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[109 Senate Hearings]
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S. Hrg. 109-228
SAVING DOLLARS, SAVING LIVES: THE IMPORTANCE OF PREVENTION IN CURING
MEDICARE
=======================================================================
HEARING
before the
SPECIAL COMMITTEE ON AGING
UNITED STATES SENATE
ONE HUNDRED NINTH CONGRESS
FIRST SESSION
__________
WASHINGTON, DC
__________
JUNE 30, 2005
__________
Serial No. 109-11
Printed for the use of the Special Committee on Aging
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SPECIAL COMMITTEE ON AGING
GORDON SMITH, Oregon, Chairman
RICHARD SHELBY, Alabama HERB KOHL, Wisconsin
SUSAN COLLINS, Maine JAMES M. JEFFORDS, Vermont
JAMES M. TALENT, Missouri RUSSELL D. FEINGOLD, Wisconsin
ELIZABETH DOLE, North Carolina RON WYDEN, Oregon
MEL MARTINEZ, Florida BLANCHE L. LINCOLN, Arkansas
LARRY E. CRAIG, Idaho EVAN BAYH, Indiana
RICK SANTORUM, Pennsylvania THOMAS R. CARPER, Delaware
CONRAD BURNS, Montana BILL NELSON, Florida
LAMAR ALEXANDER, Tennessee HILLARY RODHAM CLINTON, New York
JIM DEMINT, South Carolina
Catherine Finley, Staff Director
Julie Cohen, Ranking Member Staff Director
(ii)
C O N T E N T S
----------
Page
Opening Statement of Senator Herb Kohl........................... 1
Opening Statement of Senator Gordon Smith........................ 3
Opening Statement of Senator Ron Wyden........................... 4
Panel I
Douglas Holtz-Eakin, director, Congressional Budget Office,
Washington DC.................................................. 5
Panel II
Dr. William Evans, director of Nutrition, Metabolism, and
Exercise Laboratory, Donald W. Reynolds Institute on Aging,
University of Arkansas for Medical Services, Little Rock, AR... 33
Bill Herman, vice president of Human Resources, Highsmith, Inc.,
Fort Atkinson, WI.............................................. 41
Stephen J. Brown, president and CEO, Health Hero Network, Inc.,
Mountain View, CA.............................................. 46
Steven H. Woolf, professor, Departments of Family Medicine,
Epidemiology and Community Health, Virginia Commonwealth
University, Fairfax, VA........................................ 72
APPENDIX
Prepared Statement of Senator James Talent....................... 95
Questions from Senator Blanche Lincoln for Mr. Evans............. 95
(iii)
SAVING DOLLARS, SAVING LIVES: THE IMPORTANCE OF PREVENTION IN CURING
MEDICARE
---------- --
THURSDAY, JUNE 30, 2005
U.S. Senate,
Special Committee on Aging,
Washington, DC
The committee met, pursuant to notice, at 10:03 a.m., in
room SH-216, Hart Senate Office Building, Hon. Herb Kohl,
presiding.
Present: Senators Smith, Talent, Kohl, Wyden, and Lincoln.
OPENING STATEMENT OF SENATOR HERB KOHL
Senator Kohl [presiding]. This hearing will come to order,
and we welcome you all here today, where we will explore ways
to contain growth in Medicare spending by helping seniors lead
healthier lives.
As always, we thank our Chairman, Senator Gordon Smith, for
working with us in a bipartisan manner to examine issues
affecting seniors. It is not secret that the Federal Government
will face fiscal challenges as the Baby Boomers begin to retire
and become eligible for Medicare.
From the year 2000 to 2030, the number of people on
Medicare will nearly double from 40 million to 78 million. In
fact, in the next 25 years, Federal spending on Medicare,
Medicaid, and Social Security will almost equal what we now
spend on the entire Federal Government.
So we know these costs are looming and yet our nation
remains woefully unprepared. Net Federal spending on Medicare
was more than $300 billion in 2004. But what many people don't
know is that a small share of Medicare beneficiaries account
for a very large share of total Medicare spending.
Just 10 million of the 40 million Medicare beneficiaries
account for 85 to 90 percent of the program's costs every year.
As we will hear today, much of this spending is for
patients suffering from multiple chronic diseases. Studies show
that Medicare spends 2 out of every 3 dollars on people with
five or more chronic conditions, such as diabetes, emphysema,
heart disease, arthritis, or osteoporosis.
These chronic conditions are largely preventable,
treatable, and their onset can often be delayed through proper
nutrition and exercise. At a time when our nation is growing
older, it is clear that the successes we have in preventing
chronic diseases will directly affect our ability to contain
future growth in Medicare spending.
We need to get the word out that prevention is not
something that only children and younger adults can benefit
from. Seniors need to understand that it is never too late to
benefit from a healthier lifestyle.
It is also important to note that this not just a challenge
for the Federal Government. Rising health care costs will
continue to be an issue for all American families and
businesses, and so we need more prevention, nutrition, and
exercise by younger generations also.
Today, we will hear from Bill Herman from Highsmith,
Incorporated, a company in Fort Atkinson, WI, on their award-
winning prevention programs to keep their employees healthy and
their insurance costs low.
This makes sense for businesses, but also for our country,
for, after all, unless we find a way to prevent and treat
chronic diseases early on, Medicare will inherit even more
costly problems as more people join the program.
I am pleased to have the director of the Congressional
Budget Office here today to present CBO's recent report on
Medicare High-Cost Beneficiaries.
We also look forward to hearing from our second panel of
witnesses who will discuss ways to successfully prevent and
affordably treat chronic diseases.
In particular, we need to find ways to educate seniors and
boomers that it is never too late to change their lifestyle and
improve their health and improve Medicare's finances at the
same time.
We need to make sure that seniors know about the preventive
benefits that Medicare offers and why they are so important to
take advantage of.
We should look for ways to use technology to give seniors
and health providers more tools to take control of their
health.
We know that many of the Senators on this committee share
this concern for skyrocketing costs of health care,
particularly Medicare. We know that we will all take away some
good recommendations from today's hearing, and continue working
together to stem this growing problem.
So, again, we thank everyone for their participation here
today, and now turn to our Chairman, Gordon Smith, for his
opening remarks.
OPENING STATEMENT OF SENATOR GORDON H. SMITH, CHAIRMAN
The Chairman. Thank you, Senator Kohl, and thank you for
arranging this hearing on such a vital topic. Today's hearing
is, as he has stated very well on the importance of prevention
in helping to slow the growth of Medicare spending. We have two
excellent panels of witnesses today, and I will look forward to
a productive discussion.
Over 40 million elderly and disabled Americans rely on
Medicare for their health care coverage. In 2004, total
Medicare spending exceeded $300 billion and is expected to grow
significantly in the coming decades as the Boomer Generation
approaches retirement.
With this impending challenge, we must find ways to control
the growth of Medicare spending if we are to preserve this
critically important part of our health care safety net for our
seniors and the disabled.
It is vital that we identify where spending is the greatest
under Medicare and develop comprehensive strategies in which to
lower expenditures in these areas. A May 2005 Congressional
Budget Office report, which this hearing will examine, may have
identified one such area. According to the report, a relatively
small group of high-cost Medicare beneficiaries account for a
large share of the program spending.
According to CBO, only 10 million of the 40 million
Medicare beneficiaries account for 90 percent of the program's
cost.
Further, three-quarters of these 10 million high-cost
beneficiaries suffer from multiple chronic diseases, such as
diabetes, emphysema, heart disease and stroke, arthritis, and
osteoporosis.
Such diseases require extensive care and often serve as the
catalyst for many other conditions and ailments. Many of these
chronic conditions are preventable through a regimen of proper
nutrition and exercise.
Additionally, the cost of treating these conditions can be
significantly reduced by the implementation of chronic disease
management programs.
That is why this hearing will also examine some innovative
technologies currently being used by institutional health care
providers, such as the Veterans' Administration, to monitor and
manage high cost patients more efficiently. Our ability to
prevent and affordable treat chronic disease is key to our
ability to contain the anticipated growth in Medicare spending.
So I thank all of our witnesses for coming today to discuss
this issue, and look forward to the testimonies. Thank you.
Senator Kohl. Thank you very much. Senator Smith, we also
have with us the other Senator from Oregon, Ron Wyden.
OPENING STATEMENT OF SENATOR RON WYDEN
Senator Wyden. Thank you very much. I want to commend both
of you. I think this is an excellent topic, and I thank you,
both, for your leadership.
What I think is so striking about this is that for all
practical purposes the Federal Government doesn't run health
care programs. What the Federal Government does is run sick
care programs, and probably nothing shows it more graphically
than the topic that we are going to examine today under the
leadership of my two friends and colleagues.
The Federal Government is going to spend a boatload of
money for what is essentially a chronic care program. That is
what Medicare has become today, and that is what Mr. Holtz-
Eakin and his capable folks document, you know, once more.
What is so striking is that if you look at the two parts of
Medicare, Part A of Medicare will pay an astounding sum for
essentially institutional care. What Senator Smith and I see in
our state is essentially the insurance carrier that runs
Medicare for our state will write out a check for $40,000,
$50,000, some prodigious sum of money, for a seniors hospital
coverage under Part A, and then there will be very little spent
on prevention under the outpatient portion of Medicare Part B.
Senator Kohl is absolutely right. There is a little bit of
coverage. We got to do a better job of getting the word out
about those preventive benefits under Part B. I really hope
that as we work together on a bipartisan basis and have the
very valuable assistance, Mr. Holtz-Eakin, that we can
essentially revamp this program. Let us do a better job of
targeting the resources where they are most needed, which is
essentially what Senator Kohl and Senator Smith have said in
terms of chronic care, and then let us do a better job of
prevention so that we are not always playing catch-up ball
under Part A when somebody is flat on their back in the
hospital.
I want my two colleagues to know that as part of the
bipartisan legislation that Orrin Hatch and I have written, the
Health Care that Works for All Americans Act, which, in effect,
will kick in this October when the information about health
care spending goes online, and we start walking the country
through the choices, that I really want to see that law follow
up on the good work that you have done, Senator Kohl and
Senator Smith. It is an important hearing. Thank you, both,
Senators. Mr. Holtz-Eakin has worked with my office on a
variety of issues, and we appreciate all his cooperation as
well, and I look forward to the testimony.
Senator Kohl. Thank you very much, Senator Wyden.
We are pleased to welcome our first witness, Dr. Douglas
Holtz-Eakin, director of the Congressional Budget Office.
Dr. Holtz-Eakin was appointed to a 4-year term in 2003;
previously served for 18 months as chief economist for the
President's Council on Economic Advisors, where he also served
as the senior staff economist in 1989 and 1990.
So we are very pleased that you are here, and we welcome
your testimony.
STATEMENT OF MR. DOUGLAS HOLTZ-EAKIN, DIRECTOR, CONGRESSIONAL
BUDGET OFFICE, WASHINGTON, DC
Mr. Holtz-Eakin. Well, thank you, Senator Kohl. Thank you,
Chairman Smith, Senator Wyden.
I am pleased that the CBO could be here to talk about our
report, and this important issue. The starting point, as has
already been mentioned by both the Chairman and Senator Kohl is
the concentration of Medicare spending among a very few
beneficiaries.
In 2001, the data in the report show that 25 percent of the
beneficiaries accounted for 85 percent of Medicare spending. It
is useful to note that this is not unique to Medicare. National
health spending has the same character, actually a bit more
concentrated. This is the kind of pattern one would expect in
an insurance program, where a relatively small number of
claimants in any year would account for the bulk of the
spending.
But it does raise some questions and possibilities. First,
of course, is, ``Can we save some Medicare costs in examining
this?'' Is it possible that these are always the same people? I
mean, we use 2001, but could it be the same people every year;
and if so, is there a way to address their health so that they
are either less expensive to begin with or are less expensive
to Medicare in the future in some way.
The report tries to take a look at this. The second figure
that we look at examines the question of whether these are, in
fact, the same people put differently, is there some
persistence in these expenditures from year to year?
What we do is try to track the high cost Medicare
beneficiaries, those in the top 25 percent, over time. The
graph that we have in front of you and is on the screens shows
the high-cost folks in 1997, and then looks back a few years to
what they were costing before that, and then follows them for
years after 1997 up to 2001 to see what the expenditure looks
like.
The dark bar represents this group, and what you can see is
that it ramps up prior to 1997. They were high cost in 1997,
but they were accelerating in their costs prior to that, and
then ramping down past 1997. This is consistent with a pattern
that you would expect--one in which there are some acute care
expenses. Someone breaks a leg and has an episode of high
costs, but it goes away. Another part of the mixture is
chronic, ongoing expenditures for the kinds of chronic care
they might require. It is also important to note a key feature
of the post-97 experience, which is the large fraction of these
beneficiaries who are close to death, and indeed die in the
years thereafter. That pattern is consistent with about 25
percent of the spending each year that goes to those in the
last year of life.
Now, where are these costs coming from? If we go to the
third figure, they are coming from the fact that, while these
high-cost beneficiaries do the same things that other people
do--they go to the doctor, for example--they are much more
likely to do other things--go to the emergency room, have a
hospital admission, or be in a skilled nursing facility.
Regardless of which of those things they are involved in, they
tend to use more services at the same time. So they have a
greater propensity to have all those events than in the
population as a whole.
This raises the question, could we identify these
individuals and prevent in some way, either their entry into
these expensive episodes or lower the utilization given that
you might have an entry.
One issue we addressed in our report--and I won't go into
it--is sort of whether you could just look at them on the basis
of their demography and say these are likely to be the high
cost folks. The answer is pretty much no. Although they are a
bit older, they don't stand out in any other particular way.
If you look at their health, however, a key feature is the
presence of chronic conditions, particularly multiple chronic
conditions, where compared to the typical population, 75
percent have one or more chronic conditions versus about 40
percent in the rest of the population. About half of them have
two or more for sure.
So that does stand out. So that becomes one of a series of
illustrative strategies that we used in the report to see if we
could identify high-cost Medicare beneficiaries. That is the
final slide, where we took three that we thought of as stylized
strategies that one might undertake to pick out who is going to
be expensive in the future. Take a person who has multiple
chronic conditions and then see how they turn out. Look at
someone who has had a hospital admission and then track them.
Or look at someone who is simply very expensive in the
beginning year and see if they continue to be expensive in the
years thereafter.
What the slide shows is a comparison of those groups versus
a random sample of Medicare beneficiaries. We look at them in
initial year, 1997; identify them using one of these
strategies; and then see if we could predict that they would be
more costly in the years to come on the basis of that
identification.
Indeed, to some extent, this appears to be the case. It is
suggestive that this kind of strategy might be successful in
identifying high-cost beneficiaries.
Compared to the control group, each has greater spending
certainly in the base year, but also in subsequent years. For
those who get admitted to the hospital or who are expensive,
you see a bigger drop off. For those who have the chronic
conditions, their spending drops off less. It tends to stay
elevated in the years thereafter.
Now, the final question, of course, is whether this would
allow the Medicare program to somehow control their costs in
the future, and there it raises the hope that something like a
disease management program might be successful in reducing
overall costs. We can come back to this in the discussion
later, but I think that the things that I would note at this
point are that disease management means different things to
different people. There is a variety of different elements of
either education or patient monitoring and, thus, practice, or
care coordination, or case management. So exactly what goes
into disease management is not always the same. It is worth
investigating that.
Asking whether it works is really a question of first
comprehensively measuring costs over the entire future of a
patient's experience and comparing that to a comparable patient
without the disease management. That is a high scientific
standard. None of the work that we have examined to date meets
exactly that standard and at each point stepping down the
standards, you have to ask whether we have got the evidence we
need.
Then finally, even if this strategy works, the important
issue for this committee is a tradeoff in costs. It may be the
case that some sort of preventive disease management program
will work for Medicare beneficiaries--in the sense that it will
lower costs other than what they would have been--but it will
be costly to identify the people who enter into such a program
out of large population of seniors. The question is whether it
is cost effective in both senses. You may spend so much finding
the folks that will ultimately benefit from disease management
that you overwhelm any cost saving you would get from putting
them in the program.
Those are the two elements of the decision, and that is the
difficult design issue that would face someone trying to put
this into place in the Medicare population as a whole.
So we are pleased to be here. That is the high speed
overview of the report. I will be happy to answer your
questions and pursue it any way you like. Thank you.
Senator Kohl. Well, thank you. I am curious with respect to
your opinion on the following thought: are there people who
have some chronic conditions who use the system--and we are
talking about them now--and to a great extent those are the
ones who--the 25 percent who cost us 85 to 90 percent of
Medicare, but others who are seniors who have similar
conditions who just do not check in that often, use the system
that much, manage to deal with these problems in a way that
doesn't require them to be so involved with Medicare?
Mr. Holtz-Eakin. There are certainly those who would have
one of our list of seven chronic conditions. Diabetes stands
out. Among the high cost beneficiaries are those with diabetes.
However, if you look in the low-cost population, there are lots
of folks with diabetes as well, three times as many, in fact.
So it is not the case that if you are diabetic, you are
automatically high cost, and it is not the case that if you
have one of our chronic conditions, you always--you
inevitably--end up there. They are in both populations. This
goes to the last point I made, which is that you have to be
able to find the diabetic who will benefit from some sort of
intervention to lower costs.
Senator Kohl. But is it true that there may be two similar
people who are seniors who have conditions that are not
entirely dissimilar?
Mr. Holtz-Eakin. Oh, yes.
Senator Kohl. One will access the system an awful lot and
prove costly in a dollar and sense way. The other one will
access the system an awful lot less and be less costly, just
because they are a different kind of individuals.
Mr. Holtz-Eakin. Certainly, and we could probably go into
the data that we used for this report and find people with
chronic conditions and show you the averages on both sides of
that observation.
Senator Kohl. All right. Thank you. Senator Smith.
The Chairman. Doug, I am interested in whether or not you
all have factored in the impact of Part D, and what it might do
to Part A expenditures?
Mr. Holtz-Eakin. It is not the first time this has come up,
which is not surprising. We certainly have tried to look very
closely at the degree to which additional therapies in the form
of pharmaceuticals might lower costs elsewhere. But it is hard
to get that out of the data for a variety of reasons.
No. 1, the Part D really covered the costs of
pharmaceuticals. People were taking the drugs they needed
anyway in many cases, so you haven't really changed their
therapy in any deep way. So you wouldn't expect a change in the
costs. So that is sort of the major reason.
The Chairman. OK. I understood in your testimony that where
there is simply private coverage and Medicare is not involved,
these same populations are still using those kind of resources?
Mr. Holtz-Eakin. Yes.
The Chairman. So probably not the savings we might hope
for?
Mr. Holtz-Eakin. No.
The Chairman. OK. Do you believe there is any benefit to
comparing data from Medicare managed care plans that employ
chronic disease management programs with the data you have
compiled for the fee-for-service programs? Are the Mr. Holtz-
Eakin. It is hard to imagine that it wouldn't be valuable to
compare them as long as you were careful about the comparisons.
You know the key issue is what constitutes the same kind of
group going in, and given that the people who chose to go into
the managed care versus the fee-for-service do so voluntarily,
they are, by definition, not identical. They have chosen
differently, and so you have to somehow get a handle on that
before you start doing comparisons across the groups.
Senator Kohl. Senator Wyden.
Senator Wyden. Thank you, Mr. Chairman, and I want to thank
Dr. Holtz-Eakin for excellent testimony.
I am curious what CBO has in terms of numbers as it relates
to spending on health care in the last 6 months of an
individual's life. You know there are constantly studies, you
know, thrown around on this point, and I am wondering, you
know, what, if anything, CBO uses as statistical documentation
on that point?
Mr. Holtz-Eakin. We rely on the Medicare claims data, so it
would be among those folks. For the numbers I have for this
hearing, we can try to see if there is more detail in the last
6 months or for the last year. Twenty-five percent of Medicare
spending is in the last year of life ballpark. So it is a
fairly substantial sum.
It is, of course, one of those backward looking
computations in that you don't know when the last year of life
will be necessarily. But looking back, those are the facts.
Senator Wyden. That will be an area I want to follow up
with you on as well for the Citizens' Health Care Working Group
because those issues, of course, were tough before the Terry
Schiavo case. They are now infinitely harder and my hope is
that we can find some common ground. Senator Smith and I have
introduced bipartisan legislation, the Conquering Pain Act, to
try to create some options for folks, but we will be anxious to
work with you on that.
I wanted to also explore with you a topic you and I have
talked about. Senator Sununu and I have been concerned about
the fact that public programs, programs like Medicaid, the
Public Health Service, the VA, are paying for prescription
costs, you know, advertising. In effect, those programs end up
getting shellacked, you know, twice. There are tax breaks for
the pharmaceutical folks to advertise on TV. Nobody is
quarreling with that, trying to take it away. But after that
expenditure is made with taxpayer money, then more money gets
spent for in effect like Medicaid to pay for all those purple
pills, you know, dancing across everybody's television set. So
we are trying to address this issue and obviously advertising
increases utilization of prescription drugs and, of course, the
program.
Let me ask it this way: The official sources on drug
advertising seems to be that the country spends between $3
billion and $5 billion a year on prescription drug advertising.
According to the bipartisan experts, after the Medicare drug
benefit kicks in, Medicaid is expected to be about 10 percent
of the prescription drug market. That seems to be a kind of
consensus recommendation.
So Senator Sununu and I are interested and working on the
language of this and would very much like your counsel so as to
focus on utilization and focus on market share. It is our sense
that if we do that, the government could save about $300
million to $500 million a year on Medicaid, in effect over a
billion dollars over a 5-year period.
Do you feel that that is essentially a reasonable kind of
analysis?
Mr. Holtz-Eakin. Yes, given that the language was tight
enough, that it could find a way to actually recoup the costs,
and that we can, you know, get a sense that the numbers are on
the mark. They certainly seem reasonable. Yes.
Senator Wyden. Well, I appreciate that, and I would like to
work with you on the language because I know that the way it is
framed so as to focus on utilization and market share is
really, really key, and if we could follow up with your
technical folks. They have been very helpful to us already.
This is a bipartisan bill, and I just point it out because we
have Chairman Smith here, and he has done excellent work on the
Medicaid program. He is trying to get $10 billion worth of
savings without hurting people on Medicaid, and I would just
like to make it clear for the record that Dr. Holtz-Eakin has
said we could get more than a 10 percent of the savings in the
target that Chairman Smith is looking at by the advertising
provisions along the lines of what Senator Sununu and I have
been talking about. So we will be anxious to follow up with
you, and we got to figure out how to save $10 billion on
Medicaid, and we all want to do it without hurting people. We
just on the record a way to in the ballpark to get 10 percent
of the money. That is what we ought to be trying to do is
sharpen our pencils.
Chairman Kohl, I thank you for this, and Dr. Holtz-Eakin
for all his analysis.
Mr. Holtz-Eakin. Thank you.
Senator Kohl. Thank you, Senator Wyden. We also have with
us this morning Senator Blanche Lincoln from Arkansas. Senator
Lincoln.
Senator Lincoln. Thank you. A special thanks to Senator
Smith and Senator Kohl. They have been tremendous leaders in
the Aging Committee, helping us focus on the important issues
that face this country, both financially as well as for all us
emotionally because one of these days we are all going to be
old. We are all aging, and we are grateful to both of you.
Mr. Holtz-Eakin, we should have you as an honorary member
of the committee. We have heard from you a great deal, and we
certainly appreciate all the work that you at CBO have done in
helping us realize that we can do a better job in administering
these programs, particularly for these high-cost beneficiaries.
I would urge you to take a look at legislation I have been
working on as well, S. 40, and would appreciate getting any
help with scoring it. I would love to work with CBO on a way to
ensure that a new Medicare benefit for geriatric assessment and
chronic care management of individuals with multiple chronic
conditions would save money to the program. I know in my own
personal experience with my father who went through a long
period with Alzheimer's, Disease with other diagnoses, I saw
how important it was to have coordination of all the medical
professionals, in treating his multiple chronic diseases.
Fortunately for us in Arkansas, we have the Don Reynolds Center
on Aging, which focuses on patients with multiple chronic
conditions and management of chronic illnesses, which makes all
the difference in the world. My constituents see a difference
when they go from visiting six or seven different health care
providers to a care team that manages all of these chronic
diseases together.
You said in your report that reducing spending among the
high-cost beneficiaries would ultimately rest on the ability to
devise and implement effective intervention strategies,
clinical or otherwise, to change beneficiary use of medical
services. I think that by giving an individual a geriatric
assessment, which assesses a person's medical condition,
functional and cognitive capacity, primary caregiver needs, and
environmental and psycho-social needs would go really a long
way toward reducing some of the unnecessary and expensive
medical services.
I just wanted to see what you thought about that in terms
of the research that you have done. Would that assessment be
beneficial and could it be helpful to us in saving financial
resources?
Mr. Holtz-Eakin. It is on the list of appealing strategies
that comes up all the time, and in that regard it always falls
to me to throw a little cold water on some of the hopes. The
first is that in many cases you could not see lower costs, but
it would still be worth it. You know, you are paying more and
people have better health for longer periods and function
better in their lives. That is not a cost saving issue, but it
is still a good step.
Then the second caveat I am compelled to offer is that
there isn't any systematic evidence to date that we can, in any
broad way, get a lot of savings out of the Medicare population
from this. That doesn't mean that it isn't true. It means that,
to the extent that researchers have gone and looked at to the
best of their ability groups with and without these kinds of
checkups or other services, you can't find a compelling
scientific case that the costs are lower for the group where
you have undertaken the new treatments. There are lots of
reasons why that might be the case, and I would be happy to
work with you on that.
But it is largely the difficulty in setting a high
scientific bar in a very difficult area. Most of the studies
just really aren't conclusive enough to feel confident that I
could say to you, ``Yes, this is a great idea and you will save
a lot of money.''
Senator Lincoln. Mm hmm. Well, I am not necessarily saying
that we have got to save all the money in that category, but if
we can do something that actually does help us in terms of
better use of our resources and providing better care, it seems
to me it is a no brainer that it is something we should
certainly be looking at.
So you are saying that there is no conclusive studies that
show that not only assessments but also the new medical
physical in the Medicare program, are cost effective. Is that
what you are saying?
Mr. Holtz-Eakin. Yes.
Senator Lincoln. You don't feel like those produce some
cost benefit?
Mr. Holtz-Eakin. There are two levels to it, and I will
give you a longer answer than you deserve for that reason.
The first is just at the level of the economics. Does it
save money? That is the kind of question where the research is
inconclusive at this point because it is difficult to actually
do the experiment you would like, which is give some people the
checkup, exactly identical people don't get the checkup, and
then track their health care costs from that point forward to
the end of their lives. Then just compare the two. That is just
not doable.
So there are a whole series of halfway houses in which the
scientists live that are short of that. They try to extrapolate
from their experience to that experiment that we can't do, and
that is just simply hard to do.
So the research, which we tried to survey pretty carefully
in a letter we wrote to then Senator Don Nickles, was really
about how difficult this is--to conclusively decide whether it
will save money. So that is No. 1.
No. 2 is, Will it show up on the Federal budget? If this is
really a good thing and it is saving money, it could be that
people are doing it already. If you then put it into the
Medicare Modernization Act, all you do is then cover the cost
of it. You put the cost on the Federal books, but you don't get
any of the savings because they were doing it anyway. So the
answer is a mixture of those two things. One, would it really
lower total economic costs in the health system? Two, would
those costs show up in lower Federal outlays?
That is why it is difficult to give really definitive
answers in this area for things that are otherwise very
appealing ideas.
Senator Lincoln. Thank you, Mr. Chairman.
Senator Kohl. Thank you, Senator Lincoln. Dr. Holtz-Eakin,
before we let you go, you are the director of CBO, so would you
place this into context versus Social Security, the costs for
which we do not have any sources of revenue over the next 50
years, one versus the other. It is our understanding that there
is no comparison in terms of Medicare versus Social Security.
Would you put that into context?
Mr. Holtz-Eakin. Certainly. There is no comparison, and I
have told many people that it is my job to say apocalyptic
things about our fiscal outlook in public, and this is really
how it sizes up. Right now we spend about four cents on a
national dollar on Social Security, a bit above. We spend about
four cents on our national dollar on Medicare and the Federal
share of Medicaid. So they are about even right now. If we
repeat the experience of the past 3 decades, over the next 50
years, and we layer in the demographics, Social Security will
rise from 4 to about 6\1/2\ cents. Medicare and Medicaid will
rise from 4 to 20 cents or the current size of the Federal
Government. It is not even close. The great spending pressures
are in the health programs.
Senator Kohl. So of all the problems fiscally that we are
facing in terms of Medicare, Medicaid, Social Security, this
Medicare-Medicaid is clearly the big elephant, the 800-pound
gorilla?
Mr. Holtz-Eakin. They are certainly the big Federal dollars
and they reflect the underlying growth of health care costs in
the United States. It is not just the programs. It is the
underlying health care system as a whole.
Senator Kohl. That is dramatic. Well, we thank you so much
for being here. You have been really important to this
Committee, and your experience and knowledge is invaluable, and
we look forward to continue to work with you.
The Chairman. Mr. Chairman?
Senator Kohl. Yes.
The Chairman. May I ask one other question. In light of
that and as we try to wrestle with how we get additional
revenues or how we find a way to meet this obligation, the
population that is using so much of the resources currently are
any of these chronic conditions the result of personal choices
that lead them to this, that would warrant that they bear some
greater portion of their own co-pay or something like that? I
mean
Mr. Holtz-Eakin. The seven we looked at, I will just run
down.
The Chairman. OK.
Mr. Holtz-Eakin. You know, they are asthma, obstructive
pulmonary disease, renal failure, congestive heart failure,
coronary artery disease, diabetes, and senility.
The Chairman. I am thinking of smoking. I am thinking of
you know some people would say alcoholism is not a choice. It
is a disease in itself. But a lot of these conditions, not all
of them, are taken on by people's individual choices and that
is not fair to everyone else who is making the right kind of
health choices.
Mr. Holtz-Eakin. Certainly, lifestyle figures in many of
these chronic conditions. I think that is clear. It is not the
sole determinant. But it certainly figures in that, and the
degree to which those lifestyles are altered as a matter of
choice would alter these outcomes.
The Chairman. Well, it seems to me people do respond to
incentives, and if there is an additional incentive to
lifestyle choices that like smoking, I would just I find it
repulsive to say to everyone else who is making the right
choices, you have got to pay for everybody making the wrong
choices, and I don't know. I am just thinking out loud.
Senator Lincoln. Can I add something to that?
The Chairman. Yeah.
Senator Lincoln. That is why I think the screening is so
important, because if it is something like alcoholism, the
earlier the screening and the earlier the diagnoses, the
treatment is less costly. So it would seem that the screening
and the other things that I think are so important, you are
saying that there is not a scientific ability to be able to
figure out what the cost savings would be for that, but I mean
just commonsense tells you that if you can treat an ailment
earlier, you can diagnose and treat it earlier, then the long-
term costs are not going to be as much.
But I understand your side. I am married to a research
physician, so I know there are scientific things that you have
to use, but, still, I think commonsense plays a little bit in
what we decide.
Mr. Holtz-Eakin. I am economist by training. I left
commonsense behind. I am an incentives guy.
Senator Kohl. Again, just to put this thing it its context,
would you agree that looking ahead at our fiscal condition, as
the director of CBO, perhaps the single most important
challenge we face is Medicare and trying to contain its
projected cost?
Mr. Holtz-Eakin. Yes. I think that the rising cost of
health care is the single most important domestic challenge the
United States has today. It is very simple.
Senator Kohl. Thank you very much.
Mr. Holtz-Eakin. Thank you.
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Senator Kohl. We will now call our second panel. The first
witness on the second panel is from Arkansas, and so we would
like to recognize Senator Lincoln to introduce her constituent.
Senator Lincoln. Well, thank you, Mr. Chairman, and as our
panelists are taking their seats, I have a real pleasure today
to introduce Dr. William J. Evans, who is director of the
Nutrition, Metabolism, and Exercise Laboratory in the Donald W.
Reynolds Institute on Aging at the University of Arkansas for
Medical Sciences, UAMS, where he is also a professor of
geriatric medicine, physiology, and nutrition.
Dr. Evans, I just have to say I routinely bring up the Don
Reynolds Institute on Aging and UAMS in this Committee and in
the Finance Committee, so I am so pleased that I now have a
representative from there who can speak to the tremendous work
that's going on in terms of the dealings with multiple disease
diagnosis and coordination of care.
Dr. Evans is also a research scientist in the Geriatric
Research, Education, and Clinical Center in the Central
Arkansas Veterans' Health Care System. He is author or co-
author of more than 190 publications and scientific journals.
His research has examined the powerful interaction between diet
and exercise in elderly people. Along with Dr. Erwin Rosenberg,
Evans is the author of Biomarkers: The Ten Determinants of
Aging That You Can Control, and the author of Astrofit.
His work has been featured in numerous newspapers,
including the New York Times, the Boston Globe, the Chicago
Tribune, as well as the CBS Evening News, CBS Morning Show, 20/
20, CNN, and the PBS Series, the Infinite Voyage.
His landmark studies have demonstrated the ability of older
men and women to improve strength, fitness, and health through
exercise, which we all want information for, even into the 10th
decade of life. I am not sure that he has met my husband's
grandmother, who is 108 this year, living out in Parkway
Village, Dr. Evans, so she is a great one to consult.
Dr. Evans receives grant support from the National
Institute of Health, the Veterans Administration, NASA, private
industry, and other sources. He is a fellow of the American
College of Sports Medicine, and the American College of
Nutrition, and an honorary member of the American Dietetic
Association.
I am enormously proud to be here to introduce you to Dr.
Evans and to share your wealth of knowledge with this Committee
and I thank the Chairman and the two Senators here, Chairman
Smith and Chairman Kohl.
Dr. Evans. Thank you Senator Lincoln. It is a real honor
and pleasure Senator Kohl. Thank you, and we will just go
through it, and then we will get to your testimony.
Senator Lincoln. Oh, good.
Senator Kohl. Our next will be Bill Herman who is vice
president of Human Resources at High Smith in Fort Atkins in
Wisconsin.
Highsmith has been nationally recognized for its innovative
employee wellness programs, and so we are pleased that Mr.
Herman is here today to share the keys to the success of his
company. Thank you so much for being here.
Senator Smith, would you like to welcome your guest?
The Chairman. Thank you, Mr. Chairman. It is my privilege
to welcome our next witness as well, Mr. Stephen J. Brown,
president and CEO of Health Hero Network, founded in 1988. His
company is a recognized leader in the development and
implementation of innovative technologies used to monitor or
manage traditionally high-cost patients.
Their technology is currently being used by a number of
institutional health care providers, including the Veterans'
Administration, to more efficiently manage patients with heart
failure, pulmonary cardiovascular disease, diabetes, asthma,
post acute care, mental health, and many other chronic
conditions.
Additionally, Health Hero Network and Bend Memorial Clinic
in Bend, OR, are partnering to see how this technology can be
used to coach and monitor Medicare patients with severe chronic
illness and prevent them from going to the hospital and
developing further complications.
So we thank you, Stephen for being here, and I look forward
to hearing more about your technologies.
Senator Kohl. Our final witness on this panel will be Dr.
Steven Woolf, professor of the Departments of Family Medicine,
Epidemiology, and Community Health at Virginia Commonwealth
University.
Dr. Woolf's career has focused on preventive medicine, and
he is a senior advisor to the Partnership for Prevention.
We welcome you all, and Mr. Evans we will start with your
testimony.
STATEMENT OF DR. WILLIAM EVANS, DIRECTOR OF NUTRITION,
METABOLISM, AND EXERCISE LABORATORY, DONALD W. REYNOLDS
INSTITUTE ON AGING, UNIVERSITY OF ARKANSAS FOR MEDICAL
SERVICES, LITTLE ROCK, AR
Dr. Evans. Thank you very much. It is a real honor to be
here.
I am in only the second department of geriatrics in the
United States, which is an indication of the relative lack of
attention toward geriatrics in this country, and it is only now
changing, and so we are very fortunate to be in this wonderful
new center.
As we know, attitudes toward aging have been around a very
long time. As Shakespeare describes the ages of man, he says
the second childishness and mere oblivion, sans teeth, sans
eyes, sans tastes, sans everything.
This attitude toward aging I think is now beginning to
change. I think we are at the beginning of a revolution in how
we think about aging, because for the first time, we can
actually separate what is biological aging from how we go about
living our lives, as we have just talked about.
One of the features of aging we know is a loss of muscle.
We think that that is critical. These are data from the
Baltimore Longitudinal Study on Aging. The yellow line happens
to be loss of muscle. This is a lifelong process. We have
coined a term for it. We call it sarcopenia, and that simply
means the age-related loss of skeletal muscle mass.
We think that this is an enormous problem. It leads to
reduced protein reserves, the decreased ability of elderly
people to respond to stress, decrease strength and functional
capacity, leading to frailty and falls, reduced aerobic
capacity, and reduced needs for calories.
Recently, health care costs directly attributed to
sarcopenia have been estimated. There is enormous prevalence of
this problem: greater than 20 percent of people over the age of
65 suffer from sarcopenia. In the year 2000, sarcopenia could
be attributed to more than $18.5 billion, which is 15 percent
of total health care expenditures. That translates to an excess
of $860 for each sarcopenic man and $933 for each sarcopenic
woman.
A 10 percent reduction in sarcopenia prevalence would save
$1.1 billion (dollars adjusted to 2000 rates) per year in U.S.
healthcare costs.
This is what sacropenia looks like. These are the cross
sections of the thighs of two women, a 21-year-old woman and
63-year-old woman. You can see the astonishing and remarkable
change in body composition, with an impressive decrease in
muscle and an equally as impressive increase in fatness.
Do elderly people respond to exercise? This is a study we
did some time ago where we asked the question. We trained young
and old people with bike exercise. Our older subjects gained
more than 20 percent of their aerobic capacity in 12 weeks.
They had regained in 12 weeks what they had lost in 15 years.
But the biggest problem we think in older people is weakness.
These are data from the Framingham Study showing that for women
between 75 and 85, 65 percent report that they cannot lift 10
pounds, and 35 percent of men. That translates directly into
reduced independence, decreased dependence on social services
and other issues.
So can we get older people stronger? The answer to the
question is yes. The first study we did was in older men, doing
just weightlifting 12 weeks. We were able to triple their
muscle strength in just 12 weeks so that many of these men who
were in their mid-60's were not only stronger than most men of
their age, they were stronger than they had ever been in their
lives.
We were able to show the size of their muscle increased
dramatically, at 15 percent. We next looked at the ability of
older women to respond to this type of exercise. We know that
one in two women and one in eight men aged 50 and over will
have an osteoporotic-related fracture in their lifetime. The
costs of osteoporosis are tremendous and rising.
We did a simple study, again funded by the National
Institutes of Health. We took post-menopausal women. We
randomized them to an exercise group two days a week of weight
lifting exercise versus a control group. This is what their
bone density looked like. So the exercising women showed no
age-related loss in bone in that year; in fact, an increase in
bone density. The control group lost bone. If you look at the
evidence of the new generation of anti-osteoporosis drugs that
are so expensive, none of them have an effect like this. They
don't affect other factors related to falls related to
fracture. So this one simple intervention increased strength,
increased muscle, improved balance, and increased their levels
of physical activity. In totality, this simple exercise program
has far greater effects of reducing risk of above fracture than
any medication.
Then the final studies I wanted to show you was the ability
of very, very old people to respond to exercise. The first
study that we did we reported in JAMA and we got a lot of
press. This is a cartoon that appeared in Sports Illustrated of
all places when they did a report on our study.
We did that. In another study we published in the New
England Journal of Medicine that I am going to highlight. In
this study, our subjects range in age between 72 and 98; 69
percent were over the age of 85. This is a population with
multiple chronic disease. These were nursing home patients.
At least half of them were somewhat demented. Half of them
had arthritis. Forty-four percent had pulmonary disease. Forty-
four percent had a previous osteporotic fracture. Thirty-five
percent were hypertensive. Twenty-four percent had a diagnosis
of cancer. Sixteen percent were diabetic, and 13 percent had a
myocardial infarction. They were all allowed into the study. We
showed that we could triple their strength. We improved their
balance, decreased the risk of falling. Their walking speed
improved. Their ability to climb stairs improved. They were
able to get up and move around a lot more. They told us that
they didn't need to ring for a nurse in the middle of the night
anymore to use the toilet. They told us that they could get up
and move around and get their meals. So not only can we improve
their independence, but we can improve the quality and dignity
of their life.
Importantly, there was a significant decrease in depression
in the group that exercised.
So it is possible. They are quite responsive. We have a
number of different very, very positive effects of this type of
exercise that is enormously important and powerful. I just
wanted to show a couple of statewide exercise programs that I
designed. One was in Massachusetts, where I was a faculty
member at Tufts University for 15 years. I designed a program
for the state called Keep Moving, and every year we had an
event called the Governor's Cup for Seniors, and this was the
line for two of the races; lots of grey hair in there. They
love these programs. We also designed a program at--when I was
at Penn State, called PEPPI, Peer Exercise Program Promotes
Independence, which we are now implementing in Arkansas. It
says we trained community-based peer leaders using the Triple
A's in Pennsylvania--very inexpensive, very effective. This is
one of the groups in Altoona, PA. This is a newspaper that
somebody sent me with all of the PEPPI programs that are in
their community. Currently, there are 250 groups, with a total
participation of more than 5,000.
A recent survey of this program showed that 82 percent say
they can walk better. Ninety-five percent are better able just
to get up from a seated position. Seventy-eight percent say
they can climb stairs more easily. Many of them have improved
balance.
Even more importantly, 99 percent of the participants state
that their health has improved and 87 percent say they are more
independent.
So we hope that this will be the future of nursing homes.
Finally, I was privileged to be at a joint press conference
with Senator Glenn after his space flight to talk about
similarities between space flight and aging and found a
wonderful quotation that described the Senator perfectly well
and also revealed that Shakespeare was probably a geriatrician.
We know that these things can prevent debility and though I
look old, yet I am strong and lusty, for in my youth, I never
did apply hot and rebellious liquors in my blood, nor did not
with unbashful forehead woo the means of weakness and debility.
Therefore, my age is as a lusty winter, frosty, but kindly. Let
me go with you. I'll do the service of a younger man in all
your business and necessities.
So Senator Glen certainly is the epitome of successful
aging. Thank you very much.
[The prepared statement of Dr. Evans follows:]
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Senator Kohl. Thank you, Mr. Evans. Mr. Herman, tell us
about your company.
STATEMENT OF MR. BILL HERMAN, VICE PRESIDENT OF HUMAN
RESOURCES, HIGHSMITH, INC., FORT ATKINSON, WI
Mr. Herman. I am happy to, Senator. Good morning.
It is a pleasure to be here.
Like most businesses in our country, Highsmith is a small
business. We are a family owned distribution company located in
rural Wisconsin, halfway between Milwaukee and Madison.
We have approximately 220 employees. Our customers are
libraries and schools.
Over the last 10 years, we have received a remarkable
number of awards and a flood of national publicity for our
wellness and employee development initiatives. We earned that
recognition by managing our health care costs; at the same
time, we improved the quality and productivity of our
workforce. In fact, those two things are closely linked. But we
really set out to accomplish much more.
We set out to ensure the long-term vitality and viability
of a growing business.
Our response to the crisis in health care costs and health
risk management has always served that goal. In fact, my point
today is that wellness and employee development have been
successful at Highsmith because we have made them a part of our
business plan.
We have learned the value of a well thought out strategic
approach to implementing and sustaining health and wellness
concepts within our organization, concepts that continue to
influence and effect the lives of employees after they retire.
Our culture is supportive of health lifestyle choices and
encourages good nutrition and lifestyle activity.
At Highsmith, wellness is not viewed as just a program, but
rather as a strategic initiative to nurture the human capital
necessary to meet corporate goals and objectives.
Over time, we found that traditional definitions of
wellness and health promotion often fell short of encouraging
personal responsibility for health and wellbeing.
Highsmith undertook a fundamental transformation in our
view of wellness. We think the terms wellness and employee
development are interchangeable. Engaging employees in their
jobs, emphasizing learning and development, providing tools to
balance work life responsibilities, along with health and
wellness have all been integrated at Highsmith.
This initiative encompasses a carefully managed blend of
seven components: job-career development, work life enrichment,
personal wellbeing, self-care, physical wellbeing, monetary
incentives as applied to health insurance premiums, and a
comprehensive array of benefits.
A key piece is the monetary incentives. If an employee and
spouse qualify for the incentive, Highsmith pays 75 percent of
their single or family health insurance premium. If one doesn't
participate, we pay only 60 percent. The voluntary eligibility
requirements to qualify for the incentive are enrollment in our
health insurance plan, to be a non-user of all tobacco
products, participation in our annual health screening, plus
age and gender specific physical exams.
Eighty-three percent of our employees on our health plan do
participate.
The annual health screening for employees and spouses
measures height and weight, blood pressure, a carbon monoxide
screen to determine if one smokes, a full blood lipid panel,
glucose, and a treadmill fitness test.
Participants also complete a coronary risk profile. The
most critical part of the health screening is delivering
immediate feedback and helping people understand it.
There are four distinct feedback stations as part of the
health screening. One of the stations is a focus on emotional
wellbeing. Some of the results that we have been able to
measure in the period 2000 through 2004 are we have had a 53
percent decrease in total participants with high-risk
cholesterol levels. We have had a 52 percent decrease in total
participants with high blood pressure; a 72 percent decrease in
total participants whose VO2 submax was high risk--how healthy
your heart is. We have normal blood glucose levels in 84
percent of all participants.
We have experienced an average increase in health insurance
premiums of only 5.4 percent over the last 4 years. Employee
turnover is single digit, and our average tenure is 14 years.
Utilization of our employee assistance program was 22.8
percent for 2004. The national average hovers between 4 and 6
percent.
So in conclusion, I would like to reiterate that wellness
and health promotion is not a program at Highsmith. It is not a
stand alone. It is really a strategy initiative to have the
human capital necessary to meet our corporate goals and
objectives. Thank you.
[The prepared statement of Mr. Herman follows:]
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Senator Kohl. Thank you very much, Mr. Herman.
Mr. Brown.
STATEMENT OF MR. STEPHEN J. BROWN, PRESIDENT AND CEO, HEALTH
HERO NETWORK, INC., MOUNTAIN VIEW, CA
Mr. Brown. Mr. Chairman and Committee members, I am Steve
Brown, and I am the CEO of Health Hero Network, a technology
company in Mountain View, CA.
We serve people struggling with chronic illness. Our
technologies are designed to enable caregivers to coach and
monitor patients at home. I am going to talk about some of the
commonsense things that Senator Lincoln talked about, and I am
also going to talk about some of the programs we are involved
with, which hopefully will make the CBO happy about the results
as well.
My view is that health care does not start when we are
wheeled into the emergency room, and it does not start at the
doctor's office.
Health care starts at home, with our own behavior and with
prevention.
Most people in Medicare have a chronic illness. For them,
prevention means reducing the complications of chronic illness
and living independently longer. From our work with the
Veterans' Administration, we have seen that when caregivers and
patients work together on daily management and prevention, they
can improve the quality of life and reduce costs.
To illustrate this point, I am going to introduce Wally
Browning from Huntington, WV, who recently was interviewed in
his local paper. I included this in the written testimony.
Wally Browning is a Vietnam veteran. He served our country
in Vietnam, and now he is being served by the VA and by Health
Hero Network.
Wally has congestive heart failure, one of those high-cost,
high-risk conditions that require very close attention and
management. It is also one of the leading causes of hospital
admissions for Medicare.
Every day a nurse at the VA checks in on how well Wally is
doing, remotely, by sending message to a device installed in
Wally's home, called Health Buddy, and I brought that for you
to see too.
With simple push buttons, Wally is able to answer questions
that appear on the screen and tell his nurse how he is doing;
tell his nurse about new symptoms transmit data about his blood
pressure and his weight and also get feedback and coaching from
his nurse about his condition and about his health program and
about healthy choices that he needs to make.
A VA nurse uses a computer with a secure Internet
application to analyze Wally's data every day and flag
potential problems before they become worse. The result has
been fewer emergencies, fewer stays in the hospital, greater
piece of mind, and cost savings for the VA. As Wally puts it,
after he checks in with his Health Buddy, he feels like he is
good for another day.
Wally is like 20 million Americans with complex chronic
illnesses who are at risk of going to the hospital any day.
Many of these hospital admissions can be prevented if we coach
and monitor patients at home.
The reason our health care system is in trouble, even
though we spend nearly $2 trillion a year on it, is that we are
not paying for the right model of chronic care. For 40 years,
Medicare payment has been based on episodic, face-to-face
encounters with a doctor, usually in reaction to a crisis.
But chronic illness is not episodic. It is long-term, and
it needs to be managed every day.
If we want to prevent hospitalizations, we need to coach
and monitor patients at home before a crisis occurs.
We know it is possible because we are doing this every day
across America for thousands of veterans. According to the VA,
hospital admissions for patients in the program were 63 percent
lower than for a comparison group with similar high-risk
conditions.
Last year, we worked with the Information Technology
Association of America to look at the question. What if
Medicare could achieve similar results to the VA with similar
patients? The answer published by the ITAA--and that report is
also in the written testimony--is that we would save over $30
billion a year.
As a result of your leadership and that of your colleagues,
the Medicare Modernization Act starts to recognize that people
with complex chronic illness need continuity of care and
prevention rather than more episodic crisis management. That is
a major step forward for Medicare, and now the challenge is
execution. We are participating in two large-scale chronic care
improvement pilots authorized by the Medicare Modernization
Act. We are also working with the American Medical Group
Association and its physician groups, like the one in Bend, OR,
to create a chronic care model based on coaching and monitoring
patients at home, under the supervision of their primary
physician.
Part of the wisdom of the recent Medicare initiatives is in
recognizing how technology can play a vital role in
transforming the model of care for chronic illness.
Information technologies can extend care into the home and
coach patients to improve their own lives and change their own
behavior. Caregivers can detect early and deliver the right
care at the right time before there is a crisis.
Health care and prevention starts at home, and the right
technology can help people struggling with chronic illness and
connect them to better care. I thank you for inviting me to
testify today.
[The prepared statement of Mr. Brown follows:]
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Senator Kohl. Thank you for being here, Mr. Brown. Mr.
Woolf?
STATEMENT OF MR. STEVEN H. WOOLF, PROFESSOR, DEPARTMENTS OF
FAMILY MEDICINE, EPIDEMIOLOGY AND COMMUNITY HEALTH, VIRGINIA
COMMONWEALTH UNIVERSITY, FAIRFAX, VA
Dr. Woolf. Thank you, Senator Kohl, Senator Smith, other
members of the Committee.
My name is Steven Woolf. I am a family physician and a
specialist in preventive medicine and public health. I serve as
professor of Family Medicine, Epidemiology and Community Health
at Virginia Commonwealth University.
I am pleased to talk with you this morning about prevention
and seniors.
The prevention of disease is the cornerstone of healthy
aging. The underlying logic is obvious. The major diseases that
claim the lives of seniors and account for the rising cost of
health care are caused largely by our health habits, such as
smoking, lack of exercise, and poor diet. These behaviors
account for one out of three deaths in the United States.
We spend great sums on treating the complications of
disease, and far too little on helping the public avoid getting
sick in the first place. As Arkansas Governor Mike Huckabee has
said, rather than building a fence at the top of a cliff, our
health care system keeps sending ambulances to the bottom.
Paying for prevention is a smarter use of scarce resources.
Many seniors wrongly believe they are too old to benefit
from a change in health habits, but the facts are that seniors
live longer and live healthier if they abandon unhealthy
behaviors, obtain recommended vaccines and receive certain
screening tests that catch diseases early. Prevention can
improve function and postpone disabilities, as we have just
heard.
Healthy again ought to begin early in life when it is more
effective, but reducing risks for disease pays off at any age.
Prevention has always been important, but is taking on
greater urgency now when more Americans are growing older and
the costs of health care loom large.
At a time when we worry about how Medicare will afford
these costs, it is a mistake to ignore the business case for
prevention.
In the face of these benefits, it is concerning that so
many older adults in our country engage in health habits that
increase their risk. In an average group of 100 Americans who
are age 65 and older, 25 of the 100 are obese; 25 get no
exercise; and 10 smoke cigarettes.
Altogether, five million seniors in this country smoke
cigarettes. Obesity rates are climbing, and the averages I am
quoting for America's seniors obscure higher rates of risk
factors among subgroups, such as African Americans, Hispanics,
and Native Americans.
Millions of seniors have not received recommended vaccines.
For example, one out of three have not received the
pneumococcal vaccine, which helps prevent deaths from
pneumonia. Congress has worked for many years now to expand
coverage for preventive services under Medicare, thereby,
removing a major barrier to access. The Medicare Modernization
Act in 2003 introduced the Welcome to Medicare visit and
expanded coverage for cardiovascular and diabetes screening.
Yet, we see that Medicare coverage by itself does not make it
happen.
The GAO found that only 10 percent of beneficiaries had
received five cancer tests and immunizations that are covered
under Medicare.
The problem is worse among beneficiaries who are poor or
among minorities. For example, whereas the proportion of
Medicare beneficiaries who have received a recent flu shot is
67 percent for Whites, it is 53 percent for Hispanics, and 43
percent for African Americans. This is among Medicare
beneficiaries.
This Committee already knows that life expectancy is lower
among minorities, but the scope of the problem is less well
known.
People aged 65 to 74 are almost 50 percent more likely to
die in the next year if they are African American than if they
are white.
We spend billions of dollars in this country to make better
drugs and medical devices, thinking this will save lives, and
indeed it does. But far more lives could be saved by correcting
health disparities. For every life saved by medical advances,
five would be saved if African Americans had the same death
rate as Whites.
Congress has enacted legislation to address disparities,
but that investment is actually a small fraction of the
billions we spend on research. Most of those billions are in
the pursuit of medical advances, a worthy aim, but if
correcting disparities saves more lives than medical advances,
do we have our proportions right?
Certainly, we must continue to invest heavily in new drugs
and technology, but perhaps we should tip the scales a bit and
make more substantive investment in removing barriers to
receiving those treatments.
Enabling all Americans to enjoy aging is not only ethical,
it will save more lives and will go further to control the
costs of medical care.
With that background, let me devote my remaining minutes to
some policy options for promoting prevention among seniors.
I offer seven examples, but I urge the Committee to gather
broader input from other experts, assemble a longer list of
policy options, and choose from the best.
We owe it to America's seniors to pursue the most
innovative and effective strategies to promote healthy aging.
My written testimony elaborates on the following seven
suggestions.
No. 1, Congress should use its visibility with the public
and the media to launch a public education campaign aimed at
America's seniors to emphasize prevention. Getting the message
out that prevention is important to the health of seniors is
the first step toward changing public attitudes and creating a
new culture for healthy aging.
No. 2, Congress should encourage the Centers for Medicare
and Medicaid Services, CMS, to become more proactive in
encouraging Medicare beneficiaries to adopt healthy lifestyles.
My written testimony explains that existing CMS initiatives
concentrate on making beneficiaries aware of expanded coverage
benefits, but they tread lightly on giving health advice.
Congress should encourage CMS to adopt a new role in which
health advice is disseminated by CMS to serve beneficiaries, to
lower disease burden, and to save money through prevention. CMS
need not develop this health advice from scratch. Prevention
guidelines for seniors and health education messages have
already been developed by other HHS agencies, but are less
familiar to CMS due to stovepiping.
No. 3, looking ahead to the future, the Committee should
consider how to redesign communities to support lifestyle
change. It does little good to advise a senior to do light
gardening or take a daily walk when he or she is surrounded by
highways or has no safe place to walk.
Seniors living in poor urban neighborhoods are often miles
from a supermarket that offers healthy food choices. Fast food
chains predominate, as do billboards that promote cigarettes
and alcohol.
Congress should work with the food industry and retailers
to explore ways to promote profits and healthy customers.
Ultimately, creating a community that fosters healthy aging
requires a partnership across community sectors involving
churches, restaurants, park authorities, senior centers, and
urban planners.
No. 4, cigarette smoking remains the leading cause of death
and cannot be overlooked in any serious discussion of healthy
aging. The Committee should look again at the 10
recommendations issued in 2003 by the Department of Health and
Human Services' Interagency Committee on Smoking and Health.
Setting aside the recommendation on excise taxes, which
received a cool reception, the plan includes nine other
excellent recommendations that would substantially reduce the
death toll from smoking-related illness among seniors.
One example is telephone quit line programs, which give
seniors access to high quality assistance in quitting smoking.
No. 5, the failure of so many seniors to receive
recommended preventive services is a symptom of a larger
problem with the nation's health care delivery system. Experts
have warned for years that the quality of health care in
America is in jeopardy unless bold system redesigns are
undertaken. Mapping the human genome, robotic surgery, and
other sensational breakthroughs make the evening news, but
Congress could save more lives by directing its attention
elsewhere.
Take reminder systems, for example, which alert people when
screening tests or vaccinations are due. Such systems are not
glamorous, but are among the most effective ways to close the
gaps in the delivery of health care. Yet, they are rare in our
health care system. You are more likely to get a notice from
your car dealership that it is time to change your oil than you
are to be notified by your doctor that your mammogram is
overdue.
Our research team has shown that making such systems
routine would save far more lives than the advances in drug
therapies on which billions of dollars are now spent.
I urge Congress to confront the political challenges and to
press for modernizing the health care system to deliver
consistent high-quality care.
No. 6, information technology is an important tool for
healthy aging. Congress is already promoting electronic health
records to improve record keeping and reduce medical errors,
but information technology and web sites for seniors can do far
more by empowering consumers with information to make healthy
lifestyle choices, learn more about the tests they need, and
obtain e-mail reminders when they are due.
Congress should steer the health IT movement beyond its
basic role, serving providers as a tool for patient care, to a
broader role in helping the public maintain good health.
Finally, No. 7, given the urgency of the problems I have
discussed, Congress should increase the funding for AHRQ, the
Agency for Healthcare Research and Quality, which receives one
penny for every dollar given to NIH. Yet, it is AHRQ that has
lead responsibility for all that we have discussed--prevention
guidelines, improving the quality of health care, tracking
racial disparities, developing information technology, and so
on.
Solving these problems is not a luxury on the margins of
NIH. Without the answers, the cutting edge advances made at NIH
cannot reach Americans.
Doubling the budget of AHRQ sounds extravagant at this time
of belt tightening. But the extra penny taken from the NIH
dollar could go much farther in saving lives. The threat to the
nation's health and economy posed by the struggling health care
system makes it risky public policy to not invest generously in
tackling these problems. Thank you.
[The prepared statement of Dr. Woolf follows:]
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Senator Kohl. Thank you, Mr. Woolf.
Dr. Evans, in your testimony you describe some of the
benefits that seniors receive through fitness and strength
training, which includes a decreased likelihood of depression
and also the ability to do things without the assistance of a
health aid.
Through your research were you also able to see a reduction
in the need for prescription drugs or costly medical and
surgical procedures?
Dr. Evans. Senator, in our studies now we see, for example,
one of the great epidemics of aging is chronic renal failure.
We have just completed a study, funded by the Veterans'
Administration, that demonstrates that we can, for example,
delay or postpone or completely eliminate the need for dialysis
through a good exercise and diet program.
So while my studies are relatively small in nature, the
preponderance of the evidence now, through epidemiologic
studies, show a tremendous decrease in disability with
exercise, cutting across the barriers.
We know, for example, that obese older people who exercise
regularly don't have the same complications of even leaner
older people who don't do any physical activity. So it is a
tremendous effect.
Senator Kohl. There is a decreased use of prescription
drugs?
Dr. Evans. Decreased use of prescription drugs. For
example, many of our subjects come into the study diabetic, and
over the course of an 18-month study that we have done, many of
them don't need insulin anymore; don't need the anti-
hyperglycemic agents, and that is, for example, the evidence of
our Governor, who was diagnosed with Type II Diabetes, and this
past year ran the Little Rock Marathon.
So it is quite possible, and I think the important point--
and maybe the most important point to say--is that we stand to
gain the most from intervening in older people right now. If we
want to save the most money, clearly, prevention programs in
children and young people is absolutely important. But the real
central message is that any older person, no matter how many
chronic diseases they have, can benefit tremendously and reduce
their need for both drugs and for social services.
Senator Kohl. Mr. Herman, we certainly want to commend you
for the great job that your company, Highsmith, has done----
Mr. Herman. Thank you.
Senator Kohl [continuing]. In keeping health care costs
down. It is dramatic that Highsmith's ability to keep health
care cost premiums to only 5.4 percent increase, when premiums
have typically been increasing in the double digits year after
year for most other business, your 5.4 percent is certainly
outstanding.
How was your company able to get your employees excited
about changing their nutrition and physical activity? How long
did it take before you started to see real results after the
program began?
Mr. Herman. Well, thank you for the question, Senator. It
doesn't happen overnight. It takes years, and it starts in
developing a culture and environment that is conducive to
healthy lifestyle choices--the little touches, from eliminating
donuts and cookies at meetings, and instead serving fruit and
fruit juices.
We put into place something we call a Twinkie Tax, where we
increase the cost of high fat food items in the vending
machines, and use the incremental amount to subsidize the cost
of the lower fat items.
So just spending time and time encouraging and nudging
healthy lifestyle choices and creating a culture that is
supportive of that.
Senator Kohl. Why are you self-insured?
Mr. Herman. Why are we or are we not?
Senator Kohl. You are self-insured?
Mr. Herman. No we are not self-insured. We are in managed
care environment, but we have a self-insured variation with our
HMO.
Senator Kohl. I am still not fully aware of how you are
able to keep your increases down to 5.4 percent. It must
require tremendous involvement and participation from your
employees.
Mr. Herman. Very much.
Senator Kohl. Say a little bit more about what you do to
get that result?
Mr. Herman. I certainly will.
Our premise, if you will, is if you feel good about
yourself, if you feel good about what you do, we believe you
are going to be healthier and more productive. You are going to
be safer in the work environment, and you are going to stay.
So there is a lot of influencers that come into play as to
whether one feels good about one's self, and there is a lot of
influencers that come into play as to whether one feels good
about what you do.
So we try to provide resources, tools, and an environment
to assist employees in feeling good about themselves. We work
very hard in engaging employees in their jobs to get them a
part of what they are doing.
So we think that all comes together in promoting and
helping employees have less health care utilization. So we have
a full array of programming at Highsmith. We focus in from job
career development, personal wellbeing, self-care, work life
enrichment, and physical wellbeing. Over the years, we have
just been able to make such significant strides that it has
finally paid off for us.
Senator Kohl. How did this program originate?
Mr. Herman. Well, it originated because we had a 53 percent
increase in our health insurance premiums in about 1990. So
that certainly got our attention. It became one of our fastest
rising costs of doing business. So we began some wellness
initiatives. We started introducing monetary incentives and
just over time it started evolving and developing.
Senator Kohl. Did it evolve at the very top of your
company?
Mr. Herman. That is where it started, at the top of our
company. Really it is the leadership by example that makes the
difference I think in any environment. It takes that role
modeling to effect change.
Senator Kohl. Is there any reason why what you have
accomplished cannot be duplicated throughout our economy?
Mr. Herman. Oh, I think what we are doing can very easily
be replicated. I don't think necessarily the same types of
initiatives, but variations. Yes, Senator, I do.
Senator Kohl. Thank you.
Mr. Herman. You are welcome.
Senator Kohl. Mr. Brown, Mr. Woolf, prevention is the most
cost effective way to stem the tide of chronic disease for the
future as we all know. But we already have 10 million Medicare
beneficiaries who are suffering from one or more chronic
diseases.
What more can we be doing within Medicare and other
government programs to stem the skyrocketing costs associated
with providing treatment for people with chronic conditions?
Mr. Brown. I think you need to look at those high-cost
beneficiaries--as the first place where you have an immediate
impact. One way to look at it is to imagine standing at the
door of your hospital and watching people coming in being
admitted to the hospital and saying how many of these hospital
admissions could have been prevented if we had just known about
these problems a little bit sooner and maybe changed behavior.
I think you will find that probably a majority of hospital
admissions certainly for chronic illness could have been
prevented if they were managed and problems had been caught
earlier.
If you then go to the Health Care Utilization Project of
AHRQ, which keeps a database of every hospital admission in
this country, and you look through the data base sort it by
disease and say who is admitted for what, and if you say who is
admitted for a complication of a chronic condition, like heart
failure, or a complication of diabetes or of emphysema or
asthma, and you say who is actually paying the bills for those
admissions, you will find that half of the hospital admissions
for chronic illness are in Medicare. You find another 20
percent of the hospital admissions are Medicaid. You find a few
uninsured in some other programs and then a scattering of
health plans and other programs. You see that 50 percent is
actually paid for by Medicare.
So what Medicare does is critical in solving this problem.
Medicare has traditionally not paid for anything long term. The
statutes and the way that Medicare has been implemented, it has
been based on paying for face-to-face encounters and episodic,
not long term care. If you don't pay for anything long term,
how can you truly manage chronic illness? Because chronic
illness is not episodic. It is long term.
If you only pay for a face-to-face encounter at the
hospital or a doctor's office, then you are not going to be
able to prevent crisis because you need to get to people at
home before you get to the doctor's office. So you have to find
a way to pay for care that is remote, if you are going to
prevent hospital admissions, and you have to find a way to pay
for care that is long term and continuous, not episodic, if you
want to manage chronic illness.
Senator Kohl. Mr. Woolf.
Dr. Woolf. Thank you, Senator. I think I can use the same
answer to respond to your question and the one you asked
earlier to the gentleman from CBO about whether there is a
difference between two seniors with the same disease and why
one ends up in the pool of costing so much and the other
doesn't. As a physician, I think I have a different perspective
than he might as an economist.
We talk about primary prevention, secondary prevention, and
tertiary prevention. I think all three represent strategies for
reducing the burden of those 10 million beneficiaries.
No. 1, primary prevention is cutting off the number of
people who enter that chronic disease pool, so encouraging
Americans to live healthy lifestyles, as we have discussed,
reduces the incidence of chronic disease. It prevents the
diseases from occurring in the first place.
Secondary prevention is detecting the disease at an early
stage, when its outcomes can be treated more effectively and
complications can be prevented. So many of the examples that
have been given--cancer screening tests and many other
modalities--are very important and explain part of the reason
why some diabetics end up in that pool of 10 million and some
diabetics don't. In other words, studies show that people with
diabetes who have good glycemic control and their conditions
are detected early have lower complications from diabetes than
their counterparts.
Then the third, which I think is very important is tertiary
prevention. As Dr. Evans pointed out, people with existing
diseases can have better outcomes and lower complications
through pursuing healthy behaviors and good management of their
diseases. For example, again, using diabetes as an
illustration, complications or the progression of diabetes is
cut by 50 percent through regular physical activity. The No. 1
killer in the United States is coronary artery disease. People
who have had heart attacks can markedly reduce their risk of a
recurrence or second heart attack through the use of certain
medications, but also through healthy behaviors such as smoking
cessation and physical activity.
So through all three arms--primary, secondary, and tertiary
prevention--we can make the difference.
Senator Kohl. Thank you. Senator Lincoln? She is not here.
Senator Talent?
Senator Talent. Thank you, Mr. Chairman. I really
appreciate your putting this hearing together. You are touching
on what to me is the essential issue regarding Medicare and I
would say health care as a whole, both from the standpoint of
relieving human suffering, which is No. 1, but also for
disability. I think all the witnesses have touched on that.
Let me ask them to address this issue, and I will have a
statement for the record, Mr. Chairman.
I think we see where you all are going and the techniques,
tactics that each of you have used in your own settings, and I
can certainly see why they have been effective or would be
effective.
Now, the question always for me is how do we get from here
in the Congress to on the ground replicating in so many
different settings the kind of successes or maybe, Mr. Herman,
that you have had in an employee-employer setting, or Mr.
Brown, that you have had in a VA setting or Dr. Woolf, in your
arena.
How do we get from here to there? I want to just suggest
that kind of a tactic that I am more and more excited about and
get your view on it.
I agree about removing barriers and the rest of it. Then
the question is, OK, the barrier is removed. How do you still
get people to access the care? I am a big believer in the
clinic model of community health centers, which are empowering,
mediating-type of institutions that work with people face to
face. You have done that as the employer. In other words, you
have initiated this and so it has worked.
Do you have any suggestions along those lines? How might we
accomplish that as we change Medicare policy, not just saying
this is where we want to go and this is the funding we are
providing or the barriers we are removing, but how do we still
ensure that somebody is getting in contact with these patients
and doing these things? Can we rely on hospitals, who are
organized also along the traditional medical model, for
example, to do that? Do we need to do more than just change
reimbursement incentives for them? Do any of you have any ideas
along these lines?
Dr. Evans. I just might say that in most states there
already is a well developed infrastructure for dealing with
seniors. I am really talking about Medicare beneficiaries and
those are typically senior centers and Triple A's. Triple A's
are often the line that supplies nutrition services to older
people, but often not many other services.
We have attempted to deliver exercise programs through
Triple A's, and what we do is we go in and we train peer
leaders, and they can be--just people from the community or
Triple A employees--and in every place that we have done that
the Triple A's say well not too many people are interested in
this. They get five or six times more older people joining
these programs than they ever anticipated. So I think that
there is a great desire of older people to improve their
health. They know what is looming. You know, they don't want to
access health care dollars as much as we don't want them to.
They want to improve their health. They just don't have access
to it.
So I think that there is an already developed
infrastructure that we can develop delivery these programs
through at a relatively low cost, but we need some I think
political will to be able to deliver these types of programs.
Senator Talent. So you are suggesting working through Older
American Act institutions, which would seem to be a commonsense
first step.
Dr. Evans. I believe so. The infrastructure is already
there. They have access to millions of elderly people right
now. They are trusted and then working through the state
agencies. Most state agencies, like Arkansas, has a Department
of Health that now is interested in senior health. They have a
Department of Aging that usually interacts more with the Triple
A's. So I think that instead of creating a new infrastructure,
there is one already available.
Senator Talent. Anybody else have comments?
Dr. Woolf. I agree, although I----
Senator Talent. If you disagree with my premise, by all
means, say so.
Dr. Woolf. I don't disagree, Senator. In fact, I think you
are heading in the right direction. I think that we definitely
need to provide those social support systems in order to help
seniors navigate the system. The problem is that there is
tremendous fragmentation in our system currently. Although Area
Agencies on aging and other senior centers that exist in most
communities are there for that purpose, as a primary care
physician, I can tell you that there is a big divide and wall
sometimes in between their world and the medical care delivery
system, not that either one doesn't want to reach out to the
other, but the infrastructure for those connections is not well
developed.
What we really need is an infrastructure that integrates
the different components of the community that need to support
the senior in promoting healthy behaviors and in getting health
care services. All the pieces are there, it is tying them
together that is necessary. My practical suggestion: there is
already work that CDC is doing through the STEPS Program that
was initiated in recent years, where communities and regions
around the country are testing these models for integration.
Continuing to support that kind of innovation and creativity in
communities and then extrapolating and generalizing those
models out more broadly I think has real promise to tap the
resources that are available in the community.
Senator Talent. Yes. We have been supporting through grants
the naturally occurring retirement community program that our
local Jewish community has been doing within its community. I
think it is largely what you are talking about, an attempt to
integrate services and service providers in these institutions
that deal with seniors or with whom seniors interact, so that
we can collect what is out there and send consistent and
healthy messages to seniors that way. It is just so difficult
to get it from our minds here into legislation that will then
produce the right results.
I think we are going to have to figure out some way to get
the traditional medical providers on board and enthusiastic
about this, and then it may naturally happen. I don't know
whether it is reimbursement changes or pilots as with the
Medicare Modernization Act but I think it is the key to getting
this idea in the community. Mr. Brown, it is your turn.
Mr. Brown. The market forces for the traditional health
care provider world are not in the direction of prevention and
reducing hospital admissions. They are really in the opposite
direction, and that is one of the problems. If we go to a
hospital administrator and say we have a program that can help
you reduce hospital admissions by 50 percent, most hospital
administrators look at that and say I am not sure that is a
good idea for my business.
We actually have worked with hospitals linked to community
health centers and have worked with case management programs
where nurses and case managers and social workers tried to
coach and monitor patients at home to prevent hospital
admissions, and those programs were at least for uninsured
patients and were seen as cost effective for the hospital.
But when you get to the sort of bread and butter business
of a hospital, the business model is around the existing DRGs
and codes and how they get paid. This isn't in there.
Prevention is not in there. In fact, there are a lot of
disincentives for it from an economic perspective.
If you look at the DRG and now they have designed so, you
know, if you are readmitted within 30 days, the hospital pays
the bill still. If you have got somebody who gets admitted to
the hospital three times in a year, that is 3 months out of the
year that the hospital worries about that patient from an
economic perspective, and 9 months out of the year where the
hospital has really no interest economically in that patient.
That is a lot of discontinuity, and that gap needs to be
bridged. There may be ways to do this through reimbursement
mechanisms or through tweaks of the existing way things are
coded. But somehow that gap has to be filled.
Senator Talent. People have talked about paying for
performance type, which, if you could define the outcomes that
you wanted in the proper way so it didn't have negative side
effects, has potential because it creates an impetus within the
system to produce a healthier result for seniors. But defining
that, I think, would be difficult so that you don't get a
negative.
Well, Mr. Chairman, I am not--I have probably trespassed on
my time already. Thank you for calling the hearing.
Senator Kohl. Thank you, Senator Talent.
Senator Talent. Thank you all for your work.
Senator Kohl. Gentlemen, we thank you very much for your
participation here today and thank you very much for your
expertise.
We appreciate very much what you have said as we continue
to look forward to find ways to contain the growth in Medicare,
primarily by helping seniors and people throughout our society
lead healthier lifestyles.
Thank you so much, and this hearing is adjourned.
[Whereupon, at 11:35 a.m., the committee was adjourned].
A P P E N D I X
----------
Prepared Statement of Senator James Talent
Thank you, Mr. Chairman, for convening this important
hearing to examine the role of prevention in the Medicare
program.
I cannot over emphasize the importance of disease
management services to help seniors live longer, more
productive lives with the additional benefit of saving Medicare
dollars. I have traveled all around my home state of Missouri
visiting with seniors on Medicare, and discussing the
beneficial disease management provisions in the Medicare
Modernization Act, which I supported.
Nearly half of all Americans live with chronic illnesses
such as hypertension, asthma, diabetes, and heart disease.
Approximately 78 percent of Medicare beneficiaries have at
least one chronic disease, while 32 percent have four or more
chronic conditions. Individuals with multiple chronic
conditions are more likely to be hospitalized, fill more
prescriptions, and have more physician and home health visits.
Nearly two-thirds of all Medicare spending is for beneficiaries
with five or more chronic conditions.
We know that approximately five percent of the costliest
Medicare beneficiaries consume about half of total Medicare
spending. That is why I advocated for Senate provisions in the
Medicare Modernization Act to create demonstration projects to
examine disease management and care coordination for our
nation's seniors and the disabled. I continue to support this
legislation, and look forward to next year when the full
Medicare benefit goes into effect as I believe it will help
millions of seniors in Missouri and across our country lead
healthier lives.
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Questions from Senator Blanche Lincoln for Mr. Evans
Question. Do adequate performance measures exist that cross
multiple aspects of disease, such as function?
Answer. Yes, functional capacity in elderly people is a
very powerful predictor of mortality, morbidity, and risk of
admission to a nursing home. Dr. Jack Guralnik at the National
Institute on Aging has developed what he terms the short
physical performance battery (SPPB) (3) that is easy to
perform, even in a doctors office and should be used by
physicians in examining their geriatric patients. The test
consists of a 6-meter walk time, chair stand time (how long it
takes to stand up from a seated position) and a balance test.
Guralnik and his co-workers (2) have demonstrated that among
nondisabled older people living in the community, objective
measures of lower-extremity function were highly predictive of
subsequent disability. Disability among elderly people is
associated with increased hospitalization and a greatly
increased cost to Medicare. These studies reveal that early
identification of functional problems and treatment has the
potential of preventing disability. The SPPB should be a
standard component of a geriatric assessment.
Question. How would one identify those who might benefit
most from nutrition and exercise interventions in terms of
health and cost-savings, such as certain frail elderly persons?
And should we target these interventions to those with multiple
chronic illnesses (including diabetes and chronic Heart
Failure) to obtain the ``biggest Bang for the buck'' in our
``high cost'' Medicare beneficiaries? This secondary prevention
approach might be easier and cheaper to implement in a smaller
group of chronically ill seniors. If so, do you think
legislation allowing for a new Medicare care coordination
benefit, such as the Geriatric and Chronic Care Management Act
I have introduced, achieves this goal?
Answer. It is clear that there are a number of geriatric
problems that may be identified before they develop into
serious of life-threatening issues. There is only one way of
identifying the potential problems in a comprehensive way and
that with a geriatric assessment. In this way correctible
nutritional problems, functional limitations, infections, over
prescription of medication, and other problems may be
identified and treated. For example, one of the untreated
diseases that occurs in elderly people in epidemic levels is
chronic renal failure that, if left untreated, will progress to
kidney death and dialysis. Use of certain medications and
nutritional interventions can prevent kidney death and the
extremely high cost and decreased quality of life of dialysis.
Early identification and treatment of loss of appetite, eating
or swallowing problems, or involuntary weight loss can have a
powerful effect on improving life expectancy and quality of
life. However, left untreated, these issues can have a
devastating effect on the lives of elderly people. Muscle
weakness and poor balance must be identified and treated before
it leads to a devastating fall or loss of independence. All of
these issues (and many more) would be considered secondary
treatment. This treatment, even in those with multiple chronic
diseases, can have a powerful effect on decreasing the cost of
treatment and improving quality of life. The Geriatric and
Chronic Care Management Act will go a long way towards
implementing a comprehensive geriatric assessment that will be
critical in the identification of treatable problems and the
prevention of late-life disability. Ferucci et al (1) found
that in the year when they become severely disabled, a large
proportion of older persons are hospitalized for a small group
of diseases. They concluded that hospital-based interventions
aimed at reducing the severity and functional consequences of
these diseases could have a large impact on reduction on severe
disability. Thus the potential for large savings in Medicare
expenses may be seen in the most ``at risk'' population of
older people.
Question. On symptom or consequence of sarcopenia is
osteoporosis and increased falls, especially in women. Recent
clinical trials have shown improved quality and decreased costs
from greater falls assessment and treatment in frail elderly
populations, including increase in activities as you have
highlighted in your testimony. However, Medicare coverage of
falls assessment and treatment is minimal. Perhaps changes to
Medicare, such as the enactment of my legislation the Geriatric
and Chronic Care Management Act, a Medicare care coordination
benefit, could allow for better coverage of services such as
these. What do you think?
Answer. Clearly the early identification of those at
greatest risk of falling and of developing osteoporosis is
critical in preventing a devastating bone fracture. Part of a
comprehensive geriatric assessment should be measure of
functional status and bone density. These two simple and
inexpensive assessment tools can be used to begin a treatment
plan that is appropriate for the elderly person. For those ``at
risk'' individuals, change in diet to emphasize increased
calcium and vitamin D intake as well as a structured exercise
program can mitigate this risk. For those identified with
osteoporosis, a more aggressive treatment including a new
generation of drugs to treat low bone density along with diet
and exercise can prevent a bone fracture. We know that one of
the most important nutritional factors that increases muscle
weakness and accelerates loss of bone is vitamin D deficiency,
a problem that is found in far to many elderly people (5) due
to inadequate time in the sun (sunlight is used to make vitamin
D by the skin) nor do they drink much milk (fortified with
vitamin D). Balance training, including participation in Tai
Chi exercises can prevent falls in elderly people Coordination
of all these interventions begins with a geriatric assessment
described in the Geriatric and Chronic Care Management Act.
Question. This week, the Senate Finance Committee is
working on ``pay for performance'' legislation which would
allow for the development and implementation of reporting and
quality based measures for greater accountability and reliance
on quality-based health care for providers. Do adequate
measures exist in the area of falls? Would a frail elderly/
geriatric population with multiple chronic conditions benefit
from some unique measures, such as a falls measure, when
compared to the ``regular'' elderly population who may be
evaluated under more general measures having to do with one
chronic disease, i.e. diabetes or heart disease?
Answer. Adequate measures do exist in the area of falls.
The short physical performance battery (described, above) is
easily performed and identifies those at greatest risk of
falling and suffering a bone fracture. This use of this simple
tool in a geriatric assessment can be the first step in a
treatment plan to prevent a devastating fall. This plan might
include identification of medications that may cause balance
problems, nutritional deficiencies, muscle weakness due to low
muscle mass, obesity, and other potential causes. In fact lower
extremity physical performance (gait speed and chair stand
time) has been shown to be highly predictive of hospitalization
for a number of geriatric conditions (such as dementia,
decubitus ulcer, hip fractures, other fractures, pneumonia,
dehydration, and acute infections even among people who are not
currently disabled (4).
References used:
1. Ferrucci, L, JM Guralnik, M Pahor, MC Corti, and RJ
Havlik. Hospital diagnoses, Medicare charges, and nursing home
admissions in the year when older persons become severely
disabled. JAMA;277.728-34.,1997.
2. Guralnik, JM, L Ferrucci, EM Simonsick, ME Salive, and
RB Wallace. Lower-extremity function in persons over the age of
70 years as a predictor of subsequent disability. N Engel J
Med;332:556-61.,1995.
3. Guralnik, JM EM Simonsick, L Ferrucci, RJ Glynn, L F
Berkman, D G Blazer, P A Scherr, and RB Wallace. A short
physical performance battery assessing lower extremity
function: association with self-reported disability and
prediction of mortality and nursing home admission. J.
Gerontol.: Med. Sci.;49:M85-M94,1994.
4. Penninx, BW, L Ferrucci, SG Leveille, T Rantanen, M
Pahor, and JM Guralnik. Lower extremity performance in
nondisabled older persons as a predictor of subsequent
hospitalization. J Gerontol A Biol Sci Med Sci;55:M691-7.,2000.
5. Semba, RD, E Garrett, BA Johnson, JM Guralnik, and LP
Fried. Vitamin D deficiency among older women with and without
disability. Am J Clin Nutr; 72:1529-34.,2000.
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