Demographic Tsunami, or Apocalypse No?

Transcription

1 Demographic Tsunami, or Apocalypse No? Canada s demographic future projecting health and health care costs small area variations in health care implications for the fisc Michael Wolfson, uottawa (please use normal view or notes page to see speaking text) 1

2 Age 60+ Demographic Ratios for Selected Countries 2009 and 2050 Turkey Mexico Brazil Argentina Republic of Korea Russian Federation United States Poland Australia Canada Netherlands Hungary Spain United Kingdom France Belgium Sweden Germany Italy Japan

3 Age 80+ Demographic Ratios (%) for Selected Countries 2009 and 2050 Turkey Mexico Brazil Republic of Korea Argentina Russian Federation Poland Hungary United States Canada Australia a Netherlands United Kingdom Spain Belgium Germany France Sweden Italy Japan

4 Alternate Views of the Aging Burden (LifePaths estimates) Demographic Ratios Old Age Ratio 0.25 Total Ratio Boomerangst 2021 Vancouver 2031 Feb 2011

5 Alternate Views of the Aging Burden (LifePaths estimates) Demographic Ratios Old Age Ratio 0.25 Total Ratio Boomerangst 2021 Vancouver 2031 Feb 2011

6 Working Life Table Results, Canada average age at number of entry to retirement labour retire- working Year force ment death years years

7 Alternate Views of the Aging Burden (LifePaths estimates) Demographic Ratios Annual Paid Hours of Work / Person Female Male All 0.30 Old Age Ratio Total Ratio Boomerangst 2021 Vancouver 2031 Feb

8 Trends in Annual Paid Hours per Worker (1990 to 2002, OECD) 8

9 National Labour Supply Per Capita (~2000) Annual Hours, Emp / Pop Annual Hours Per Country Employed Ratio (%) Capita Italy 1, Belgium 1, France 1, Germany 1, Netherlands 1, Spain 1, Sweden 1, United Kingdom 1, Canada 1, United States 1,

10 0.50 Alternate Views of the Aging Burden (LifePaths estimates) Demographic Ratios Annual Paid Hours of Work / Person Female Male All 0.30 Old Age Ratio Total Ratio Boomerangst 2021 Vancouver 2031 Feb

11 Demo Doom: Really? 11 Canada s old age demographic ratio is projected to approach < 25% by 2031, when the trailing edge of the baby boom cohort reaches age 65 but a number of rich EU countries already have old age demographic ratios ~25% and using a more relevant measure, paid hours per capita, Canada s level is projected to fall by less than 10% and will remain about 30% higher than a number of wealthy EU countries that today already have 25% old age demographic ratios

12 Simulated Disability-Institutional Status by Age: 2001 Male Female Projected Canadian Disability Prevalences from 2001 to 2021 based on Statistics Canada s LifePaths 0 model, and disability dynamics estimated from the NPHS 1994 to , , , , , ,000 Simulated Disability-Institutional Status by Age: 2021 Male Female 90 about 800,000 more 80 moderately or severely 70 disabled or 60 institutionalized age in 2021 vs , , , ,000 Boomerangst Vancouver 200,000 Feb ,000

13 (PBO FST p16) PBO Data on Health Care Costs 13

14 (PBO FST p16) PBO Data on Health Care Costs Aging 14

15 (PBO FST p16) PBO Data on Health Care Costs population and health care enrichment will put significant pressure on health spending (PBO FST p20) 15

16 Public Expenditures on Health Care, Constant 1997 $, , CIHI 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2, <

17 EC Health Care Cost Projections (2009 Aging Report, p28) projected increase in health care spending is driven mostly by the change in the demographic structure of the population the "pure demographic scenario" projects an average increase of 1.7% of GDP health status, rather than age, is the predominant causal factor behind health care spending. Under more optimistic assumptions about the health status evolution demographic pressure on health care expenditure could be reduced by over a half, to only 0.7% of GDP past trends in health care expenditure suggests that technological developments are responsible for a significant part of overall costs growth, which is not captured in the projection. effective management of technology seems to be of utmost importance; otherwise the expenditure savings resulting from lower unit costs could easily be outstripped by the costs of meeting additional demand for new and better treatments 17

18 Health Care Expenditure population aging will generate increasing costs but these increases are small compared to the cost changes arising i from other, nonaging, factors do we understand d these other factors??? health care expenditures ought to buy improved health status what evidence is there? crucial concept health outcomes 18

19 Definition - Health Outcome health intervention health status before health status after other factors 19 health outcome change in health status attributable to a health intervention (for an individual)

20 Health Outcomes and Quality are Old Ideas -- E. A. Codman and W.E. Deming Codman: early 1900s Boston surgeon famous for End Results Cards to keep track of surgical patients and follow them up one year later to observe outcomes systematically learn from experience 110 years later: not yet widely implemented in health h care Deming: post WW II concern with product quality in manufacturing father of field of statistical process quality control 60 years later: not yet widely implemented in health care 20

21 21 Codman s End Results "merely the common-sense notion that every hospital should follow every patient it treats, long enough to determine whether or not the treatment has been successful, and then to inquire 'if not, why not?' with a view to preventing a similar failure in the future." based on an "end result card" on which were to be entered "in the briefest possible terms," the symptoms, the diagnosis that governed the treatment, the treatment plan, the complications that occurred in the hospital, the diagnosis at discharge, and "the result each year afterward, until a definitive determination of the results could be made. (quoted in Donabedian, Millbank, 1989)

22 Berwick on Codman (1989) the average health care provider of today goes on as if Codman never lived. Ask a doctor about outcome measures; search a hospital for its end results recording system; study a nursing home for its continual improvement of process based on systematically acquired data from patients. Nearly a century after Codman began, none will be found. Why not? Codman met in his time the resistance of arrogance, the molasses of complacency, the anger of the comfortable disturbed. (Millbank, 1989) 22

23 Wall of Ignorance 23

24 Platitudes? You can t manage what you can t measure You get what you measure (and you re unlikely to get what you don t measure) Don t ask how many (health care) events per pound; ask how much health per pound. D. Berwick, BMJ

25 Medicare Spending by Hospital Referral Region (HRR, quintiles of end of life expenditure index ) (fisher 1) Fisher et al.,

26 Characteristics of US HRRs by Quintile 26

27 (fisher 3) Fisher et al. Medicare Analysis (cont d) Do the regions that spend more get better outcomes? NO! Q1 to Q5: quintiles (fifths) of hospital referral regions with increasing levels of an index of Medicare spending (based on end of life expenditures) Cohorts: subsets of the Medicare population with selected conditions (MCBS = Medicare Beneficiary Survey) Conclusion: if anything, more spending increases mortality 27

28 OECD 2010 Health Care Expenditure Per Capita versus Life Expectancy Joumard, I., C. André and C. Nicq (2010), Health Care Systems: Efficiency and Institutions, OECD Economics Department Working Papers, No. 769, OECD Publishing. doi: /5kmfp51f5f9t-en 28

29 OECD 2010 Health Care Expenditure Per Capita versus Life Expectancy Joumard, I., C. André and C. Nicq (2010), Health Care Systems: Efficiency and Institutions, OECD Economics Department Working Papers, No. 769, OECD Publishing. doi: /5kmfp51f5f9t-en 29

30 It can t happen here (Frank Zappa, Mothers of Invention) but what about data for Canada? 30

31 Charles Wright on Vancouver Cataracts pre- and post-surgery patient self-completed questionnaires 31% of patients booked for cataract surgery report a visual function score of 91 points or more on a scale of 100. These data tend to confirm the observation that cataract surgery is now occurring in many patients with minor degrees of self-reported visual disability. The overall results are positive, but 27% of patients show either no change or deterioration of VFA (Visual Function Assessment) score after the operation. 31

32 Variation in Hospitalization Rates Across Health Regions with and without Adjustments (visits per 1,000) Crude (Unadjusted) Rate (2.3 fold) Health Regions Statistics Canada Statistique Canada 24/09/2008

33 Variation in Hospitalization Rates Across Health Regions with and without Adjustments (visits per 1,000) Crude (Unadjusted) Rate (2.3 fold) Adjusted dfor Age and ds Sex (2.2 (22fold) Health Regions Statistics Canada Statistique Canada 24/09/2008

34 Variation in Hospitalization Rates Across Health Regions with and without Adjustments 200 (visits per 1,000) Crude (Unadjusted) Rate (2.3 fold) Adjusted for Age and Sex (2.2 fold) Also Adjusted for Illness, Health Care Use, Risk Factors (2.0) Health Regions Statistics Canada Statistique Canada 24/09/2008

35 Variation in Hospitalization Rates Across Health Regions with and without Adjustments 200 (visits per 1,000) Crude (Unadjusted) d)rate (2.3 (23fold) Adjusted for Age and Sex (2.2 fold) Also Adjusted for Illness, Health Care Use, Risk Factors (2.0) Also Adjusted for SES Factors (1.7 fold) Health Regions Statistics Canada Statistique Canada 24/09/2008

36 Underlying Patient Trajectory Information for Heart Attack / Revascularization Analysis observation period follow-up period (excluded) Heart Attack (AMI) Treatment t (revascularization = bypass or angioplasty) Death time 36

37 Heart Attack Survival in Relation to Treatment by Health Region, Seven Provinces Johansen et al., 2009

38 Heart Attack Survival in Relation to Treatment by Health Region, Seven Provinces Johansen et al., 2009

39 Important Caveats for the AMI Revascularization Mortality Results 39 other clinical aspects of treatment not taken into account, e.g. thrombolysis, post discharge Rx no risk factors considered e.g. obesity, physical fitness, smoking, hypertension, lipids no socio-economic factors considered n.b. in related analysis, co-morbidity (Charlson Index) was included, with one-year (versus 30 day) mortality follow-up results essentially unchanged revascularization is also intended to relieve symptoms, but no health-related l t quality of life data available 24/09/2008

40 Technical Progress Generally Increases Productivity 40

41 What is IBM Really After With Watson? 41

42 Hmmm, Will Doctors be Next? 42

43 Concluding Comments population aging is relatively small as a factor likely to account for future increases in health care expenditures in Canada Canada s health care system is not being managed based on analysis of which expenditures generate the greatest health benefits the cost of inappropriate i care and inefficiency i in health care is possibly larger than the total impact of population aging over coming decades 43