HEALTH CARE & THE ELDERLY: MYTHS, MISPERCEPTIONS, & DANGERS U.S. Demographic Trends & Health Care Costs in PerspectiveDave Kingsley, PhD
Aging &Health Care Cost: The Issues • Increasing 65+ population • Increase in life expectancy • Cost increase as a function of age • End of life care: intensive care services • Natural history of chronic disease • Critical analysis: logic, statistics, scientific method
To Which Group Are We Devoting Our Health Care Dollars? Are we favoring one group over another group? Are we blaming any particular group for health care cost inflation? What is the narrative concerning health care reform and cost containment? Is the predominant narrative framed in such a manner as to divert our attention from real causes? What is the media saying versus policy and medical research? Should the narrative be of major concern to bioethicists?
WHAT DOES THE DATA & LITERATURE & PROFESSIONALS SAY? • Data: Agency for Healthcare Research & Quality (AHRQ) Health Cost & Utilization Project DatabaseBureau of the Census: Life tables, 2010 Census Data & Other Sources • Lit Review: Medical Journals, Government Reports, Monographs/Books, Working Papers • Interviews
HP&M 873: Research Project Medical Colleague • Michael Waxman, MD • Medical Director, Medical Surgical ICU, Research Medical Center, Kansas City, MO • Clinical Assistant Professor, Kansas University Medical Center • Clinical Associate Professor of Medicine, University of Missouri, Kansas City • Private Practice, Kansas City Pulmonary Practice • Medical Director, Kindred LTAC Hospital
Our World If all humanity disappeared, would there still be a world? No. There would be no one to call it a world. Our world is socially constructed.
The Narrative • When you accept a particular narrative, you ignore or hide realities that contradict it.George Lakoff (2009), The Political Mind. New York: Penguin Books, p. 37 • The narrative is a story about our World. Composed of frames Narratives consist of sub-narratives Include symbols, metaphors, allegories, myths, misinformation, and emotion (think “entitlement”).
Sunrises, Sunsets, Unicorns, Welfare Queens, & Baby Boomers: The Fallacy of Reification
Reification & Mental Errors • “…our tendency to convert abstract concepts into entities.”Steven J. Gould (1981), The Mismeasure of Man. New York: W.W. Norton & Co. • Other related fallacies and mental errors: fallacy of composition fallacy of division failure to disaggregate & control for other variables (e.g., Simpson’s Paradox) Over-generalization Salience & failure to consider background info Ascribing the average as a characteristic to all observations • Examples of reification: IQ, “The Greatest Generation,” “Baby Boomer,” “The Dumbest Generation,” “Millennials,” & “Teen Drivers”
Ageism • “systematic stereotyping of and discrimination against people because they are old” (Butler, 1969) • Microlevel: “ageist predispositions shared by a community are likely to be organized into a coherent set of cognitions and practices that are verbalized and reinforced in social contexts. (Braithwaite, “Reducing Ageism” in Nelson, 2004, p. 311) • In the absence of resistance, ageism inevitably frames the ways in which policymakers think and shapes policy design.”
“Greedy Geezer” Sub-Narrative “I’ve got mine, good luck getting yours.” James Surowiecki “Greedy Geezers, ”New Yorker, November 22, 2010
SILVER TSUNAMI This metaphor leads the public to believe that “Baby Boomers” will hit the health care system in one big wave.The implications: Elderly a threat Elderly a burdenThe shift in population demographics: 65+ will increase from 13% proportion of total population to 21% by 2035, and will stabilize at that level
Stereotyping & Blaming Elderly In the Mainstream Media: • David Brooks, New York Times columnist, regular guest on PBS News Hour, & NPR commentator – “Far from serving the young, the old are taking from them.” “First, they are taking money.” “Second, they are taking freedom.” “Third, they are taking opportunity.”February 2, 2010, NYT column entitled “The Geezers’ Crusade:”
INVIDEOUS COMPARISON BETWEEN GENERATIONS “Our parents were the ‘Greatest Generation,’ and they earned that title by making enormous sacrifices and investments to build us a world of abundance. My generation, ‘The Baby Boomers,’ turned out to be … ‘The Grasshopper Generation.’ We’ve eaten through all that abundance like hungry locusts.”*Thomas L. Friedman, “Root Canal Politics,” The New York Times Op-Ed, October 25, 2010
BLAMING AND FOMENTING INTER-GENERATION CONFLICT • “If anyone should be complaining about deficits, it should be the 20-somethings who will have to pay for all those meds-popping boomers moving into the comfort of Medicare and Social Security.”Timothy Egan, “Save Us, Millennials,” The New York Times Op-Ed, June 4, 2010
Letter to The Editor re: Grasshoppers • “Thomas L. Friedman is right. The Greatest Generation built the most prosperous society in history with its blood, sweat and tears, giving its children a tremendous head start. How have responded? By consuming our way to insolvency. And now we’re robbing future taxpayers of wealth that has yet to be produced.The Grasshopper Generation may be too kind a term for us boomers. Even Grasshoppers don’t eat their young.Michael Smith, Cynthiana, KY, Letter to the Editor, New York Times, May 10, 2010
Misinformation Supporting Ageism • Ross Douthat, New York Times columnist –“As the population ages – by 2030, there will be more Americans over 65 than under 18 – the power of the elderly may become almost absolute.” August 17, 2009, NYT column entitled “Telling Grandma ‘No’:”
The Mantra: Typical Opinion in Reporting • “After decades of warnings that budgetary profligacy, escalating health care costs and an aging population would lead to a day of fiscal reckoning, economists and the nation’s foreign creditors say … .” “He [Senator Bayh] is hardly alone in sounding an alarm about the long-term budgetary outlook, which has Medicare, Medicaid, and Social Security Costs growing at unsustainable rates … .”NYT, February 10, 2010front page, above the fold: “Party Gridlock Feeds New Fear of a Debt Crisis” –
Even Health Care Experts Inadvertently Oversimplify & Distort the Picture “Utilization of services increases with age, as physical and mental health deteriorates and chronic conditions progress.” P. L. Barton (2010) Understanding the U.S. Health Services System. Chicago, IL: Foundation of the American College of Health Care Executives:
Today, Focus Will be Primarily on Age as It Impacts Acute Care Costs • Demographics of Age in Perspectivea. Current configuration of U.S. populationb. Trends: 1946 – 2050 • Diseases: Treatment & Costs in Hospitalsa. Diagnoses & procedures & cost by 5-year age categories
Health Care Costs & Demographics: Objectivity In the Conversation • DemographyThe study of populations • EpidemiologyThe study of diseases in populations • Health Care Finance ResearchThe Study of Costs in various facets of the Health Care System
Why Is This Discussion Important? • Stereotyping age groups: Ageism • Blaming & Scapegoating: A result of ageism • Discrimination: A result of ageism & scapegoating • We need a reasonable rational discussion to address the real issues in health care
POPULATION GROWTH • The 65+ population currently accounts for 13% of the total U.S. population • The 65+ population will gradually increase to 21% of the U.S. population by 2035 – this is a gradual 25 year increase, not a tsunami • This growth is manageable while other health cost drivers, as they are now, will not be.
WILL MOST OF THE “ABSOLUTE” GROWTH BE IN THE 65+ AGE GROUP? • NO • AN AGING POPULATION IS A CRISIS FOR A CAPITALIST ECONOMIC SYSTEM • THE U.S. WILL NOT HAVE AN “AGING CRISIS” (Japan, Germany, & Italy have an aging crisis) • THE CHILD (0 – 18) POPULATION HAS BEEN GROWING STEADILY SINCE 1986
The Children • The “baby boom” commenced in 1946 • The child population was 47 million in 1950 • The “baby boom” peaked in 1964 at 70 million • A “baby dip” (not “bust”) occurred between 1968 and 1986 (bottomed at 64 million) • A “baby resurgence” (not echo or boomlet) began in 1986 • Reached 70 million in 1996 • Currently 75 million • Will reach 101 million in 2050
GROWTH BELIES AGING POPULATION PERCEPTIONS • U.S. POPULATION2010 312,000,0002020 341,000,0002030 373,000,0002040 405,000,0002050 439,000,000
Acute Care Costs & Aging • This portion of the presentation focuses on hospital charges as they relate to age categories. • The question is: “Is aging the cause of past and future escalation in the cost of treating disease?” • What is the significance of the demeaning phrase (metaphor if you will) “unplugging granny?”
Primary Sources for Cost & Aging • NIH: Agency for Health Quality & Research (AHRQ or “ARK”)Analysis of HCUP (Health Cost & Utilization Project) databases 20% sample of hospital admissions & discharges in U.S. Approximately 8 million cases in 2007 (latest year) • Triangulation of Statistical AnalysisMedical JournalsScholarly Monographs & TextbooksInvestigative JournalismMedia in generalGovernment Agencies: Bureau of Census, CDC, etc.
ANALYZING HEALTH CARE DATA CAN BE TRICKY • Flaw of Averages: Cost data is highly skewed Geometric Mean (logarithmic transform) The largest group of patients are maternity cases most of which have no complications but many of which have the most expensive complications
THE FLAW OF AVERAGES • Average Hospital Charge for 65+ = $23,400 • Average Hospital Charge for under age 65 = $17,335 • Is it fallacious to dichotomize average hospital charges in this manner?
Exposing Aggregation Fallacies • AVERAGE CHARGES BY 10 YR AGE CAT:40 TO 49: $19,70650 TO 59: $23,37260 TO 69: $25,58170 TO 79: $24,47080 TO 89: $22,02490+ :$18,516
Age 67 & +2 SD: Primary Diagnoses & Procedures • Heart Disease: 25% • Septicemia: 10% • Respiratory Failure: 6% • Back Disorders: 5% • Complication of Device, Implant, Graft, Surgery: 8% • Diabetes: 2% • Lung Cancer: 1% • Pneumonia: 3% • Heart Surgery: 30% • Spinal Fusion: 7% • Intubation & Ventilation: 10% • Tracheostomy: 4% • Other OR Procedures on Vessels Other than Head & Neck: 4% • Colorectal Resection: 3% • Blood Transfusion: 2%