Is Prevention Cost-Effective for Controlling Long-Term Care Costs?

Older adults’ health and well-being are a major focus for governments, communities, and for all who are involved in the care of this rapidly growing population. All indicators point to the significance of lifestyle interventions in successful aging, in both quality and quantity of life, as well as the potential cost-effectiveness of these strategies.

In 2008, there were approximately 38.7 million persons age 65 years and older living in the United States. This number is expected to increase to 88.5 million by 2050,¹ representing roughly 20% of the U.S. population. For many years now, healthcare costs have been increasing at double the rate of inflation, and reached $2.5 trillion in 2009.² National healthcare cost per U.S. resident in 1970 was $356, which rose to $2814 in 1990 and is projected to be $13,100 in 2018.³ The healthcare costs for older Americans is also on the rise, as noted in the trend from 1987 to 1999 ($157 billion to $386 billion).⁴

Increased need for long-term care (LTC) with advancing age has led to higher per capita and total LTC spending for older Americans⁴; annual Medicare LTC expenses per beneficiary grew from $5370 in 2002 to $7064 in 2005.⁵ In addition, Medicare spending for LTC as a percentage of national healthcare expenditure is projected to grow from 17.2% in 2005 to 20.7% in 2017.⁵ According to the Congressional Budget Office, the total LTC expenditure for seniors in 2000 was approximately $125.5 billion.⁶ The Office projected the expenditure trend to be $160.7 billion, $207.3 billion, $295.0 billion, and $346.1 billion for the years 2010, 2020, 2030, and 2040, respectively.⁷ Clearly, there is a need to evaluate all strategies, including preventive lifestyle interventions, that can help control the growing costs of LTC in the United States.

Government-sponsored programs have been instrumental in promoting healthy lifestyles among older people. The Older Americans Act (OAA) was enacted in 1965 to promote the well-being of older adults and to help them remain independent in their homes and communities. The OAA provides funding for the Elderly Nutrition Program (ENP), which oversees nutrition services (congregate meals and home-delivered meals) and Home and Community-Based Services (HCBS). The goals of these programs are to promote healthy lifestyles through nutrition education and routine physical activity. The federal funding for the ENP was maintained at a relatively constant level from 2005-2007: $719 million (2005), $715 million (2006), and $712 million (2007).⁸ Nonfederal resources from state, local, private, and community donations leverage the ENP funding. Every dollar in federal funding leverages $1.70 and $3.55 for congregate and home-delivered meals, respectively.⁹As a result of such resource utilization, the ENP was able to expand its services to at least two times the level that would be possible with ENP federal funding alone.⁹

The congregate meal program as a part of ENP is designed to combat not only poor nutrition but also to prevent social isolation among older adults. The program is often carried out in senior centers and coordinated with other social services providing health screenings, nutrition and physical education, and all types of fitness programs such as yoga, tai chi, aerobics, etc. These centers act as clearinghouses of health information and provide tools for healthy behaviors. The congregate meal program has been found effective in improving physical health, emotional health, and quality of life of the elderly population.^10,11 The study by Gitelson et al¹⁰ illustrated the important role of congregate meals in providing a social environment and a feeling of belonging, thus creating the improved perception of quality of life. A study by Fodero and Wunderlich¹¹ provided quantitative evidence of significant improvement in specific health biomarkers such as blood pressure among the congregate meal participants from the four-year longitudinal study. It was reported that the ENP has been cost-effective for improving health and quality of life by serving 2.7 million older adults in 2006.¹²

The HCBS programs offer alternatives to institutionalization by providing services such as nutrition counseling, health promotion, physical fitness programs, and adult day care that participants can choose to meet their needs. The federal funding for HCBS maintained at approximately $350 million from 2005-2007.⁸ The ENP and HCBS are vital programs that allow older adults to stay in their homes, delaying or avoiding LTC institutionalization, which is more costly. There is evidence that investment in HCBS is cost-saving in the long run. For example, states that invested in HCBS experienced slower growth in nursing home spending than states with a low HCBS investment. The states of Oregon and Washington, for instance, served more beneficiaries and slowed the growth of LTC expenditure by expanding HCBS, saving $49 million and $75 million in 1994, respectively.^13-15 The analysis of LTC expenditure per enrollee among Medicaid beneficiaries showed that those who used institutional services spent approximately $38,780, whereas spending for those who used HCBS was $17,176, less than half of the cost of the former.¹⁶ Hence, a short-term increase in government expenditure may be inevitable to expand HCBS; however, HCBS programs are cost-effective by preventing or deferring the necessity of LTC in the future.

The cost of one day in a hospital equals the cost of one year of ENP, as noted in the 2005 State Program Report.¹ The dynamic effect of the ENP incorporating lifestyle intervention cannot be overlooked because a comprehensive ENP could create a norm in the community that invites healthy lifestyles. Nevertheless, the funding for ENP is still lagging behind other state programs: $758 million versus $464.5 billion in 2008 (ENP vs Medicare). Even with the American Recovery and Reinvestment Act of 2009, which provides an additional $100 million for food/nutrition education and counseling services for seniors,¹⁸ funding has yet to keep up with the demand of the growing senior population because the need for ENP incorporating lifestyle intervention to at-risk older adults currently exceeds the resources of existing programs.

Although the topic of health promotion and disease prevention has received increased attention in recent years, it takes some time to make significant changes in the lifestyle of Americans to reduce obesity, which is one of the main factors in developing chronic diseases such as diabetes and hypertension.¹⁹ According to the National Health and Nutrition Examination Survey 2001-2002,²⁰ Healthy Eating Index 2005 total score of the older Americans (ages ≥ 65 yr) was 68 out of a maximum of 100, which signaled their diet needing improvement. Moreover, only 22% of the older Americans reported to engage in regular leisure time physical activity in 2005-2006 per the National Health Interview survey.²¹ The good news, however, is that such health indicators as diet quality and physical activity are modifiable through health promotion geared to prevent or delay onset of chronic diseases. As the prevalence of chronic diseases increases with age, older adults utilize healthcare more than any other age group, thereby inflating the healthcare cost. Many of the chronic health conditions that result in frailty and disability, loss of independence, and reduced quality of life in older adults are preventable at a low cost through lifestyle intervention incorporating proper nutrition and physical activity.^22,23 Several studies showed the cost-effectiveness of such intervention: $3586 less healthcare cost/person/year; 22.3% fewer hospital admissions²⁴; 538% return on investment in the intervention,²⁵ and $1878 less disease remission/year.²⁶

Health promotion programs incorporating nutrition education and physical activity can play an important role in preventing and delaying costly and debilitating chronic diseases. The theme of Healthy People 2010²⁷ is enabling Americans to live long, healthy, and worthwhile lives. Guidelines for older adults are focused to improve their health by encouraging them to adopt healthier behaviors, participate in organized health promotion activity, and increase food security to reduce hunger.²⁷ Older adults, in fact, want and need nutrition education and other lifestyle changes to improve their health status.² It is never too late to improve health, and small lifestyle changes can make a difference at any age.²⁹ Therefore, older adults can maximize the benefit from government-sponsored programs that encourage lifestyle changes through nutrition education, counseling, and physical activity classes. In the climate of expanding budget deficits, rising healthcare costs, and constant threats of cutting social programs, it is imperative to ensure that effective health promotion programs such as ENP and HCBS that produce valuable outcomes receive continuous and additional governmental support to reduce our overall healthcare and LTC costs.

The authors report no relevant financial relationships.

From the Department of Health and Nutrition Sciences, Montclair State University, Montclair, NJ.

References

1. U. S. Department of Commerce. An older and more diverse nation by midcentury. U. S. Census Bureau News; 2008, Aug 14. http://www.census.gov/Press-Release/www/releases/archives/population/012496.html. Accessed April 29, 2010.

2. Health care facts: Costs. September 2009. National Coalition on Health Care. http://nchc.org/sites/default/files/resources/Fact%20Sheet%20-%20Cost.pdf. Accessed April 29, 2010.

3. Trends in health care costs and spending. 2007. The Henry J Kaiser Family Foundation. http://www.kff.org/insurance/upload/7692_02.pdf. Accessed April 29, 2010.

4. Keehan SP, Lazenby HC, Zezza MA, Catlin AC. Age estimates in the national health accounts. Health Care Financ Rev 2004;1:1-16. http://www.cms.hhs.gov/HealthCareFinancingReview/Downloads/Keehan.pdf. Accessed April 29, 2010.

5. Medicare spending and financing. September 2008. The Henry J. Family Foundation. http://www.kff.org/medicare/upload/7305_03.pdf. Accessed April 29, 2010.

6. Wang Z, Gu D, Yi Z. Projections of elderly disability, care needs, and care costs for the states of California, Florida, Minnesota, and North Carolina-A pilot study. Paper presented at: 2007 Annual Meeting of the American Population Association; March 29-April 3, 2007; New York, NY http://paa2007.princeton.edu/download.aspx?submissionId=70585. Accessed April 29, 2010.

7. Congressional Budget Office. Projections of expenditures for long-term care services for the elderly. March 1999. http://www.cbo.gov/doc.cfm?index=1123&type=0. Accessed April 29, 2010.

8. U.S. Department of Health and Human Services. FY2007 budget in brief. Administration on Aging. http://www.hhs.gov/budget/07budget/aoa.html#NutritionP. Accessed April 29, 2010.

9. Millen BE, Ohls JC, Ponza M, McCool AC. The elderly nutrition program: An effective national framework for preventive nutrition interventions. J Am Diet Assoc 2002;102(2):234-240.

10. Gitelson R, Ho CH, Fitzpatrick T, et al. The impact of senior centers on participants in congregate meal programs. J Park and Recreation Administration 2008;26(3):136-151.

11. Fodero KM, Wunderlich SM. The use of the mini nutrition assessment tool to measure the nutrition status of community-dwelling seniors taking part in government-sponsored programs. Top Clin Nutr 2008;23(2):139-148.

12. Walker EL. Statement on programs under the Older Americans Act (OAA) before the Special Committee on Aging. U.S. Senate. March 5, 2008. http://www.hhs.gov/asl/testify/2008/03/t2009035a.html. Accessed April 29, 2010.

13. Kaye HS, LaPlante MP, Harrington C. Do non-institutional long-term care services reduce Medicaid spending? Health Aff 2009;28(1): 262-272.

14. Mollica RL, Kassner E, Walker L, Houser A. Taking the long view: Investing in Medicaid home and community-based services is cost-effective. 2009. http://assets.aarp.org/rgcenter/il/i26_hcbs.pdf. Accessed April 29, 2010.

15. Government Accounting Office. Successful state efforts to expand home services while limiting costs. August 1994. http://archive.gao.gov/t2pbat2/152298.pdf. Accessed April 29, 2010.

. 16. Medicaid and uninsured. November 2006. The Henry J. Family Foundation. http://www.kff.org/medicaid/upload/7576ES.pdf. Accessed April 29, 2010.

17. 2005 White House Conference on Aging. The booming dynamics of aging. 2005. http://www.whcoa.gov/. Accessed April 29, 2010.

18. The American Recovery and Reinvestment Act of 2009 (ARRA). 2009. http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:h1enr.pdf. Accessed April 30, 2010.

19. Centers for Disease Control and Prevention. Overweight and obesity. http://www.cdc.gov/nccdphp/dnpa/Obesity/. Accessed April 29, 2010.

20. U.S. Department of Health and Human Services. Centers for Disease Control and Prevention. National Center for Health Statistics. National Health and Nutrition Examination Survey (NHANES), 2001-2002. http://www.icpsr.umich.edu/icpsrweb/ICPSR/studies/25502. Accessed May 6, 2010.

21. Federal Interagency Forum on Aging-Related Statistics. Older Americans 2008: Key Indicators of Well-Being. Health Risks and Behaviors. Federal Interagency Forum on Aging-Related Statistics, Washington, DC: U.S. Government Printing Office. March 2008. http://www.agingstats.gov/agingstatsdotnet/Main_Site/Data/Data_2008.aspx. Accessed April 30, 2010.

22. Bowman S. Low economic status is associated with suboptimal intakes of nutritious foods by adults in the National Health and Nutrition Examination Survey 1999-2002. Nutr Res 2007;27:515-523.

23. Meyyazhagan S, Palmer RM. Nutritional requirements with aging. Prevention of disease. Clin Geriatr Med 2002;18:557-576.

24. Wolf AM, Siadaty M, Yaeger B, et al. Effects of lifestyle intervention on health care costs: Improving Control with Activity and Nutrition (ICAN). J Am Diet Assoc 2007;107(8):1365-1373.

25. Coombs J. The role of nutrition screening and intervention programs in managed care. Manag Care Q 1998;6(2):43-50.

26. Dalziel K, Segal L. Time to give nutrition interventions a higher profile: Cost-effectiveness of 10 nutrition interventions. Health Promot Int 2007;22(4):271-283. Published Online: October 4, 2007.

27. U.S. Department of Health and Human Services, Healthy People 2010. 2nd ed. Volume I and II. Washington, DC: Government Printing Office; 2000.

28. Duerr L. Assessing nutrition education wants and needs of older adults through focus groups. J Nutr Elder 2003;23(2):77-91.

29. Wellman NS. Prevention, prevention, prevention: Nutrition for successful aging. J Am Diet Assoc 2007;107(5):741-743.