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Economics of Dementia
Julie Bynum, MD MPHDecember 7, 2010
Disease Specific Costs
• Why Discuss them?
Stella Marr’s postcard
To Lobby for More Research Funding
Alzheimer’s 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 Projected
Low cost
Intermediate
High cost
Medicare Part A (Health Insurance) Trust Fund Balance, 2001-2018
Under High Cost, Low Cost, and Intermediate Assumptions
Bottom Line
Direct 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?
Alzheimer’s Research Trust, 2010
Health
Social
Informal Care
Productivity loss
Medical
Psychiatric & Behavioral
Supervision
Safe housing
Functional Supports (eating, dressing etc)
EXAMPLES
Spousal support
Unpaid caregiving
Reduced hours due to informal care giving
“Sandwich Generation”
Distribution of costs is different in dementia from other diseases.
Direct Costs
Who are the stakeholders?Alt. (Who pays the bills?)
Community
Nursing home
Assisted Living
HOSPITAL
Local Care System
Local Care System
Community
Nursing home
Assisted Living
HOSPITALHHA SNF
Clinic
TransitionsCommunity
Nursing home
Assisted Living
Funding Transitions
Assisted Living HOSPITAL Nursing home
MedicarePrivate Pay MedicaidMedicare SNF Private Pay
HOSPITAL
Expenditures Community vs. Institution in Dementia
Bynum, Unadjusted Data MCBS 2004
Expenditures Compared to Other Diseases
Bynum, Unadjusted Data MCBS 2004
Difficulty Comparing Costs to Other Diseases
• Avg. 4 chronic conditions compared to 1 without dementia.
Bynum, Unadjusted Data MCBS 2004
Bynum JAGS 2004
Hospitalization
In Medicare approximately 50% of costs are for hospital care.
Bynum JAGS 2004
Ask ourselves why?
• Behavioral issues/psychiatric admissions
• Inability to self manage chronic disease
• Caregiver stress and burnout
• Clinician uncertainties about diagnosis and management
Biopsychosocial Model of Health
Engel, 1977
Physical
SocialPsychological
Biopsychosocial Model of Costs for the Dementia Patient
Physical
SocialPsychological
Consider how costs might be different in the future
Current
How Much Does Social Care Cost?2010 Median Annual Rate for the US
Nursing home (private rm): $75,190
Nursing home (semi-private rm): $67,525
Assisted Living (1Br-single): $38,220
Home Health Aide: $43,472
Home Maker Services: $41,184
Adult Day Care: $15,600
Genworth Report 2010
What if we delayed progression of disease?
• Delay progression reduces number in late stage of disease with high social and informal care costs
• Cost 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 rates
• If disease onset could be delayed, how much would be saved after 10 yrs?◦ 1-yr: save $10 Billion annually◦ 6-mo: save $4.7 Billion annually
Brookmeyer, AJPH 1998
What if we did non-medical care differently?
A Family Intervention to Delay Nursing Home Placement of Patients with Alzheimer’s 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 area
Intervention enrolled over 3.5 yrs:
1. Indiv. & Family counseling: task oriented, teaching techniques for problem solving, improve communication and support of primary caregiver
2. Caregivers joined a support group (any)
3. 24 hr available counselor for crises or questions
F/u up to 8 years
Funding: NIMH
Results: Delay of Institutionalization 329 Days
Mittelman MS et al. JAMA 276:1725-1731, 1996
Spouse-Caregiver Intervention Drug Study: Donepezil
Interventions Studied to Delay Nursing Home Placement in People with Alzheimer’s Disease
Delay Placement by 329 Days No Effect on Nursing HomeMittelman MS et al. JAMA 276:1725-1731, 1996 AD2000 Collaborative Group Lancet 2004;363:2105-15.
Costs of Two Interventions(Estimates since no published data)
Caregiver Intervention• 2.4 FTE counselor with
85pt caseload• Salary 35-45K/yr inflated
for benefits• $1280-1600/patient/yr
Drug Intervention• Donepezil $1560/pt/yr
Added cost• 329 days in Nursing
Home = $43,428/pt
Where Do People With Where Do People With AlzheimerAlzheimer’’s Disease Live?s Disease Live?
Home/ALHome/AL70%70%
NHNH30%30%
Source: AlzheimerSource: Alzheimer’’s Association, 2004s Association, 2004
“Not everything that counts can be counted, and not everything that can be counted counts.”
Albert Einstein