2
Health Status and Health Care Service Utilization

CHAPTER SUMMARY

Older adults use far more health care services than do younger groups. Although older adults vary greatly in terms of health status, the majority of them have at least one chronic condition that requires care. Older adults also vary in their demographic characteristics, which leads to differences in their demand for and utilization of health services. Projections of the utilization 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.

Over the coming decades, the total number of Americans ages 65 and older will increase sharply. As a result, an increasing number of older Americans will be living with illness and disability, and more care providers and resources will be required to meet their needs for health care services. In order to design effective models of care delivery and prepare a health care workforce to serve this future population, one needs to understand both the projected health status of this population and the demand for health services under the current system. Such an understanding will help identify what changes will need to be made in the health care workforce (in terms of its size, distribution, and training) to fulfill its looming charge.

This chapter begins with an overview of the current health status and health services utilization patterns of older adults. Older adults today en-



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2 Health Status and Health Care Service Utilization CHAPTER SUMMARY Older adults use far more health care serices than do younger groups. Although older adults ary greatly in terms of health status, the majority of them hae at least one chronic condition that requires care. Older adults also ary in their demographic characteristics, which leads to differences in their demand for and utilization of health serices. Projections of the uti- lization of health and long-term care serices often suffer from important methodological limitations, but all projections indicate that the demand for serices 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 delier those serices. Over the coming decades, the total number of Americans ages 65 and older will increase sharply. As a result, an increasing number of older Americans will be living with illness and disability, and more care providers and resources will be required to meet their needs for health care services. In order to design effective models of care delivery and prepare a health care workforce to serve this future population, one needs to understand both the projected health status of this population and the demand for health services under the current system. Such an understanding will help identify what changes will need to be made in the health care workforce (in terms of its size, distribution, and training) to fulfill its looming charge. This chapter begins with an overview of the current health status and health services utilization patterns of older adults. Older adults today en- 

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0 RETOOLING FOR AN AGING AMERICA counter a number of health challenges as they age and, on average, use a relatively large volume of health care services. However, the older adult population is quite heterogeneous, with individual members displaying an array of health statuses and needing a variety of services. Box 2-1 presents some hypothetical examples to illustrate the diversity of the current older population by describing several typical older adult profiles. The chapter continues with a review of projections of the future health status and utilization patterns of older adults as well as a description of the assumptions and limitations of those projections. 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. If current patterns continue, the financial and human re- sources required to meet the projected demand for services will be strained well beyond today’s supply. THE HEALTH AND LONG-TERM CARE NEEDS OF OLDER ADULTS The health status of older Americans has improved over the past sev- eral decades (Crimmins, 2004). Older adults today have greater longevity and less chronic disability than did those of previous generations (Federal Interagency Forum on Aging Related Statistics, 2006; Manton et al., 1997, 2007). While these improvements appear to be related in part to declines in smoking rates and better control of blood pressure (Cutler et al., 2007), the causation has not been conclusively proven. Studies also show improve- ments in the reported physical functioning of older adults, such as the ability to lift, carry, walk, and stoop (Freedman et al., 2002), as well as declines in limitations in instrumental activities of daily living (IADLs), such as shopping for groceries, preparing hot meals, using the telephone, taking medications, and managing money. The evidence for declines in limitations in activities of daily living (ADLs), such as eating, bathing, dressing, using the toilet, transferring (such as from bed to chair), and walking across the room is less strong (Freedman et al., 2004a). Finally, the percentage of older adults who self-report their health as “fair” or “poor” has declined (Martin et al., 2007). Despite these improvements, however, older adults still do have high rates of chronic disease and disability, particularly as compared to younger adults (Table 2-1), and disease prevalence has risen as longevity has increased (Crimmins, 2004). It is important to note that if one looks just at aggregate data, such as those on disease prevalence (Table 2-1), it obscures important differences in

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 HEALTH STATUS AND HEALTH CARE SERVICE UTILIZATION BOX 2-1 Typical Profiles of the Older Adult Population Mrs. S is a 75-year-old divorced woman who is retired from her job as an execu- tive secretary and now lives in a retirement community where she plays golf three times a week. She lives without assistance and frequently drives 45 minutes to babysit for her daughter’s children. Mrs. S had breast cancer 20 years ago, which was treated with a mastectomy, and now has hypertension, which is treated with a diuretic. She sees her primary care physician twice a year and her oncologist once a year. Mr. Y is an 82-year old man who lives in an apartment with his wife. He has diabe- tes with peripheral neuropathy, hypertension, coronary artery disease, and chronic obstructive pulmonary disease. He continues to drive and has been assuming many of the instrumental activities of daily living because of his wife’s failing health; she has moderate dementia. Mr. Y sees a primary care physician every three months, a pulmonary specialist twice a year, a cardiologist once a year, and a diabetes educator once a year. He participated in pulmonary rehabilitation fol- lowing a hospitalization for pneumonia 3 months ago. His primary care physician recently gave him the name of a social worker to consult with about possibilities for getting additional support in the home (e.g., a homemaker and an attendant to help bathe and dress his wife) and community-based resources (e.g., adult day health programs, caregiver support). Mrs. M is a 97-year-old woman who has had severe Alzheimer’s disease for 8 years. She recognizes her son and speaks to him, but her speech has no mean- ingful content other than to indicate when she is uncomfortable. Over the past decade she has gotten progressively more immobile, and she stopped walking 3 years ago. She has been cared for at home by her son, who retired to be able to care for his mother. Mrs. M takes no medications. 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. Mr. R is an 88-year-old man who is widowed. His medical problems include heart failure, hypertension, polymyalgia rheumatica, and prostate cancer. He has been living in a nursing home since falling and sustaining a hip fracture 1 year ago. Although he can ambulate with a walker, he is dependent in several activities of daily living. He has a niece who visits approximately once a month. Prior to his relocation to the nursing home, he saw several specialists, but none of them make nursing home visits. His primary care physician sees him every 3 months as well as in between these routine visits when an acute problem arises. None of his specialist physicians sees him in the nursing home. NOTE: These are hypothetical examples developed for illustrative purposes and are not actual patient summaries.

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 RETOOLING FOR AN AGING AMERICA TABLE 2-1 Indicators of Health Status, by Age Group, 2006 (Percent) Ages 18 Ages Ages 75 and Over 65-74 and Older Prevalence of Chronic Disease Hypertension 22.9 52.9 53.8 Chronic joint symptoms 25.2 42.7 44.2 Heart disease 10.9 26.2 36.6 Any cancer 7.1 17.2 25.7 Diabetes 7.7 18.6 18.3 Stroke 2.6 7.6 11.2 Asthma 7.3 7.8 6.1 Chronic bronchitis 4.2 5.6 6.7 Prevalence of Disability/Limitations Trouble hearing 16.8 31.9 50.4 Vision limitations, even with glasses or contacts 9.5 13.6 21.7 Absence of all natural teeth 8.0 22.8 29.4 Any physical difficulty 14.6 30.2 48.1 Overall Health Status Self-assessed health status as fair or poor 12.1 22.5 27.5 NOTE: Does not contain information on the institutionalized adult population. SOURCE: Pleis and Lethbridge-Çejku, 2007. the health status among subgroups of older adults. Many older adults are actually in very good health, for example—44 percent of adults in the 65-74 age range and 35 percent of adults 75 and older report their health status to be “very good” or “excellent” (Pleis and Lethbridge-Çejku, 2007). And a sizable minority, approximately 20 percent, have no chronic illnesses (AOA, 2006; CDC and Merck Company Foundation, 2007). These healthier older adults tend to be community-dwelling individuals who require only preven- tive and episodic health services. On the other hand, a large majority of older adults (approximately 82 percent) have at least one chronic disease that requires ongoing care and management, with hypertension, arthritis, and heart disease being the most common (Table 2-2). These chronic conditions damage older adults’ quality of life, they contribute to a decline in functioning, and they have become the primary reason why older adults seek medical care (Hing et al., 2006). In fact, Medicare beneficiaries with more than one chronic condition visit an average of eight physicians in a year (Anderson, 2003). 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). Data from the 2001 Medical Expenditure Panel Survey show that almost all

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 HEALTH STATUS AND HEALTH CARE SERVICE UTILIZATION TABLE 2-2 Chronic Disease Prevalence, Cost, and Physician Use Among Medicare Beneficiaries Number of Chronic Conditions 0 1 2 3 4 or more Percent of all Medicare 18% 17% 22% 19% 24% beneficiaries, 1999 Average Medicare expenditures, $211 $1,154 $2,394 $4,701 $13,973 1999 Percent that sees more than 10 6% 18% 40% 61% Not available different physicians per year, 2003 SOURCE: MedPAC, 2006; Wolff et al., 2002. Medicare spending and 83 percent of Medicaid spending is for the provi- sion of services to individuals with chronic conditions. In addition, many older adults experience one or more geriatric syn- dromes, clinical conditions common among older adults that often do not fit into discrete disease categories. Examples include delirium, depression, falls, sensory impairment, incontinence, malnutrition, and osteoporosis. The syndromes tend to be multifactorial and result from an interaction be- tween identifiable patient-specific impairments and situation-specific stress- ors (Flacker, 2003; Inouye et al., 2007). Geriatric syndromes are prevalent conditions even among community-dwelling older adults and can have a substantial effect on older adults’ quality of life (Cigolle et al., 2007). Es- timates of incontinence, for example, range from 17 percent to 55 percent in older women and from 11 percent to 34 percent in older men. Almost half of older men and 34 percent of older women (ages 65 and older) report trouble hearing. Although estimates vary across surveys, data from the 2002 Health and Retirement Study indicate that 27 percent of community-dwelling adults ages 65 and older (8.7 million people) need assistance with one or more ADLs or IADLs (Johnson and Wiener, 2006). Approximately 6 percent of older adults living in the community (2.0 million people) are severely disabled, reporting difficulty with 3 or more ADLs (Johnson, 2007). This group of older adults requires more intensive care in the home, particularly personal-care services. Approximately 6.5 percent of older adults live in a long-term care facil- ity. 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). Those over age 85 are much more likely to live in a long-term care setting than younger older

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 RETOOLING FOR AN AGING AMERICA adults. In fact, those over age 85 are four times as likely to live in a nursing home as those aged 75 to 84 (Jones, 2002). 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. Residents of long-term care facilities often have the additional need for symptom management and palliative care, that is, for noncurative care that is focused on alleviating physical symptoms and addressing psychologi- cal, social, and spiritual needs (Moon and Coccuti, 2002). Approximately 80 percent of deaths in the United States occur among older adults (Kung et al., 2008). The leading causes of death among older adults are diseases of the heart, malignant neoplasms, cerebrovascular dis- eases, chronic lower respiratory diseases, and Alzheimer’s Disease (NCHS, 2007). Studies indicate that older adults follow different trajectories of dying (IOM, 1997). Some have normal functioning but then die suddenly. Others die after a distinct terminal phase of illness, such as occurs with many types of cancer. Still others have a slower decline with periodic crises before dying from complications, as is the case with stroke or dementia. On average, about one-fourth of Medicare outlays occur in the beneficiary’s last year of life, with 38 percent of beneficiaries spending at least some time in a nursing home and 19 percent using hospice services (Hogan et al., 2001). About half of Medicare patients who die from cancer use hospice services in the last year of life. Deciding whether to use palliative care or curative treat- ment for illness during these times is a very personal choice and depends on the individuals being affected (Moon and Coccuti, 2002). Mental Health Conditions Vulnerability to mental health conditions tends to increase as older adults age and become more likely to encounter stressful events, including declines in health and the loss of loved ones. Approximately 20 percent of adults ages 55 and older have a mental health condition, the most com- mon being anxiety disorders (e.g., generalized anxiety and panic disorders), severe cognitive impairment (e.g., Alzheimer’s disease), and mood disorders (e.g., depression and bipolar disorder) (AOA, 2001). Cognitive impair- ment with no dementia (CIND) has been described as the intermediate state between normal cognitive function and dementia, a chronic illness characterized by a decline in memory and other cognitive functions. The prevalence of dementia increases with age, escalating from about 5 percent among individuals aged 71 to 79 to about 37 percent among those aged 90 and older (Plassman et al., 2007). In 2007, 42 percent of adults 85 years or older had Alzheimer’s disease (Alzheimer’s Association, 2007), although estimates have varied somewhat. Additionally, suicide rates for men 65

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 HEALTH STATUS AND HEALTH CARE SERVICE UTILIZATION and older are higher than any other age group and are more than twice the national rate for all persons (NCHS, 2007). Mental health conditions are also more prevalent among community- dwelling older adults with ADL and IADL limitations. In 2002 approxi- mately 31 percent of persons with disabilities and 45 percent of severely disabled persons reported depressive symptoms, and 15 percent of older adults with disabilities and 25 percent of severely disabled older adults had cognitive impairments (Johnson and Wiener, 2006). The prevalence of mental health conditions is even higher among nursing home residents. In 2005 nearly half of nursing home residents had dementia, and 20 percent had other psychological diagnoses (Houser et al., 2006). One reason for these trends may be that mental and physical health are interrelated (New Freedom Commission on Mental Health, 2003). While the direction of causality between the two remains unclear, the correlation between them has been well documented. Persons with dementia and CIND have more serious comorbidity than those without cognitive impairment (Lyketsos et al., 2005). Physically disabled adults report higher rates of mental health conditions. People with depressive symptoms often experi- ence 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). In addition, depres- sion in later life is associated with poor health habits and diminished adher- ence to treatment for co-existing medical disorders. Among older adults, the combination of heavy alcohol or substance use with depressive symptoms has been shown to be associated with high risk for suicidal ideation and poor physical well-being (Bartels et al., 2006a,b). CURRENT UTILIZATION OF HEALTH CARE SERVICES Older adults have much higher rates of health services utilization than do non-elderly persons. Although they represent about 12 percent of the U.S. population, adults ages 65 and older account for approximately 26 percent of all physician office visits (Hing et al., 2006), 35 percent of all hospital stays (Merrill and Elixhauser, 2005), 34 percent of prescriptions (Families USA, 2000), and 90 percent of nursing home use (Jones, 2002). Utilization data for several acute-care services are displayed in Table 2-3. On average, older adults visit physicians’ offices twice as often as do people under 65, averaging 7 office visits each year and totaling approxi- mately 248 million visits in 2005 (NCHS, 2007). Older adults are more likely to visit a physician’s office for a chronic problem or for a pre- or post-surgery visit, but they are less likely than younger persons to seek pre- ventive care. In 2004 the most common reasons for older adults to make office visits were all related to chronic conditions: hypertension, malignant

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 RETOOLING FOR AN AGING AMERICA TABLE 2-3 Health Services Utilization by Age Group, 2005 Ages Ages 75 All Ages 65-74 and Over Number of physician office visits per 100 persons 329 647 768 Number of preventive care visits per 100 personsa 51.0 50.6 48.1 Number of injury-related visits per 100 personsa 36.5 60.0 73.6 Number of hospital outpatient visits per 100 persons 31 41 38 (not including ED) Number of ED visits per 100 persons 40 37 60 Number of days of hospital care per 100 persons 55.4 139.8 259.4 Average hospital length of stay 4.8 days 5.3 days 5.7 days NOTE: Data are for non-institutionalized persons. ED = Emergency Department. aData are for 2004. SOURCE: Hing et al., 2006; NCHS, 2007. neoplasms (i.e., cancer), diabetes, arthropathies and related disorders (i.e., problems with joints), and heart disease (Hing et al., 2006). Older adults frequently made visits to internal and family-medicine physicians, but more than half of their visits were to specialists (NCHS, 2007). Older adults also tend to visit multiple physicians. In 2003 half of Medicare patients visited between two and five different physicians, 21 percent visited six to nine physicians, and 12 percent visited ten or more different physicians (MedPAC, 2006). Although there are many specialists for which older adults constitute a large percentage of visits (e.g., 35 percent for internal medicine, 30 percent for neurology), older adults account for only 9 percent of visits to psychiatrists (ADGAP, 2007). The stigma associated with seeking men- tal health services presumably contributes in part to this low utilization, but limited coverage by Medicare for psychiatric services is also a reason (Manderscheid, 2007). Medicare requires a 50 percent copayment for out- patient mental health services as compared with only 20 percent for most other outpatient services. 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 vis- its to emergency departments (EDs); the reasons for these visits were similar to those for visits to office-based physicians (Middleton and Hing, 2006). Older adults account for a disproportionate share of emergency ser- vices. In fact, the rate of use of emergency medical services (EMS) by older adults is more than four times that of younger patients, and older adults account for 38 percent of all EMS responses (Shah et al., 2007). Between 1993 and 2003 ED visits by patients between the ages of 65 and 74 in-

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 HEALTH STATUS AND HEALTH CARE SERVICE UTILIZATION creased by 34 percent, and adults over age 65 had the greatest increase in visit rate of all age groups (Roberts et al., 2008). In 2004 older adults made 15.7 million visits to EDs, which accounted for 14 percent of all ED visits. More than one-third of older adult ED patients arrived by ambulance, us- ing ambulance transport at more than double the rate of ED patients as a whole (McCaig and Nawar, 2006). Despite older adults’ higher rates of using emergency services, many EDs are not prepared to address the unique needs of older patients (Hwang and Morrison, 2007; Wilber et al., 2006). These EDs do not have the expertise, equipment, or policies to provide optimal care for older patients. Once they have been treated, older adults are more likely to have an overnight hospital stay and also more likely to have multiple overnight hospitalizations. In 2002 older adults accounted for more than 13 mil- lion inpatient discharges. The most common inpatient diagnoses included coronary atherosclerosis (hardening of the heart arteries and other heart disease), congestive heart failure, and pneumonia (Merrill and Elixhauser, 2005). Forty-two percent of older adults receive some post-acute care services after discharge from the hospital. Approximately 27 percent of older adults are discharged to another institution, such as a skilled nursing facility (SNF) or rehabilitation center; another 15 percent receive home health care (AHRQ, 2007). Medicare covers up to 100 days (20 days of full coverage and 80 days of partial coverage) in a SNF after a hospitalization of at least three consecutive days (MedPAC, 2007b). The average length of SNF stays covered by Medicare in 2005 was 26 days (MedPAC, 2007a). Overall, almost 3 million Medicare beneficiaries received home health services in 2006, including skilled nursing, physical therapy, speech-language pathol- ogy services, aide service, and medical social work (MedPAC, 2007a). Medicare provides home health care to homebound beneficiaries needing part-time (fewer than 8 hours per day) or intermittent (temporary but not indefinite) skilled care to treat their illness or injury. Personal care and other non-skilled needs are not covered by Medicare. Older adults are especially vulnerable as they transition between types of care. A lack of coordination among providers in different settings can lead to fragmentation of care, placing older adults at risk for absence or duplication of needed services, conflicting treatments, and increased stress (Parry et al., 2003). For example, medication changes, which are a common cause of adverse drug events, are not unusual in the transition from hospital to long-term care settings such as nursing homes and private home settings (Boockvar et al., 2004; Foust et al., 2005; Levenson and Saffel, 2007). Incomplete procedures during hospital discharge may also be linked to unnecessary rehospitalizations (Halasyamani et al., 2006; Kripalani et al., 2007). This type of fragmented care can also result from a lack of coordi-

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 RETOOLING FOR AN AGING AMERICA nation among providers who concurrently care for older adults in different settings, exemplifying the failure of the health care system to meet the stan- dards of quality (most notably safety, efficiency, and patient-centeredness) as described in the IOM’s Crossing the Quality Chasm (IOM, 2001). Coor- dination of care and the use of interdisciplinary teams, is discussed in more detail later in this report. Long-term care services include health and personal services provided to chronically disabled persons over an extended period of time. Estimat- ing the total amount of long-term care services received by older adults is difficult because utilization data are not often collected in a consistent man- ner across settings or care providers. Just over 60 percent of disabled older adults living in the community obtain some long-term care services, most commonly basic personal-care services and help with household chores, averaging about 177 hours per month (Johnson and Wiener, 2006). Infor- mal caregivers provide the vast majority of these services. Approximately 5.7 million older adults received some unpaid services in 2000 (Johnson et al., 2007). Only about 18 percent of long-term care services provided to disabled older adults in their homes are delivered by formal paid sources. Medicaid accounts for about 41 percent of total long-term care expendi- tures (including non-elderly persons), while Medicare and out-of-pocket costs each account for 22 percent of expenditures (Kaiser Commission on Medicaid Facts, 2007). As noted earlier, while approximately 1.45 million older adults live in nursing homes, another 750,000 older adults live in alternative residential care facilities, which provide housing and services outside nursing homes for those unable to live independently (Spillman and Black, 2006). In fact, assisted-living facilities have been the most rapidly expanding form of residential care for older adults (Maas and Buckwalter, 2006). At the same time, the percentage of older adults living in nursing homes declined from 21 percent to 14 percent between 1985 and 2004, consistent with the preferences of older adults to live in the community (Alecxih, 2006b). While the Veterans Health Administration (VHA) allots 90 percent of its long-term care resources toward nursing homes, about 56 percent of formal long-term care service recipients receive community-based care (Kinosian et al., 2007). In 2005 about 870,000 Medicare beneficiaries received hospice care, accounting for $7.92 billion in total Medicare payments (OIG, 2007). Twenty-eight percent of these beneficiaries received some hospice care in a nursing facility. In addition to their increased needs for assisted housing and other types of care, older adults account for a disproportionate share of pre- scription and over-the-counter medications (ACCP, 2005). They consume 34 percent of all prescriptions dispensed and account for about 40 percent

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 HEALTH STATUS AND HEALTH CARE SERVICE UTILIZATION of every dollar spent on prescriptions (Families USA, 2000). According to physician office records and hospital outpatient records, the most common medications used by older adults in 2004-2005 included anti-hypertensives (133.3 drugs per every 100 older adults), cholesterol control drugs (128.1), non-narcotic analgesics for pain relief (104.7), and diuretics for high blood pressure and heart disease (95.4) (NCHS, 2007). In 2002, prior to the implementation of Medicare Part D, the average Medicare enrollee aged 65 and older filled 32 prescriptions (including refills), 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). Besides the traditional forms of health care discussed so far, surveys on the use of complementary and alternative medicine (CAM) estimate that anywhere from 30 percent to 88 percent of older adults use some form of CAM. Studies often vary in terms of which forms of CAM are examined. According to data from the National Health Interview Survey, prayer for health is among the most common forms of CAM practiced among older adults (Barnes et al., 2004). Data from the Health and Retirement Study, which did not examine prayer, found that the most common forms of CAM used by older adults included dietary supplements (65 percent) and chiro- practic services (46 percent), though personal practice (breathing exercises and meditation), massage therapy, and herbal supplements were also com- monly used (Ness et al., 2005). There are also a number of different types of providers, such as nurse practitioners, social workers, psychologists, dentists, and pharmacists, for which utilization data have not been discussed in this section. Visits to these providers are typically not captured by national surveys of older adults, but the numbers are likely to be considerable. DIFFERENCES BY DEMOGRAPHIC CHARACTERISTICS The data presented above mask important differences in the health status of and the health care service use by older adults in various demo- graphic categories, including sex, race, and socioeconomic status. For ex- ample, women and men face different challenges in maintaining their health and have different patterns of service utilization. Men have higher rates of heart disease, cancer, diabetes, and emphysema and have more inpatient hospital stays than women (Robinson, 2007). On the other hand, women have higher rates of osteoporosis, arthritis, asthma, chronic bronchitis, and hypertension, and women are more likely to report depressive symptoms (Federal Interagency Forum on Aging Related Statistics, 2006). Because women have longer life expectancy than men and greater age-adjusted dis-

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 RETOOLING FOR AN AGING AMERICA TABLE 2-8 Number of Older Adults Receiving Long-Term Care Services, by Disability Scenario, 2000 and 2040 (in Millions) Year 2040 Year 2000 Low Intermediate High Any unpaid help 5.7 8.2 11.2 13.1 Unpaid help from children 2.8 3.7 5.0 5.8 Unpaid help from other sources 3.9 5.7 7.9 9.3 Paid home care 2.2 3.9 5.3 6.2 Nursing home care 1.2 2.0 2.7 3.1 SOURCE: Johnson et al., 2007. is projected to remain steady or to decline (Figure 2-2). Nevertheless, in the intermediate scenario, the average number of paid help hours per month is projected to increase from 163 to 221 over the 40-year time period. The average number of hours of unpaid at-home care received from children would remain relatively constant, and the number of hours of unpaid help received from others would decline slightly (Johnson et al., 2007). 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 2040 40 27.8 25.5 30 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. 2-4.eps SOURCE: Johnson et al., 2007.

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 HEALTH STATUS AND HEALTH CARE SERVICE UTILIZATION adults, but they do not describe a complete picture. Most of the projections rely heavily on data collected from large national surveys that ask about a limited number of illnesses and types of health services used. 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. What all of the projections described above have in common is that they extrapolate data from the past in order to predict the future. Although it may be the best approach available in many cases, it is not without its limitations and certainly not without controversy (Olshansky, 2005). For example, one limitation of these projections is that they cannot predict changes in utilization patterns that result from changing patient demands. The models will project sizable increases in nursing-home use because of the growing number of older adults, even though the use rates have been falling. Demographers and health service researchers regularly debate whether assumptions about future rates of disability or illness are inappropriately high or low; regardless of the precise assumptions used, however, the qualitative interpretations of the findings are clear and consistent. Even among the most optimistic projections in which the future cohort of older adults is healthier than today’s, the growth in the absolute number of older Americans will result in a greater total volume of illness and disabil- ity and a greater collective need for services from the health care system. Estimates of the magnitude may vary, but again, even the most optimistic scenarios indicate that the change will be considerable—and, in particular, that it will be one that warrants a high level of attention and action today so that the system is better prepared by 2030. IMPLICATIONS FOR FINANCIAL RESOURCES Although an examination of health expenditures is beyond the scope of the committee’s charge, a consideration of the tremendous growth ex- pected in the use of health services would not be complete without turning some attention to its cost. In 1999 per capita health care spending for the population under age 65 was $2,793; for the older adult population it was $11,089, and for nursing home residents it was $44,520. The vast majority of health care costs for older adults was borne by Medicare (52 percent) and Medicaid (12 percent) (ASPE, 2005). In 2006 Medicare paid $406 bil- lion in benefits (Federal HI and SMI Trust Funds Board of Trustees, 2007).

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 RETOOLING FOR AN AGING AMERICA In 2003 Medicaid paid $263 billion in benefits, including $105 billion for dually eligible beneficiaries, the vast majority of whom are older adults, and $68 billion for other aged and disabled Medicaid beneficiaries (Holahan and Ghosh, 2005). The 2007 report of the Federal Hospital Insurance and Supplemental Medical Insurance Board of Trustees contained a Medicare funding warn- ing: The projected growth rates are not sustainable under current financing arrangements. The hospital insurance trust fund, which funds Medicare Part A, is projected to be exhausted by 2019 (Federal HI and SMI Trust Funds Board of Trustees, 2007). The financial outlook for Medicaid is hardly better. Medicaid is the second largest program in state budgets, growing faster than other state programs. Medicaid spending grew 9.5 percent in 2004, compared to a 3.4 percent growth in state revenue. States have implemented a number of measures designed to slow the rate of spend- ing, including reductions in eligibility and benefits (Smith et al., 2004). The budgetary situation of these two programs is dismal, and policy changes will likely occur prior to 2030 in order to address them. Although the committee did not consider policy options for addressing the financial viability of the two programs, committee members were mind- ful of the financial realities during the course of their deliberations. Insuf- ficient funding for Medicare and Medicaid will place strains on the ability of health care professionals to provide quality health care services. It will also exacerbate issues of recruitment and retention—a particular concern in the case of providers qualified in geriatrics, whose presence in the field is already dreadfully low. The financing of care is only part of the problem, however, and simply allocating more funding or resources will not fully address the deficiencies in the care of older adults. CONCLUSION Older Americans today have longer life expectancies than did previous generations of older adults. As the population ages, however, the actual numbers of older adults living with disability or illness are rapidly increas- ing. Many older adults live their extra years with higher rates of chronic health conditions that require vigilant care on the part of their health pro- viders. As a result, older adults account for a disproportionate amount of the health care services delivered in the United States. Furthermore, because of the variety of physical and mental illnesses seen among older adults and the variety of care sites in which they receive services, the care of today’s older adults is especially complex. Future generations of older Americans may have different health care needs because of changes in the distribution of many demographic charac-

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 HEALTH STATUS AND HEALTH CARE SERVICE UTILIZATION teristics, including race, socioeconomic status, and geographic location, and also because of changes in personal preferences about how they care for their health and where they receive their health care services. It is difficult to make exact projections of these needs because of uncertainties regarding the effects of changes in demographics, lifestyle, and disease prevalence. Utilization patterns may also change markedly because of these effects and also because of changes in the health care marketplace and innovations in medical diagnostic and treatment modalities. While projections are dif- ficult, one conclusion is certain—that the absolute growth in the number of older Americans will strain the current health care system if patterns of care remain the same. If the health care workforce—already too low in numbers and com- petence levels to provide adequate care to the current population of older adults—is to be prepared for the coming spike in demand for services, serious reforms need to be considered. This will include redesign in the way that health care teams deliver their services. 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. Chapter 3 examines a number of these new models as well as strategies to support their further development. REFERENCES AAMC (Association of American Medical Colleges). 2007. Forecasting the supply of and demand for oncologists. Washington, DC: AAMC. Aaron, H. J., W. B. Schwartz, and M. Cox. 2005. Can we say no? The challenge of rationing health care. Washington, DC: Brookings Institution Press. ACCP (American College of Clinical Pharmacy). 2005. Pharmacy practice, research, educa- tion, and advocacy for older adults. Pharmacotherapy 25(10):1396-1430. ADGAP (Association of Directors of Geriatric Academic Programs). 2007. Geriatrics in psy- chiatry residency programs. Training & Practice Update 5(1):1-7. AHA (American Hospital Association). 2007. When I’m . Chicago, IL: American Hospital Association. AHRQ (Agency for Healthcare Research and Quality). 2005. National healthcare disparities report. Rockville, MD: AHRQ. AHRQ. 2006. Health care for minority women. Rockville, MD: AHRQ. AHRQ. 2007. Welcome to HCUPnet. http://hcupnet.ahrq.gov/ (accessed January 7, 2008). Alecxih, L. 2006a. Long term care financing in the U.S. Paper presented at Alliance for Health Reform Briefing, Washington, DC. November 9, 2006. Alecxih, L. 2006b. Nursing home use by “oldest old” sharply declines. Washington, DC: The Lewin Group. Alzheimer’s Association. 2007. Alzheimer’s disease facts and figures. Chicago, IL: Alzheimer’s Association. Anderson, G. 2003. Chronic care. Public Health & Policy 3(2):110-111.

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 RETOOLING FOR AN AGING AMERICA AOA (Administration on Aging). 2001. Older adults and mental health: Issues and opportuni- ties. Washington, DC: U.S. Department of Health and Human Services. AOA. 2006. A statistical profile of older Americans aged +. Washington, DC: U.S. Depart- ment of Health and Human Services. ASPE (Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Hu- man Services). 2005. Long-term growth of medical expenditures—public and priate. Washington, DC: ASPE. Barnes, P. M., E. Powell-Griner, K. McFann, and R. L. Nahin. 2004. Complementary and alternatie medicine use among adults: United States, 00. Hyattsville, MD: National Center for Health Statistics. Bartels, S. J., F. C. Blow, A. D. Van Citters, and L. M. Brockmann. 2006a. Dual diagnosis among older adults: Co-occurring substance abuse and psychiatric illness. Journal of Dual Diagnosis 2(3):9-30. Bartels, S. J., K. M. Miles, T. E. Oxman, S. Zimmerman, L. A. Cori, A. S. Pomerantz, B. H. Cole, A. D. Van Citters, and N. Mendolevicz. 2006b. Correlates of co-occurring depressive symptoms and alcohol use in an older primary care clinic population. Journal of Dual Diagnosis 2(3):57-72. Boockvar, K., E. Fishman, C. K. Kyriacou, A. Monias, S. Gavi, and T. Cortes. 2004. Adverse events due to discontinuations in drug use and dose changes in patients transferred be- tween acute and long-term care facilities. Archies of Internal Medicine 164(5):545-550. Boyle, J. P., A. A. Honeycutt, K. M. V. Narayan, T. J. Hoerger, L. S. Geiss, H. Chen, and T. J. Thompson. 2001. Projection of diabetes burden through 2050: Impact of changing demography and disease prevalence in the U.S. Diabetes Care 24(11):1936-1940. Brand, M. 2007. The future healthcare workforce for older Americans: Rural recruitment and retention. Presentation at Meeting of the Committee on the Future Health Care Workforce for Older Americans, San Francisco, CA. June 28, 2007. CDC (Centers for Disease Control and Prevention) and The Merck Company Foundation. 2007. The state of aging and health in America 00. Whitehouse Station, NJ: The Merck Company Foundation. Chen, A. Y., and J. J. Escarce. 2004. Quantifying income-related inequality in healthcare delivery in the United States. Medical Care 42(1):38-47. Cigolle, C. T., K. M. Langa, M. U. Kabeto, Z. Tian, and C. S. Blaum. 2007. Geriatric con- ditions and disability: The health and retirement study. Annals of Internal Medicine 147(3):156. Crimmins, E. M. 2004. Trends in the health of the elderly. Annual Reiew of Public Health 25(1):79-98. Cutler, D. M., E. L. Glaeser, and A. B. Rosen. 2007. Is the US population behaing healthier? Working paper 0. Cambridge, MA: National Bureau of Economic Research. Damron-Rodriguez, J., S. Wallace, and R. Kington. 1994. Service utilization and minority elderly: Appropriateness, accessibility and acceptability. Gerontology & Geriatrics Edu- cation 15(1):45-64. Del Webb Corporation. 2003. Baby boomer report: Annual surey. Bloomfield Hills, MI: Pulte Homes, Inc. Enders, S. R., D. A. Paterniti, and F. J. Meyers. 2005. An approach to develop effective health care decision making for women in prison. Journal of Palliatie Medicine 8(2): 432-439. Families USA. 2000. Cost oerdose: Growth in drug spending for the elderly, -00. Washington, DC: Families USA.

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 HEALTH STATUS AND HEALTH CARE SERVICE UTILIZATION Federal HI and SMI Trust Funds Board of Trustees. 2007. 00 annual report of the boards of trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance trust funds. http://www.cms.hhs.gov/ReportsTrustFunds/downloads/tr2007.pdf (accessed January 29, 2008). Federal Interagency Forum on Aging-Related Statistics. 2006. Older Americans update 00: Key indicators of well-being. Washington, DC: U.S. Government Printing Office. Fisher, E. S., D. E. Wennberg, T. A. Stukel, D. J. Gottlieb, F. L. Lucas, and E. T. L. Pinder. 2003. The implications of regional variations in medicare spending. Part 2: Health outcomes and satisfaction with care. Annals of Internal Medicine 138(4):288-298. Flacker, J. M. 2003. What is a geriatric syndrome anyway? Journal of the American Geriatrics Society 51(4):574-576. Fontaine, K., S. Haaz, and M. Heo. 2007. Projected prevalence of US adults with self-reported doctor-diagnosed arthritis, 2005 to 2050. Clinical Rheumatology 26(5):772-774. Foust, J. B., M. D. Naylor, P. A. Boling, and K. A. Cappuzzo. 2005. Opportunities for im- proving post-hospital home medication management among older adults. Home Health Serices Quarterly 24(1-2):101-122. Freedman, V. A., and L. G. Martin. 1998. Understanding trends in functional limitations among older Americans. American Journal of Public Health 88(10):1457-1462. Freedman, V. A., and L. G. Martin. 1999. The role of education in explaining and forecasting trends in functional limitations among older adults. Demography 36(4):461-473. Freedman, V. A., L. G. Martin, and R. F. Schoeni. 2002. Recent trends in disability and functioning among older adults in the United States: A systematic review. Journal of the American Medical Association 288(24):3137-3146. Freedman, V. A., E. M. Crimmins, R. F. Schoeni, B. C. Spillman, H. Ayakan, E. Kramarow, K. Land, J. Lubitz, K. G. Manton, L. G. Martin, D. Shinberg, and T. Waidmann. 2004a. Resolving inconsistencies in trends in old-age disability: Report from a technical working group. Demography 41(3):417-441. Freedman, V. A., L. G. Martin, and R. F. Schoeni. 2004b. Disability in America. Population Bulletin 59(3):1-32. Girosi, F. 2007. Projections of health status and utilization for older Americans. Presentation at Meeting of the Committee on the Future Health Care Workforce for Older Americans, Washington, DC. March 27, 2007. Goldman, D. P., P. G. Shekelle, J. Bhattacharya, M. Hurd, G. F. Joyce, D. N. Lakdawalla, D. H. Matsui, S. J. Newberry, C. Panis, and B. Shang. 2004. Health status and medical treatment of the future elderly. Santa Monica, CA: RAND Corporation. Goldman, D. P., B. Shang, J. Bhattacharya, A. M. Garber, M. Hurd, G. F. Joyce, D. N. Lakdawalla, C. Panis, and P. G. Shekelle. 2005. Consequences of health trends and medical innovation for the future elderly. Health Affairs 24(Suppl 2):W5-R5-W5-17. Gornick, M. E. 2003. A decade of research on disparities in Medicare utilization: Lessons for the health and health care of vulnerable men. American Journal of Public Health 93(5):753-759. Halasyamani, L., S. Kripalani, E. Coleman, J. Schnipper, C. van Walraven, J. Nagamine, P. Torcson, T. Bookwalter, T. Budnitz, and D. Manning. 2006. Transition of care for hos- pitalized elderly patients—development of a discharge checklist for hospitalists. Journal of Hospital Medicine (Online) 1(6):354-360. Hayward, M. D., and M. Heron. 1999. Racial inequality in active life among adult Americans. Demography 36(1):77-91. Hing, E., D. K. Cherry, and B. A. Woodwell. 2006. National ambulatory medical care surey: 00 summary. Adance data from ital and health statistics; no . Hyattsville, MD: National Center for Health Statistics.

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0 RETOOLING FOR AN AGING AMERICA Hogan, C., J. Lunney, J. Gabel, and J. Lynn. 2001. Medicare beneficiaries’ costs of care in the last year of life. Health Affairs 20(4):188-195. Holahan, J., and A. Ghosh. 2005. Dual eligibles: Medicaid enrollment and spending for Medi- care beneficiaries in 00. Washington, DC: The Henry J. Kaiser Family Foundation. Houser, A., W. Fox-Grage, and M. J. Gibson. 2006. Across the states: Profiles of long-term care and independent liing. Washington, DC: AARP Public Policy Institute. HRSA (Health Resources and Services Administration). 2003. Changing demographics: Impli- cations for physicians, nurses, and other health workers. Washington, DC: HRSA. HRSA. 2006a. The critical care workforce: A study of the supply and demand for critical care physicians, report to Congress. Rockville, MD: HRSA. HRSA. 2006b. Physician supply and demand: Projections to 00. Rockville, MD: HRSA. Hwang, U., and R. S. Morrison. 2007. The geriatric emergency department. Journal of the American Geriatrics Society 55(11):1873-1876. Inouye, S. K., S. Studenski, M. E. Tinetti, and G. A. Kuchel. 2007. Geriatric syndromes: Clini- cal, research, and policy implications of a core geriatric concept. Journal of the American Geriatrics Society 55(5):780-791. IOM (Institute of Medicine). 1997. Approaching death: Improing care at the end of life. Washington, DC: National Academy Press. IOM. 2001. Crossing the quality chasm: A new health system for the st century. Washing- ton, DC: National Academy Press. IOM. 2002. Unequal treatment. Washington, DC: The National Academies Press. IOM. 2004. Critical perspecties on racial and ethnic differences in health in late life. Wash- ington, DC: The National Academies Press. Jacobson, G. A. 2007. Comparatie clinical effectieness and cost-effectieness research: Back- ground, history, and oeriew. Washington, DC: Congressional Research Service. Johnson, R. W. 2007. The burden of caring for frail parents. Paper presented at testimony before the Joint Economic Committee, Washington, DC. May 16, 2007. Johnson, R. W., and J. M. Wiener. 2006. A profile of frail older Americans and their caregiers. Washington, DC: The Urban Institute. Johnson, R. W., D. Toohey, and J. M. Wiener. 2007. Meeting the long-term care needs of the baby boomers: How changing families will affect paid helpers and institutions. Wash- ington, DC: The Urban Institute. Jones, A. 2002. The national nursing home surey:  summary. Hyattsville, MD: National Center for Health Statistics. Kaiser Commission on Medicaid Facts. 2007. Medicaid and long-term care serices and sup- ports. http://www.kff.org/medicaid/upload/2186_05.pdf (accessed February 8, 2008). Kaplan, M. S., N. Huguet, B. H. McFarland, and J. T. Newsom. 2007. Suicide among male veterans: A prospective population-based study. Journal of Epidemiology and Commu- nity Health 61(7):619-624. Kemper, P., H. Komisar, and L. Alecxih. 2005. Long-term care over an uncertain future: What can current retirees expect? Inquiry 42:335-350. Kinosian, B., E. Stallard, and D. Wieland. 2007. Projected use of long-term-care services by enrolled veterans. Gerontologist 47(3):356-364. Kripalani, S., A. T. Jackson, J. L. Schnipper, and E. A. Coleman. 2007. Promoting effective transitions of care at hospital discharge: A review of key issues for hospitalists. Journal of Hospital Medicine 2(5):314-323. Kung, H. C., D. L. Hoyert, J. Xu, and S. L. Murphy. 2008. Deaths: Final data for 00. National Vital Statistics Reports 56(10). Hyattsville, MD: National Center for Health Statistics. Lakdawalla, D. N., J. Bhattacharya, and D. P. Goldman. 2004. Are the young becoming more disabled? Health Affairs 23(1):168-176.

OCR for page 39
 HEALTH STATUS AND HEALTH CARE SERVICE UTILIZATION Leatherman, S., and D. McCarthy. 2005. Quality of health care for Medicare beneficiaries: A chartbook. Washington, DC: The Commonwealth Fund. Levenson, S. A., and D. Saffel. 2007. The consultant pharmacist and the physician in the nursing home: Roles, relationships, and a recipe for success. The Consultant Pharmacist 22(1):71-82. Lyketsos, C. G., L. Toone, J. Tschanz, P. V. Rabins, M. Steinberg, C. U. Onyike, C. Corcoran, M. Norton, P. Zandi, J. C. S. Breitner, and K. Welsh-Bohmer. 2005. Population-based study of medical comorbidity in early dementia and “Cognitive Impairment, No Demen- tia (CIND).” Association with functional and cognitive impairment: The Cache County Study. American Journal of Geriatric Psychiatry 13(8):656-664. Maas, M. L., and K. C. Buckwalter. 2006. Providing quality care in assisted living facilities: Recommendations for enhanced staffing and staff training. Journal of Gerontological Nursing 32(11):14-22. Manderscheid, R. W. 2007. Testimony before the Subcommittee on Health. Paper presented at House Committee on Ways and Means, Washington, D.C. March 27, 2007. Manton, K. G., L. Corder, and E. Stallard. 1997. Chronic disability trends in elderly United States populations: 1982-1994. Proceedings of the National Academy of Sciences 94(6): 2593-2598. Manton, K. G., X. Gu, and V. L. Lamb. 2006. Change in chronic disability from 1982 to 2004/2005 as measured by long-term changes in function and health in the U.S. elderly population. Proceedings of the National Academy of Sciences 103(48):18374-18379. Manton, K. G., G. R. Lowrimore, A. D. Ullian, X. Gu, and H. D. Tolley. 2007. From the cover: Labor force participation and human capital increases in an aging population and implications for U.S. research investment. Proceedings of the National Academy of Sciences 104(26):10802-10807. Martin, L. G., R. F. Schoeni, V. A. Freedman, and P. Andreski. 2007. Feeling better? Trends in general health status. Journals of Gerontology B: Psychological Sciences and Social Sciences 62(1):S11-S21. McCaig, L. F., and E. W. Nawar. 2006. National hospital ambulatory medical care surey: 00 emergency department summary. Hyattsville, MD: National Center for Health Statistics. McDonough, P., G. J. Duncan, D. Williams, and J. House. 1997. Income dynamics and adult mortality in the United States, 1972 through 1989. American Journal of Public Health 87(9):1476-1483. MedPAC (Medicare Payment Advisory Commission). 2006. Report to the Congress: Increas- ing the alue of Medicare. Washington, DC: MedPAC. MedPAC. 2007a. Report to the Congress: Medicare payment policy. Washington, DC: MedPAC. MedPAC. 2007b. Report to the Congress: Promoting greater efficiency in Medicare. Wash- ington, DC: MedPAC. Merrill, C. T., and A. Elixhauser. 2005. Hospitalization in the United States, 00: HCUP fact book no. . Rockville, MD: AHRQ. Middleton, K. R., and E. Hing. 2006. National hospital ambulatory medical care surey: 00 outpatient department summary. Rockville, MD: National Center for Health Statistics. Moon, M., and C. Coccuti. 2002. Medicare and end of life care. Washington, DC: The Urban Institute. NCHS (National Center for Health Statistics). 2007. Health, United States, 00. Hyattsville, MD: U.S. Government Printing Office. Ness, J., D. J. Cirillo, D. R. Weir, N. L. Nisly, and R. B. Wallace. 2005. Use of complementary medicine in older Americans: Results from the health and retirement study. Gerontolo- gist 45(4):516-524.

OCR for page 39
 RETOOLING FOR AN AGING AMERICA New Freedom Commission on Mental Health. 2003. Achieing the promise: Transforming mental health care in America. Rockville, MD: DHHS. OIG (Office of the Inspector General, Department of Health and Human Services). 2007. Medicare hospice care: A comparison of beneficiaries in nursing facilities and beneficia- ries in other settings. Washington, DC: DHHS. Olshansky, S. J. 2005. Projecting the future of U.S. health and longevity. Health Affairs (Proj- ect Hope) 24(Suppl 2):W5-R86-W5-R89. Olshansky, S. J., D. J. Passaro, R. C. Hershow, J. Layden, B. A. Carnes, J. Brody, L. Hayflick, R. N. Butler, D. B. Allison, and D. S. Ludwig. 2005. A potential decline in life ex- pectancy in the United States in the 21st century. New England Journal of Medicine 352(11):1138-1145. Ormel, J., F. V. Rijsdijk, M. Sullivan, E. van Sonderen, and G. I. J. M. Kempen. 2002. Tempo- ral and reciprocal relationship between IADL/ADL disability and depressive symptoms in late life. Journals of Gerontology B: Psychological Sciences and Social Sciences 57(4): P338-P347. Parry, C., E. A. Coleman, J. D. Smith, J. Frank, and A. M. Kramer. 2003. The care transitions intervention: A patient-centered approach to ensuring effective transfers between sites of geriatric care. Home Health Care Serices Quarterly 22(3):1-17. Partnership for Solutions National Program Office. 2004. Chronic conditions: Making the case for ongoing care: September 00 update. Baltimore, MD: Johns Hopkins University. Plassman, B. L., K. M. Langa, G. G. Fisher, S. G. Heeringa, D. R. Weir, M. B. Ofstedal, J. R. Burke, M. D. Hurd, G. G. Potter, W. L. Rodgers, D. C. Steffens, R. J. Willis, and R. B. Wallace. 2007. Prevalence of dementia in the United States: The aging, demograph- ics, and memory study. Neuroepidemiology 29(1-2):125-132. Pleis, J. R., and M. Lethbridge-Çejku. 2007. Summary health statistics for U.S. adults: National health interiew surey, 00. Hyattsville, MD: National Center for Health Statistics. Roberts, D. C., M. P. McKay, and A. Shaffer. 2008. Increasing rates of emergency depart- ment visits for elderly patients in the United States, 1993 to 2003. Annals of Emergency Medicine 51(6):769-774. Robinson, K. 2007. Trends in health status and health care use among older women. Hyatts- ville, MD: National Center for Health Statistics. Rosenheck, R. A., and A. F. Fontana. 2007. Trends: Recent trends in VA treatment of post- traumatic stress disorder and other mental disorders. Health Affairs 26(6):1720-1727. Schoeni, R. F., L. G. Martin, P. M. Andreski, and V. A. Freedman. 2005. Persistent and grow- ing socioeconomic disparities in disability among the elderly: 1982-2002. American Journal of Public Health 95(11):2065-2070. Shah, M. N., J. J. Bazarian, E. B. Lerner, R. J. Fairbanks, W. H. Barker, P. Auinger, and B. Friedman. 2007. The epidemiology of emergency medical services use by older adults: An analysis of the National Hospital Ambulatory Medical Care Survey. Academic Emer- gency Medicine 14(5):441-447. Singer, B. H., and K. G. Manton. 1998. The effects of health changes on projections of health service needs for the elderly population of the United States. Proceedings of the National Academy of Sciences 95:15618-15622. Skinner, J., E. S. Fisher, and J. E. Wennberg. 2001. The efficiency of Medicare. Cambridge, MA: National Bureau of Economic Research. Smith, V., R. Ramesh, K. Gifford, E. Ellis, R. Rudowitz, and M. O’Malley. 2004. The continu- ing Medicaid budget challenge: State Medicaid spending growth and cost containment in fiscal years 00 and 00. Washington, DC: The Henry J. Kaiser Family Foundation.

OCR for page 39
 HEALTH STATUS AND HEALTH CARE SERVICE UTILIZATION Soldo, B. J., O. S. Mitchell, R. Tfaily, and J. F. McCabe. 2006. Cross-cohort differences in health on the erge of retirement. Cambridge, MA: National Bureau of Economic Research. Spillman, B. C., and K. J. Black. 2006. The size and characteristics of the residential care population. Washington, DC: ASPE. Stone, R. I. 2000. Long-term care for the elderly with disabilities: Current policy, emerging trends, and implications for the twenty-first century. New York: Milbank Memorial Fund. U.S. Census Bureau. 2000. Projections of the resident population by age, sex, race, and His- panic origin. Washington, DC: U.S. Census Bureau. U.S. Census Bureau. 2008. Statistical abstract of the United States: 00. Washington, DC: U.S. Census Bureau. Waidmann, T. A., and K. Liu. 2000. Disability trends among elderly persons and implications for the future. Journals of Gerontology B: Psychological Sciences and Social Sciences 55(5):S298-S307. Warden, D. 2006. Military TBI during the Iraq and Afghanistan wars. Journal of Head Trauma Rehabilitation 21(5):398-402. Wilber, S. T., L. W. Gerson, K. M. Terrell, C. R. Carpenter, M. N. Shah, K. Heard, and U. Hwang. 2006. Geriatric emergency medicine and the 2006 Institute of Medicine re- ports from the Committee on the Future of Emergency Care in the U.S. Health System. Academic Emergency Medicine 13(12):1345-1351. Wolf, D. A. 2001. Population change: Friend or foe of the chronic care system? Health Af- fairs 20(6):28-42. Wolff, J. L., B. Starfield, and G. Anderson. 2002. Prevalence, expenditures, and compli- cations of multiple chronic conditions in the elderly. Archies of Internal Medicine 162(20):2269-2276. Zabinski, D. 2007. Medicare in the 21st century: Changing beneficiary profile. 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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