Want to know if an older adult is likely to use lots of medical care? Just ask if she needs help with living activities such as bathing, dressing, or getting out of bed.

In a new study with important implications for both caregivers and policymakers, researchers at the Long-Term Quality Alliance (LTQA) found that Medicare spends an average of three times as much on an older adult who has these functional limitations than on a senior who does not. Even after adjusting for age, the number of chronic conditions, or Medicaid eligibility, the pattern is the same: If you have severe functional limitations or cognitive impairments such as dementia, Medicare will spend far more on your medical care than if you do not. Earlier studies, including one in 2011 by Judy Feder and Harriet Komisar reached similar conclusions.

Striking results

This study is important because it highlights the consequences of the flawed way we care for older adults:  Medicare does not pay for personal assistance yet those who need it are likely to be very high users of medical care, which Medicare does pay for. The study results imply that we could reduce Medicare’s medical costs if we provide cost-effective personal care for older adults.

The numbers are striking: In 2011, Medicare spent an average of about $7,100 on enrollees who had no need for long-term supports and services but about $20,200 for older adults who needed significant help with personal care and were living at home.

Since people who need supports and services tend to be older, the researchers broke down their analysis by age. The pattern was the same: Medicare spent an average of $5,300 on people age 65-74 with no need (or low levels of need) for personal assistance but nearly $19,500 on those living in the community who did need help with daily activities. For those aged 80 and over, Medicare spent about $10,000 on those without personal care needs and more than $21,000 on those living at home who did need assistance.

Not just dual eligibles

The study also looked at whether the story changed for those dually enrolled in both Medicare and Medicaid. While the variation of spending was somewhat different, the basic story was the same. Among those living at home, Medicare spent nearly three times as much for non-Medicaid recipients with personal care needs (roughly $19,800 v. $6,600). For those on Medicaid, Medicare spent a bit less than twice as much for those who needed help with daily activities ($21,100 v. $11,200).

This suggests that policymakers who are looking for ways to better integrate long-term supports and services with medical costs need to broaden their focus beyond just those on both Medicaid and Medicare. Until now, almost all policy initiatives have been focused on those dual-eligibles.

This study shows that looking for ways to provide personal assistance to those eligible for Medicare only may also be a fruitful way to reduce program costs. It suggests that policy changes such as the Senate-passed bill called the CHRONIC Act, which for the first time would allow Medicare to provide some supports and services, may be one way to go.

For data geeks, a quick word on the study:  It was based on fee-for-service care only, thus excluded Medicare managed care. It matched Medicare claims with the National Health and Aging Trends Study (NHATS) for 2011. It defined those with personal care needs as those who need assistance with two or more Activities of Daily Living (such as bathing, dressing, toileting, eating, and transferring). This is roughly equal to a level of need that would trigger private long-term care insurance or Medicaid benefits.

The LTQA study is the latest evidence that dividing personal care and medical treatment raises health care costs. And it suggests we ought to keep looking for ways to better integrate care, which could both save money and improve people’s quality of life.

Full disclosure: I served as an unpaid member of the technical panel that helped design this study.