Geriatrics - Dr. Walter Wodchis

Deconstructing the 1-5%
Walter P Wodchis
November 3, 2014
Health Achieve Geriatrics Session
Leveraging the Culture of Performance Excellence in Ontario’s Health System
1
HSPRN is an inter-organization Network funded by the Ontario Ministry of Health and Long Term Care
Overview
•  What does it mean “The 1-5%”?
•  Where do the 1-5% use care and how
does that differ for older adults? •  Who are the 1-5% in the 65+
population? What conditions do they
have? •  Multimorbidity
•  System improvement challenges
2
Total Health Spending in Millions
Total Health Spending in Ontario
$1,200
2008 and estimated 2031 Total Annual Health System
by projecting population and using 2008 spending
patterns
$1,000
$800
$600
$400
$200
$0
0
5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
2008
2031
Age
3
Average Annual Government Health Spending in Ontario
Average Annual Total Health System Cost
by Age & Sex Ontario
$20,000
$15,000
$10,000
$0
0
4
8
12
16
20
24
28
32
36
40
44
48
52
56
60
64
68
72
76
80
84
88
92
96
100
$5,000
Male
Female
Most people are healthy throughout their lives and incur their
highest costs later in life. This is borne out in higher average
costs for just about every sequential age.
*note increase at age 65 in spending attributable to ODB coverage at age 65
4
The Concentration of
Healthcare Spending in Ontario
0%
1
5
10%
10
20%
34%
30%
Expenditure
Threshold (2009 35%
Dollars)
$41,526 Expenditure
Threshold (2010 33%
Dollars)
Expenditure
Threshold (2011
Dollars)
$44,906 $42,499 40%
50%
50
66%
65%
$7,597 78%
$7,718 77%
$7,961 $3,668 $3,709 $3,815 66%
60%
70%
78%
80%
98%
98%
98%
90%
$307 100%
Population
$316 $333 Health Expenditure 2009 Health Expenditure 2010 Health Expenditure 2011
Health System Spending is highly concentrated year after year after year
5
Where are costs incurred? Total System Spending by Sector
in Entire Population and Among Top 1% and Top 2-5% of Spending
A) All residents
B)Top
Top1%
1%
C) Top 2-5%
Acute care
ED visits
SDS
CCC
Rehab
Physician visits
Drugs
LTC
Home Care
The largest costs are incurred in acute, physician and longterm care (LTC) with LTC contributing relatively more in the
highest 1% of the population.
6
How does the top 1-­‐5% vary by age? Ontario
population
ranked in order
of health system
spending
0%"
1"
5"
10%"
10"
Proportion of Total System Spending by Age
0-17
18-64
65+
Expenditure"
Threshold""
(2011"Dollars)"
20%"
Expenditure"
Threshold""
(2011"Dollars)"
16%"
83,039"
44%"
45,203"
38%"
30%"
36%"
22,070"
8,383"
40%"
50%"
Expenditure"
Threshold""
(2011"Dollars)"
50"
59%"
2,329"
60%"
61%"
5,446"
70%"
70%"
1,281"
74%"
22,508"
64%"
2,610"
80%"
95%"
90%"
195"
97%"
298"
95%"
2,211"
100%"
Popula4on"
Age"0917"
Age"18964"
Age"65+"
Higher Total and Lower Concentration of healthcare
spending among older adults.
7
Types of spending in top 1% varies by age A) Age 0 to 17 (N=4,518)
B) Age 18 to 64 (N=23,007)
C) Age 65+ (N=110,056)
Acute care
ED visits
SDS
CCC
Rehab
Physician visits
Drugs
LTC
Home care
Among the population with the highest 1% of total system spending, older
adults incur majority of costs in acute and LTC.
8
What condi=ons do the 65+ have? -­‐ Mostly Chronic Disease
% of Total Acute
Admissions
Class
Top 10 CMGs
65y plus
Heart Failure without Cardiac Catheter
5.3%
Chronic Obstructive Pulmonary Disease
4.8%
Fixation/ Repair Hip/ Femur
2.8%
Viral/Unspecified Pneumonia
2.8%
Myocardial Infarction/ Shock/ Arrest without
Cardiac Catheter
2.6%
Lower Urinary Tract Infection
2.3%
Ischemic Event of Central Nervous System
1.8%
General Symptom/Sign
1.8%
Hip Replacement with Trauma/ Complication
of Treatment
1.8%
Arrhythmia without Cardiac Catheter
1.5%
9
Why? - Chronic Disease is Normal
• 
Source: Canadian Institute for Health Information: Seniors and the Health Care
System: What Is the Impact of Multiple Chronic Conditions? July 2001
10
Multi-morbidity is Normal for Older Adults
• 
Source: The Chief Public Health Officer’s Report on the State of Public Health in Canada.
2010 : Growing Older – Adding Life to Years
11
Why focus on chronic multi-morbidity ?
•  Primarily community-based care
•  High acute readmission rate
•  High LTC admission rate
•  High system burden (cost)
12
Implications for Sustainability
1.  Most of the projected spending
increase is for older persons (mostly
with complex medical needs)
2.  Future spending will be about 80%
higher if we don’t change the way
that we care for older adults (in
today’s dollars)
13
Implications for Sustainability
3.  We cannot continue to spend the way
that we are spending.
4.  We need to improve health of older
adults.
5.  We need to better manage spending
for older adults. 6.  …but not necessarily all older adults.
14
What’s it all about
•  It’s about popula,on-­‐based health And... •  it’s about person-­‐centered health care for (par,cular) popula,ons 15
It’s not that many people
•  We need to be;er manage the health of 13.2 Million Ontarians •  But we don’t need to be;er manage the health care of 13.2 Million Ontarians. •  50% of the popula,on or 6.7 Million Ontarians use $333 or less in health care each year totalling 2% of all spending We do need to be;er manage the care of complex older adults •  Top 1% spenders in the popula,on is about 132,000 people •  110,000 of these are aged 65+ •  1% of the popula,on aged 65+ is about 18,000 people •  5% of the popula,on aged 65+ is about 92,000 people 16
High cost population
How well do we manage care? … for the high cost population?
Focus for a moment on those aged 65
or over with 2 or more Ambulatory Care
Sensitive Chronic Conditions. (ACSC: Asthma, COPD, CHF, Diabetes, Hypertension, Angina,
Seizure Disorder) 17
Ontario Spending for Multiple ACSC
Aged 65+ in 2009: Many Providers
Hospitalized with Multiple ACSC
6,513 people…$177+ Million
$25,068,472 Acute care
ED
Rehab
$17,766,513 $77,561,363 $18,279,938 CCC
LTC
HC
MD
Pharma
$11,905,337 $1,154,922 $13,872,822 $11,424,818 18
How well do we manage their care?
Why focus on care after discharge?
Too much care
Hospital
Disease intensity
Hospital
Rehab
Hospital
Rehab
Care intensity
Long-term care
Home
Home
Home
Not enough care
Irfan Dhalla,
Time
HSPRN Generating Innovative Strategies for Care of the Elderly with Complex Needs. March 29, 2011
19
Patients see different providers
Percent of MACSC by Number of Different
Providers in One Year
12.00
Percent of Population
10.00
8.00
6.00
4.00
2.00
0.00
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
Number of Different Providers
20
Number of MACSC Patients
0
'300+
230-234
280-284
260-264
250-254
240-244
230-234
215-220
220-224
205-209
195-199
181-185
185-189
170-174
160-164
150-154
140-144
130-134
120-124
110-114
100-104
90-94
80-84
70-74
60-64
50-54
40-44
30-34
20-24
10-14
1-4
Some patients have many encounters
Patient encounters in one year for all providers
900
800
700
600
500
400
300
200
100
Number of Health System Encounters
21
Adjusted* Total Annual Health Care Costs 10,000 9,000 8,000 Mean costs ($) 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 1 2 3 4 ≥5 Number of medical condi=ons * Adjusted for Age and Sex
< 65 years old ≥65 years old 22 Incremental Total Costs (≥65 years) 10,000 9,000 Mean costs ($) 8,000 $3,831
7,000 6,000 5,000 $1,652
4,000 3,000 $1,280
2,000 $1,026
1,000 0 1 2 3 4 Number of medical condi=ons ≥5 23 Burden is High, Care is Sub-Optimal
• 
Seniors with three or more reported chronic
conditions account for 40% of reported health
care use among seniors
• 
Gaps exist in preventive and collaborative care
for seniors
• 
Though most seniors have access to PHC:
w 
• 
fewer than half (48%) reported talking at least
some of the time to a health professional
about their treatment goals.
Source: Canadian Institute for Health Information: Seniors and the Health Care System: What Is the Impact of
Multiple Chronic Conditions? July 2001. Based on data from the Statistics Canada Canadian Survey of Experiences
With Primary Health Care, 2008. Canadian Institute for Health Information
24
What do we get?
•  High costs
•  Low primary care accessibility
•  High acute hospitalizations for
ambulatory care sensitive conditions
•  High readmission rates
•  Poor continuity of care
25
Multi-morbidity is a complex issue
•  Very few Clinical Practice Guidelines address multimorbidity (multiple CPGs are impractical & may be harmful
in some cases of multi-morbidity)
•  Trial-based evidence gap: multi-morbid groups are
excluded
•  Some co-occurring conditions may be managed
synergistically (e.g. ace inhibitors in diabetes and hypertension)
•  Chances of adverse effects from medications may
be related to severity of other diseases (e.g. Cox-2
inhibitors in individuals with severe diabetes or hypertension).
A few key authors: Elizabeth Bayliss, Chad Boult, Cynthia Boyd, Martin Fortier,
Alex Jadad, Andres Cabrera, Renee Lyons, etc
26
What to do ?
•  It costs a lot to care for people with many
conditions… but perhaps we can do better? •  Many good intervention ideas – integrating care.
•  Key is to identify “service package” for different
clients.
•  Targeting is also important:
w  Who is at risk for what outcome ?
w  What is the best intervention to avoid that outcome ?
w  i.e. Which risks are modifiable / what are the
gaps in care? 27