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Geriatric Rehabilitation,L, Socialand EconomicImplications of Aging

Gregory M. Vl/orsowicz, MD, MBA, Deborsh G, Stewart, MD, Edward M, Phillips, MD, David X Cifu, MD

ABSTRACT. WorsowiczGM, StewartDG, Phillips EM, Chronologicage is probablythe mostuniversally accepted Cifu DX. Geriatricrehabilitation. l. Social and economic andmost frequently used system. Old ageis oftendefined as 65 implicationsof aging.Arch PhysMed Rehabil2004;85(Suppl yearsand older, but this is an arbitraryfigure that is basedon J l:sJ-o. policy or societalnorms. Terms that are usedinclude aged, elderly,young old (60+), old old (75+), oldestold (85+), This self-directedleaming module highlights the social and older adults(75+), and centenarians.s'6Other descriptorsof economic implications part guide of aging. It is of the study on "old age"include older workers (40+) andeligibility to join geriatric rehabilitation in the Self-Directed Physiatric Educa- the AmericanAssociation of RetiredPeople (AARP; 50y or tion Program practitioners physicat for and traineesin medicine older).7 and rehabilitation and geriatric medicine. This article specifi- cally focuseson the epidemiology of aging, the economicsof 1.2 EducationalActivity: To discussthe impact of the aging, informal and formal social support systems,ageism and changingaging demographicson rehabilitationser- societal issues,and care and treatmentsettings. vice needswith a residentin physicalmedicine and Overall Article Objective: To summarize the social and rehabilitation. economic implications of aging in the context of physical medicine and rehabilitation. In 2001,national health care expendituresexceeded $1.4 Key Words: Ageism;Epidemiology; Geriatrics; Rehabilita- trillion or 14.1%of the grossdomestic product.r The aging tion; Social support. populationis a highuser ofthese health care services. In 1999, @ 2004 by the American Acaclemyof Physical Medicine and 25%of all physicianoffice visits ( I 92.2million) in theUnited Rehabilitation Stateswere by adults65 andolder.8 The hospitalization rate in 1999for adultsbetween the agesof 65 and 74 yearswas 1.9 l.l Educational Activity: To advise a medical student on timeshigher than that for the overallpopulation, whereas for population the demographicsof the aging for which people75 and over,it was2.7 timeshigher.E Medicare is the providing he/shewill be care. largestsingular payer for theseservices, and two thirds of f N 1900,THERE WERE 3 million peoplein the UnitedSates Mcdicarespending is accountedforby 20o/oofits beneficiaries. I at or over the age 65 years (4% of the total US population), This 20% of high end-usershave 5 or more chroniccondi- while in 2000,35 million (35%) peoplewere age 65 or older. tions.e As the baby boom generationages, it is predicted that 1 in 5 BecauseMcdicare is thelargcst single payer of healthcare Americanswill be 65 or older by the year 2030.The 85-and- for the elderly US population,governmental policy plays a older-agecategory is the most rapidly growing segmentof the criticalrole in eligibilityand services provided. In 1997,Con- US population.It is estimatedthat this group will increasefrom gresspassed the BalancedBudget Act (BBA), which has 2Yo to 5% over the next 50 years.r'2In the United States,life producedchanges in the reimbursementsystems for home expectancyfor a person reaching65 years is l8 years; an healthservices, skilled nursing facilities (SNFs), and inpatient 85-year-oldperson's life expectancyis 6 to 7 years.3The aging rehabilitationfacilities (lRFs). These changes are predicted to of the US populationpresents challenging issues for govern- produce$393.8 billion in Medicaresavings between 1998 and ment, health care, and society. 2007.toThe BBA (1997)changed the reimbursement pattern There is no single universally recognizeddescription, clas- for homehealth services, and the frequenciesof homehealth sification, or grouping of the older population.Although chro- servicesdropped during 1997 and 1998from 8277to 5058per nologic, biologic, physiologic,and emotionaldescriptors are 1000enrollees. The Centersfor Medicareand Medicaid Ser- often used, functional classifications,such as a person's activ- vicesnow reimbursesIRF for servicesbased on a prospective ities of daily (ADLs), hisiherlevel of living dependency,num- paymentsystem (PPS). The IRF-PPS1ris basedon theassign- ber of concurrentmedical morbidities, living arrangement,and mentof patientsto specificcase-mix groups (CMG). The CMG employment status,may be more relevant to clinicians.a assignmentis determinedby a patient'sprimary diagnosis or rehabilitationimpairment category @lC) andhis/her FIM in- strumentmotor score, FIM cognitivescore, and age on admis- sion.Specific categories for patientswith shortstays, death, or earlytransfer to anotherMedicare rehabilitation facilify, long- From ths Departmcnt of Physical Medicine and Rchabilitation, Univcrsity of term carehospital, inpatient hospital, or nursinghome were Missouri, Columbia, MO (Worsowicz); Brooks Health System Administration, Jack- sonville, FL (Stewart); Deperfinent of Physical Medicine and Rehabilitation, Hanard alsodeveloped. The IRF-PPSwas developedin an attemptto Medical School, Spaulding Rehabilitation Hospital, Boston, MA (Phillips); and reimbursefacilities according to a patient'sseverity ofdisabil- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth Uni- ity and his/herrequired use of resources.The more disabled versity/Medical College of Virginia, Richmond, VA (Citu). patients,who will havehigher CMG scoreswithin their RIC, No commercial party having a direct financial interest in the results of the reseuch supporting this article has or will confer a benefit upon the authors(s) or upon any are predictedto requirea greateruse of resourcesand, there- organization with which the author(s) is/are associated. fore,are assigned higher reimbursement.r2 Reprint requeststo Gregory M. Worsowicz, MD, MBA, Univ of Missouri, PM&R, ln 1942,the AmericanGeriatric Society (AGS) was devel- I Hospital Dr DC046 00, Columbia, MO 65212, e-mail: worsowiug@heallh. oped.Their websitet3offers important information and links. missoui.edu. Aging 0003-9993/04/8507-92I 4$30.00/0 ln 1974,Congress approved the NationalInstifute on doi: 10.I 0l 6/j.apmr.2004.03.005 (NIA) as 1 of the centersfor the NationalInstitutes of Health.

Arch PhysMed RehabilVol 85,Suppl 3, July 2004 s4 SOCIAI AND ECONOMICIMPLICAT|ONS OF AG|NG.Worsowicz

Themission of NIA is to provideleadership in agingresearch, support,education, and respitecare can prolonga person's training,health information, information dissemination, and communityliving. Socialsupports are a complexnetwork of otherprograms for the olderpopulation.la The VeteransHos- programs,services, funding, and people that servethe myriad pital Administrationinitiated the funding for training geriatric of needsof elderlypersons. fellowsin geriatricresearch and for clinicalcenters in 1980.In 1,4 1988,certification for addedqualifications in geriatricmedi- EducationalActivity: To criticizethe influenceof age- cine was sponsoredby both internalmedicine and family ism on the care of an 85-year-oldretired physician practice.l3In 1991,NIA developedan older Americansre- with worseningarthritis who is being encouragedto stop driving pain, searchprogram of independencecenters (Pepper Centers). As becauseof wrist thesecenters have developed,other agenciesand advocacy Ageism2tis thepejorative belief system, generally not sup- groupsfor theelderly have grown. The AARP offersa resource portedby the literature,that old age is synonymouswith book that containsresearch information provided bv current dementia,depression, dependence, and debility. The negative agenciesand programsand laws that are pertinentto the societalview that j agingnecessarily represents pain, isolation, elderly.t fear,and asexuality are ageist in theirnature. Important issues within 1.3 ClinicalActivity: To evaluatethe formal and informal ageisminclude how eldersview themselvesand the social support systemsavailable for an 85-year-old largersocietal expectations ofpeople reaching their later years. Ageism leads widowwho is livingalone in her childhoodhome and to discriminationagainst the elderlyin the has begunto developfunctional decline. workplace,in socialsettings, and in medicalcare. Health care professionalsmust remain vigilant to combatnegative attitudes Socialsupport systems in theUnited States are comprised of thatbecome manifest in medicalcare provision-for example, both formal andinformal networks.aFormal structures include that pain in the elderlyis not worth treatingaggressively and government-sponsoredagencies and programsand services that decreasedfunction is inevitablewith aging. coveredby privateinsurance. Formal care or serviceis paidby The ageist,negative self-perception of someelders impacts somethird party, not by theuser or theprovider ofthe service. on their own healthand function.People with positiveself- Medicare,a programsponsored by the federalgovemment, perceptionsof aging experiencebenefit on their functional paysfor mostofthe healthcare provided to people65 yearsor health.22Moreover, modifying negative stereotypes can benefit older.Part A ofthe Medicareprogram covers hospital services, olderpeople: common age-related gait changeswere shown to whereasPart B coversphysician services, durable medical be reversiblewith exposureof eldersto positiveimages of equipment(DME), andhome health. Medicare sets allowable aging.23 chargesand then reimburses providers 80% of thoseallowable Someaspects of ageismare generational. Societal expecta- charges.Medicaid is a state-administeredprogram that pays for tions of aging will undoubtedlyevolve with the aging and additionalservices if, becauseof his/hcrfinancial resources, a oncomingretirement of 76 millionbaby boomers, persons born personmeets the programdefinitions of being"medically in- between1946 and,1964. The MacArthurFoundation studies digent."Other formal supportscan includeagencies such as summarizedin Rowe and Kahn'sSuccessfitl Aging2a present Adult ProtectiveServices and Area Agencies on Aging,which extensiveevidence refuting common ageist stereotypes. Be- are locally run and provide social serviccs,advocacy, and yondthe goals of merelyavoiding disease and disability and guardianship. prolonginglongevity, appropriate lifestyle choices permit the Informalresources, which include families, church communi- positiveanticipation of maintainedcognitive and physical ca- ties,and serviceclubs, generally provide nonreimbursed assis- pacityinto latelife. tance.Most caregiving in theUnited States is informal,accounting Counteractingageism in healthcare will requirea broader for about7 5% of all careprovided to theeldcrly. Seventy percenl educationalcurriculum. Elderly persons should be involvedin of caregiversare women, either wives or daughters.Caregiving is the planningand teaching.Medical school coursework must generallyprovided daily, for 4 to 8 hourson average,lasting includeissues of agingin all sr.rbjects.Clinical course work from weeksto a decadeor more,and primarily involves ". . . emo- shouldinclude working with older adultsacross the clinical tional support,followed by help with shopping,transportation, spectrumfrom acutecare to nursinghome to communityset- householdtasks, and personal 661s."te(p33s) tings. Residentsand practicingphysicians can benefitfrom Socialdependency is morecommon in elderlywomen, who readilyavailable resources, including those from theAGS.2s,26 aremore likely to be widowedbecause their life expectancyis The carethat physiatristsand otherhealth care professionals longerthan men's. Only 40% of women65 yearsor older-are providefor the growingpopulation of elderly must include qalried, comparedwith 80% of men in the sameage group. proactlvemanagement of commonsequelae of aging. In a Elderlymen are more likely to havethe support of a wife who sense,we medicalprofessionals are trainingthe providersof is typically youngerand in betterhealth.'? The numberof carefor our own lateryears. socialsupports an individualhas directly impactshappiness and life satisfactionand is associatedwith better physical 1.5 ClinicalActivityt From the healthcare continuum, healthand lower mortality.ts'te recommenda levelof care that will best addressthe Althoughgender influences social supports, race and ethnic- needsof an 85-year-oldwoman with a hip fracture lvho needspostsurgical ity may alsoaffect caregiving. A reviewofracial, ethnic,and rehabilitation. cultural differencesin caregivingof elderswith dementiare- Medicareis a federallysponsored program, so its coverageis vealed ..adult that black caregiverswere more likely to be an uniform throughoutthe United States.Any personwho has child, friend,or otherfamily member,while white caregivers paid into the federaltax systemfor 40 quarters(or was ever weremore likely to be a spouse."20(p361) marriedto someonewho has)and meets any of the following Social supportsystems, both formal and informal, can pre- 3 criteriais eligiblefor Medicarepart A at no cost:(l) age65 vent instifutionalization.Maintaining the integrityof support yearsor older,(2) disabledand on SocialSecurity Disability particularly networks, the informal supports,can make the Insurancefor more than 2 years,or (3) has end-stagerenal differencebetween a person'sliving in the communifyor not.4 disease.Medicare reimburses inpatient and SNF rehabilitation Helping to reducecaregiver burden by providing psychologic services.Medicare Part B, which,for a monthlyfee, is avail-

ArchPhys Med Rehabl! Vol 85, Suppl 3, Juty2004 SOCIALAND ECONOMICIMPIICATIONS OF AGING,Worsowicz s5 able to peopleon Medicarepart A reimbursesfor physician Beyond financial considerationsfor levels ofcare, determin- services,home health services, and outpatienttherapies. ing the level of servicesmost appropriatefor a given patient is As noted,Medicare Part A insuranceprovides payment for a primary function of a physiatrist.How to assign patients to acutemedical and rehabilitation hospitalization and short-term the most appropriatecare delivery setting requiresknowledge skilled nursingcare. Acute medicalhospitalization is reim- of payer sources; community resources;and patient-specific bursed in lump sum amountsbased on diagnosis-related variables such as endurance, medical acuity, stabilify, and groups.Reimbursement for rehabilitationservices in IRFs or disposition options. Each level of care in the rehabilitation SNFsis reimbursedunder the PPS, also in lumpsum amounts, continuum has specific characteristicsand efficacies. basedon the person'sCMG. Peoplewho receivecare for the Acute care is the most commonly used health care service samediagnosis at both an IRF andan SNF do not receiveany after physician office visits for personsage 65 years or older. additionalreimbursement for the subsequentSNF stay (thus Although persons in this age group account for 13% of US requiringthe reimbursementto be shared).Beneficiaries are population, they use 47% of all inpatient days of care. Up to responsiblefor a copaymentin eachsetting, often approxi- 35oh of elderly patients admitted to acute care facilities will 1 or more areas of basic ADLs. Func- mately2QYo of theMedicare-determined total. Importantly, on lose independencein tional decline is relatedto severalfactors including immobility, average,75% of Medicarepatients admitted to an IRF must poor nutritional status,sensory deprivation, altered sleep-wake meet I of 10 establisheddiagnoses for the IRF to qualifufor cycles, medication interactions,polypharmacy, environmental payments. "75% neglectsmany of the This rule" unfortunately changeor alteredroutines, and iatrogenicillness. Severalstud- currentrehabilitation diagnoses (eg, post coronaryartery by- ies have identified risk factorsfor functional decline and nurs- pass graft care, post total hip replacement)that were not ing home placement. These risk factors include older age commonplacewhen it was institutedmore than 20 yearsago. (>70y), mental status changes,premorbid functional impair- For peoplewho needskilled nursingcare (eg, wound care, ment, low social activify before admission, and premorbid managementof indwellingcatheters), Medicare pays for 100 depressionor depressivesymptoms. All of thesefactors predict daysofthat careafter the beneficiary has been discharged after poor functional outcome.2T'28Assessing and managing these an acutehospital stay ofat least3 daysand within 30 daysof issuesalong with the primary and secondaryconditions are para- the hospitaldischarge. Medicare Part A paysfor the first 20 mount to successfulmedical and rehabilitation management. days of skillcd carewith a coinsuranccamount paid by the Rehabilitation intervcntionscan be delivered in various set- beneficiaryon days21 to 100.Coverage by Medicareis mea- tings, each characterizedby different intensity, outcome, and suredin benefitperiods. A benefitperiod bcginswhen the rclative cost. Allocation of servicesis currently basedmore on beneficiaryis admittedto the hospitaland ends when the payer tolerancethan on best outcome. Outcome data for vari- beneficiaryhas been out of thehospital or skilledt'acility for 60 ous levels of care are often not availableor are incomplete. consecutivedays. These individuals typically receive some Greatvariability exists across the United States.One analysis rehabilitationserviccs (cg, physical therapy, occupational ther- found that, in Florida, l0% of stroke survivors were admitted apy,speech and language pathology) in additionto ongoing to rehabilitationhospitals or units,in contrastto 3loh in Hous- medicaland nursing management. The condition requiring care ton, TX.ze'ro in the skilled facility must be the same as the reasonfor Funding sourcealso plays a role in rehabilitation setting. In hospitatizationto qualiff for Medicarecoverage. The benefi- an analysisof traditionalMedicare beneficiaries compared with ciarymust be certifiedby a licensedphysician as requiring the health maintenanceorganization Medicare beneficiaries,stroke care,at thatlevel, to be eligiblefor coverage. patients who had traditional Medicare reimbursement were DME, such as gait aidesor adaptiveequipment, is also more likely to be admitted to acute rehabilitation settingsthan reimburscdunder Medicare,as long as it is orderedby a to skilled or subacutesettings. Costs in acuterehabilitation are licensedphysician and is medicallyjustified. Outpatient reha- estimatedto be twice as high as those for subacuterehabilita- bilitation therapy,home health services,and inpatientand tion.3r In a study32to evaluate whether better outcomes are outpatientphysician care are reimbursed by Medicarebut only associatedwith higher costsof inpatientrehabilitation, analysis for beneficiarieswho receivePart B. A physicianmust order showed that stroke patients admitted to acute rehabilitation the servicesor equipmentand must provide a detailedplan of were 3.3 times more likely to be dischargedhome than patients care.Home health services are limited to skilledcare, such as admittedto subacutesettings. Other rehabilitationinterventions nursingor rehabilitationtherapy. Home health aide provisions strongly associatedwith improved outcomeafter strokeinclude arevery limited. Guidelines for lcngthand type of servicesand early interventionofrehabilitation (within 72h poststroke)and equipmentare available based on diagnoses,with someoutlier rehabilitation provided in an interdisciplinary versus a multi- provisions.Hospice care and its associatedservices are also disciplinary inpatient setting.33 coveredby Medicare.tT Data supporting acute rehabilitation servicesover subacute Medicaidalso providesreimbursement (that varies from rehabilitation services for hip fractures are less convincing, stateto state)for inpatient(acute medical, rehabilitation), out- suggestingthat only certain patients may benefit from acute patient,home health, skilled nursing home, DME, andphysi- rehabilitation.3aHowever, it is clear that outcomes are best cian benefits.However, Medicaid is fypicallynot a primary when careful attention is focused on avoiding medical prob- sourceof healthinsurance for older adultsbut, rather,may lems. Identiffing which patientsrequire acute rehabilitation- serveas a copayment(as may commercialinsurances). Re- with its broad array of services, a minimum of 3 hours of cently,many managed care Medicaid programs have become therapy a day, interdisciplinaryapproach, and intensemedical available,further increasing the diversityof coveredservices, and nursing supervision-is multifactorial and is best deter- in this caseeven within a state.Importantly, at present,Med- mined by a physiatrist. icaid pays for more than 85% of all custodialnursing home care (which is not reimbursedby Medicare)in the United References States.Older adults who continueto work or who werefederal 1. FederalInteragency Forum on Aging RelatedStatistics. Older andrailroad employees typically have commercial or managed Americans2000: key indicatorsof wellbeing'Washington (DC): careinsurance as their primaryfunding source. US GovernmentPrinting Office; 2000.

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