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    Testimony

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    Statement by
    David W. Fleming, M.D.
    Acting Director,
    Centers for Disease Control and Prevention,
    U.S. Department of Health and Human Services
    on
    CDC's Role in Improving the Health
    of Older Americans

    before the
    Subcommittee on Oversight and Investigations
    Committee on Energy and Commerce

    May 23, 2002

    Thank you, Mr. Chairman, and Members of the Committee, for the opportunity to speak to you today about an issue that is of critical and increasing importance at the Centers for Disease Control and Prevention (CDC), and indeed for the American people. We at CDC are pleased to join our federal and non-federal partners in addressing the challenges facing Medicare, and identifying opportunities to improve the health of older.

    Before talking more specifically about improving the health of older adults, I would like to provide some context. Chronic diseases account for nearly 75 percent of the deaths in this country, are the leading causes of disability and long-term care needs, and represent nearly 75 percent of all health-related costs. Although chronic diseases are not limited to older adults, these conditions, such as cardiovascular disease, cancer, diabetes, and arthritis are heavily concentrated in adults age 50 and over. Among the 10 leading causes of death, the top six are concentrated in older adults. Premature death and much of the illness and disability associated with these diseases is preventable, even among older adults.

    This is critically important because we are now entering the time in our nation's history when the population of older adults - both in number and in proportion - is increasing at a much faster rate than we have ever experienced. The current anxiety and debate around Medicare costs is motivated by the aging of the baby boomers. The baby boom generation's leading edge is currently 56 years old. As this segment of the population ages, the proportion of adults age 65 and over in the U.S. will more than double, such that by 2030, 20 percent of all Americans will be older adults. If we don't take some steps now to do what we can to influence the health habits of the baby boomers, we may never catch up to the upcoming demands on the health care system.

    Current health and aging trends may have enormous implications for the public health system, the health care system, and our existing network of aging and social services. The cost of health care for a 65-year-old person is four times as much as that for a 40 -year old. People age 65 and over even now consume 33 percent of our health care dollars, or more than $300 billion each year. By 2030, those costs will increase by 25 percent, for the sole reason that our population will be older--even before inflation and the costs of new technology are taken into account.

    Recent CDC projections of just one major disease — diabetes — illustrate the magnitude of what we face if we don't act. Today diabetes alone accounts for about 6 percent of Medicare costs. The number of people with diabetes is expected to almost triple from 11 to 29 million by 2050. Aging baby boomers will contribute to the increased number of cases, but what's alarming is that among adults, diabetes rates increased 49 percent between 1990 and 2000, in large part due to unhealthy lifestyles. Clearly, we may not be able to sustain our current health care system unless we address in a more aggressive manner the prevention of chronic diseases and injuries. Until now, we have not maximized our prevention opportunities among older Americans. Too many believe the myth that older adults have lived beyond the time when prevention can be beneficial.

    The evidence is convincing that prevention is worth the investment for the health and safety of older adults. A recent Institute of Medicine report noted that the return on investment in medical care for cardiovascular disease reaped benefits at 4 to 1, but investment in behavioral change returned a remarkable 30 to 1 advantage. We should bring the health advantages of prevention to older adults across the country.

    We at CDC, together with Centers for Medicare and Medicaid Services (CMS), National Institutes of Health (NIH), the Administration on Aging (AoA), and others are committed to improving health and independence, and reducing long-term care needs among older adults. Medicare coverage has a critical role to play here - and we should maximize the use of currently covered services and identify additional effective prevention and control measures that can enhance the health of Medicare beneficiaries.

    Through basic research at NIH and other institutions, CDC's prevention research programs, and other institutions, we know quite a lot about how to prevent or postpone illness, injury, and disability experienced by older adults today. Unfortunately, just knowing what works is not enough. Even when covered by Medicare, older adults often may not be receiving recommended preventive services.

    For example, only two-thirds of adults age 65 and older reported receiving a flu shot in the previous year, and more than half report that they have never been vaccinated against pneumococcal disease - even though Medicare covers the cost of both immunizations.

    Despite the lifesaving benefits of screening and early detection for chronic disease, one in five women age 65-69 has never had a mammogram, and half of older adults do not receive recommended screening for colorectal cancer. Again, Medicare covers both of these screening services.

    It is clear that solving the basic research problem - developing proven prevention measures – is just the first step. There are significant gaps in getting what we know about prevention to individuals who can benefit. We are likely close to the limits of what the health care system as currently structured can do to increase preventive services. Research conducted at RAND with support from CMS showed that immunizations and screening improve when health care organizational changes are made and patients are involved in their own management. Clearly, improvements in prevention services for older adults will require creative approaches that support new ways of delivering preventive services and links to the community.

    We can do better. To help ensure prevention benefits currently covered through Medicare reach beneficiaries, we would propose more closely linking CDC's public health expertise in disease prevention and health promotion with the aging expertise and extensive outreach capability of the aging network - the Administration on Aging and its state and local counterparts. This network, analogous in ways to the public health network but with a specific population focus, reaches into virtually every community in the country with its network of over 600 area agencies on aging and associated senior centers. CDC and AoA are currently working with state chronic disease directors and state units on aging to stimulate local prevention activities. To commemorate Older Americans Month in May, mini-grants of $5,000 to $10,000 will be announced that will allow state and local representatives to develop prevention programs that reflect local priorities.

    While Medicare has made preventive services a priority through the PROs, some creative approaches for increasing preventive services have been tested that link the health care system to community-based resources.

    At CDC, we provided some funding to a program aptly named SPARC, or Sickness Prevention Achieved through Regional Collaboration. This program, serving counties where the borders of New York, Connecticut, and Massachusetts meet, acts as a broker to bring together existing health care and community resources. SPARC does not deliver services; instead, it consolidates and coordinates, serving as the missing catalyst, or the glue. Because providers do not see SPARC as a competitor, they welcome a service that helps them and their patients.

    SPARC has helped the communities it serves achieve dramatic results in extending critical preventive health services to older adults. For example, Medicare data shows that in 1997 in Litchfield County, Connecticut, a community served by SPARC, pneumococcal immunizations increased at twice the rate compared to seven surrounding counties without the benefit of SPARC. The SPARC model has demonstrated its value in bringing lifesaving preventive services to older adults. Communities around the country could benefit from innovative and successful models like SPARC.

    CDC also participated in CMS's recent effort to permit "standing orders" that allow institutions like nursing homes to routinely provide immunizations without requiring providers and staff to coordinate new written orders annually for individual patients. Support for this type of systems change is critical in improving prevention under Medicare.

    While there are real gains to be achieved through the broader use of covered preventive services, Medicare has just begun to support benefits that target lifestyle issues so critical to reducing the toll of chronic illness.

    Research has shown that practicing a healthy lifestyle is more influential than genetic factors in helping older people avoid the deterioration traditionally associated with aging. Several weeks of inactivity take a greater toll on the body than decades of aging. People who are physically active, eat a low-fat, high-fiber diet, and do not use tobacco products significantly reduce their risk for chronic disease, such as cardiovascular diseases, diabetes, chronic obstructive lung disease and arthritis, as well as for injuries related to falls. Perhaps more important, practicing just these three healthy habits delays the onset of disability by more than a decade on average. For a society concerned about the public and private costs of long-term care, delaying disability has enormous potential economic implications.

    For the purposes of today's hearing, I'd like to focus on physical activity as a preventive tool that deserves Medicare's support. Besides reducing the risk for a variety of chronic diseases, regular activity also helps older adults reduce their risk of falling, alleviate anxiety and depression, maintain a healthy body weight, and improve joint strength and mobility. And yet, nowhere is the gap wider between what we know and what we do.

    Two-thirds of older adults do not get regular physical activity. Less than half of older adults served by Medicare say that their healthcare provider asks them about physical activity. The potential exists to reverse this by ensuring that older adults have access to physical activity programs that address their unique health, lifestyle, functional, and motivational needs. Even the frailest of elders can benefit from low-stress activities tailored for their needs, such as gardening —which, by the way, is the third most popular physical activity among seniors. All individuals, and particularly older adults, should receive counseling from their health care providers on the benefits of physical activity.

    Let me give you an example of what moderate physical activity can mean for people at high risk for diabetes, with its debilitating complications and enormous Medicare costs each year. In a recent NIH study, in which CDC collaborated, overweight adults with above-normal glucose levels who walked five times a week and lost as few as five pounds were able to reduce their risk of developing diabetes by nearly 60 percent. People in the study aged 60 and older were among those most successful in reducing their risk.

    There is a groundswell of interest across the country in promoting physical activity among older adults. Over 800 candidate communities recently registered their intent to apply for funding available from the Robert Wood Johnson Foundation for the "Active for Life" program. Unfortunately, only eight sites will receive funding for this program to increase physical activity among older adults. Given the benefits of physical activity, CDC is currently working with the National Institute on Aging (NIA) and the Older Women's League to evaluate the effectiveness of NIA's recently developed physical activity materials in getting older adults to exercise.

    There is recognized, science-based value in physical activity programs, but they aren't reaching older adults. Learning how to get the benefits of such programs out to seniors in communities across the country should be a national priority.

    Physical activity also plays a key role in reducing an older person's risk of falling. One of every three older Americans - about 12 million seniors - falls each year, with devastating consequences. More than 10,000 will die from the fall; another 340,000 will sustain a hip fracture. Half of the older adults who break their hip in a fall are never able to return home and live independently again. The risk of falling and loss of independence has been shown to be a primary concern for older adults. A recently-published study involving women age 75 and older found that 80 percent would rather be dead than experience the loss of independence and quality of life from a bad hip fracture and admission to a nursing home.

    Risk factors for falls include: a previous fall, muscle weakness, problems with balance and walking, being underweight, vision and hearing loss, taking four or more medications or psychotropic drugs (such as sleeping pills and tranquilizers). Reducing the risk of falls would make an enormous impact on reducing disability and long-term care needs. Every year, falls among older people cost the nation more than $20 billion, and these costs will rise to an estimated $32 billion by 2020.

    Weight resistance exercises and regimens such as Tai Chi help seniors maintain and improve balance, strength, and coordination at any age. Other means to address fall risk include insuring proper medication management for older people — a current priority of the Assistant Secretary for Health, Dr. Slater; making physical changes in the home environment; and educating seniors and their caregivers, formal and informal, about factors that contribute to falls. Simple changes in an older person's home, such as securing rugs and adding grab bars in bathrooms can quickly and easily reduce fall risk. Because vision problems can increase a person's risk for falling by as much as 60 percent, improved lighting in the home is also an effective strategy for preventing falls. Despite the known benefits of such measures, more than two million older Americans live in homes that have not had simple modifications that can reduce their risk of falls. One-fourth of older adults have an outdated or wrong eyeglass lens prescription, contributing to poor vision and the increased likelihood of falls.

    Screening older adults for fall risk should be a routine part of medical care, just as we screen for cancer or diabetes complications. Such screening should include identifying adults who have previously fallen or who have multiple fall risk factors as I cited above, followed by appropriate and necessary treatment, for example, training to improve balance and muscle weakness, medication review and management, vision screening and correction, and assessment of and education on needed home modifications. Such efforts are already underway in other developed nations, where collaboration between government agencies and aging networks are providing easily accessed and effective physical activity and falls prevention programs for seniors.

    Another area of importance to Medicare beneficiaries is medical errors occurring while hospitalized or as a resident of a long-term care facility. Based on a landmark report by the Institute of Medicine, medical errors are responsible for 44,000 to 98,000 deaths each year with additional healthcare costs of 17 to 29 billion dollars each year. CDC is working with several partners including the Agency for Healthcare Research and Quality, the Veterans Administration, and the Centers for Medicare and Medicaid Services, along with private sector partners, to better understand why these events occur, and to implement programs to prevent them.

    Finally, I'd like to address one last area today that holds considerable promise in improving seniors' health and quality of life, and in reducing the demands on the health care system. That area is self-care for those with chronic diseases or for those at increased risk for disease or complications.

    Self-care can be undertaken in a variety of ways and for a variety of conditions, from diabetes to arthritis. We know that people will "self-manage" their disease even when they are pursuing remedies with no known health benefits. Programs are widely available, but no criteria exist to determine what the programs should include. The challenge, and the opportunity, is to ensure that older adults receive the quality education they need to become knowledgeable about what they can do to take responsibility for their own health and disease management.

    For an individual with diabetes, this might mean optimally managing blood glucose levels. The individual not only fares better physically but derives benefit and satisfaction from being an active participant in his or her own care. Self-management has been shown to be of particular value for people with arthritis, the leading cause of disability and a problem for almost two-thirds of Medicare enrollees. In selected states and in cooperation with the Arthritis Foundation, CDC supports an arthritis self-management education program that teaches people how to better manage their arthritis and lessen its disabling effects. This six-week course has been shown to reduce arthritis pain by 20 percent and physician visits by 40 percent. Again, however, there is a gap in getting the benefits of this program out to individuals. Currently, less than one percent of the 43 million Americans with arthritis participate in such programs and courses are not offered in all areas.

    In conclusion, I would like to thank the Committee again for its leadership and commitment in the important area of older adult health. While the risk for disease and disability clearly increases with advancing age, poor health does not have to be an inevitable consequence of aging. Far from being too old for prevention, Medicare recipients offer some of our most promising prevention opportunities. The science base is compelling, but we should refocus our attention on the real barriers to implementation and financing. Priority needs are evaluating promising programs in real-world settings and making the system flexible enough to accommodate the new types of benefits that are required. Our nation has contributed to an unprecedented increase in the human life span during the 20th century through improvements in public health and medical care. Since the 1960s we have been committed to providing health care for older adults. Our challenge now is to insure that added years are quality years and to create a sustainable health care system that provides the very best opportunities and incentives to stay healthy and independent as long as possible.

    Thank you. I'd be happy to answer any questions.


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Last revised: May 24, 2002