April 2006

Elder health crisis ‑‑ and opportunity

by Robert H. Blanks, PhD, president, Research and Clinical Science

There have been several major events over the past few years that should cause every chiropractor and chiropractic patient advocate to stop and take a sobering look at the current health care crisis and the run‑away cost of Medicare. Even in such a developing crisis, there is an opportunity for the profession to help policy makers face the challenge of understanding and managing future Medicare spending. My article this month examines the crisis and the resulting opportunities.

The first major event was actually the passage of the Medicare Drug Improvement and Modernization Act of 2003, also known as the Medicare Modernization Act (MMA) that went into effect January 1, 2006. This complex series of three new provisions to the Medicare Act provides major cost savings for Medicare eligible individuals, particularly as a result of the first‑time coverage of prescription medications. While this provides a substantial cost savings for the insured, the added cost for the new provisions to the government are staggering. Under current projections, the cost of Medicare will rise from 2.6 percent of the gross domestic product to about 9.2 percent in 2050 according to many experts.

The second event is the impact of four studies by investigators at the RAND Corporation [1‑4] that vividly characterize the negative impact on Medicare costs from the unfavorable demographics resulting from the first wave of baby boomers turning 65 years old in 2010. The key findings of their reports, and their serious implications for future Medicare spending, are summarized as 1) Medical innovations will result in better health and longer life, but they will likely increase, not decrease, Medicare spending in the future, 2) Eliminating any one disease will not save Medicare money, and 3) Obesity might be an important exception to this rule but the full economic impact of obesity on health and Medicare costs needs to be determined.

The RAND team was composed of economists and physicians from the RAND Corporation, Stanford University, and the representatives from the Veterans Affairs Greater Los Angeles Healthcare System. They explored changes in health technology, disease care, and disability spending in relation to Medicare spending practices, and then developed a predictive model about Medicare cost using three scenarios 1) assuming continued improvement in the health status of the elderly, 2) assumes the new cohorts entering the Medicare system have the same health status as the old (1990) cohort, and 3) uses information about the younger (and healthier) cohorts. Their FEM (Future Elderly Model) utilized a representative sample of approximately 100,000 Medicare beneficiaries age 65 and older drawn from the Medicare Current Beneficiary Surveys. Results of the model, summarized below, produced the sobering realizations about cost and how these are impacted (or not impacted) by patient health status, patient life expectancy, disease states, and medical innovation.

How might the health status of the elderly affect Medicare spending? In spite of the fact that the health of the population over age 65 has been improving since 1980, there has been an alarming increase in obesity and diabetes among younger cohorts that will soon off‑set these earlier accomplishments. The increases in disability among younger individuals suggest that future Medicare beneficiaries might be less healthy than current ones. The RAND team found that lower disability rates do translate into lower health care costs per beneficiary. However, total Medicare spending under the three scenarios test by the model (see above) does not differ much, and even the most optimistic assumptions about cost savings in healthier population are only about six percent. They conclude that cumulative Medicare spending is relatively unaffected by the health status of new beneficiaries because healthier people live longer. Thus, they have more years in which to accumulate costs.

How might technological innovation affect Medicare spending? The RAND team developed a detailed cost/benefit analysis of medical technology innovation across 10 of the top disease entities (e.g., cardiovascular disease, cancer, aging, neurological disease, etc. ). It revealed that whereas the new technologies improve health status and quality of life, the cost per additional year of life is significant and adds substantially to overall costs to Medicare. Thus, some technologies improve health and survivability but at a very high price (e.g., intra‑ventricular defibrillators at a cost of $132,000 per additional year of life and total projected treatment costs of $14 billion in 2015. Other technologies have modest costs per additional life year (e.g., $11,000 per additional year of life), but they increase health care spending substantially because they would be utilized by a substantially greater percentage of the Medicare population. In particular, the anti‑aging compounds (drugs to increase life expectancy) underscore the conflict inherent in medical innovations; they keep people alive longer, but as a result, people incur more health care costs.

Does reducing chronic illness affect Medicare spending? In short, the RAND team predicts that there is only a modest cost savings to Medicare by reducing the incidence of chronic illness. To be sure, chronic illness such as heart disease, cancer, and diabetes are expensive to treat and they affect life expectancy. The reduction in life expectancy ranges from 0.3 years for a beneficiary with hypertension to about three years for a beneficiary with stroke or diabetes. All of these chronic diseases increase annual health care costs over the life of the insured compared to individuals without the disease. The increase in cost with disease is only modest and is often offset by the fact that the chronically ill live fewer years. Thus, whereas many of the chronic diseases are preventable or their burden can be greatly reduced, their prevention has only modest effect on Medicare's future health care costs.

However, what about obesity? Obesity is a serious health risk for heart disease, type II diabetes, stroke, and other ailments, and its occurrence is on the rise in the United States. The RAND team concluded that obesity produces a double threat for Medicare because it raises annual health care expenditures but does not affect patient longevity and thereby the number of years spent in the Medicare system. They concluded that obese seniors will spend on average 40% more time disabled than their normal weight counterparts, and the life expectancy of a 70 year‑old obese patient is no different than one of normal weight.

Could the generalized use of chiropractic wellness care save money for Medicare? The answer to this question is likely yes, as summarized recently by Kent. [5] The problem is how to impact the necessary changes to generalize the chiropractic wellness culture.

Chiropractors should be aware of the results of several patient‑based studies suggesting that chiropractic care may result in significant savings of health care dollars among Medicare‑eligible patients. An analysis of an insurance database comparing patients over 75 receiving regular chiropractic care vs. those not receiving care [6] demonstrated that those receiving regular chiropractic care reported better overall health, spent fewer days in hospitals and nursing homes, used fewer prescription drugs, and were more active than non‑chiropractic patients. Furthermore, the chiropractic group reported 21% less time in hospitals over the previous three years.

Similarly, very favorable results were obtained from another study of patients, ages 65 and older, who received chiropractic care for five years or longer. The chiropractic patients reported spending only 31% of the national average for health care services compared with US citizens of the same age. [7] Moreover, the chiropractic patients in this study experienced 50% fewer medical provider visits and better overall health lifestyle behaviors than the general population, including decreased use of cigarettes.

Moreover, a recent study employing sophisticated structural equation modeling on a data set of quality of life data from 2,818 patients undergoing Network Spinal Analysis demonstrated a distributed chiropractic benefit on self‑reported health [8, 9, 10] in patients undergoing care an average of 21 months. The statistical term "distributed" means that chiropractic had both direct and indirect influences on self‑reported health and health behaviors.

The direct influences (benefits) were an improvement in physical symptoms (15% average improvement), mental/emotional status (17% average improvement), stress evaluation (20% average improvement), and overall life enjoyment (17% average improvement). The indirect influences (benefits) were accrued due to favorable changes in patient health risk behavior (8% decrease in smoking, 26% decrease in caffeine consumption), favorable changes in dietary practices (39% increase in vegetarian diet, 45% increase in vitamin use, 46% increase in organic food consumption), and major improvement in health lifestyle behaviors (46% increase in exercise, 20% increase in Tai Chi/Yoga, 48% increase in meditation, and 46% increase in relaxation techniques).

Although additional studies will be important to establish causality and to examine subpopulations, etc., this study provides good evidence that wellness care provided by doctors of chiropractic can improve patient‑reported quality‑of‑life, improve health behaviors, and may reduce health care costs.

The question remains...why could chiropractic be successful in substantially lowering Medicare costs when the RAND team concluded that many factors (improved health technology, disease care, and disability spending) are predicted to show little or no impact on health costs? I think the answer lies in the fact that patients undergoing a chiropractic wellness care program have undergone favorable changes in their health behavior (e.g., better food choices, exercise, meditation and stress reduction utilization), impacting also the obesity issue, and not simply symptom reduction. By modifying their health behavior, their utilization of the health system is substantially lower (as evidenced above) by fewer days in hospitals and nursing homes, fewer prescription drugs, and fewer medical provider visits. Lower health care utilization converts to lower overall health care costs.

The challenge in the next phase of our research will be to acquire sufficient data on populations undergoing chiropractic wellness care to examine the economic impact of the chiropractic lifestyle on the FEM (Future Elderly Model) as employed by the RAND research team.

References

1. Goldman DP, Shang B, Bhattacharya J, Garber AM, Hurd M, Joyce GF, Lakdawalla D, Panis C, Skekelle P. "Consequences of Health Trends and Medical Innovation for the Elderly of the Future." Health Affairs ‑‑ Web Exclusive, Sept 26, 2005, pp. W5‑R3‑W‑R15.

2. Matsui D, Newberry S, Panis C, Shang B. "Health Status and Medical Treatment of the Future Elderly: Final Report," RAND Corporation, TR‑169‑CMS, 2004.

3. Joyce GF, Keeler EB, Shang B, Goldman DP. "The lifetime Burden of Chronic Disease among the Elderly." Health Affairs ‑‑ Web Exclusive, September 26, 2005, pp. W5‑R16‑W5‑R27.

4. Lakdawalla DN, Goldman DP, Shang B. "The Health and Cost Consequences of Obesity Among the Future Elderly." Health Affairs ‑‑ Web Exclusive, September 26, 2005, pp. W5‑R28‑W5‑R39.

5. Coulter ID, Hurwitz EL, Aronow HU, et al, "Chiropractic patients in a comprehensive home‑based geriatric assessment, follow‑up and health promotion program." Topics in Clinical Chiropractic 1996:3(2):46.

6. Rupert RL, Manello D, Sandefur R. "Maintenance care: health promotion services administered to the US chiropractic patients aged 65 and older, Part I." Journal of Manipulative and Physiological Therapeutics 2000;23(1):10.

7. Kent C. "How chiropractic wellness care can improve your quality of life and save you money." The Chiropractic Journal, March 2004.

8. Blanks RHI, Schuster TL, Dobson M. "A retrospective assessment of Network care using a survey of self‑reported health, wellness and quality of life." Journal of Vertebral Subluxation Research 1997;1(4):15.

9. Schuster TL, Dobson M, Jaregui M, Blanks RHI. "Wellness Lifestyles 1: A Theoretical Framework Linking Wellness, Health Lifestyles, and Complementary and Alternative Medicine." J. Alternative and Complementary Med. 2004;10(2):349‑356.

10. Schuster TL, Dobson M, Jaregui M, Blanks RHI. "Wellness lifestyles II: Modeling Relationships Between Wellness, Health Lifestyle Practices, and Network Spinal Analysis." J. Alternative and Complementary Med. 2004;10(2):357‑368.

11. Schuster et al, 2004

12. Schuster et al, 2004

(RCS co‑founder and President Dr. Robert Blanks is Professor in the Department of Biomedical Sciences at Florida Atlantic University and a past Professor of Anatomy and Neurobiology at the University of California, Irvine. Prior to this he spent two years at the Max Planck Institute for Brain Research in Frankfurt, Germany and two years in the Department of Anatomy at Harvard Medical School. Dr. Blanks is on the Advisory Board of the International Spinal Health Institute, is a Board Member of the Council on Chiropractic Practice and is actively involved in chiropractic research. To learn more about health outcomes research and RCS, call 800‑909‑1354 or 480‑303‑1694.)