The predicted effects of chronic obesity in middle age on medicare costs and mortality.

BACKGROUND: The prevalence of adult obesity has increased in recent decades. It is important to predict the long-term effect of body weight, and changes in body weight, in middle age on longevity and Medicare costs in older ages. METHODS: The relationships between individuals' characteristics in middle age and subsequent Medicare costs and mortality were estimated from the linkage of the National Health and Nutrition Examination Survey I Epidemiologic Follow-up Study to Medicare administrative records (1991-2000) and mortality information (1971-2000). We predicted longevity and lifetime Medicare costs via simulation for 45-year-old persons by body weight in 1973 and changes in body weight between 1973 and 1983. RESULTS: Obese 45-year-olds had a smaller chance of surviving to age 65 and, if they did, incurred significantly higher average lifetime Medicare costs than normal-weight 45-year-olds ($163,000 compared with $117,000). Those who remained obese between ages 45 and 55 in 1973 to 1983 incurred significantly higher lifetime Medicare costs than those who maintained normal weight. Other weight change categories did not differ significantly from those who maintained normal weight in terms of life expectancy at age 65, but overweight and obese people who lost weight had less chance of surviving to age 65 and the lowest estimated life expectancies thereafter. CONCLUSIONS: Chronic obesity in middle age increases lifetime Medicare costs relative to those who remained normal weight. As the survival of obese persons improves, it is possible that Medicare costs may rise substantially in the future to meet the health care needs of today's obese middle-aged population. Thus, active engagement by both the private and public sectors to prevent and to reduce obesity are critically needed.

Estimation of multi-state life table functions and their variability from complex survey data using the SPACE Program.

The multistate life table (MSLT) model is an important demographic method to document life cycle processes. In this paper, we present the SPACE (Stochastic Population Analysis for Complex Events) program to estimate MSLT functions and their sampling variability. It has several advantages over other programs, including the use of micro-simulation and the bootstrap method to estimate the variance of MSLT functions. Simulation enables researchers to analyze a broader array of statistics than the deterministic approach, and may be especially advantageous in investigating distributions of MSLT functions. The bootstrap method takes sample design into account to correct the potential bias in variance estimates.

Health, life expectancy, and health care spending among the elderly.

BACKGROUND: Life expectancy among the elderly has been improving for many decades, and there is evidence that health among the elderly is also improving. We estimated the relation of health status at 70 years of age to life expectancy and to cumulative health care expenditures from the age of 70 until death. METHODS: Using the 1992-1998 Medicare Current Beneficiary Survey, we classified persons' health according to functional status and whether or not they were institutionalized and according to self-reported health. We used multistate life-table methods and microsimulation to estimate life expectancy for persons in various states of health. We linked annual health care expenditures with transitions between health states. RESULTS: Elderly persons in better health had a longer life expectancy than those in poorer health but had similar cumulative health care expenditures until death. A person with no functional limitation at 70 years of age had a life expectancy of 14.3 years and expected cumulative health care expenditures of about 136,000 dollars (in 1998 dollars); a person with a limitation in at least one activity of daily living had a life expectancy of 11.6 years and expected cumulative expenditures of about 145,000 dollars. Expenditures varied little according to self-reported health at the age of 70. Persons who were institutionalized at the age of 70 had cumulative expenditures that were much higher than those for persons who were not institutionalized. CONCLUSIONS: The expected cumulative health expenditures for healthier elderly persons, despite their greater longevity, were similar to those for less healthy persons. Health-promotion efforts aimed at persons under 65 years of age may improve the health and longevity of the elderly without increasing health expenditures.

Cardiovascular risk profile earlier in life and Medicare costs in the last year of life.

BACKGROUND: Health care costs are generally highest in the year before death, and much attention has been directed toward reducing costs for end-of-life care. However, it is unknown whether cardiovascular risk profile earlier in life influences health care costs in the last year of life. This study addresses this question. METHODS: Prospective cohort of adults from the Chicago Heart Association Detection Project in Industry included 6582 participants (40% women), aged 33 to 64 years at baseline examination (1967-1973), who died at ages 66 to 99 years. Medicare billing records (1984-2002) were used to obtain cardiovascular disease-related and total charges (adjusted to year 2002 dollars) for inpatient and outpatient services during the last year of life. Participants were classified as having favorable levels of all major cardiovascular risk factors (low risk), that is, serum cholesterol level lower than 200 mg/dL (<5.2 mmol/L), blood pressure 120/80 mm Hg or lower and no antihypertensive medication, body mass index (calculated as weight in kilograms divided by the square of height in meters) lower than 25, no current smoking, no diabetes, and no electrocardiographic abnormalities, or unfavorable levels of any 1 only, any 2 only, any 3 only, or 4 or more of these risk factors. RESULTS: In the last year of life, average Medicare charges were lowest for low-risk persons. For example, cardiovascular disease-related and total charges were lower by 10,367 dollars and 15,318 dollars compared with those with 4 or more unfavorable risk factors; the fewer the unfavorable risk factors, the lower the Medicare charges (P for trends <.001). Analyses by sex showed similar patterns. CONCLUSION: Favorable cardiovascular risk profile earlier in life is associated with lower Medicare charges at the end of life.

Health, technology, and medical care spending.

The RAND Future Elderly Model illustrates important principles about the relation among medical technologies, health spending, and health. New technologies add to spending because the costs of the new technologies and the health care costs during the added years of life they bring outweigh reductions in annual spending from better health. Many technologies with a low cost per patient per year result in high aggregate costs because of an expanded population being treated. However, the jury is still out on whether a better health-risk profile among future sixty-five-year-olds could moderate health spending for the elderly.

Patterns of health care and disability for Medicare beneficiaries under 65.

Disabled people under age 65 are a vulnerable and growing segment of the Medicare population, yet Medicare reform has focused on the needs of the aged. This study linked the Medicare Current Beneficiary Survey to Social Security Administration records to analyze patterns of health care for disabled beneficiaries by reason for disability. We found substantial variation in average health care costs by type of service, including prescription drugs, and in sources of payment. Rates of institutionalization were high among some disability categories and there was heavy reliance on Medicaid and other public programs for payment. It is essential that the special needs of the disabled not be overlooked as policymakers consider fundamental modifications to Medicare and Medicaid.

Trends in the coronary heart disease risk profile of middle-aged adults.

PURPOSE: To examine recent trends in the coronary heart disease (CHD) risk profiles of the population aged 45 to 64 in the United States. METHODS: Data from the National Health and Nutrition Examination Surveys (NHANES) from 2 time periods (1988-1994 and 2005-2008) are used to estimate the CHD risk functions derived from the Framingham Heart Study. The risk functions take account of levels of blood pressure (systolic and diastolic), total and high-density lipoprotein serum cholesterol, diabetes (doctor diagnosed or based on fasting glucose), and smoking status to estimate the 10-year risk of myocardial infarction or coronary death. We estimate the risk functions by gender, race, and age group (45-54 and 55-64). RESULTS: The CHD risk profile of middle-aged adults has improved over time. For example, the mean 10-year risk of heart attack or CHD death among persons 55 to 64 years has declined from 7.1% to 5.2%. Declines are seen among both men and women and among non-Hispanic Blacks and non-Hispanic whites. CONCLUSIONS: Despite increases in diabetes and obesity, the CHD risk profile of middle-aged adults improved during the period from 1988-1994 to 2005-2008.

Trends in late-life activity limitations in the United States: an update from five national surveys.

This article updates trends from five national U.S. surveys to determine whether the prevalence of activity limitations among the older population continued to decline in the first decade of the twenty-first century. Findings across studies suggest that personal care and domestic activity limitations may have continued to decline for those ages 85 and older from 2000 to 2008, but generally were flat since 2000 for those ages 65-84. Modest increases were observed for the 55- to 64-year-old group approaching late life, although prevalence remained low for this age group. Inclusion of the institutional population is important for assessing trends among those ages 85 and older in particular.

Long-term trends in Medicare payments in the last year of life.

OBJECTIVE: To update research on Medicare payments in the last year of life. DATA SOURCES: Continuous Medicare History Sample, containing annual summaries of claims data on a 5 percent sample from 1978 to 2006. STUDY DESIGN: Analyses were based on elderly beneficiaries in fee for service. For each year, Medicare payments were assigned either to decedents (persons in their last year) or to survivors (all others). RESULTS: The share of Medicare payments going to persons in their last year of life declined slightly from 28.3 percent in 1978 to 25.1 percent in 2006. After adjustment for age, sex, and death rates, there was no significant trend. CONCLUSIONS: Despite changes in the delivery of medical care over the last generation, the share of Medicare expenditures going to beneficiaries in their last year has not changed substantially.

Retrospective information on health status and its application for population health measures.

Healthy life expectancies are almost always calculated by using health data from cross-sectional surveys. This type of calculation is done partly because data from longitudinal surveys are not always available, and when they are available, they are collected at intervals that are longer than one year. In such cases, collecting health information retrospectively for the years skipped by the survey is useful. The main purpose of this paper is to show how retrospective health information can be used to estimate life expectancies in different health states. Healthy life expectancies are estimated with and without using data on retrospective health information, and the corresponding estimates are compared. The two sets of estimates are similar. We conclude that retrospectively assessed health information based on a one-year recall period can be used to estimate years of life in various health states and that estimates based on such information will closely approximate estimates based on concurrent health information.

Evaluation of a method for fitting a semi-Markov process model in the presence of left-censored spells using the Cardiovascular Health Study.

We used a longitudinal data set covering 13 years from the Cardiovascular Health Study to evaluate the properties of a recently developed approach to deal with left censoring that fits a semi-Markov process (SMP) model by using an analog to the stochastic EM algorithm--the SMP-EM approach. It appears that the SMP-EM approach gives estimates of duration-dependent probabilities of health changes similar to those obtained by using SMP models that have the advantage of actual duration data. SMP-EM estimates of duration-dependent transition probabilities also appear more accurate and less variable than multi-state life table estimates.

Was there compression of disability for older Americans from 1992 to 2003?

Medical advances and the growth of the elderly population have focused interest on trends in the health of the elderly. Three theories have been advanced to describe these trends: compression of morbidity, expansion of morbidity, and dynamic equilibrium. We applied multistate life table methods to the Medicare Current Beneficiary Survey to estimate active and disabled life expectancy from 1992 to 2003, defining disability as having difficulty with instrumental activities of daily living or activities of daily living. We found increases in active life expectancy past age 65 and decreases in life expectancy with severe disability. These trends are consistent with elements of both the theory of compression of morbidity and the theory of dynamic equilibrium.

Trends in the health of older Americans, 1970-2005.

The health of Americans age sixty-five and older has improved on nearly all major indicators: longevity, self-reported health, and functioning. Both health care services use and health spending have risen. The increased use of restorative procedures and prescription medicines suggests that medical advances have had an important role in the better health of older Americans. Factors that might limit prospects for future improvements include rising rates of obesity and diabetes, particularly among the middle-aged.

New estimates of lifetime nursing home use: have patterns of use changed?

OBJECTIVES: The elderly population at risk for costly nursing home care is increasing. It is important to understand patterns of lifetime nursing home use and their implications for public and private payers. We provide new lifetime nursing home use estimates, project future use, and discuss cost implications. METHODS: Data are next-of-kin reports of nursing home use for representative samples of decedents from the 1986 and 1993 National Mortality Followback Surveys. Future use is based on projected mortality from the Social Security Administration. RESULTS: The proportion of elderly decedents who ever used a nursing home rose modestly between 1986 and 1993, with increased use before the last year of life. Rising longevity after age 65 and older the next 20 years will increase the risk for a 65 year old ever entering a nursing home to 46%. With increased survival to age 65, the number of 65 year olds ultimately using nursing homes will double by 2020. CONCLUSIONS: Disability declines and changes in Medicare policy between 1986 and 1993 had little impact on overall patterns of nursing home use. Barring dramatic changes in health status or other factors, population aging will make nursing home costs a growing share of national health spending. More needs to be known about relationships between nursing home use and alternative care settings and the cost and quality implications of shifts from one setting to the other. A key issue is how constraints on Medicare SNF and home health benefits will affect use and the distribution of costs.

Payment source and length of use among home health agency discharges.

PURPOSE: Our study compared (1) length of use among home health care (HHC) discharges with Medicare, Medicaid, or private health insurance between 1991 and 2000 and (2) factors associated with length of HHC use among discharges with Medicare, Medicaid, or private health insurance. METHODS: Data were obtained from the 1992, 1994, 1996, 1998, and 2000 National Home and Hospice Care Surveys (n = 18,416). Logistic regressions and stratified analyses by primary payment source were applied. RESULTS: After adjusting for covariates, Medicare HHC patients were from 0.52 to 0.75 times less likely to be discharged within 30 days in 1991-1996 than in 1997-1998. Medicaid patients were 0.37 times less likely to be discharged within 30 days in 1991-1992 than in 1997-1998. Patients with private insurance were 2.05 times more likely to be discharged within 30 days in 1993-1994 than in 1997-1998. No significant difference in length of use was found at the multivariate level between 1997-1998 and 1999-2000 among HHC patients with Medicare, Medicaid, or private health insurance. Results for being discharged within 60 days were similar to these described above. CONCLUSIONS: Our study shows that length of HHC use among Medicare discharges decreased after the implementation of the Medicare interim payment system. We did not find a spillover effect of the Medicare interim payment system on length of HHC use among discharges with Medicaid or private health insurance. Our results can help health professionals and policy makers better understand the dynamic associations between payment systems and length of use of HHC services.

Resolving inconsistencies in trends in old-age disability: report from a technical working group.

In September 2002, a technical working group met to resolve previously published inconsistencies across national surveys in trends in activity limitations among the older population. The 12-person panel prepared estimates from five national data sets and investigated methodological sources of the inconsistencies among the population aged 70 and older from the early 1980s to 2001. Although the evidence was mixed for the 1980s and it is difficult to pinpoint when in the 1990s the decline began, during the mid- and late 1990s, the panel found consistent declines on the order of 1%-2.5% per year for two commonly used measures in the disability literature: difficulty with daily activities and help with daily activities. Mixed evidence was found for a third measure: the use of help or equipment with daily activities. The panel also found agreement across surveys that the proportion of older persons who receive help with bathing has declined at the same time as the proportion who use only equipment (but not personal care) to bathe has increased. In comparing findings across surveys, the panel found that the period, definition of disability, treatment of the institutionalized population, and age standardizing of results were important to consider. The implications of the findings for policy, national survey efforts, and further research are discussed.