The Aging Population in the Twenty-First Century Statistics for Health Policy (1988) / Chapter Skim
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1 Introduction and Summary of Recommendations
1 Introduction and Summary of Recommendations
Pages 1-51
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From page 1... ...
Furthermore, recent scientific evidence on the modifiable nature of health and functional transitions among the old and oldest-old populations suggests that many aspects of current data collection are inadequate to support policy analysis. Efforts dedicated to methodological development of unproved analytic and forecasting tools are even more deficient.
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Seven federal agencies that shared this concern the Veterans Administration and six agencies of the U.S. Department of Health and Human Services: the Health Care Financing Administration, the National Center for Health Statistics, the National Institute of Mental Health, the National Institute on Aging, the Office of the Assistant Secretary for Planning and Evaluation, and the Social Security Administration joined forces and sponsored a study by the National Research Council to address these problems.
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In making its recommendations, the pane! has dealt with data requirements for the immediate future and has also provided a longrange planning guide for the collection and analysis of statistical ata for policy analysis for the elderly population over the next decade.
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A major concern of the panel relates to remedying this situation and ensuring availability of information adequate in scope and timeliness for policy purposes. Careful attention has been paid to the most urgent improvements needed in the existing surveys and in the use that can be made of systems of administrative records.
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Legislation for national health insurance was considered by Congress but, after much debate, no legislation was adopted and further consideration of national health insurance was dropped. Concern about hospital cost containment continued and was addressed by the Social Security Amendments of 1983, which gave rise to the prospective payment system for Medicare based on diagnosis-related groups.
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What alternative health delivery systems can be developed to meet the needs for health care for the elderly in the next decade? How can health promotion and disease prevention be advanced among the elderly?
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The monitoring of hospital performance was mandated through provisions of the Social Security Amendments of 1972, requiring that professional standards review organizations (PSROs) be established to ensure that health care services provided
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We relied on our knowledge about aging and our experience with data requirements and data gaps in past policy analyses to make determinations about the relevance and importance of data for these generic policy issues. General-purpose statistics and statistics derived from administrative records for federal programs cannot be expected to supply all the data needed by policy analysts, although the two types of data taken together can answer many questions.
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is more tenuous. The basic data source would be the health service utilization data for ages 62-64 in the National Medical Expenditure Survey.
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Policy development for these issues requires trend data on the health expenditures of the elderly and also longitudinal data on the use of medical care as a person ages. In addition, evaluation of policy questions related to the Medicare program would be facilitated by improved access to the Medicare statistical system.
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In addition, the National Death Index of the National Center for Health Statistics and state health department death records should be used to identify the year and cause of death of each sampled person. Priority Recommendation 2: The panel recommends that the Health Care Financing Administration develop files designed for easy access to the Medicare Statistical System (including the Medicare Automated Data Retrieval System)
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Since significant changes in health status frequently start to occur in the decade prior to age 65, it is important for longitudinal studies to start following people at age 55. Extensive additional data about the individuals sampled in the NMES are available from administrative records of the Health Care Financing Administration, the Social Security Adrn~nistration, and the Internal Revenue Service.
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Despite the obvious attractiveness of the Medicare files for analytic purposes, these files were established primarily to assist with administration and monitoring of the Medicare program. To make the Medicare administrative data more accessible and less costly for research use, a new file has been designed the Medicare Automated Data Retrieval System (MADRS)
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The National Nursing Home Survey, conducted by the National Center for Health Statistics in 1973-1974, 1977, and
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Over time, the National Nursing Home Survey should be expanded to include all types of long-term care institutions (i.e., chronic disease hospitals, mental health facilities, rehabilitation centers, board and care homes, psychiatric halfway houses, and residential facilities. Expanding the coverage of the survey in this manner would make it possible to compare the costs of other modes of providing Tong-term care services, costs that are essential to planning the organization and delivery of long-term care services.
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that modules of health promotion and disease prevention items (including those concerned with attitudes, knowledge, and behavior) be developed that are appropriate for the elderly and subgroups of the elderly population at risk for particular diseases, illnesses, disabilities, or conditions, which can be used with a variety of population-based surveys; (b)
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From page 17... ...
linkage with Medicare records be performed on a routine basis for persons age 65 and over who are respondents to population surveys that collect health data and (b) the Health Care Financing Administration and the National Center for Health Statistics explore linking the Health Interview Survey with the Medicare Automated Data Retrieval System, when the latter becomes operational.
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Many population surveys, including the National Health Interview Survey, the National Medical Expenditure Survey,
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Priority Recommendation 9: The pane] recommends that agencies having cognizance of national data systems, whether based on administrative records or survey data, (a)
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Many of the specific items required are included in surveys that are already operational or about to start; others are dependent on the extension of existing items or the introduction of new ones. Candidates are found in the National Health Interview Survey and its supplements on aging and prevention, the National Nursing Home Survey, the National Health and Nutrition Examination Survey, the National Ambulatory Medical Care Survey (NCHS)
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For data from administrative records or from the decennial census, the failure to meet these needs of policy analysts is a matter of presentation. The single most useful standard that agencies could adopt is to provide information for standard age categories in publications and public use files.
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The purpose of the newly established Forum on Aging-Related Statistics, which includes representatives from all the federal agencies that collect statistical information on the elderly, is to encourage cooperation among these agencies in the development, collection, analysis, and dissemination of data on the older population. General Recommendations The preceding priority recommendations come from a substantially larger set of specific recommendations that reflect the full range of the panel's findings and conclusions.
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And these reinterview programs need to be supplemented by the linkage of the survey records to Medicare Part A and B data files and to death certificates identified through the National Death Index. The minnnal core of longitudinal surveys for adequate population coverage are the survey programs that produced the 1984 Health Interview Survey, the Supplement on Aging (SOA)
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l~trocluce design changes in other major survey programs to improve their usefulness for studying the health of the elderly, health care expenditures, and quality of care. A number of existing major surveys such as the National Medical Expenditure Survey (on the health expenditures of the general U.S.
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There is much to be gained from the standardization of certain basic content modules to facilitate comparability across surveys. For example, basic income and assets questions might be standardized, as might certain basic instrumentation for functional assessment, for health promotion and disease prevention activities, and for measuring quality of care.
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Provide an adequate ferret of support for statistical and forecast~ng research. Federaldata collection efforts, to tee maximally effective, must be supported by appropriate methodological research on the analysis of longitudinal data from repeated cross-sectional and longitudinal surveys.
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recommendations to augment the scope or content of data sources, to increase the periodicity of surveys, to follow samples of existing surveys to obtain longitudinal data, and to increase survey sample size to provide age detail for the elderly. Half the recommendations fall in the first group, and although these recommendations are not cost-free, they do not entail additional costs.
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Chapter 10 addresses statistical problems that cut across the federal statistical system. Chapter 11 discusses methodological issues common to many of the data collection efforts and to the use of the data in policy analysis.
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Chapters 3 and 4 review the data series available for monitoring health status, quality of life, and health transitions and make recornrnendations to fill serious data gaps. Chapter 5: Health Promotion and Disease Prevention In this chapter health promotion and disease prevention are defined and their relevance and the appropriateness of this approach for the elderly are discussed.
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This chapter reviews the capacity of national data systems to track users of Tong-term care services over time and to measure and report the services they use. Chapters 8 and 9: Fmanc~ng and Utilization of Health Care Services Chapter 8 describes current mechanisms for financing health care services for the elderly, including the federal Medicare and state Medicaid programs, Veterans Administration services, and private health insurance programs.
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From page 31... ...
Chapter 11: Methodological and Statistical Moues The final chapter discusses methodological and statistical issues relevant to an aging society under four headings: the design and analysis of longitudinal studies, linkage of data bases, forecasting the characteristics of future elderly cohorts, and the quantification of uncertainty of projections. Projecting and Dete~n~ng Statistical Needs Several considerations cut across the data requirements for health policy issues addressed in subsequent chapters of the report and provide a unifying framework for the report.
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From page 32... ...
Collecting more information on the well and independent elderly will contribute to a better understanding of the factors that lead to positive health and the conditions under which the elderly are able to cope electively with advancing age. Data on Functioning to Supplement Diagnostic Formation While health status and the presence or absence of illness and disease are major sources of satisfaction or dissatisfaction with life for older persons, it is the ability to function independently-physically, cognitively, emotionally, and socially that is crucial to a feeling of well-being and a high quality of life.
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From page 33... ...
With the introduction of prospective payment systems, based on hospital diagnosis-related groups, there is some evidence that elderly persons are being discharged from acute care facilities sooner than was the case previously, and thus there is the strong possibility that long-term care facilities are receiving more acutely ill persons than they did in the past. Furthermore, the acute care needs of the elderly are different from those of younger persons, and improved data regarding the use and costs of acute and long-term care services by the elderly could assist health care facilities and providers in planning for increased demands on them from the growing elderly population.
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Whereas between 1950 and 1980 the population age 65 and over more than doubled, the subpopulation age 85 and over quadrupled in that period, increasing in number from 577,000 in 1950 to 2.2 million in 1980. Inadequate provision has been made for developing information through national surveys for various subgroups of the elderly population.
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Accordingly, the Veterans Admi~istration will face the problems of increased health needs and costs. The data needs identified in this report for the elderly population are relevant for the Veterans Administration, modified by special conditions such as benefit entitlement provisions and availability of health care resources.
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In fact, many of the recommendations from the panel regarding data gaps, the need for longitudinal studies, and improved methodologies are relevant for both types of data sources, despite their differences. National systems can identify major characteristics of healthrelated problems and progress in dealing with them.
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From page 37... ...
also recognizes that cross-national and international studies that deal with the elderly can be a valuable source of informotion. Examination of the characteristics of the elderly in countries with different risks for disease, different lifestyles, and different health care systems contribute to a better understanding of factors that affect health status, utilization, and expenditures for health care of the elderly in the United States.
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From page 38... ...
Valuable as the three types of data sources discussed are for policy makers, the proving ground for determining the effectiveness of alternative proposals to meet the health care needs of the elderly is demonstration programs with evaluation components. The Health Care Financing Administration has funded projects that test the cost-effectiveness of community-based case management approaches for altering dependence on nursing homes among the elderly and has introduced waivers of restriction in Medicare and Medicaid benefits to assess the value of coordinated long-term care through capitation reimbursement.
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