Medications, Medicare & Our Aging Population
Both the fastest growing segment of the population and the largest group of healthcare consumers, many elderly are physically, emotionally and economically fragile.
Many must manage multiple conditions, requiring them to navigate between multiple providers and take multiple, sometimes contraindicated medications. Sadly, some of the most tragic, incapacitating illnesses strike later in life. Enter the IHPI storm chasers: health services researchers taking on the most perplexing issues, engaging with patients, payers and policy makers and leading the charge to educate and empower the elderly.
The biggest challenge to healthcare, now and for the next few decades, is the aging population. It will place huge financial and clinical challenges on the system and on caregivers and family members. – Donovan Maust, M.D., who studies serious mental illness in older adults
Righting the wrong prescription
Older patients with psychiatric illnesses face a number of significant medication-related risks. Although older adults who are seen by doctors are twice as likely as younger adults to be prescribed psychiatric medications, they are less likely to be under the care of psychiatrists, preferring to receive treatment in the primary care setting, where providers may have less experience in managing the side effects and interactions associated with psychiatric drugs. Another concern: as many as one-third of older adults with dementia have been prescribed an antipsychotic to calm aggressive and agitated behaviors, despite the fact that this class of drugs is linked to an increased risk of death in these patients.
The use of antipsychotics in nursing homes has taken on new importance, as it is now a factor considered in the Medicare nursing home rating system. A recent U.S. General Accounting Office report found that while antipsychotic use in long-term care is decreasing, the amount of decrease varies significantly across states. IHPI members are helping develop and evaluate various nondrug strategies for caregivers to help manage the behavioral issues that can accompany dementia, and are working to make these more common first-line treatments.
The evidence for non-pharmaceutical approaches to the behavior problems often seen in dementia is better than the evidence for antipsychotics, and far better than for other classes of medication. The challenge is that our healthcare system has not incentivized training in alternatives to drug use, and there is little to no reimbursement for caregiver-based methods.– Helen C. Kales, M.D., director of the U-M Program for Positive Aging, who develops non-drug approaches for treating dementia patients’ common symptoms
“In decades past we used to worry that seniors weren’t receiving attention for mental health issues,” says U-M assistant professor of psychiatry and IHPI-member investigator Donovan Maust, M.D., M.S. “Today that is still a concern, but we also want to make sure the attention they do receive is appropriate.”
Maust, a geriatric psychiatrist who sees patients at both the U-M Geriatrics Center and the Ann Arbor VA, is at the forefront of exploring how the healthcare system can better meet the mental health needs of older patients. “We know that for a number of reasons, the current healthcare system is failing older patients with cognitive or mental health disorders,” he says. His research raises concerns about a wide range of psychiatric medications commonly prescribed in both outpatient settings and nursing homes. Maust’s work reveals that seniors seen in healthcare settings are twice as likely to be on mental health drugs as younger adults, but see psychiatrists and receive psychotherapy far less frequently. Older adults prefer to be cared for in the primary care setting rather than making a separate appointment to see a psychiatrist, but they also may not be able to get an appointment with a psychiatrist even if they would like to. That means that a lot of the prescribing of psychiatric drugs happens in the primary care setting. “While primary care physicians may have received some training in psychiatric medications,” says Maust’s research mentor, U-M Professor of Psychiatry and IHPI colleague Helen C. Kales, M.D., “we don’t believe they have received enough training on when and how to use psychotropics, and when to think about alternatives.”
Elderly patients tend to take more medications than their younger counterparts, and are more likely to experience side effects, drug interactions or other adverse events from most medications, including psychiatric prescriptions.
Anti-anxiety drugs may be relatively safe for younger adults, but carry a higher risk of accidents, falls, fractures and worsening cognition or memory for older patients.
Antidepressants can interact with blood thinners and painkillers to raise blood pressure. “Especially for milder depression and anxiety, the safer treatment for those who take multiple medications might be more therapy-oriented,” Maust adds.
“But very few seniors receive this sort of care.” Kales, also a geriatric psychiatrist, is founder and director of the U-M Program for Positive Aging, a program focused on improving mental health and dementia care for older adults and their families. She is also considered a national and international expert on dementia care.
Part of Kales’ research has focused on a disturbing aspect of pharmaceuticals and the elderly: the overreliance on antipsychotic medications and other psychiatric drugs to manage behavioral symptoms of dementia. According to one study, one-third of older adults with dementia in nursing homes and 14 percent of those living in the community were prescribed an antipsychotic – this despite an FDA black box warning and a number of significant studies by Kales’ research group showing that the drugs can cause death in people with dementia.
Providers rely on the ‘off label’ use of these drugs, developed to treat schizophrenia and bipolar disorder, for their sedating properties in order to manage the variety of behaviors common in dementia patients. Her work includes quantifying the magnitude of risk to patients of pharmacologic approches, and educating providers, insurers, and family members about established non-drug alternatives.
She and Maust recently examined data on more than 90,000 patients in VA hospitals. Over a six-month period, four different antipsychotics were each shown to cause incremental deaths in patients. The study further confirmed that the risk rose as the dosage rose, and that patients at the greatest risk were those prescribed more than one antipsychotic drug. This work led Kales to a new line of research to which she is highly committed: helping providers move away from antipsychotics and other psychiatric drugs as the ‘go to’ first-line for dementia behaviors.
“Quite simply, I realized that it was not enough to tell providers what NOT to do. They need help on what TO do instead,” says Kales. “We don’t believe that doctors are prescribing antipsychotics out of incompetence or cruelty or greed, but rather because the behavioral symptoms of dementia are so challenging, and providers are not trained in alternative approaches,” Kales said. “As the saying goes, ‘if all you have is a hammer, everything looks like a nail.’”
Seeing this large research-practice gap, Kales led a national expert panel in 2011 to create a model called “DICE” to help providers and caregivers identify and respond to the underlying causes of distress when patients can’t articulate their troubles. Called DICE for Describe, Investigate, Evaluate, and Create, the model tailors approaches to each person with dementia, uncovering problems like irritability, agitation, depression, anxiety, sleep problems, apathy or delusions. It also aids in addressing other “hidden” medical concerns – such as urinary tract and other infections, constipation, dehydration, pain and drug interactions – that can worsen behavioral issues in dementia patients.
“Our goal is to provide caregivers with a framework to help these patients, so they don’t feel like medication is their only option and so that they can actually work to modify the real underlying causes of behaviors rather than medicating “over” them,” explains Kales.
The building blocks of the DICE approach:
- D: Describe – Asking the caregiver, and the person with dementia if possible, to describe the “who, what, when and where” of situations where problem behaviors occur and the physical and social context for them. Caregivers could take notes about the situations that led to behavior issues, to share with health professionals during visits.
- I: Investigate – Having the health provider look into all the aspects of the person’s health, dementia symptoms, current medications and sleep habits, that might be combining with physical, social and caregiver-related factors to produce the behavior.
- C: Create – Working together, the patient’s caregiver and health providers develop a plan to prevent and respond to behavioral issues in the person with dementia, including everything from enhancing the patient’s activities and environment, to educating and supporting the caregiver.
- E: Evaluate – Giving the provider responsibility for assessing how well the plan is being followed and how it’s working, or what might need to be changed. Kales and colleagues from Johns Hopkins University are completing a National Institute of Nursing Research-sponsored clinical trial to test the DICE approach through a web-based tool for caregivers called the WeCareAdvisor™. The tool enables family caregivers to assess, manage and track dementia behaviors and their contributing factors while providing them with strategies for in-home non-pharmacologic behavioral management that are tailored to the caregiver and person with dementia. The tips are designed to prevent or mitigate possible triggers for common behavioral symptoms such as pacing, repetitive questioning, restlessness, or shadowing. For instance, de-cluttering the environment, using music or simple activities that help to engage a person with dementia, or using a calm voice instead of being confrontational, could help greatly to reduce behavioral symptoms, Kales says. And making sure that caregivers get breaks from their responsibilities and take care of themselves, especially in the home, can help them
To that end, the tool also includes a daily motivational messaging feature for caregivers to encourage them in their role as well as taking care of themselves. In addition, the tool contains a Caregiver Survival Guide™ which is an extensive compendium of information for dementia caregivers (e.g. “one-stop shopping”) that they can read when time allows. Given their research findings on the overreliance and risks of psychiatric medication use in elders including those with dementia, Maust and Kales hope to see further research and policy efforts to move non-pharmacological/ecopsychosocial strategies into the mainstream of treatment. And they plan to be in the forefront of research efforts to provide the evidence base to stakeholders in order to do so.
Big data in the Big House: The U-M Health and Retirement Study
U-M is home to a powerful tool in the development of evidence-based approaches to senior healthcare: the U-M Health and Retirement Study (HRS). A nationally representative, ongoing study launched in 1992 and funded by the National Institute on Aging, the HRS collects wide-ranging data every two years from a sample of approximately 20,000 people in the United States over the age of 50, and also gathers information from those individuals’ loved ones after their deaths. HRS is fueling a number of innovative projects ranging from quantifying the relationship between health literacy among seniors and their use of web-based health information, to better defining the role of end-of-life treatment options in our care of older adults. HRS houses information on more than 35,000 seniors, and is fueling innovative projects like these:
- Kenneth Langa, M.D., Ph.D., has been using the HRS to better understand the trends in the prevalence and costs of dementia in the United States, as well as the amount and types of medical care that older adults receive in their last years of life. Langa, Cyrus Sturgis Professor of Internal Medicine, Gerontology and Health Management and Policy, and associate director of the HRS, says his team is using the HRS “to study key clinical and policy issues that will affect older adults, their families, and public programs such as Medicare and Medicaid, as the U.S. population ages in the decades ahead.”
- Helen Levy, Ph.D., is analyzing HRS data to quantify the relationship between an elderly individual’s level of health literacy and his or her use of the internet to obtain health information. According to Levy, a research professor in the Institute for Social Research, School of Public Health, and Ford School of Public Policy, only about one in 10 seniors with low health literacy uses the web for health information, compared to about one in three with adequate health literacy. “The least health literate are vulnerable because they are less likely to benefit from new technologies like electronic health records and online health portals,” she says.
As an economist, I’ve always been interested in health insurance because for decades, insurance coverage has been the biggest differentiator between the ‘haves’ and the ‘have-nots’ when it comes to healthcare.– Helen Levy, Ph.D., HRS co-investigator
End-of-life healthcare spending surprises
Last-ditch, high-tech heroic treatments. Days in the hospital intensive care unit. You might think this is what makes dying in America so expensive—and that it’s where we should focus efforts to spend the nation’s healthcare dollars wisely. But IHPI research using Medicare data is finding that for nearly half of older Americans, the pattern of high spending on healthcare was already in motion a full year before they died. That’s due to the care they received for their multiple chronic health conditions—including many doctor visits and regular hospital stays over the year, not just in their final days. As a result, the last year of life for this large group of seniors costs the Medicare system five times as much as the care received by the much smaller group of seniors who have a sudden burst of very expensive care in their last few weeks of life. The findings have clear implications for efforts to improve care, and contain the growth of costs, at the end of life.
Our research points to having to do a better job taking care of people who have multiple chronic conditions in a way that maintains or improves the quality of care they receive, but with cost in mind.– Matthew A. Davis, Ph.D., M.P.H., whose team is working to identify spending patterns in end-of-life care
Drug treatments for macular degeneration: cost ≠ value
One of the biggest challenges in healthcare policy is determining the value of healthcare interventions. Case in point: the use of injectable drugs in the treatment of progressive eye diseases like macular degeneration (MD). Diagnosed in more than 200,000 U.S. seniors each year, MD has no cure, but can be treated to slow vision loss. The drug ranibizumab, marketed under the name Lucentis, was developed to treat MD and related conditions. Many patients require up to 12 treatments a year, at just over $2,000 per dose. In YEAR, doctors discovered that the cancer drug bevacizumab (brand name Avastin) could be reformulated as an equally-effective MD treatment. The cost of prescribing Avastin ‘off label’ (for a purpose not indicated by the FDA): about $55 per dose So why not secure FDA approval to use Avastin to treat eye disorders? The answer requires a quick course in law and economics. By law, unlike private health insurers, Medicare (ironically, the country’s largest health insurer) cannot negotiate prices directly with drug companies. When prescribing a drug to treat a Medicare patient, a doctor is reimbursed by Medicare for the average sales price of the drug plus 6 percent. The resulting doctor’s profit is $95 per dose for prescribing Lucentis, $29 for Avastin. There is also no financial incentive for the drug manufacturer (both Lucentis and Avastin are Genentech products) to make the switch. The dose of Avastin used to treat cancer is more than 100 times that needed for an eye injection. Since Avastin was never intended to be used in such a small dose, it was never priced to do so.
Diving headfirst into this quagmire is IHPI member David Hutton, Ph.D., associate professor of health management and policy and of industrial and operations engineering. He and his colleagues have developed a mathematical model to determine the lowest and highest possible spending levels over a 10-year-period if doctors changed their prescribing patterns. “According to our study, the total cost of treatment of MD using either drug accounted for one-sixth of the entire Medicare Part B drug budget in 2010,” says Hutton. “Right now both Medicare and most private insurers will pay for either therapy. But insurance policies could be altered to favor Avastin as a first-line therapy. Over the next ten years, we estimate that switch could save Medicare $18 billion, and patients $5 billion in insurance copayments.”
As the Medicare-eligible population continues to grow, identifying savings while maintaining quality patient care is increasingly important. People don’t like to think there are tradeoffs between health and costs, but we certainly do need to think about cost when healthcare is 18 percent of the GDP and growing.– David Hutton, Ph.D., whose research evaluates the cost-effectiveness of new public health policies and the use of new drugs and devices
IHPI’s sights are set on improving the quality, efﬁciency, responsiveness, and cost of healthcare for older adults by developing a more thorough understanding of their needs and values, and the policies and systems that support their care. By tapping into the perspectives of patients, caregivers, providers, and policymakers on issues related to health, healthcare, and health policy affecting Americans 50 years of age and older, we aim to inform decisions around healthy aging and contribute to new avenues of research and discovery that can benefit this population.
But IHPI research using Medicare data is finding that for nearly half of older Americans, the pattern of high spending on healthcare was already in motion a full year before they died.
That’s due to the care they received for their multiple chronic health conditions—including many doctor visits and regular hospital stays over the year, not just in their final days.
As a result, the last year of life for this large group of seniors costs the Medicare system five times as much as the care received by the much smaller group of seniors who have a sudden burst of very expensive care in their last few weeks of life. The findings have clear implications for efforts to improve care, and contain the growth of costs, at the end of life.