APPENDIX

PREPARED STATEMENT OF SENATOR JAMES TALENT

Thank you, Mr. Chairman, for convening this important hearing to examine the role of prevention in the Medicare program.

I cannot over emphasize the importance of disease management services to help seniors live longer, more productive lives with the additional benefit of saving Medicare dollars. I have traveled all around my home state of Missouri visiting with seniors on Medicare, and discussing the beneficial disease management provisions in the Medicare Modernization Act, which I supported.

Nearly half of all Americans live with chronic illnesses such as hypertension, asthma, diabetes, and heart disease. Approximately 78 percent of Medicare beneficiaries have at least one chronic disease, while 32 percent have four or more chronic conditions. Individuals with multiple chronic conditions are more likely to be hospitalized, fill more prescriptions, and have more physician and home health visits. Nearly two-thirds of all Medicare spending is for beneficiaries with five or more chronic conditions.

We know that approximately five percent of the costliest Medicare beneficiaries consume about half of total Medicare spending. That is why I advocated for Senate provisions in the Medicare Modernization Act to create demonstration projects to examine disease management and care coordination for our nation's seniors and the disabled. I continue to support this legislation, and look forward to next year when the full Medicare benefit goes into effect as I believe it will help millions of seniors in Missouri and across our country lead healthier lives.

QUESTIONS FROM SENATOR BLANCHE LINCOLN FOR MR. EVANS

Question. Do adequate performance measures exist that cross multiple aspects of disease, such as function?

Answer. Yes, functional capacity in elderly people is a very powerful predictor of mortality, morbidity, and risk of admission to a nursing home. Dr. Jack Guralnik at the National Institute on Aging has developed what he terms the short physical performance battery (SPPB) (3) that is easy to perform, even in a doctors office and should be used by physicians in examining their geriatric patients. The test consists of a 6-meter walk time, chair stand time (how long it takes to stand up from a seated position) and a balance test. Guralnik and his co-workers (2) have demonstrated that among nondisabled older people living in the community, objective measures of lower-extremity function were highly predictive of subsequent disability. Disability among elderly people is associated with increased hospitalization and a greatly increased cost to Medicare. These studies reveal that early identification of functional problems and treatment has the potential of preventing disability. The SPPB should be a standard component of a geriatric assessment.

Question. How would one identify those who might benefit most from nutrition and exercise interventions in terms of health and cost-savings, such as certain frail elderly persons? And should we target these interventions to those with multiple chronic illnesses (including diabetes and chronic Heart Failure) to obtain the “biggest Bang for the buck" in our "high cost" Medicare beneficiaries? This secondary prevention approach might be easier and cheaper to implement in a smaller group of chronically ill seniors. If so, do you think legislation allowing for a new Medicare care coordination benefit, such as the Geriatric and Chronic Care Management Act I have introduced, achieves this goal?

Answer. It is clear that there are a number of geriatric problems that may be identified before they develop into serious of life-threatening issues. There is only one way of identifying the potential problems in a comprehensive way and that with a geriatric assessment. In this way correctible nutritional problems, functional limitations, infections, over prescription of medication, and other problems may be iden

tified and treated. For example, one of the untreated diseases that occurs in elderly people in epidemic levels is chronic renal failure that, if left untreated, will progress to kidney death and dialysis. Use of certain medications and nutritional interventions can prevent kidney death and the extremely high cost and decreased quality of life of dialysis. Early identification and treatment of loss of appetite, eating or swallowing problems, or involuntary weight loss can have a powerful effect on improving life expectancy and quality of life. However, left untreated, these issues can have a devastating effect on the lives of elderly people. Muscle weakness and poor balance must be identified and treated before it leads to a devastating fall or loss of independence. All of these issues (and many more) would be considered secondary treatment. This treatment, even in those with multiple chronic diseases, can have a powerful effect on decreasing the cost of treatment and improving quality of life. The Geriatric and Chronic Care Management Act will go a long way towards implementing a comprehensive geriatric assessment that will be critical in the identification of treatable problems and the prevention of late-life disability. Ferucci et al (1) found that in the year when they become severely disabled, a large proportion of older persons are hospitalized for a small group of diseases. They concluded that hospital-based interventions aimed at reducing the severity and functional consequences of these diseases could have a large impact on reduction on severe disability. Thus the potential for large savings in Medicare expenses may be seen in the most "at risk” population of older people.

Question. On symptom or consequence of sarcopenia is osteoporosis and increased falls, especially in women. Recent clinical trials have shown improved quality and decreased costs from greater falls assessment and treatment in frail elderly populations, including increase in activities as you have highlighted in your testimony. However, Medicare coverage of falls assessment and treatment is minimal. Perhaps changes to Medicare, such as the enactment of my legislation the Geriatric and Chronic Care Management Act, a Medicare care coordination benefit, could allow for better coverage of services such as these. What do you think?

Answer. Clearly the early identification of those at greatest risk of falling and of developing osteoporosis is critical in preventing a devastating bone fracture. Part of a comprehensive geriatric assessment should be measure of functional status and bone density. These two simple and inexpensive assessment tools can be used to begin a treatment plan that is appropriate for the elderly person. For those “at risk” individuals, change in diet to emphasize increased calcium and vitamin D intake as well as a structured exercise program can mitigate this risk. For those identified with osteoporosis, a more aggressive treatment including a new generation of drugs to treat low bone density along with diet and exercise can prevent a bone fracture. We know that one of the most important nutritional factors that increases muscle weakness and accelerates loss of bone is vitamin D deficiency, a problem that is found in far to many elderly people (5) due to inadequate time in the sun (sunlight is used to make vitamin D by the skin) nor do they drink much milk (fortified with vitamin D). Balance training, including participation in Tai Chi exercises can prevent falls in elderly people Coordination of all these interventions begins with a geriatric assessment described in the Geriatric and Chronic Care Management Act. Question. This week, the Senate Finance Committee is working on "pay for performance" legislation which would allow for the development and implementation of reporting and quality based measures for greater accountability and reliance on quality-based health care for providers. Do adequate measures exist in the area of falls? Would a frail elderly/geriatric population with multiple chronic conditions benefit from some unique measures, such as a falls measure, when compared to the "regular" elderly population who may be evaluated under more general measures having to do with one chronic disease, i.e. diabetes or heart disease?

Answer. Adequate measures do exist in the area of falls. The short physical performance battery (described, above) is easily performed and identifies those at greatest risk of falling and suffering a bone fracture. This use of this simple tool in a geriatric assessment can be the first step in a treatment plan to prevent a devastating fall. This plan might include identification of medications that may cause balance problems, nutritional deficiencies, muscle weakness due to low muscle mass, obesity, and other potential causes. In fact lower extremity physical performance (gait speed and chair stand time) has been shown to be highly predictive of hospitalization for a number of geriatric conditions (such as dementia, decubitus ulcer, hip fractures, other fractures, pneumonia, dehydration, and acute infections even among people who are not currently disabled (4).

References used:

1. Ferrucci, L, JM Guralnik, M Pahor, MC Corti, and RJ Havlik. Hospital diagnoses, Medicare charges, and nursing home admissions in the year when older persons become severely disabled. JAMA;277.728-34.,1997.

2. Guralnik, JM, L Ferrucci, EM Simonsick, ME Salive, and RB Wallace. Lowerextremity function in persons over the age of 70 years as a predictor of subsequent disability. N Engel J Med;332:556-61.,1995.

3. Guralnik, JM EM Simonsick, L Ferrucci, RJ Glynn, L F Berkman, D G Blazer, P A Scherr, and RB Wallace. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J. Gerontol.: Med. Sci.;49:M85-M94, 1994.

4. Penninx, BW, L Ferrucci, SG Leveille, T Rantanen, M Pahor, and JM Guralnik. Lower extremity performance in nondisabled older persons as a predictor of subsequent hospitalization. J Gerontol A Biol Sci Med Sci;55:M691–7.,2000.

5. Semba, RD, E Garrett, BA Johnson, JM Guralnik, and LP Fried. Vitamin D deficiency among older women with and without disability. Am J Clin Nutr; 72:1529-34.,2000.