Economics of Dementia Julie Bynum, MD MPH December 7, 2010.

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  • Economics of DementiaJulie Bynum, MD MPHDecember 7, 2010

  • Disease Specific CostsWhy Discuss them?

  • To Lobby for More Research FundingAlzheimers Research Trust, 2010

  • Understand what needs to be done for better outcomes in the future (or at least as good)

  • Canary in a coal mine

  • Fund balance as % of annual expenditures:NOTE: The Medicare Trustees recommend that the HI Trust Fund assets should be maintained at a level of at least 100% of annual expenditures. SOURCE: Kaiser Family Foundation based on 2009 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. Actual ProjectedLow costIntermediateHigh costMedicare Part A (Health Insurance) Trust Fund Balance, 2001-2018

    Under High Cost, Low Cost, and Intermediate Assumptions

  • Bottom LineDirect Dementia Care Costs are three times the Cost of Other Chronic Illnesses.

    We currently deliver care in an expensive way that might be less costly and better quality in a different model.

  • How are dementia costs different from other diseases?Alzheimers Research Trust, 2010

  • HealthSocialInformal CareProductivity lossMedicalPsychiatric & BehavioralSupervisionSafe housingFunctional Supports (eating, dressing etc)EXAMPLESSpousal supportUnpaid caregivingReduced hours due to informal care givingSandwich Generation

  • Distribution of costs is different in dementia from other diseases.

  • Direct CostsWho are the stakeholders?Alt. (Who pays the bills?)

  • Local Care System

  • TransitionsHOSPITAL

  • Expenditures Community vs. Institution in DementiaBynum, Unadjusted Data MCBS 2004

  • Expenditures Compared to Other DiseasesBynum, Unadjusted Data MCBS 2004

  • Difficulty Comparing Costs to Other Diseases

    Avg. 4 chronic conditions compared to 1 without dementia.Bynum, Unadjusted Data MCBS 2004Bynum JAGS 2004

  • HospitalizationIn Medicare approximately 50% of costs are for hospital care.Bynum JAGS 2004

  • Ask ourselves why?Behavioral issues/psychiatric admissionsInability to self manage chronic diseaseCaregiver stress and burnoutClinician uncertainties about diagnosis and management

  • Biopsychosocial Model of HealthEngel, 1977

  • Biopsychosocial Model of Costs for the Dementia Patient

  • Consider how costs might be different in the future

  • How Much Does Social Care Cost?2010 Median Annual Rate for the US

    Nursing home (private rm): $75,190Nursing home (semi-private rm): $67,525Assisted Living (1Br-single): $38,220Home Health Aide: $43,472Home Maker Services: $41,184Adult Day Care:$15,600Genworth Report 2010

  • What if we delayed progression of disease?Delay progression reduces number in late stage of disease with high social and informal care costsCost argument current medications

  • Acetyl Cholinesterase Inhibitors and Controversies

  • What if we delayed onset of disease?By 2050, estimates number of cases 4x higher based on current incidence ratesIf disease onset could be delayed, how much would be saved after 10 yrs?1-yr: save $10 Billion annually6-mo: save $4.7 Billion annuallyBrookmeyer, AJPH 1998

  • What if we did non-medical care differently?

  • A Family Intervention to Delay Nursing Home Placement of Patients with Alzheimers Disease: A Randomized Controlled TrialMittelman MS et al. JAMA 1996;276:1725.Sample: Referred, volunteer 206 spouse-caregivers of AD pts living at home with > 1 relative in areaIntervention enrolled over 3.5 yrs: Indiv. & Family counseling: task oriented, teaching techniques for problem solving, improve communication and support of primary caregiverCaregivers joined a support group (any)24 hr available counselor for crises or questionsF/u up to 8 yearsFunding: NIMH

  • Results: Delay of Institutionalization 329 DaysMittelman MS et al. JAMA 276:1725-1731, 1996

  • Spouse-Caregiver Intervention

    Drug Study: Donepezil Interventions Studied to Delay Nursing Home Placement in People with Alzheimers DiseaseDelay Placement by 329 DaysNo Effect on Nursing HomeMittelman MS et al. JAMA 276:1725-1731, 1996AD2000 Collaborative Group Lancet 2004;363:2105-15.

  • Costs of Two Interventions(Estimates since no published data)Caregiver Intervention2.4 FTE counselor with 85pt caseloadSalary 35-45K/yr inflated for benefits$1280-1600/patient/yrDrug InterventionDonepezil $1560/pt/yr

    Added cost329 days in Nursing Home = $43,428/pt

  • Where Do People With Alzheimers Disease Live?Source: Alzheimers Association, 2004

  • Not everything that counts can be counted, and not everything that can be counted counts.Albert Einstein

    *Why do generalist providers need to pay attention? Much published on the topic is in specialist journals.*A BRIEF ASIDE OF WHY THIS IS SO IMPORTANT***Much literature on caregiver and social aspect as well as psychiatric. But little on the physical and how these spheres interact.All aspects need to be addressed in order to improve functionRemember there is extreme variability in individual functioning in all of these areas.


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