Happy 50th Birthday, Medicare. Your Patients Are Getting Healthier

by Richard Harris
Here’s a bit of good news for Medicare, the popular government program that’s turning 50 this week. Older Americans on Medicare are spending less time in the hospital; they’re living longer; and the cost of a typical hospital stay has actually come down over the past 15 years, according to a study in the Journal of the American Medical Association.

Doctors, hospitals and government administrators have put a lot of effort into making Medicare more efficient in the past 15 years. Dr. Harlan Krumholz and colleagues at Yale University took on a study to see whether that effort has paid off.

“The results were rather remarkable,” says Krumholz, a cardiologist and leading health care researcher. “We found jaw-dropping improvements in almost every area that we looked at.”

The researchers looked at the experience of 60 million older Americans covered by traditional Medicare between 1999 and 2013. They found that mortality rates dropped steadily during that time, and people were much less likely to end up in the hospital.

“If the rates had stayed the same in 2013 as they had been in 1999, we would have seen almost 3.5 million more hospitalizations in 2013,” Krumholz says.

“People who were being hospitalized were having much better outcomes after the hospitalization,” he says. “They had a much better chance of survival.”

And the average cost of a hospital stay dropped too, he says, from $3,290 to $2,801 in inflation-adjusted dollars over the 15-year period for patients in the traditional Medicare program. (Researchers couldn’t quantify the experience in Medicare Advantage, the managed-care alternative to Medicare).

Krumholz attributes the improvement to a wide variety of measures designed to boost patients’ health, from prevention programs to advances in medical care. He says some of the savings also came about because medical care shifted from hospitals to less expensive outpatient clinics.

“They’re pointing out a very good thing in the medical system,” says economist Craig Garthwaite at the Kellogg School of Management at Northwestern University. He says the recession, which helped slow rising health care costs overall, apparently played a minor role in this story of Medicare.

Costs really are being contained, Garthwaite says. One other reason that’s happening is that the federal government is reimbursing hospitals and doctors less for treating Medicare patients.

“That’s an easy way to get control of medical spending in Medicare,” Garthwaite says, but “it’s just not something we can do in the private market, and we have to worry about how sustainable it is for the Medicare program overall.”

With the post-World War II baby boom now reaching retirement age, more and more people are turning 65 and becoming eligible for Medicare. That growth continues to drive up the overall cost of the program, even as that average cost per illness or hospitalization comes down. And as older Americans live longer lives, they use Medicare for more years than previous generations did.

Coordinating care for high-risk patients was expected to save money and improve quality of care. A Medicare experiment didn’t pan out.

Medicare is still running a bit of a deficit, but the situation is improving. The program’s trustees say its trust fund will be solvent through 2030. Some adjustments would be needed to keep the program in good financial health beyond that date.

Garthwaite says other recent trends could make matters worse, with one especially worrisome example being sharply rising drug prices.

“Some of these [new cancer] products are providing only a few months of life for several hundred thousand dollars,” he says. And the system doesn’t do a good job of making difficult judgments in situations like that.

Joseph Antos, an economist in health policy at the American Enterprise Institute, agrees that the good news from the Yale study doesn’t assure a rosy future. He’s concerned about the financial health of Medicare if, for example, an effective drug for Alzheimer’s disease is developed.

“I would argue that if anybody came up with an effective treatment for Alzheimer’s today, that treatment would be hailed as a major breakthrough and we wouldn’t be looking at the cost,” Antos says.

And that would almost certainly break the pattern that’s been documented over the past 15 years, where improving health has actually helped drive down the cost of medical care.
http://www.npr.org/sections/health-shots/2015/07/28/426740179/happy-50th-birthday-medicare-your-patients-are-getting-healthier

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What Makes Older People Happy

by Judith Graham
Every year, my husband and I wonder what kind of birthday gift to give his dad, now 86 years old. The newest gadget, which may be admired but almost surely will be put in a drawer? Something much more ordinary, like one of the cardigan sweaters he wears day in and day out?

We know very well what Mel would really enjoy: a weeklong visit with us and our children, with lots of time spent eating out in comfortable restaurants where he doesn’t have to strain to follow the conversation. But that is hard to engineer, since we all live far away.

A recent study helps me better why understand Mel so appreciates the same tried-and-true interactions that provoke a “not again” groan from my husband. The report, scheduled for publication this year in The Journal of Consumer Research, finds that the kinds of experiences that make people happy tend to change over time.

When we’re young and believe we have a long future ahead, the authors found, we prefer extraordinary experiences outside the realm of our day-to-day routines. But when we’re older and believe that our time is limited, we put more value on ordinary experiences, the stuff of which our daily lives are made.

Why? For young people trying to figure out who they want to become, extraordinary experiences help establish personal identities and are therefore prized, said Amit Bhattacharjee, the lead author of the study and a visiting assistant professor of marketing at Dartmouth College. As people become more settled, ordinary experiences become central to a sense of self and therefore more valued.

“It’s just what you would expect, this emphasis on savoring what you already have when your time starts to become limited,” said Peter Caprariello, an assistant professor of marketing at Stony Brook University who wasn’t involved in the research.

The study findings are drawn from eight experiments all revolving around the same theme. In one of them, Dr. Bhattacharjee and co-author Cassie Mogilner, an assistant marketing professor at the University of Pennsylvania, asked people aged 18 to 79 to recall an experience that was extraordinary or ordinary, and then asked them to rate their emotional responses. The conclusion: happiness derived from extraordinary experiences remained fairly constant, but pleasure from ordinary experiences increased as people got older.

Another experiment demonstrated that an individual’s perception of the future — whether it was open-ended or limited — was a critical factor in explaining the results. This is consistent with studies by Laura Carstensen, a professor of public policy and psychology at Stanford University, which posit that older adults’ sense that time is limited alters their emotional perspective, causing them to invest energy in what is most meaningful to them.

“I really like this paper because it ties together several important lines of research,” said Jim Bettman, a professor of business at Duke University. Previous research has shown that experiences make people happier than material possessions and that sharing experiences with others generates the most pleasure.

Adding a developmental perspective, Dr. Mogilner demonstrated in 2011 that the perception of happiness changes over time, with younger people feeling more rewarded by feeling excited and older adults getting a bigger boost of satisfaction from peace and calm.

One notable limitation in this new study is the relatively small sample of people in their 70s who participated in the experiments. “It would be nice to know how long the effect they’ve observed persists, but this can’t be established,” Dr. Caprariello said.

The implications? The things we enjoy aren’t necessarily what will make our older parents or relatives happy. The point isn’t to rip them from their routines and get them to try something new because you think that’s good for them. Like my father-in-law, they may much prefer to do the things they do ordinarily with us at their side.
http://newoldage.blogs.nytimes.com/2014/02/11/what-makes-older-people-happy/?_r=0

More Caregivers Are No Spring Chickens Themselves

by Paula Span

Gail Schwartz wants to keep her 85-year-old husband out of a nursing home as long as she can, but it isn’t easy.

Because David Schwartz, a retired lawyer, has vascular dementia and can no longer stay alone in their home in Chevy Chase, Md., she tends to his needs from 1 p.m. to 11 p.m. every Monday through Saturday and all of Sunday. When she dashes out for errands, exercise and volunteer work in the morning, she checks in by phone with the aides she has hired. “I’m always on alert,” she said. “At the grocery store, I’m thinking, ‘Is David O.K.?’ ”

An aide now stays overnight, too, because Mr. Schwartz awakened so frequently, disoriented and upset, that his wife began to suffer the ill effects of constantly disrupted sleep. She has moved into the bedroom across the hall. “I need my rest,” she said. “I’m no spring chicken myself.”

Indeed, Gail Schwartz is 78. While she thinks her husband does better at home — “he’s getting 24-hour attention, and you don’t get that in a nursing home,” she said — friends point out that the arrangement is much harder on her. She worries, too, about costs climbing as Mr. Schwartz’s health declines and his needs increase. For now, though, she manages, part of an apparently growing phenomenon: the old taking care of the old.

Every few years, the National Alliance for Caregiving and the AARP Public Policy Institute survey the state of American caregiving; their latest report, published last month, focused in part on caregivers over 75. They constitute 7 percent of those who provide unpaid care to a relative or friend, the survey found — more than three million seniors helping with the so-called activities of daily living (bathing, dressing, using a toilet), instrumental activities of daily living (shopping, transportation, dealing with the health care system) and a rising tide of medical and nursing tasks.

Almost half of them report caring for a spouse; the others assist siblings and other relatives, friends or neighbors, most also 75 or older. About 8 percent of these oldest caregivers still care for parents.

The aging of the population has thrust more seniors into this role, said Gail Hunt, president and chief executive of the National Alliance for Caregiving. “There didn’t use to be so many 95-year-olds,” she said, “and someone’s caring for those 95-year-olds.”

That’s challenging for anyone, though the extent of what’s called “caregiver burden” remains a subject of debate. For years, researchers have presented caregiving stress as a potential source of depression, compromised health, even premature death. Some of those findings are being reassessed; a recent study in The Gerontologist, for instance, argues that the picture is “overly dire” and that several studies find benefits for caregivers — the “healthy caregiver” hypothesis. (My own hypothesis: Both responses can be true, with caregiving providing purpose and activity in some situations but proving exhausting in others.)

People over 75, however, can find caregiving particularly taxing. They spend an average of 34 hours a week on caregiving tasks, the National Alliance for Caregiving report found, 10 hours more than caregivers over all, and they are less apt to have other unpaid help.

Because 46 percent take care of spouses, they are also more likely to be live-in caregivers, a known source of strain. “You’re responsible for their safety,” Ms. Hunt said. “You have to interact with the person all day long and maybe all night long, so your sleep is disturbed. It’s more stress than if you’re coming over periodically to help.”

The typical older caregiver in the study had been providing care for over five years. “Just the physical part of it, the lifting and bathing and all of that, can hurt you,” said Donna Wagner, dean of the College of Health and Social Services at New Mexico State University and a longtime researcher on family caregiving. Older caregivers, typically women, have their own health issues.

“My mother is a perfect example,” Dr. Wagner said, describing her as a 4-foot-10 woman who cared for her husband, an obese man with heart disease and diabetes, for seven or eight years. “I don’t even know how she managed,” Dr. Wagner said. After he died at 85, “it didn’t take her long to slide right into dementia. It’s as if she put it off while she had responsibility for him. There are a lot of mysteries.”

http://www.nytimes.com/2015/07/07/health/more-caregivers-are-no-spring-chickens-themselves.html?ref=health