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Geriatric Rehabilitation, L, Social and Economic Implicationsof AgingGregory M. Vl/orsowicz, MD, MBA, Deborsh G, Stewart,

ABSTRACT. Worsowicz GM, Stewart DG, Phillips EM,Cifu DX. Geriatric rehabilitation. l. Social and economicimplications of aging. Arch Phys Med Rehabil 2004;85(SupplJ l : sJ -o .

This self-directed leaming module highlights the social andeconomic implications of aging. It is part of the study guide ongeriatric rehabilitation in the Self-Directed Physiatric Educa-tion Program for practitioners and trainees in physicat medicineand rehabilitation and geriatric medicine. This article specifi-cally focuses on the epidemiology of aging, the economics ofaging, informal and formal social support systems, ageism andsocietal issues, and care and treatment settings.

Overall Article Objective: To summarize the social andeconomic implications of aging in the context of physicalmedicine and rehabilitation.

Key Words: Ageism; Epidemiology; Geriatr ics; Rehabil i ta-tion; Social support.

@ 2004 by the American Acaclemy of Physical Medicine andRehabilitation

l. l Educational Activi ty: To advise a medical student onthe demographics of the aging populat ion for whichhe/she wil l be providing care.

f N 1900, THERE WERE 3 mil l ion people in the United SatesI at or over the age 65 years (4% of the total US population),while in 2000, 35 mil l ion (35%) people were age 65 or older.As the baby boom generation ages, it is predicted that 1 in 5Americans wil l be 65 or older by the year 2030. The 85-and-older-age category is the most rapidly growing segment of theUS population. It is estimated that this group will increase from2Yo to 5% over the next 50 years.r'2 In the United States, lifeexpectancy for a person reaching 65 years is l8 years; an85-year-old person's l i fe expectancy is 6 to 7 years.3 The agingof the US populat ion presents chal lenging issues for govern-ment, health care, and society.

There is no single universally recognized description, clas-sification, or grouping of the older population. Although chro-nologic, biologic, physiologic, and emotional descriptors areoften used, functional classifications, such as a person's activ-i t ies of dai ly (ADLs), hisiher level of l iv ing dependency, num-ber of concurrent medical morbidities, living arrangement, andemployment status, may be more relevant to clinicians.a

From ths Departmcnt of Physical Medicine and Rchabilitation, Univcrsity ofMissouri, Columbia, MO (Worsowicz); Brooks Health System Administration, Jack-sonville, FL (Stewart); Deperfinent of Physical Medicine and Rehabilitation, HanardMedical School, Spaulding Rehabilitation Hospital, Boston, MA (Phillips); andDepartment of Physical Medicine and Rehabilitation, Virginia Commonwealth Uni-versity/Medical College of Virginia, Richmond, VA (Citu).

No commercial party having a direct financial interest in the results of the reseuchsupporting this article has or will confer a benefit upon the authors(s) or upon anyorganization with which the author(s) is/are associated.

Reprint requests to Gregory M. Worsowicz, MD, MBA, Univ of Missouri, PM&R,I Hospital Dr DC046 00, Columbia, MO 65212, e-mail: worsowiug@heallh.missoui.edu.

0003-9993/04/8507-92 I 4$30.00/0doi: 10. I 0l 6/j.apmr.2004.03.005

MD, Edward M, Phillips, MD, David X Cifu, MD

Chronologic age is probably the most universally acceptedand most frequently used system. Old age is often defined as 65years and older, but this is an arbitrary figure that is based onpolicy or societal norms. Terms that are used include aged,elderly, young old (60+), old old (75+), oldest old (85+),older adults (75+), and centenarians.s'6 Other descriptors of"old age" include older workers (40+) and eligibil i ty to jointhe American Association of Retired People (AARP; 50y orolder).7

1.2 Educational Activity: To discuss the impact of thechanging aging demographics on rehabilitation ser-vice needs with a resident in physical medicine andrehabil itation.

In 2001, national health care expenditures exceeded $1.4trillion or 14.1% of the gross domestic product.r The agingpopulation is a high user ofthese health care services. In 1999,25% of all physician office visits ( I 92.2 million) in the UnitedStates were by adults 65 and older.8 The hospitalization rate in1999 for adults between the ages of 65 and 74 years was 1.9times higher than that for the overall population, whereas forpeople 75 and over, it was 2.7 times higher.E Medicare is thelargest singular payer for these services, and two thirds ofMcdicare spending is accounted forby 20o/o ofits beneficiaries.This 20% of high end-users have 5 or more chronic condi-tions.e

Because Mcdicare is the largcst single payer of health carefor the elderly US population, governmental policy plays acrit ical role in eligibil i ty and services provided. In 1997, Con-gress passed the Balanced Budget Act (BBA), which hasproduced changes in the reimbursement systems for homehealth services, skil led nursing facil i t ies (SNFs), and inpatientrehabil itation facil i t ies (lRFs). These changes are predicted toproduce $393.8 bil l ion in Medicare savings between 1998 and2007.to The BBA (1997) changed the reimbursement patternfor home health services, and the frequencies of home healthservices dropped during 1997 and 1998 from 8277 to 5058 per1000 enrollees. The Centers for Medicare and Medicaid Ser-vices now reimburses IRF for services based on a prospectivepayment system (PPS). The IRF-PPS1r is based on the assign-ment of patients to specific case-mix groups (CMG). The CMGassignment is determined by a patient's primary diagnosis orrehabilitation impairment category @lC) and his/her FIM in-strument motor score, FIM cognitive score, and age on admis-sion. Specific categories for patients with short stays, death, orearly transfer to another Medicare rehabilitation facilify, long-term care hospital, inpatient hospital, or nursing home werealso developed. The IRF-PPS was developed in an attempt toreimburse facilities according to a patient's severity ofdisabil-ity and his/her required use of resources. The more disabledpatients, who will have higher CMG scores within their RIC,are predicted to require a greater use of resources and, there-fore, are assigned higher reimbursement.r2

ln 1942, the American Geriatric Society (AGS) was devel-oped. Their websitet3 offers important information and links.ln 1974, Congress approved the National Instifute on Aging(NIA) as 1 of the centers for the National Institutes of Health.

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s4 SOCIAI AND ECONOMIC IMPLICAT|ONS OF AG|NG. Worsowicz

The mission of NIA is to provide leadership in aging research,training, health information, information dissemination, andother programs for the older population.la The Veterans Hos-pital Administration initiated the funding for training geriatricfellows in geriatric research and for clinical centers in 1980. In1988, certification for added qualifications in geriatric medi-cine was sponsored by both internal medicine and familypractice.l3 In 1991, NIA developed an older Americans re-search program of independence centers (Pepper Centers). Asthese centers have developed, other agencies and advocacygroups for the elderly have grown. The AARP offers a resourcebook that contains research information provided bv currentagencies and programs and laws that are pertinent to theelderly.t j

1.3 Clinical Activity: To evaluate the formal and informalsocial support systems available for an 85-year-oldwidow who is l iving alone in her childhood home andhas begun to develop functional decline.

Social support systems in the United States are comprised ofboth formal and informal networks.a Formal structures includegovernment-sponsored agencies and programs and servicescovered by private insurance. Formal care or service is paid bysome third party, not by the user or the provider ofthe service.Medicare, a program sponsored by the federal govemment,pays for most ofthe health care provided to people 65 years orolder. Part A ofthe Medicare program covers hospital services,whereas Part B covers physician services, durable medicalequipment (DME), and home health. Medicare sets allowablecharges and then reimburses providers 80% of those allowablecharges. Medicaid is a state-administered program that pays foradditional services if, because of his/hcr financial resources, aperson meets the program definitions of being "medically in-digent." Other formal supports can include agencies such asAdult Protective Services and Area Agencies on Aging, whichare locally run and provide social serviccs, advocacy, andguardianship.

Informal resources, which include families, church communi-ties, and service clubs, generally provide nonreimbursed assis-tance. Most caregiving in the United States is informal, accountingfor about 7 5% of all care provided to the eldcrly. Seventy percenlof caregivers are women, either wives or daughters. Caregiving isgenerally provided daily, for 4 to 8 hours on average, lastingfrom weeks to a decade or more, and primarily involves ". . . emo-tional support, followed by help with shopping, transportation,household tasks, and personal 661s."te(p33s)

Social dependency is more common in elderly women, whoare more likely to be widowed because their life expectancy islonger than men's. Only 40% of women 65 years or older-areqalried, compared with 80% of men in the same age group.Elderly men are more likely to have the support of a wife whois typically younger and in better health.'? The number ofsocial supports an individual has directly impacts happinessand life satisfaction and is associated with better physicalhealth and lower mortality.ts'te

Although gender influences social supports, race and ethnic-ity may also affect caregiving. A review ofracial, ethnic, andcultural differences in caregiving of elders with dementia re-vealed that black caregivers were more likely to be an ..adultchild, friend, or other family member, while white caregiverswere more likely to be a spouse."20(p361)

Social support systems, both formal and informal, can pre-vent instifutionalization. Maintaining the integrity of supportnetworks, particularly the informal supports, can make thedifference between a person's living in the communify or not.4Helping to reduce caregiver burden by providing psychologic

Arch Phys Med Rehabl! Vol 85, Suppl 3, Juty 2004

support, education, and respite care can prolong a person'scommunity living. Social supports are a complex network ofprograms, services, funding, and people that serve the myriadof needs of elderly persons.

1,4 Educational Activity: To criticize the influence of age-ism on the care of an 85-year-old retired physicianwith worsening arthritis who is being encouraged tostop driving because of wrist pain,

Ageism2t is the pejorative belief system, generally not sup-ported by the literature, that old age is synonymous withdementia, depression, dependence, and debility. The negativesocietal view that aging necessarily represents pain, isolation,fear, and asexuality are ageist in their nature. Important issueswithin ageism include how elders view themselves and thelarger societal expectations ofpeople reaching their later years.

Ageism leads to discrimination against the elderly in theworkplace, in social settings, and in medical care. Health careprofessionals must remain vigilant to combat negative attitudesthat become manifest in medical care provision-for example,that pain in the elderly is not worth treating aggressively andthat decreased function is inevitable with aging.

The ageist, negative self-perception of some elders impactson their own health and function. People with positive self-perceptions of aging experience benefit on their functionalhealth.22 Moreover, modifying negative stereotypes can benefitolder people: common age-related gait changes were shown tobe reversible with exposure of elders to positive images ofaging.23

Some aspects of ageism are generational. Societal expecta-tions of aging will undoubtedly evolve with the aging andoncoming retirement of 76 million baby boomers, persons bornbetween 1946 and, 1964. The MacArthur Foundation studiessummarized in Rowe and Kahn's Successfitl Aging2a presentextensive evidence refuting common ageist stereotypes. Be-yond the goals of merely avoiding disease and disabil ity andprolonging longevity, appropriate lifestyle choices permit thepositive anticipation of maintained cognitive and physical ca-pacity into late life.

Counteracting ageism in health care will require a broadereducational curriculum. Elderly persons should be involved inthe planning and teaching. Medical school coursework mustinclude issues of aging in all sr.rbjects. Clinical course workshould include working with older adults across the clinicalspectrum from acute care to nursing home to community set-tings. Residents and practicing physicians can benefit fromreadily available resources, including those from the AGS.2s,26The care that physiatrists and other health care professionalsprovide for the growing population of elderly must includeproactlve management of common sequelae of aging. In asense, we medical professionals are training the providers ofcare for our own later years.

1.5 Clinical Activityt From the health care continuum,recommend a level of care that will best address theneeds of an 85-year-old woman with a hip fracturelvho needs postsurgical rehabilitation.

Medicare is a federally sponsored program, so its coverage isuniform throughout the United States. Any person who haspaid into the federal tax system for 40 quarters (or was evermarried to someone who has) and meets any of the following3 criteria is eligible for Medicare part A at no cost: (l) age 65years or older, (2) disabled and on Social Security DisabilityInsurance for more than 2 years, or (3) has end-stage renaldisease. Medicare reimburses inpatient and SNF rehabilitationservices. Medicare Part B, which, for a monthly fee, is avail-

SOCIAL AND ECONOMIC IMPIICATIONS OF AGING, Worsowicz s5

able to people on Medicare part A reimburses for physicianservices, home health services, and outpatient therapies.

As noted, Medicare Part A insurance provides payment foracute medical and rehabilitation hospitalization and short-termskilled nursing care. Acute medical hospitalization is reim-bursed in lump sum amounts based on diagnosis-relatedgroups. Reimbursement for rehabilitation services in IRFs orSNFs is reimbursed under the PPS, also in lump sum amounts,based on the person's CMG. People who receive care for thesame diagnosis at both an IRF and an SNF do not receive anyadditional reimbursement for the subsequent SNF stay (thusrequiring the reimbursement to be shared). Beneficiaries areresponsible for a copayment in each setting, often approxi-mately 2QYo of the Medicare-determined total. Importantly, onaverage, 75% of Medicare patients admitted to an IRF mustmeet I of 10 established diagnoses for the IRF to qualifu forpayments. This "75% rule" unfortunately neglects many of thecurrent rehabilitation diagnoses (eg, post coronary artery by-pass graft care, post total hip replacement) that were notcommonplace when it was instituted more than 20 years ago.For people who need skilled nursing care (eg, wound care,management of indwelling catheters), Medicare pays for 100days ofthat care after the beneficiary has been discharged afteran acute hospital stay ofat least 3 days and within 30 days ofthe hospital discharge. Medicare Part A pays for the first 20days of skillcd care with a coinsurancc amount paid by thebeneficiary on days 21 to 100. Coverage by Medicare is mea-sured in benefit periods. A benefit period bcgins when thebeneficiary is admitted to the hospital and ends when thebeneficiary has been out of the hospital or skilled t'acility for 60consecutive days. These individuals typically receive somerehabil itation serviccs (cg, physical therapy, occupational ther-apy, speech and language pathology) in addition to ongoingmedical and nursing management. The condition requiring carein the skilled facility must be the same as the reason forhospitatization to qualiff for Medicare coverage. The benefi-ciary must be certified by a licensed physician as requiring thecare, at that level, to be eligible for coverage.

DME, such as gait aides or adaptive equipment, is alsoreimburscd under Medicare, as long as it is ordered by alicensed physician and is medically justified. Outpatient reha-bilitation therapy, home health services, and inpatient andoutpatient physician care are reimbursed by Medicare but onlyfor beneficiaries who receive Part B. A physician must orderthe services or equipment and must provide a detailed plan ofcare. Home health services are limited to skilled care, such asnursing or rehabilitation therapy. Home health aide provisionsare very limited. Guidelines for lcngth and type of services andequipment are available based on diagnoses, with some outlierprovisions. Hospice care and its associated services are alsocovered by Medicare.tT

Medicaid also provides reimbursement (that varies fromstate to state) for inpatient (acute medical, rehabilitation), out-patient, home health, skilled nursing home, DME, and physi-cian benefits. However, Medicaid is fypically not a primarysource of health insurance for older adults but, rather, mayserve as a copayment (as may commercial insurances). Re-cently, many managed care Medicaid programs have becomeavailable, further increasing the diversity of covered services,in this case even within a state. Importantly, at present, Med-icaid pays for more than 85% of all custodial nursing homecare (which is not reimbursed by Medicare) in the UnitedStates. Older adults who continue to work or who were federaland railroad employees typically have commercial or managedcare insurance as their primary funding source.

Beyond financial considerations for levels ofcare, determin-ing the level of services most appropriate for a given patient isa primary function of a physiatrist. How to assign patients tothe most appropriate care delivery setting requires knowledgeof payer sources; community resources; and patient-specificvariables such as endurance, medical acuity, stabilify, anddisposition options. Each level of care in the rehabilitationcontinuum has specific characteristics and efficacies.

Acute care is the most commonly used health care serviceafter physician office visits for persons age 65 years or older.Although persons in this age group account for 13% of USpopulation, they use 47% of all inpatient days of care. Up to35oh of elderly patients admitted to acute care facilities willlose independence in 1 or more areas of basic ADLs. Func-tional decline is related to several factors including immobility,poor nutritional status, sensory deprivation, altered sleep-wakecycles, medication interactions, polypharmacy, environmentalchange or altered routines, and iatrogenic illness. Several stud-ies have identified risk factors for functional decline and nurs-ing home placement. These risk factors include older age(>70y), mental status changes, premorbid functional impair-ment, low social activify before admission, and premorbiddepression or depressive symptoms. All of these factors predictpoor functional outcome.2T'28 Assessing and managing theseissues along with the primary and secondary conditions are para-mount to successful medical and rehabilitation management.

Rehabilitation intervcntions can be delivered in various set-tings, each characterized by different intensity, outcome, andrclative cost. Allocation of services is currently based more onpayer tolerance than on best outcome. Outcome data for vari-ous levels of care are often not avai lable or are incomplete.Great variabi l i ty exists across the United States. One analysisfound that, in Florida, l0% of stroke survivors were admittedto rehabil i tat ion hospitals or units, in contrast to 3loh in Hous-ton, TX.ze'ro

Funding source also plays a role in rehabilitation setting. Inan analysis of traditional Medicare beneficiaries compared withhealth maintenance organization Medicare beneficiaries, strokepatients who had traditional Medicare reimbursement weremore likely to be admitted to acute rehabilitation settings thanto skilled or subacute settings. Costs in acute rehabilitation areestimated to be twice as high as those for subacute rehabilita-tion.3r In a study32 to evaluate whether better outcomes areassociated with higher costs of inpatient rehabilitation, analysisshowed that stroke patients admitted to acute rehabilitationwere 3.3 times more likely to be discharged home than patientsadmitted to subacute settings. Other rehabilitation interventionsstrongly associated with improved outcome after stroke includeearly intervention ofrehabilitation (within 72h poststroke) andrehabilitation provided in an interdisciplinary versus a multi-disciplinary inpatient setting.33

Data supporting acute rehabilitation services over subacuterehabilitation services for hip fractures are less convincing,suggesting that only certain patients may benefit from acuterehabilitation.3a However, it is clear that outcomes are bestwhen careful attention is focused on avoiding medical prob-

lems. Identiffing which patients require acute rehabilitation-with its broad array of services, a minimum of 3 hours oftherapy a day, interdisciplinary approach, and intense medicaland nursing supervision-is multifactorial and is best deter-mined by a physiatrist.

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2. US Census Bureau. Available at: http://www.census,gov. Ac-cessed December 16, 2003.

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5. Maddox GL, editor. The encyclopedia of aging: a comprehen-sive resource in gerontology and geriatrics. 3rd ed. New York:Springer; 2001, p 435-8.

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10. Rivers PA, Tsai KL. The impact of the Balanced Budget Act of1997 on Medicare in the USA: the fallout continues. Int J HealthCare Qual Assur 2002;15:249-54.

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