Last week the AARP Public Policy Institute (PPI) sponsored a Solutions Forum on Capitol Hill (view recording HERE) that put the spotlight on groundbreaking research showing how much social isolation—lack of meaningful contacts with others—costs the Medicare program.
In two separate panels, participants in the packed room heard from experts who discussed the global problem of social isolation—or lack of meaningful contacts with others—among older adults. Susan Reinhard, Senior Vice President at AARP kicked off the event with a compelling video that put a human face on the issue. The video illustrates the negative effects of not interacting with anyone for just one week.
Issue expert Lynda Flowers, Senior Policy Advisor with PPI, highlighted social isolation as the new silent killer—a major risk factor for a host of conditions, including heart disease, high blood pressure, and early onset dementia. Most notably, however, Flowers broke some big news from PPI’s recent study: social isolation costs the Medicare program $6.7 billion in additional spending every year.
AARP Foundation President, Lisa Marsh Ryerson underscored the negative impacts that isolation has on health—likening it to smoking 15 cigarettes a day—and the importance of identifying evidence-based solutions to address the problem. Notably, Ryerson drew attention to Connect2Affect, a multi-stakeholder collaboration with the AARP Foundation. Connect2Affect is a web-based resource that features tools to help people evaluate their risk for isolation, reach out to others who may be feeling lonely and disconnected, and find practical ways to reconnect to the community.
Other important takeaways that stand to change the way we look at and address social isolation:
Global perspective. Lina Walker—Vice President for Health Security at AARP, opened up the second panel by underscoring the global nature of the issue and highlighting the importance of collaborations and shared learning among national and international stakeholders. Janet Morrison, CEO of Independent Age and Chair of the Campaign to End Loneliness in the UK, discussed promising strategies being used in the UK to raise awareness of loneliness among older adults. Janet also highlighted social isolation as it relates to family caregiving.
Saving Medicare dollars. Tricia Neuman, a leading Medicare expert with the Kaiser Family Foundation, discussed the importance of identifying effective interventions. She said that such successes would enable Medicare to improve people’s health while at the same time save billions in Medicare spending.
Screening tool needed. Jonathan Shaw, a co-author of the PPI study from Stanford University and family practitioner at a California community health clinic, called for the development of a screening tool for social isolation that clinicians and lay people can easily use.
Medicare Advantage plan working on the issue. Offering the perspective of a private Medicare plan, Humana representative Sara Stevenson stressed the importance of identifying plan members who are socially isolated. She also revealed that Humana is now in the process of trying to identify solutions to alleviate isolation among its plan members.
An important public health concern. Julianne Holt-Lunstad, a leading researcher in the field from Brigham Young University, pointed out the importance of raising awareness of social isolation as an important public health concern. According to Holt-Lunstad, social isolation meets criteria established by the Centers for Disease Control and Prevention to be considered a public health issue.
AARP Executive Vice President and Chief Public Policy Office, Debra Whitman, closed the event with a strong call to action: get involved and elevate the issue, she urged. Lives depend on it. To be sure, the issue’s visibility got a boost from the event. The Forum was live streaming around the world and the event hashtag #socialisolation was trending #2 in the Washington, D.C. area. All in all, a great success!
View Loneliness Project video and AARP Social Isolation study, infographic, and event recording.
Susan Reinhard is a senior vice president at AARP, directing its Public Policy Institute, the focal point for AARP’s public policy research and analysis. She also serves as the chief strategist for the Center to Champion Nursing in America, a resource center to ensure the nation has the nurses it needs.
Lina Walker is vice president at the AARP Public Policy Institute, working on health care issues.
Now that we’re going full throttle on the goals and leading-edge projects of 2018, I’m excited to share with you a few details concerning some important work that accelerated in 2017 and, as a result, promises to continue to bear fruit this year. AARP Public Policy Institute’s Culture of Health initiative is enabling the dissemination of some of the most innovative and usable ideas to foster good health practices in communities across the country.
As part of our Culture of Health work, we identified a group of community leaders, all over age 50, who are disrupting the health landscapes in their areas with ideas as vast and varied as their personalities. These individuals made it their mission to tackle some of the greatest health-related challenges that communities nationwide are facing, from food deserts, to the lack of access to health care, to the vicious poverty cycle that entraps so many Americans. Yet as deserving of accolades as they are, it is their ideas that demand our attention. That’s where AARP Public Policy Institute comes in—to enable good ideas to spread.
Late in 2017, three of these leaders participated in an AARP Public Policy Institute event at the National Center for Complex Health and Social Needs Conference, where they discussed their innovative programs with peers from other communities around the country. Dubbed a “Beehive” for its informal, interactive nature, the event allowed for a “cross-pollination” of ideas through participant dialogue and Q&A.
Among our Culture of Health leaders discussing their projects was Paul Leon. Struck by the magnitude of the homeless problem in Orange County, California after a friend took him to visit a shelter, Leon got the idea to turn rundown, near-forgotten motels into clean, hospitable recovery facilities for homeless people recently discharged from hospitals. With that concept, Paul started the Illumination Foundation, and the initiative has proven so successful, he’s now busy sharing his knowledge with other communities around the country.
Those who attended the conference also heard from Liz OuYang, a Chinese-American who, after battling breast cancer, created a website, www.plumblossoms.me, for other Asian American women experiencing the trials of the disease. Finally, participants listened intently as Gloria McNeal, dean of the School of Health and Human Services at Los Angeles’s National University, explained how she established nurse-managed clinics at local churches, community centers, and the Salvation Army after seeing that local residents weren’t taking advantage of vans that offered medical services because the van-based approach lacked a direct connection to the community.
You can learn more about the Culture of Health initiative and all the individuals and programs we’ve identified by going here. In the year ahead, I look forward to working with our Culture of Health community leaders to continue broadening the reach of their innovative ideas. We look forward to seeing their work inspire others across the country to follow their lead and strengthen the Culture of Health in their own communities.
Is there a disruptor who’s transforming the Culture of Health for the better where you live? If so, I’d love to know more about what that person’s doing.
The fight against the financial exploitation of older Americans is about to get a whole lot easier.
The 50+ are prime targets of financial exploitation because they own 67 percent of U.S. bank deposits – and because factors including health status, cognitive ability, and social isolation can make them more vulnerable. Beginning February 5, the Financial Industry Regulatory Authority (FINRA) will enact a pair of rules that will provide brokers with additional tools to protect their older clients and help stop financial exploitation.
The first rule tackles the threat by helping to ensure more older Americans have a trusted third-party who can be notified if problems arise or suspicious activities are observed with their financial accounts. Rule 4512 will require brokers to ask clients to designate a trusted contact the broker can contact in case of any problems, including financial exploitation. This designee will not be able to access any private information about the account, but the broker can alert the designee if something is potentially wrong. Clients will not be required to provide a trusted contact; under the rule, brokers are just required to ask.
The other rule slated to take effect, meanwhile, captures the benefits of brokers’ unique vantage point to spot dubious activity; the rule will allow brokers to delay payments from an account if something seems amiss. Specifically, Rule 2165, a “safe harbor rule,” gives a broker who suspects exploitation the ability to put a 15-day hold on any payments while the firm investigates. This hold can be extended another 10 days if necessary. Strengthening the ability to stop exploitation before it happens is crucial, particularly because it is nearly impossible to recover money once it leaves the account.
“These rules will provide firms with tools to respond more quickly and effectively to protect seniors from financial exploitation,” FINRA President and CEO Robert W. Cook said in a news release. “This project included input and support from both investor groups and industry representatives and it demonstrates a shared commitment to an important, common goal – protecting senior investors.”
The changes are built on the foundation of principles also central to BankSafe, AARP’s initiative to stop financial exploitation—that is, providing a trusted contact and enacting safe harbor rules. As such, they will better meet customers’ financial needs and safeguard their assets. This seemingly small step by FINRA to protect older Americans will make a huge dent in the fight.
According to the Bureau of Labor Statistics (BLS) January Employment Situation Summary, the unemployment rate for persons 55 and older decreased from 3.3 percent in December to 3.0 percent in January. The number of unemployed persons ages 55+ also decreased to 1.1 million, down from 1.2 million in December. The percentage of 55+ jobseekers considered long-term unemployed (those job searching for 27 weeks or more) declined from 30.6 percent in December to 24.8 percent in January. Overall the economy added 200,000 jobs in the first month of 2018, representing an increase from the 160,000 jobs (revised up from 148,000) added in December 2017. The overall unemployment rate (4.1 percent) and labor force participation rate (62.7 percent) both remained unchanged from December.
Spotlight on Occupations of the 65+
An analysis of government data on occupational distributions by age found the share of workers ages 65+ decreased in occupations with middle-range wages and salaries compared with workers ages 45 to 65. However, they increased for those ages 65+ compared with the 45 to 65 age group in occupations with both relatively high or relatively low wages and salaries.
Why might workers ages 65 and older represent a comparatively larger share of both high and low wage occupations? Possible reasons involve working conditions, finances, education, and skills. These factors could influence the share of workers ages 65+ in high and low wage occupations in different ways.
Occupations requiring low levels of education typically pay lower wages. Individuals in these occupations are more likely to be driven by financial necessity to work past traditional retirement age. Their lower incomes make it more difficult to save for retirement and they often do not have access to employer-provided retirement plans. The research found that the occupation with the greatest difference (both absolute and relative) in the share of workers from the two age groups was the food preparation and serving related group. These occupations are usually low paying, are often part-time and, in the 65+ age group, employ mostly women, who are less likely to have adequate retirement savings compared with men.
Higher-wage occupations, meanwhile, often require higher levels of education. Those occupations are in turn associated with longer career lifespans due to better opportunities and working conditions. Other occupational research has found that opportunities for older workers improved significantly between the late 1990s and the early part of this decade, however gains mainly went to better-educated older workers. The greater prospects for the highly educated to work beyond traditional retirement age, as well as higher wages and good working conditions that act as incentives to stay on the job, may be driving the increase in the share of workers ages 65+ in high wage occupation groups.
More details on the latest employment data are found in the January Employment Data Digest, PPI’s monthly review of job trends for those ages 55 and over.
Jen Schramm is a senior strategic policy advisor at the AARP Public Policy Institute. As part of the Financial Security Team, she identifies policy challenges and opportunities related to workers age 50 and above. Through research and analyses of emerging employment trends, she develops policy options to inform AARP’s strategy on work and jobs, including helping older workers find and retain jobs.
While hundreds of “low-value” medical services are driving up health care costs, eliminating these services altogether could hurt some patients by denying them access to potentially appropriate care.
Procedures such as prostate cancer screening for men over 75, MRIs for low back pain, X-rays prior to low-risk surgeries are examples of services paid for by consumers and insurance companies that may be unnecessary, or worse, harmful. As a result, many providers and policymakers want to eliminate low-value medical care.1 However, because low-value services are not the same as no-value services (e.g., prescribing antibiotics for a viral infection), some patients may still benefit from these services.
AARP Public Policy Institute researchers contend that efforts to reduce unnecessary care must ensure appropriate care is not withheld from patients.
What Are Low-Value Services?
Low-value services are medical tests or procedures with little clinical benefit for which the potential for patient harm exceeds possible health benefits.3 The American Board of Internal Medicine Foundation created the Choosing Wisely campaign to catalog potentially unnecessary medical services and promote conversations between patients and providers about these services.4
Researchers in the AARP Public Policy Institute wanted to know if the use of certain low-value services declined among adults 50 years old and older between 2009 and 2014, which straddles the launch of the Choosing Wisely campaign. Nine of the 16 services were included on Choosing Wisely.
We analyzed administrative claims data from the OptumLabs® Data Warehouse, a comprehensive, longitudinal, real-world data asset with de-identified lives across claims and clinical information.
Our results showed rates of low-value service use dropped among older adults for all but one of the services studied.2 However, our study cannot distinguish between cases of wasteful and appropriate service use. Because of this, our research prompted several questions:
For which patients does the benefit of a service outweigh the potential harm? While a particular service may be considered low-value to most patients, the same service may be a good option for certain patients.
Why are some low-value services not included on Choosing Wisely list that are also low-value? Over our six-year study period, the use of renal artery stenting dropped by approximately 75%. A 2009 study showing that renal artery stenting did not provide worthwhile clinical benefit over medical therapy could have led to this decrease.3 Is renal artery stenting another low-value candidate?
What is an acceptable utilization rate for each service? While clinicians can probably agree that imaging for every patient presenting with a headache is unnecessary and wasteful, are the head imaging rates of 19-29% in our study on target? Too high? Too low?
A Complex Issue Needs Nuanced Solutions
Health care services of little potential value are widely overused. At the same time, these services may be crucial for some patients. Moving forward, before efforts are made to eliminate low-value services from the health care system it will be necessary to 1) distinguish between low-value and no-value medical care and 2) identify patient groups for whom the benefits of low-value services may outweigh the harms.
In the meantime, Choosing Wisely recommends patients ask their provider these 5 questions before undergoing any test or procedure.
- Multi-Stakeholder Task Force Identifies “Top Five” Low-Value Services For Purchaser Action [press release]. V-BID Health2017.
- Carter EA, Morin PE, Lind KD. Costs and Trends in Utilization of Low-value Services Among Older Adults With Commercial Insurance or Medicare Advantage. Med Care. 2017;55(11):931-939.
- Wheatley K, Ives N, Gray R, et al. Revascularization versus medical therapy for renal-artery stenosis. N Engl J Med. 2009;361(20):1953-1962.
Elizabeth Carter is a senior health services research advisor at the AARP Public Policy Institute. Her research focuses on health and policy issues affecting older adults, from the prevention and treatment of chronic diseases and their complications, to health care quality and cost.
The Medicare program requires higher-income individuals to contribute more toward the cost of the program than the general population. When enrolled in Medicare, people with incomes of $85,000 (or $170,000 for couples) pay higher premiums for Medicare Part B (doctors’, other health care professionals’, and outpatient services) and Part D (prescription drugs) coverage, including if they have a Medicare Advantage plan. Over time, the proportion of people with Medicare who pay higher premiums for Medicare Part B and Part D has grown significantly.
Unfortunately, Congress is once again asking Medicare beneficiaries to pay even more, as a way to offset congressional spending on non-Medicare programs. Raising premiums on higher-income seniors, often referred to as “income-related premiums”, is bad policy. Shifting more costs onto this group of older Americans ignores how much they’ve already contributed to Medicare throughout their working lives, as well as how much they continue to contribute to Medicare through additional taxes. Furthermore, this change could drive these beneficiaries – who help contribute to the overall health of Medicare – out of the Medicare program. Congress already raised income-related premiums in 2015, and that increase will be taking effect in 2018. Asking Medicare beneficiaries to pay for non-Medicare benefit changes again will make it even harder to finance improvements and address long-term challenges in the Medicare program.
The Medicare program is already heavily income related. Currently, approximately 7 percent of beneficiaries are subject to the higher-income premiums for Part B, and approximately 6 percent of beneficiaries are subject to the higher income premiums for Part D. The higher income premium rises with income, with the highest premium – over 3 times the premium for the typical retiree – beginning at $160,000 (single) and $320,000 (couple) in 2018. While a typical senior will pay over $2,000 annually in premiums for Part B and D coverage, a high-income senior can be expected to pay over 3 times that amount – more than $6,400 annually. The income-related premium, in essence, is a premium tax on higher income seniors.
Second, higher income beneficiaries have already paid more into the system in the form of higher payroll taxes – unlike Social Security, all wage income is subject to the Medicare payroll tax without a cap. A 1.45% payroll tax is levied on both employers and employees; thus, 2.9% of total wages goes to Medicare. A typical worker earning $50,000 contributes (both employer and employee share) about $1,450 a year (2.9%). A person earning $85,000 – the threshold for income-related premiums – contributes $2,465 per year. While someone at $214,000 – the top threshold for income related premiums – contributes $6,206. In addition, for those earning wages above $200,000 (single) and $250,000 (couple), an additional 0.9% tax applies on amounts above those thresholds that goes to Medicare.
Given higher payroll taxes and current income-related premiums, we should not further single out higher income beneficiaries for higher premium payments. Shifting more and more costs onto higher-income beneficiaries could cause them to leave the Medicare program. If the beneficiaries in the highest income groups are asked to pay an even greater share of their Medicare premium, they could decide not to enroll in Medicare and seek alternative sources of insurance. This would worsen the Medicare risk pool, leaving more costly beneficiaries in the Medicare program, raising costs for everyone else.
Third, higher income seniors also pay higher taxes on their Social Security benefits for Medicare. For seniors with incomes above $34,000 (single) and $44,000 (couple), an additional 35% of Social Security benefits are subject to the income tax, with the revenue dedicated to Medicare. A typical Social Security benefit of $16,320 – with 35% of it taxed at the 28% rate – would pay another $1,600 per year into Medicare.
Finally, income-relating in the Medicare program hurts new Medicare enrollees. When determining who is subject to the income-related premium, the Medicare program relies on the beneficiary’s tax return from the prior year (which reports income made from the year before) – which means income data are at least 2 years old. Thus, new retirees (whose income may have dropped precipitously from their working years) are subject to higher income-related premiums based on their previous wages, not their current financial situation.
Additional income-relating of premiums is the wrong solution for addressing Medicare’s long-term financial challenges, and asking Medicare beneficiaries to fund non-Medicare changes will only make it more difficult to address Medicare’s own financial issues. Any contribution from Medicare beneficiaries should be used to strengthen and improve the Medicare program.