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Geriatric Rehabilitation, L, Social and Economic Implications of Aging

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Geriatric Rehabilitation, L, Social and Economic Implications of Aging s3 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 SOCIAIAND 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
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