (EDs)
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From page 47... ...
. Forty-two percent of older adults receive some post-acute care services after discharge from the hospital.
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From page 48... ...
Long-term care services include health and personal services provided to chronically disabled persons over an extended period of time. Estimating the total amount of long-term care services received by older adults is difficult because utilization data are not often collected in a consistent manner across settings or care providers.
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From page 49... ...
, but that number rose dramatically for individuals with greater numbers of chronic conditions. On average, enrollees with three or four chronic conditions filled an average of 44 prescriptions per year, and those with five or more filled 60 prescriptions per year (Federal Interagency Forum on Aging Related Statistics, 2006)
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From page 50... ...
. Despite their less frequent use of many acute-care services, African Americans tend to use nursing homes at higher rates than white older adults, reversing a historical trend (NCHS, 2007)
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From page 51... ...
. Among older adults who require medical attention, wealthier individuals are more likely to use health care services than are lower-income individuals (Chen and Escarce, 2004)
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From page 52... ...
During that time, a number of factors are likely to alter the future health status and patterns of utilization among older adults, making projections of health status and utilization uncertain. As discussed previously, health status and utilization patterns vary according to certain demographic characteristics, and the future older adult population will look somewhat different from today's older adults (Box 2-2)
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From page 53... ...
have the highest per capita utilization of health services, and that population is expected to increase from 5 million to 9 million between 2005 and 2030. Other demographic characteristics, such as net worth, family structure, and geographic distribution, may similarly affect health status and the utilization of services.
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From page 54... ...
The VHA has a remarkable history regarding the availability of a variety of geriatric care programs, including nursing home care, home care, palliative care, and acute care services for older adults; however, an influx of older veterans will surely strain this well-developed system. Finally, members of the future older adult population may bring a different stock of health capital to their older years than the current cohort of older adults has done.
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From page 55... ...
Still, even if disability rates among older adults continue to decline, the size of the future older adult population is so large that, overall, the total need for services can be expected to increase (Johnson et al., 2007)
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From page 56... ...
Additionally, more or different options for care may offer better matches to patient preferences. For example, an increase in the availability of assisted-living options may result in fewer older adults living in nursing homes (Stone, 2000)
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From page 57... ...
For example, projections include the following: • The need for critical care services will rise, increasing the need for intensivists from 1,880 in 2000 to 2,600 by 2020 if current pat terns of care continue. If utilization of critical-care physicians rises by one-third (which is, some suggest, a more appropriate level of use)
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From page 58... ...
The committee identified only a few efforts that provide projections of the future health status and health services utilization specifically for older adults. Three of those efforts are highlighted in the next section: RAND's Future Elderly Model is designed to develop projections of disability and chronic disease and the use of acute care services; the Lewin Group's Long-Term Care Financing Model projects the use of long-term care and expenditures; and the Urban Institute's DYNASIM3, coupled with data from the Health and Retirement Study, produces projections for disability and paid and unpaid long-term care.
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From page 59... ...
. Baseline projections assume improvement in the mortality rate of 1.2 percent per year and a 2 percent increase in obesity from 2004 to 2028, with a 0.5 percent increase thereafter. Results indicate a rise in the prevalence of many chronic conditions (e.g., high blood pressure, heart disease, diabetes, cancer, stroke)
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From page 60... ...
60 RETOOLING FOR AN AGING AMERICA Obesity Reduction Baseline Smoking Cessation 82 ADL3+ 78 71 65 Diabetes 53 37 ADL12 30 28 HBP Heart 25 23 18 19 Stroke 15 13 13 Cancer 10 10 10 5 0 -5 Lung -8 -17 FIGURE 2-1 Percentage change in prevalence for various conditions projected for 2004-2050 under three scenarios: baseline, assuming obesity reductions, and assum ing smoking cessation. SOURCE: Girosi, 2007.
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From page 61... ...
Quit Smoking Scenario (%) Percent Demographic Health Percent Demographic Health Change Effect Effect Change Effect Effect Office visits 155 95 5 160 85 15 Hospital days 155 100 0 170 90 10 Hospital stays 155 100 0 170 90 10 Total 170 90 10 180 80 20 expenditures SOURCE: Girosi, 2007.
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From page 62... ...
Second, data from the Health and Retirement Study were used to develop models for the provision of paid and unpaid long-term care services as a function of disability, financial resources, children's availability, and other factors. Finally, three different disability projection scenarios are used to project future long-term care services.
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From page 63... ...
The intermediate scenario, or the researchers' "best guess," assumes no particular future trend in disability rates; the variations in rates are small and depend on changing mortality rates and changes in the demographic characteristics of the population. The high scenario assumes that the older adult disability rate would increase by 0.6 percent per year from 2000 to 2014 and remain constant thereafter, similar to the rate of increase used in RAND's future elderly model.
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From page 64... ...
. Limitations of Projections The projections presented above are helpful in providing a general idea of the possible future health needs and health services utilization of older 70 57.2 60 53.8 50 2000 39.1 37.9 Percent 40 2040 27.8 30 25.5 23.9 22.2 20 12.3 12.9 10 0 Any unpaid Unpaid Unpaid Paid home Nursing help help from help from care home care children other sources FIGURE 2-2 Percentage of older adults with disability receiving long-term care services, intermediate disability scenario, 2000 and 2040.
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From page 65... ...
Although the Health Retirement Survey, the National Long-Term Care Survey, the Current Medicare Beneficiary Survey, and the National Health Interview Survey provide some limited data on geriatric syndromes, the simulation models often do not examine that data. Also, national surveys and datasets provide comprehensive information on physician visits and hospital stays but not on visits to other types of providers who deliver significant amounts of care services.
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From page 66... ...
Many older adults live their extra years with higher rates of chronic health conditions that require vigilant care on the part of their health providers. As a result, older adults account for a disproportionate amount of the health care services delivered in the United States.
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From page 67... ...
New models of care have been developed to improve the financing and organization of health care services for older adults. These models have a variety of implications for the workforce with respect to individual roles and responsibilities, scopes of practice, and payment rates.
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From page 68... ...
2007. The future healthcare workforce for older Americans: Rural recruitment and retention.
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From page 69... ...
2007. 2007 annual report of the boards of trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance trust funds.
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From page 70... ...
2007. Projected use of long-term-care services by enrolled veterans.
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From page 71... ...
2006. National hospital ambulatory medical care survey: 2004 emergency department summary.
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From page 72... ...
Home Health Care Services Quarterly 22(3)
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From page 73... ...
Presentation at Meeting of the Committee on the Future Health Care Workforce for Older Americans, Washington, D.C. March 27, 2007.
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