Is the ageing population is accounting for escalating health costs

Apols if the pretty this haven’t come out on the site. Email me and I can send them to you

Is the ageing population is accounting for escalating health costs 

In short – partially at v v v best
I got asked the question on the extent to which I believe “the ageing population is accounting for escalating health costs”.

It’s a q Id been asked a few times over the years.

 

This is something like my stock response

 

In a nutshell (to save you the both of reading)…… its a lot more complex than just “the ageing population)…. Sorry Daily Fail readers…….

 

This blog orientates you on some of the issues

 

 

1)

Some myth busters

 

a)

This is a bit partisan

http://www.nhsbill2015.org/wp-content/uploads/2015/03/Myth-of-Ageing-fact-sheet.pdf

 

b)

This is better

http://www.lse.ac.uk/LSEHealthAndSocialCare/pdf/eurohealth/VOL17No1/Mythbusters.pdf

Basically not age per se, but proximity to death

Get age specific morbidity costs under control

 

c)

http://www.euro.who.int/__data/assets/pdf_file/0006/98277/E91885.pdf

Social, work and leisure 

ie take a broader view than just health services

 

 

d) 

From QLD 

more of the same

https://www.qld.gov.au/seniors/documents/retirement/ageing-myth-reality.rtf

 
 
e)

Spikjer and MacInness

By far the best

Population ageing: the timebomb that isn’t?

http://www.bmj.com/content/347/bmj.f6598

 

key points – direct lift

· The extent, speed, and effect of population ageing have been exaggerated because the standard indicator—the old age dependency ratio—does not take account of falling mortality
· When measured using remaining life expectancy, old age dependency turns out to have fallen substantially in the UK and elsewhere over recent decades and is likely to stabilise in the UK close to its current level
· The capacity of healthcare systems to cope with increasing longevity will depend on the changing relationship between morbidity and remaining life expectancy and, in particular, the effect of education
 

 

f)

Also Appleby

Population projections: why they are often wrong

BMJ2014;349:g5184

 

A more recent cautionary tale re population projections commonly being wrong

Pop projections always come with thousands of caveats and small print. 

 

When I write caveats everyone’s eyes glaze over. Hopefully cos John has written them more folk will take note!

 

Predicting the size of future populations is important for healthcare.

Too bad our best guesses are often wrong

 

 

2)

The Kirkwood Newcastle study

Can’t find the key ref off hand but this newspaper article sums up quite well

http://www.theguardian.com/society/2012/may/29/tom-kirkwood-research-dispels-myths-ageing

Many quite well. Less poorly than commentators have us believe etc

 

 

3)

The age vs morbidity issue – the dealbreaker.

 

a)

Fig 2 of the Barnett multi morbidity study sums up the point re age vs morbidity quite well.

http://www.ncbi.nlm.nih.gov/pubmed/22579043
 

 

 

Obviously this week has seen the publication of a more cautionary tale on the epidemiology of multi morbidity that doesn’t tow the conventional wisdom….. I would encourage you to read it carefully….

 

The chronic disease explosion: artificial bang or empirical whimper

http://www.bmj.com/content/352/bmj.i1312

 

 

b)

As does table 2 of the appendix of the commonwealth fund study – look at age vs high need comparisons.

 

How High-Need Patients Experience the Health Care System in Nine Countries

http://www.commonwealthfund.org/publications/issue-briefs/2016/jan/high-need-patients-nine-countries
 

 

c)

Prof Boomla wrote a mini classic letter in BMJ highlighting the 33% difference in age specific consultation rates most and least affluent quintiles – another indicator of the age vs morbidity (here with consultation rate as – an arguably highly imperfect – proxy for morbidity)

 

GP funding formula masks major inequalities for practices in deprived areas

http://www.bmj.com/content/349/bmj.g7648
 

 

 

………So the key point is that it’s morbidity not age per se that is the marker for health care use. Age is not a great proxy for morbidity.

 

 

d)       

The ONS data

The ONS healthy life expectancy and disability data also indicate this – mostly using deprivation as the covariate to do the comparisons between populations. 

 
 

 

Economists have long held that it isn’t an ageing population per se that “causes” increased costs but proximity to death – whether at 90 or at 60…. It’s the last xxxxx months before death where the cost is incurred.

 

And with overall improving treatment outcomes and improving life expectancy overall the contention that “the ageing population will bankrupt the system” is arguably a little flaky.

 

This issue is further compounded by changing clinical and lifestyle risk profiles, changing disease profiles, better treatments, better outcomes of treatment

 

 

 

That distinction matters for all sort sorts of reasons:

Allocation of resources on basis of morbidity vs age

Leaves with impression that ‘we’re doomed there’s nothing that can be done about ageing process’

Maybe wrong sort of service response 

4)

Other issues 

And lastly long term broader social changes further compound it. Reduction of nuclear family, slow decline of community or social capital etc…(the implication being that “in the old days we could rely on neighbours to look out for our old folk, or close living family members”)…..

 

 I keep hearing interesting things from epi experts about incident rates of diabetes and dementia beginning to fall. I’m not getting overly excited yet….but these things may make a difference.

 

And that’s before we even get into changes in services, new treatments, better use of existing treatments that we currently under implement etc

 

There’s also something about how we handle broader social issues – formal and informal care, meaningful activity, other stuff that may offset the issues associated with age per se.

Look at Japan for eg – one of oldest societies in world, still with functional system 

So looking from a much broader societal perspective there’s a good deal still to play for 

 

Obviously it’s a numbers game

The basic age structure of the population isn’t changing terribly fast, the number of older people is going up.

Our pop profile & projections is that the the absolute number of people aged >65 is increasing, but the overall age structure is not changing that quickly…..certainly not as quick as many putting forward the doom scenario would have us believe.

 

My take = the three key drivers of health care cost growth are (not necessarily in order, apart from the first) population growth, deprivation (proxy for lifestyles then morbidity), age profile change (which following above I think is a proxy for no of people with a closeness to death)

 

 

Don’t get me wrong  

 

I’m saying that population ageing isn’t an issue to take seriously, but I do think it’s far more complex and nuanced than ‘ageing will cripple the system’

 

In a nutshell – (AND SORRY TO SHOUT)…..ITS NOT THE AGEING POPULATION IT IS MORBIDITY THAT IS CAUSING THE RISE.

 

ALSO BACK TO EARLIER BLOGS – YOU’VE ALSO GOT TO GET INTO THE COMPLEX ISSUES OF COST PER CASE (SOMETIME AGE SPECIFIC VERSUS NUMBER OF CASES)…

This is tricky territory, for a number of reasons….but its more complex than the Daily Fail headline would have you believe.

 

 Postscript 
Those clever people at York Centre for Health Economics also considered a linked topic
Medical Spending and Hospital Inpatient Care in England: An Analysis over Time

http://www.york.ac.uk/media/che/documents/papers/researchpapers/CHERP127_medical_spending_hospital_inpatient_England.pdf
Key points

Total NHS expenditure, which has risen in real terms by an average of 3.7% per annum since the inception of the NHS in 1948, constituted 7.9% of GDP in 2012. 
The analysis considers trends in medical expenditure and growth over 15 years of expenditure and activity in hospital inpatient health care.
NB – hospital care = 25% of total spend. caveats re whether this sector is representative of trends overall. 
Analysis consider the coincidence of observed trends in expenditure with reported activity, morbidity and the proximity of individuals to death. 
Findings – 

1)

expenditure for both elective and emergency inpatient care broadly follows activity so expenditure is mostly driven by activity rather than unit costs 

ie – it’s activity growth (ie more treatment episodes – not necessarily individuals being treated – and not cost per case) that’s growing

Whether activity growth is good proxy for true morbidity is debatable
2)

expenditure is concentrated in individuals with multiple diseases so that the prevalence and identification of complex medical conditions are important drivers of expenditure

ie – see above point re individuals v episodes

Also see ref above re cautionary tale re epidemiology of multi morbidity.
3)

Critically – 

health care activity rises substantially for individuals in the period before death so that expenditure is driven substantially by mortality in the population. 

The clever modeloids and boffins at CHE conclude these findings indicate that this element of health care expenditure in England has been substantially driven by the underlying morbidity and age of the population in conjunction with improving health care technology. 

One of my team (who is also astoundingly clever) said to cut to the chase “If you have a chance to look at anything in this report have a look at figures 13 to 16 from p20 on, re lifetime inpatient costs and in final year of life.”

So back to the earlier point – Not age per se but proximity to death that’s the real cost
And then the clincher from John – “the older the age of death then the lower is the cost in the final year of life and the cumulative lifetime costs

A hidden benefit of prevention”

More prevention please……..

As @muirgray says most problems caused by lost fitness, preventable disease & attitude

#sod70
Or 50?

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