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July 13, 2015 Silver Tsunami

State fights to keep aging population healthy, economical

PHOTO | CONTRIBUTED A Masonicare home health nurse with a patient.
PHOTO | Matt Pilon Dr. George Kuchel, a geriatrician, professor and director of UConn Health Center's Center on Aging.
By Matt Pilon

In a state where the economy relies heavily on the healthcare industry, an aging population promises to steepen the tilt.

In the next 15 years, more than 247,000 Connecticut residents are expected to move into the 65-plus age group, representing a 45 percent increase compared to 2013, according to the U.S. Census Bureau.

The change will come gradually, but experts say an older population will usher in an era of higher demand for certain healthcare services and the myriad challenges that come along with it, including figuring out how to keep seniors healthy, rein in costs, and attract and train a new and larger generation of doctors.

“This is a really big challenge for the state of Connecticut, from a budget perspective and also managing the health of the population too,” said Deborah Hoyt, president and CEO of the Connecticut Association for Healthcare at Home.

The state has already begun strategizing and experimenting with ways to lower the high cost of long-term care through its Medicaid program, which spends $1.6 billion annually on nursing homes and institutional care for low-income elderly and disabled residents.

In recent years, the state's home health industry has grown significantly, spurred by the cost savings it promises to government and private payers compared to nursing homes or other institutional care. Seeking to better coordinate care and keep the money in-house, hospitals too have dipped their toes into the homecare business.

Health technology — which carries the promise of better tracking elderly patients' conditions and medication regimens — has become a larger sector in Connecticut, fueled in part by investments made by Connecticut Innovations, the state's quasi-public investment arm.

And in-state drug developers are targeting elderly health conditions. Among them is New Haven biotech Melinta, which has raised more than $280 million to develop its antibiotic aimed at treating drug-resistant infections that affect older patients in particular.

Lifespan vs. healthspan

The highest and best aim for the state's aging population, according to doctors and state policymakers, is to keep residents as healthy and disability-free as possible as they age.

Julia Evans Starr, executive director of the state's nonpartisan Legislative Commission on Aging (LCoA), said there needs to be a shift in the way doctors and others discuss and perceive aging. A large group of people turning 65 is a positive thing if they are relatively healthy, she said.

Therefore, Starr added, the focus must be on improving health outcomes, which accomplishes two aims: It creates a higher quality of life for seniors and cuts into the high cost of long-term care, which ripples throughout the healthcare system in the form of higher premiums and costs for individuals, employers and government.

“No one wants to live longer but be sick,” said Dr. Lisa Walke, associate chief for clinical affairs in the geriatrics section at Yale School of Medicine. “Everyone wants to be healthy and be able to contribute.”

Dr. George Kuchel, a geriatrician, UConn Health Center professor and director of its Center on Aging, refers to it as “lifespan versus healthspan.”

“We want to add life to years, not vice versa,” Kuchel said. “If people live to old age, but at the cost of a lot of disease and nursing home care, that will probably not be a good thing.”

Both Walke and Kuchel said telemedicine and other technology will play a bigger role in the next few decades providing lower-cost ways to monitor elderly patients and allow them to remain in their homes. However, the development of certain technologies — Kuchel cites surgical robots — have also been a major driver of healthcare costs, with studies showing only marginal impacts on health outcomes. He hopes the ongoing, gradual shift away from fee-for-serve health care towards population-based care will weed out certain technology that is unjustifiably expensive.

Whether it's a good value or a bad one, however, technology alone isn't the answer to a healthier senior population, Kuchel said.

The healthcare industry has helped increase life expectancy by developing better treatments for stroke, heart disease and other age-related conditions, Kuchel said, but further progress in improving senior health will require a coordinated attack from multiple players including doctors, technologists, researchers, geneticists, social workers and others.

“We need to cut across silos and disciplines,” Kuchel said.

Kuchel is optimistic about a burgeoning area of medical research known as geroscience, which seeks to better understand how aging acts as a common risk factor for a variety of chronic diseases, and how different treatment strategies might better serve patients.

“The way we've approached chronic diseases in the elderly hasn't worked very well,” he said.

The high cost of long-term care

An older population is susceptible to various health conditions and disabilities that can require long-term care, which for some means a stay in a nursing home or other care facility. The number of Connecticut residents requiring long-term care is expected to increase over the next decade from nearly 39,000 to 49,000.

Medicare doesn't cover long-term care, which means most seniors and their families end up paying for those services out of pocket, unless they have long-term care insurance.

Medicaid, however, does cover long-term care for low-income elderly residents, which comes at great expense to the state. Connecticut spent $3.1 billion in 2013 on institutional long-term care, representing 12 percent of the state budget, according to the Department of Social Services.

That high cost has spurred the federal and state governments to attempt to change course.

One of the state's main strategies for controlling long-term care costs is to keep seniors out of nursing homes in favor of less expensive home-based healthcare services.

The cost difference is significant: The median annual cost for home health aide services in Connecticut, for example, is $50,336, versus $66,900 for an assisted-living facility, according to the Genworth 2015 Cost of Care Survey. A semi-private room in a Connecticut nursing home costs about $146,000 annually.

Under a federally-funded program known as “Money Follows the Person,” which has provided $56 million to Connecticut's Medicaid program, the state between 2008 and 2015 transitioned 2,974 nursing home patients into community settings, including care at home. The state's goal is 5,000 by next year.

In the past year, the state has also provided $12 million in grants to persuade nursing homes to reduce their number of licensed beds and increase hospital discharges to community-based settings.

Kuchel said he's impressed with the efforts, but rebalancing alone is unlikely to be the answer to controlling healthcare costs.

“What we're really doing is bending the curve,” Kuchel said. “We're not pushing things back, but we're certainly able to bend the curve to decrease the projected increase.”

One problem could be that homecare agencies, key cogs in the rebalancing equation that send nurses and other providers and assistants to patients' homes, view Medicaid reimbursements as too low.

Hoyt, the homecare association head, said the first 1,000 patients that have been transitioned to homecare settings were low-hanging fruit; the next wave of transitioning seniors will be much more difficult.

“Homecare agencies appreciate this attempt, but rates must go up,” Hoyt said.

Starr, head of the LCoA, said Connecticut's accomplishments thus far deserve credit.

She said rebalancing is the state's most significant effort to date to prepare for an older population.

“I don't want to suggest that there haven't been challenges along the way, but I think that's inherent to a transformation and a movement of that size,” Starr said.

Home care's time to shine

Sending a doctor, nurse or other health professional to a patient's home is not a new concept. But some experts say that home care hasn't been seen as a major part of an elusive healthcare cost solution. That is, until recently.

The federal Affordable Care Act has led to a steep increase in Connecticut Medicaid patients, which now number more than 700,000. And Medicaid administrators have increasingly looked to homecare providers as a lower-cost way to monitor certain patients.

“We've been this sleepy little industry,” said Hoyt, who today represents more than 17,000 providers in the state. “All of the sudden there's this new awareness [among payers] like 'Oh, maybe we should pay for home care.'”

Home care also includes aides who help patients cook meals and perform other household tasks.

The number of businesses offering those services has jumped in recent years, said Linda Grigerek, president of Farmington's Companions and Homemakers, which has 11 locations across the state. Grigerek said the surge is driven by payer's recognition that such services reduce costs.

“Suddenly a big light bulb went off,” Grigerek said.

Like many elderly care providers, Grigerek also said government reimbursements must rise in order to ensure the industry's future. She said clients who pay out of pocket for visiting and live-in aides provide a healthier profit margin than Medicaid clients. As a result, there are some homecare agencies that don't accept Medicaid patients.

Figuring out where additional money will come from still remains an issue, said LCoA's Starr.

“Is it the individual? Is it the state? Is it the provider?” she asks. “There's a natural tension there.”

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