Caregivers: The backbone of long-term care

Caregivers are often called the backbone of U.S. long-term care (LTC). More than 42 million are providing care for disabled Americans at any given time, and more than 61 million did so within a year’s year. who care for disabled spouses, relatives and friends provide nearly 80 percent of community-based LTC.  The estimated annual value of this unpaid, mostly female workforce: $450 billion in 2009, up from $375 billion in 2007.

The value of that care is almost as much as the 2009 gross domestic product of Belgium, the world’s 20th largest economy.

The typical caregiver is a 49-year-old woman who works and provides about 20 hours a week of unpaid care to a parent. Care-giving duties include emotional support, meal preparation, assistance with dressing and bathing, supervising and administering medication and therapy, and coordinating care with providers.

 Nearly one half of the U.S. workforce has provided some form of elder care in the past five years, and nearly 1 out of 5 are doing so currently.  About half also expects to be a caregiver within the next five years.

Until the mid-1990s, unpaid care-giving was supplemented by paid help. Since then, the trend has been toward caregivers going it alone.

The rise of widespread care-giving is a direct result of longer life expectancies. In 1900, life expectancy was 47 and many died of communicable diseases. The current life expectancy is 78, and is expected to rise to 80 years old in 2020. Most contemporary deaths are from lingering chronic conditions that often disable patients.

The percent of adult children caregivers has tripled since 1994. Of those, about 10 million were 50 or older in 2008. More than 1 out of 4 report either a moderate or significant financial hardship because of caregiving. According to an online survey, more than 4 out of 10 spend more than $5,000 annually on caregiving expenses. A separate survey found that caregivers of those over 50 years old spend more than 10 percent of their annual income on caregiving, or an average of $5,531. An analysis of lifetime income-related losses for caregivers of those over 50 exceed $300,000, including wages, benefits and pension income.

Caregivers pay an even higher price with their health. More than 2 out of 3 family caregivers say caring for a loved one was their No. 1 source of stress, outranking economic difficulties and other family problems. Family caregivers are at greater risk of their own chronic conditions, including heart disease, high blood pressure, depression and fatigue.

The supply of family caregivers is shrinking as life expectancy grows and baby boomers become elderly. Nearly 20 percent of older women do not have children. Moreover, nearly half of women are in the labor force, compared with 33 percent in 1960.

Screen Junior to diagnose the parents

The debate rages on whether all children should be screened for high cholesterol. A government panel with the longest name I think I’ve ever seen – the National Heart, Lung, and Blood Institute Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents – recommends screening children at 9 to 11 years old and again at 17 to 21 years old.

The reason, of course, is the fact that 17 percent of children are obese and many acquire adult-like chronic conditions. Opponents correctly fear an avalanche of screening and lipid-lowering medicine by aggressive, well-meaning physicians. We do not know enough about the side effects of these medications in children, but they certainly are more risky than traditional-but-effective diet and exercise.

Oddly, proponents have a new novel defense. Apparently, children with high cholesterol or high blood pressure have parents with high risk of diabetes and heart disease. A Journal of Pediatrics study found that nearly half of 12-year-olds with unhealthy lipid profiles had parents who ultimately had heart attacks, strokes and procedures to clear arteries over the next 26 years. More than one-third developed diabetes.

Whether it is because of genes or faulty household health habits, cardiovascular disease apparently runs in many families.



The rarity of optimal heart health

According to a new study, people who arrive at middle age without cardiovascular risks nearly make themselves bulletproof for the rest of their lives.

A non-smoking 45-year-old man with normal blood pressure and cholesterol, and no diabetes, has less than a 2 percent chance of having a heart attack or stroke for the rest of his life.

The researchers looked at studies that totaled more than a quarter of a million people. Unfortunately, only 5 percent of the participants had the aforementioned optimal cardiovascular profile.

The study was another piece of evidence of how elusive good health habits are in the U.S.

Four behaviors determine most chronic disease and premature death – cigarette smoking, physical inactivity, excess weight and binge drinking of alcohol. If people made the right decisions about those four, health-care costs would recede as a public-policy ticking time bomb and Americans’ quality of life would soar.

Do not smoke. Eat at least five daily servings of fruits and vegetables. Drink moderately at most. Exercise at least 30 minutes a day. Sounds easy enough. But only 3 percent of Americans do all four.

Those with the American Heart Association ideal cardiovascular profile are even rarer. According to University of Pittsburgh researchers, there are seven factors: body mass index of less than 25; untreated cholesterol under 200; blood pressure below 120/80; fasting blood sugar level below 100; exceeds the government-recommended physical activity guidelines, and follows a heart-healthy diet. Of 1,933 people between the ages of 45 and 75, only one met all seven conditions. Less than 10 percent met five or more of the criteria.

School food bans won’t stop obesity

A recent study in Sociology of Education found there was virtually no difference in the child obesity rate in schools that had banned vending machines selling soda and snacks, compared to those that had not banned them.

Schools are easy to blame for child obesity because (1) children spend so much of their day there, and (2) they are an easy target for grandstanding politicians who want to believe they are doing something about the problem.

This study reinforces other research that indicates school food is not the answer. A 2011 study found that students who do not have access to soda in schools compensate by drinking more at home.

The results of a major National Institutes of Health study targeting 5,106 schoolchildren in 56 schools in four states  were typical. Researchers did all of the things that policymakers say the schools should do: They introduced health education for pupils and their families, increased physical activity and lowered fat content in school lunches and vending machines. The result: no effect on weight.

School interventions generally are negated by whatever happens at home. Why? The parents are overweight, and poor nutrition and genetic tendencies clearly run in the family. If the causes of childhood obesity were easy to isolate, solutions would not be so elusive. However, it is a complex web of genetics, psychology, technology, sedentary lifestyle and diet that conspire to fan the flame. The two major factors are inactivity and an abundance of readily available, calorie-rich food. One-third of children eat fast food on a typical day, and only 8 percent of adolescents achieve recommended 60 minutes of daily physical activity. It is not that complicated.

Breaking deadly health habits

According to a just-released study in the journal Cancer, many lung and colorectal cancer patients continue to smoke even after their diagnoses. Nearly 40 percent of lung patients were smokers when they received their diagnosis and 14 percent were still smoking five months later. The similar statistics for colorectal cancer were 14 percent and 9 percent, respectively.

It is easy to shake a judgmental finger at people who continue destructive health habits after chronic-condition diagnoses. However, it underscores that change is difficult even after life-altering chronic conditions.

At least 40 percent of smokers who survive a heart attack continue to smoke a year later. In a group of more than 1,200 overweight heart-attack survivors, the average weight loss was .2 percent. That is less than a one-pound loss for a 220-pound man.

In another study, 884 of 2,500 heart-attack patients had eaten fast food at least once a week one month before the attack. Nearly all receive dietary advice before leaving the hospital. Three months later, 503 were still eating fast food at least once a week.


Binge nation

The federal government recently released a report on binge drinking, and it is startling. One out of 6 Americans consumes eight alcoholic beverages at a sitting about once a week. The figure comes from a survey of more than 450,000 U.S. adults.

Researchers say that survey respondents typically understate how much they drink.

According to conventional wisdom, young adults are the ones who knock back insane amounts of alcohol. However, more than 1 out of 3 binge drinkers are 35 or older. They also binge-drink more frequently than the younger crowd. Older binge drinkers are more likely to earn more than $50,000 annually.

Moderate drinking has been found to have health benefits. That is defined as two drinks a day for men and one daily drink for women.

Unlike moderate drinking, binge drinking is unequivocally bad. It is a leading preventable cause of death, killing about 79,000 Americans annually and shortening lives by about 30 years.

Heavy drinking raises the risk of liver disease, heart disease, depression, stroke and several types of cancer. But it also leads to injury and accidental death. Alcohol is a factor in about 60 percent of fatal burn injuries, drownings and homicides; 50 percent of trauma injuries and sexual assaults, and 40 percent of fatal motor-vehicle crashes, suicides and fatal falls.

The economic impact of alcohol-impaired driving is estimated at $51 billion, of which about 15 percent represents medical costs. Almost 1 out of 8 binge drinkers drive within two hours of drinking. More than half of those consume the alcohol in a bar, restaurant or club.

Professional sports events are also hotbeds of binge drinking. One out of every 12 fans leaving a game is legally intoxicated. Those who tailgated were 14 times more likely to leave the stadium with an illegal blood-alcohol level of .08 or higher. One out of 4 tailgaters had five or more drinks.

Alcohol is the lubricant of many social occasions. And drinkers are heavily influenced by how much is consumed by those around them. A study of social networks shows that people are 50 percent more likely to drink heavily if someone they are connected to does so. The network’s influence has a ripple effect. If a friend of a friend drinks heavily, the effect is 36 percent. Even a third-degree separation – a friend of a friend of a friend – raises the risk by 15 percent.


Medicare: Attracting the healthy

When insurance companies offer fitness club memberships to their beneficiaries, they attract healthier enrollees.

According to a recent study in the New England Journal of Medicine, more than 35 percent of new enrollees had “excellent” or “very good” health, compared with less than 30 percent of those in the group without the benefit. The study pointed out that the number of health plans that offer gym memberships has risen from four in 2002 to 58 in 2008.

Insurance companies often are accused of “cherry picking” healthy enrollees, often by nefarious means such as excluding applicants with pre-existing conditions or even a less-than-perfect health history. However, it is hard to be worked up about this strategy. It is open to everyone 65 and over, and gym memberships benefit both the company and the individual. It’s a win-win by any definition.

The chronic disease quagmire

The Congressional Budget Office (CBO) issued a disappointing report on the result of 10 Medicare demonstration projects designed to save money on chronic disease management. Chronic diseases account for about 75 percent of U.S. health-care costs. Six demonstrations centered on disease management and care coordination. Four used value-based payment by offering financial incentives to improve quality.

The CBO essentially said fee-for-service incentives to deliver high-volume care – and the lack of incentives for care coordination and system fragmentation – overwhelmed attempts at innovation.

Effective chronic-disease management is labor-intensive. Chronic disease hits hardest those people who are dually eligible for Medicare and Medicaid. These 7 million people have two of the greatest risk factors for ill health: being old and poor. They account for 42 percent of Medicaid costs and 25 percent of Medicare costs. Of the most expensive 1 percent of Medicaid enrollees, 83 percent have three or more chronic conditions, and about 60 percent have five or more. However, government reimbursement rates are inadequate to support disease management. The continually strapped Medicaid programs generally do not invest in these kinds of services unless they can provide immediate cost savings.

Previously, thirteen out of 15 Medicare pilot programs for management of chronic illness failed to reduce hospitalizations, which is a key aim of any such effort. The few successful programs had substantial in-person contact, which is expensive for the health-care provider and is generally not reimbursed well. Politicians become discouraged by so little success. Providers are equally discouraged by the effort’s expense.

Ultimately, solving chronic-disease management is a necessary – but not sufficient – requirement of getting health-care inflation under control.