People often say that the patients most at risk in the U.S. health system are the elderly who suffer from multiple chronic diseases. But it may be that a subset of these seniors—those with chronic disease who also need personal assistance with routine activities—are in the most jeopardy.
An important 2011 research paper finds they are the most costly to care for. Only about 15 percent of the total Medicare population suffers from 3 or more chronic diseases and faces functional limitations. But these very frail–mostly elderly–people account for 32 percent all Medicare spending, according to Harriet Komisar and Judy Feder of Georgetown University (Judy is also a colleague of mine at The Urban Institute).
On average, Medicare spent almost $16,000 on these people in 2006, twice as much as the system spent on those who had 3 or more chronic diseases but did not need assistance with daily activities such as bathing, eating, or going to the bathroom.
Medicare spends nearly twice as much for these very frail enrollees on hospital care, almost nine times as much for care in skilled nursing facilities, and almost six times as much for home health care as those with chronic conditions only. Of their average $16,000 in annual Medicare costs, 40 percent was for hospital and skilled nursing facility care—care that might have been unnecessary had they had sufficient help with personal assistance.
Keep in mind that these costs are for Medicare only. But Judy and Harriet found that about 43 percent of the very frail received both Medicare and Medicaid benefits. Because Medicaid—not Medicare– pays for the personal assistance for these “dual eligibles,” the research excluded those costs. For instance, the study looked at costs in a skilled nursing facility—covered by Medicare—but not long-term stays in a nursing home, which are not (though they may be covered by Medicaid).
Overall Medicaid spends $120 billion on long-term care services for the frail elderly and younger adults with disabilities.
Judy and Harriet conclude that these high costs are a major reason why it is important to coordinate medical and long-term care services for these patients. While they focused on costs only, it is likely that providing better, more coordinated overall care would not save money but improve these patients’ quality of life. After all, preventable events such as falls and infections, or poorly managed diseases such as congestive heart failure or diabetes may be driving these costs.
People who need help with activities of daily living—many of whom have dementia or some other cognitive impairment—are especially at risk for events such as these.
Managed care has a bad reputation among many, largely as a result of the HMO experiments of the 1990s. But whether you call it integrated care, coordinated care, organized care, or managed care, well-structured linkages between medical treatment and long-term care services and supports are critically important for the frail elderly.
The Affordable Care Act includes important experiments aimed at achieving that goal. In many ways, these are the law’s most far-reaching initiatives. Judy and Harriet’s paper is more evidence of why.
[…] The frail elderly, who have both multiple chronic diseases and personal care needs, are both the most expensive and the most difficult to care […]
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