“A Bridge to Health”
5th Annual Asian & Pacific Islander Community Health Center Conference
The Golden Years
Current Issues
Anticipating the Future
On Lok and PACE
Catherine Eng, MD, FACP
Medical Director
On Lok Senior Health Services
Clinical Professor of Medicine, UCSF
Division of Geriatrics
Old Age in America
Prior to 1850, only 2% of population were >60 years
By 1870
3% were >65
0.37% >80
Living to “old age” meant being poor and dependent
The Great Depression of 1930’s had a devastating effect
on American elders
By 1940: 2/3 of all elderly lived in poverty
Social Security Act (SSA) of 1935 provided monthly
income, but NO health insurance
Congress was OPPOSED to adding health insurance
to the SSA
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Portrait of the U.S. 65+ Population in 2006
65+ population as % of US census
12.8% in 2000
13.6% in 2010
16.5% in 2020
20% in 2050
Changing characteristics of the 65+ population
Declining disability rates
Better educated
Wealthier (persons 55 and older own 75% of wealth in US)
More diverse
Living longer
Healthcare for the 65+ is more expensive, adjusted for inflation
1960-1970: $75,000 per year of added life
1990-2000: $145,000 per year of added life
35% of Medicare expenditures used by beneficiaries in the final 2 years of life
3
POPULATION PROJECTIONS for AGED
90
80
millions
70
60
50
40
30
20
10
0
1999
2000
> 65
2025
> 75
2050
> 85
Source: 2004 CMS Statistics. US Dept. of Health and Human Services
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In the history of Western Civilization, the
last period in which there was a significant
elderly population was during the height of
the Black Death period, 1347 – 1352.
During that five year period, 33% of
European population perished. Older adults
were not as susceptible to Bubonic Plague!
At that time, 15% of the population was >60.
Excerpted from Fleming KC, Evans JM, Chutka DS. A cultural and economic
history of old age in America. Mayo Clin. Proc. 78:914-921, 2003
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Health Insurance for Elderly
1965 – Medicare legislation enacted
Prior to 1965, most elderly were uninsured
Most notably, prescription drug benefit was NOT
included
1965 – Medicaid legislation enacted
Insurance coverage for children and families with
dependent children
1973 – Medicaid expanded to cover blind and disabled poor
Paved the way for coverage of elderly poor
16% of all elderly are covered by both Medicare and
Medicaid
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Payers of Healthcare for Elderly
Medicare covers medical services
Part A: Acute hospital, post-acute SNF, Hospice
Part B: Physician services, ambulatory care, x-rays and
labs
Part C: Medicare Advantage plans
Medicare HMO’s
Special Needs Plans created by MMA 2003
Part D: Prescription Drug benefit
Long-term care is paid privately out of pocket
Nursing home: $5000 – $10,000 / month
Assisted Living facilities: $3000 - $6000 / month
When patient becomes impoverished, Medicaid covers
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Regional Concentrations of Medicare Beneficiaries
% of population
2002
All regions
13.7
Boston
15.1
New York City
14.2
Philadelphia
14.9
Atlanta
15.0
Chicago
14.0
Kansas City
15.3
Seattle
12.8
Dallas
12.1
San Francisco
11.7
Denver
11.7
• Older populations on
East Coast and Midwest
•Younger populations in
South and West
Source: 2004 CMS Statistics. US
Dept. of Health and Human Services.
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Current Medicare Beneficiaries
Less Diverse Than Generations To Come
100%
90%
2.5
3.8
3
12.6
8
5
6
11
80%
10
12.7
70%
83
60%
72
69.4
50%
US Census 2000
White
> 65 in 2003
African American
Hispanic
> 65 in 2030
Asian
Other
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Federal Healthcare Expenditure Trends
600
19.2% of
Federal
Budget
500
400
Billions of
dollars 300
200
100
0
1980
Total
Medicare
1990
2000
Medicaid
2001
2002
2003
Source: 2004 CMS Statistics. US Dept. of Health and Human Services
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Impact of Age and Chronic Illness On
Healthcare Resources in U.S.
Medicare beneficiaries
71% have 2 or more chronic illnesses
7% account for 50% of total costs
12% account for 67% of costs
18% account for 57% of drug costs
Medicaid beneficiaries
Elderly and disabled account for 67% of costs
11% are elderly and account for 27%
14% are disabled and account for 40%
Long-term Care accounts for 35% of Medicaid
expenditures – nursing home, home/personal care
Kaiser Family Foundation Report www.kff.org
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Chronic Illness and Frail Health
Dementia
Dependence on others for personal care
Medical frailty
advanced stages of chronic disease:
congestive heart failure, chronic obstructive
lung disease, kidney failure
frequent visits to the ER
more than one hospital stay within 6 months
Loss of strength, endurance, weight are
harbingers of frailty
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Innovation in Geriatric Services and Financing
On Lok
and
PACE
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On Lok…Peace and Happiness
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PACE…
Program of All-Inclusive
Care for the Elderly
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On Lok
From Local Innovation to National Adoption
15 Rural
PACE
programs
funded by
DRA 2005
Medicare
Provider
On Lok
Legislation
Opens in
35
On Lok
passed
San
First (BBA 1997) National
starts
Francisco
PACE
PACE National
programs
Sites
Medicare
Just like
operating
Demonstration
On Lok
(On Lok)
1973
1978
1986
1990
1997
2005
2006
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On Lok and PACE: Permanence
Federal legislation enacted in 1997
PACE established as a permanent Medicare
provider
PACE is a State option under Medicaid
Every State offers PACE under its Medicaid Program
All PACE programs use the protocol established
by On Lok
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Eligibility Requirements
To be eligible for PACE, a senior must:
Be
55 years or older
Reside
in the program’s defined service area
Be
certified by the State Medicaid Authority
(Dept. of Health Services in CA) as eligible for
nursing home level of care
Be
able to live in the community without
jeopardizing health and safety
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Comprehensive Services
All Medicare & Medicaid benefits
Community long-term care services
Skilled Nursing Facility when needed
Post-acute
Custodial long-term
No benefit limitations, co-payments
or deductibles
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Interdisciplinary Team Services
Primary Care
Specialists
Home
Care
Day Health
Nursing
Home
Hospital
Lab / X-ray
Medications /
DME
Nursing
Social service
OT / PT
Speech
Nutrition
Recreation
Personal care
Pharmacy
Transportation
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Primary Care
Each person has a
primary care physician
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Specialty Services
Dentistry
Optometry
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Nursing Services
Monitor status of chronic
conditions
Provide medication
management
23
Social Work and Case Management
24
Physical Therapy
Assisted or
Individual
treatments
25
Meals At the Center
26
Recreation and Exercise
27
Personal Care
28
Home Care and Home Health
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Care of Elders in the Future
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PACE and FQHC Affiliations:
Natural Collaboration in the Community
PACE
Los Angeles, CA
East Boston, MA
Boston, MA
FQHC
AltaMed Senior
AltaMed Health
Buena Care
Services
Elder Service Plan East Boston
Neighborhood
Health Center
Uphams Elder
Uphams Corner
Service Plan
Health Center
More PACE and FQHC affiliations are expected, especially in rural communities
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Summary
Growing Old in America has much to celebrate
Many more living longer
Fewer living with disability
Wealthier
Greater opportunity for leisure activities
But there are challenges
Fewer younger workers contributing to Social Security to adequately support the growing
numbers of retirees
Healthcare costs rising at an annual rate far above the inflation rate
More of the costs being paid privately, out of pocket
Medicare cannot keep up with the escalating costs of care
Resources skewed toward institutional care
Lack of coordinated healthcare options which include housing and personal care
Limited funding for community care systems
Lack of integrated information systems to link community providers
Community based care is less costly and more effective
Paradigm shift from expensive institutional care (acute hospitals and nursing homes) back to
the community
Opportunity for community based providers
Collaborate to form local networks of care: example of FQHC and PACE
Collaborate to innovate
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Thank You