《健康經(jīng)濟(jì)學(xué)》課件Chapter19

PopulationagingInrecentdecadesthepopulationofthedevelopedworld(andmuchofthedevelopingworld)hasbeenaging.Between1950and2050:Averageageworldwidewillincreasefrom25to35Ratioofinfants(under5)toelderly(over65)willflipfrom5:2to2:5!Ch19|PopulationagingandthefutureofhealthpolicyWHYISTHEWORLDAGING?Whyistheworldaging?Twomajordistincttrends:Lifeexpectancieshavebeenincreasingaroundtheworld.Fertilityrateshavebeenfallingaroundtheworld.IncreasinglifeexpectancyInpre-industrialtimes,lowlifeexpectanciesweredrivenbysky-highchildmortalityrates.Ifyousurvivedtoage5youwouldprobablylivealonglife,butsurvivingtothatagewasdifficult.In1833,Frenchlifeexpectancyatbirthwas38years;inSwedenitwas42.5.IncreasinglifeexpectancyWhythisstunningincrease?Bettersanitation:innovationslikecleandrinkingwater,andindoorplumbingImprovednutrition:before1800s,manydeathswereattributabletoperiodicfaminesMedicaladvances:antibiotics,obstetricsDecliningfertilityratesInorderforapopulationtomaintainitssizefromgenerationtogeneration,eachwomanmustgivebirthtoabout2.1childrenduringherlifetime.Thisspecialfertilityrateisoftencalledthepopulationreplacementfertilityrate.Inthelastfewdecades,however,thetotalfertilityrateinthedevelopedworldhasfallenbelowthatlevel.DecliningfertilityratesBirthrateshavefallensofarthatmanycountriesacrossEuropearenowpoisedforpopulationdecline,whilebirthratesintheU.S.arebarelyabovereplacement.Contrastthiswith1800s,whenfertilityratesinEuropeandtheUSrangedfrom4-5lifetimebirthsperwoman.Whyhavefertilityratesdeclined?Noconsensusamongeconomichistorians,butseveralplausiblecauses:AvailabilityofcontraceptionIncreasedwomen’slaborforceparticipationDeclininginfantmortality(lessneedfor“extras”)Decreasedneedforchildrenasbreadwinnersorcaretakers(old-ageincomesecurityhypothesis)Ch19|PopulationagingandthefutureofhealthpolicyHEALTHCARESYSTEMSUSTAINABILITYThesustainabilityofhealthcaresystemsManycurrenthealthcaresystemsarepyramidschemes:debtsofthecurrentgenerationarebornebythelargergenerationthatfollows,whoseevengreaterdebtsareinturnbornebytheevenlargergenerationafterthat.Thissortofhealthsystemfinancingcansucceedina1950-styleworld,withhighbirthratesandever-expandingpopulations,butnotwhenpopulationsareshrinking.Example:U.S.MedicareHistorically,therevenuescollectedthroughtheMedicarepayrolltaxhaveexceededtheamountspentonMedicarebytheU.S.government.Eachyear,theseexcesstaxcollectionswereplacedinanaccountcalledtheMedicareTrustFund.In2007,however,MedicarePartAexpendituresexceededpayrolltaxcollectionsforthefirsttime—andthetrustfundhasbeenonthedeclineeversincethen.Example:U.S.MedicareOverthecomingdecades,expendituresonMedicareareforecastedtorise,giventhat:TheU.S.populationisexpectedtoagesignificantly.Thecontinualintroductionofnew,expensivemedicaltechnologyMeanwhile,thegrowthoftheworking-agepopulation(whichpaysMedicarepayrolltaxes)willnotkeeppacewiththegrowthoftheelderlypopulation.Example:Long-termcareinJapanIn2000,Japanestablishedalong-termcareinsurance(LTCI)programtoaccommodatethegrowingnursinghomepopulationTraditionalsourcesofhomecarearedisappearingsothisisasignificantexpenseformanyfamiliesWhentheprogramwasestablished,somewereconcernedthatthepopulationofelderlywhowouldbecoveredwouldgrowtooquicklyExample:Long-termcareinJapanBy2005,expenditureswerealready25%higherthanforecastfiveyearsearlierReformstotheprogram(includingbenefitcutsandincreasedcopays)slowedgrowthsomewhat,butby2008expenditureshadreboundedabove2005levelsTheprogramisnotsustainableinthelongtermwithoutnewsourcesoffunding(e.g.increasedtaxes)Ch19|PopulationagingandthefutureofhealthpolicyFORECASTINGTHEFUTUREOFHEALTHEXPENDITURESForecastingthefutureofhealthexpendituresInthefollowingdecades,governmentsaroundtheworldwillneedtomakedifficultdecisionsabouthowtoreformtheirhealthcaresystems.Inordertounderstandtheextentoffuturebudgetaryshortfallsandbettermakesuchdeterminations,governmentsrequireaccurateestimatesoffuturehealthexpenditures.Tomakesuchprojections,trendsinbothagingandinoverallhealthmustbeconsidered.FuturemedicaltechnologyPredictingthedevelopmentoffuturemedicaltechnologyisadifficult(perhapsimpossible)task.Intheory,newmedicaltechnologyhasanambiguouseffectonfuturehealthexpenditures.Itmayhavethesameeffectofincreasingexpendituresasnewtechnologiesoverthepastfewdecades.However,itisalsopossiblethatfuturetechnologiesmayenabledoctorstoprovidebettercareatalowercost—andreduceoverallexpenditures.FuturemedicaltechnologyIn1999,RANDconvenedapanelofmedicalexpertstomakepredictionsaboutcomingdevelopmentsinmedicaltechnology.Unsurprisingly,theexpertsweretoooptimisticaboutsometechnologies,toopessimisticaboutothers,andoftendidnotcorrectlypredicthowspecifictechnologieswouldendupbeingused.Long-termforecastscannotrelyonthesesortsofpredictionswithmuchconfidenceCompressionofmorbidityDefinition:Thephenomenonofdisabilityandillnessbeingdelayedor“compressed”intotheendoflife.Manyelderlypeoplespendthelastyearsoflifeunabletoperformbasicactivitiesofdailyliving(ADLs)suchaswalkingaroundthehouseordressingthemselves.Aslifeexpectancyincreases,qualityoflifemaynotincreasewithit,unlessthesedisabilitiesarepostponedoreliminated.Yetanothercomplicationinforecastingthefuturehealthneedsofanagingpopulation.CompressionofmorbidityInthe1980saconsensusdevelopedthatthehealthoftheelderlywasimproving,andthatmorbiditywasbecomingmorecompressed.DisabilityratesamongtheelderlyintheUShaveimprovedinrecentdecadeslargelyduetoimprovedcareforthosewithchronicdiseases.Forexample,elderlypeoplewithchronicillnessesaresubstantiallylesslikelytobecomefunctionallydisabledtodaythantheywouldhavebeendecadesago,largelyowingtoimprovementsinsupportivetechnology–suchasbetterwalkingaids.ModelingfuturehealthexpendituresOnepopularapproachistoassumethathealthexpenditureswillcontinuetogrowatroughlythesamerateasinpastyears.Butsuchanapproachisinappropriateforlonger-runforecastssincetheydonotaccountforlong-termchangesintheageorhealthstructureofthepopulation.Theyarealsoinappropriateforanswering“whatif”questions.Examples:Whatifthegovernmentweretoadoptpoliciespromotingpreventativecareorlargerfamilies?Whatifexpensivenewtreatmentsareintroducedtotreatwidespreadconditions?ModelingfuturehealthexpendituresAnotherapproachistoconstructamodelthatforecastshowtheprevalenceofaspecificdiseaseislikelytoevolve,anduseittoestimatehowmuchitwillcosttocareforpeoplewiththatconditioninthefuture.Thedrawbackofsuchsingle-diseasemodelsisthattheyignorethecompetingriskproblem:Inasense,cancerandotherdiseasescompetewitheachothertobethecauseofmortality.Sincedeathisinevitable,reducingcancermortalityincreasesthesumofthemortalityrisksfromalltheothercausescombined.ModelingfuturehealthexpendituresGivencompetingrisks,healthcareexpendituresmightevenriseasaconsequenceofnewlifesavingtreatments,evenifthetreatmentsthemselvesarecostless.Example:ResearchersatRANDshowedthatifadrugwasdevelopedintheyear2000thatextendedlifespanby10%,buthadnoeffectontheprobabilityofdevelopingchronicdiseasesanddisabilityatanygivenage,thatby2030thiswouldresultinamuchlargerelderlypopulation,dramaticallyincreasednursinghomecosts,substantiallyhigherheartdiseaserates,andhigherhealthcarecostsoverall.Ch19|PopulationagingandthefutureofhealthpolicyPOLICYRESPONSESTOPOPULATIONAGINGPolicyresponsestopopulationagingOption1:ChronicdiseasepreventionFocusingonpreventingchronicdiseaseisattractivebecauseitmayreduceboththeburdenofchronicdiseasesandlongtermhealthcareexpenditures.Chronicdiseasesarefarmoreexpensivetotreatoverthecourseofalifetimethanotherconditions.Chronicdiseasepreventionprogramscantakemanyforms:Onesuchprograminvolveslifestylemodificationefforts,suchasencouragingpeopletoexerciseortoeatinhealthierways.However,programsthatworktopreventtheprogressionofchronicdiseaseseemtoshowbetterresults.PolicyresponsestopopulationagingTwodifficultiesindesigningchronicdiseasepreventionprogramsthatreducetotalhealthcareexpenditures:Policymakersmustproperlytargetinterventionstothepopulationsmostlikelytobenefitfromthem.Example:Apopulation-basedinterventionaimedatpreventingobesitywillnecessarilywastesomeresourcesonparticipantswhowerenotatriskforbecomingobese.Evenifaprogramissuccessful,healthcostsmayriseifthesurvivingpopulationspendshealthcareresourcesonotherexpensive-to-treatconditions.Onesolutionistodesignprogramsthatsimultaneouslypreventmanychronicdiseases.PolicyresponsestopopulationagingOption2:Reinventingend-of-lifecareAsubstantialshareofhealthcarespendinggoestowardsEOLcare.Intheearly1990s,about30%ofU.S.Medicareresourceswenttocareforthe5-6%ofbeneficiarieswhodiedeachyear.1

SomeofthisEOLcareiswastefulandevenprolongsthepainofdyingpatients,soeliminatingsuchprocedurescouldsavemoneywhileimprovingclinicalcare.PolicyresponsestopopulationagingTwokeystrategiesforimprovingEOLcare:Promotingandinstitutionalizinghospiceandpalliativecare.Palliativecarecanbedescribedasanapproachthatde-emphasizeslong-shotmedicaltreatmentstocombatadvancingdiseasesandinstead,focusesonprovidingpatientswithcomfortduringtheirfinaldays.MakeprovisionsforpatientstoindicatetheirownpreferencesaboutEOLcare.Thismaybeaccomplishedwithanadvancedirectiveor“l(fā)ivingwill”—abindinglegaldocumentthatindicatesapatient’swishesregardingEOLcare.PolicyresponsestopopulationagingOption3:Introduceincentivestohavek