If you could invest $56 billion each year on improving health care for older adults, how would you spend it? On a hugely expensive medication with questionable efficacy — or something else?
This isn’t an abstract question. Aduhelm, a new Alzheimer’s drug approved by the Food and Drug Administration last month, could be prescribed to 1 to 2 million patients a year, according to Biogen and Eisai, the companies behind the drug.
The total annual price tag would come to $56 billion if the average list price, $56,000, is applied to the lower end of the companies’ estimate.
That’s more than the annual budget for the National Institutes of Health (almost $43 billion this year). Yet there’s uncertainty about Aduhelm’s clinical benefits, fueling controversy over its approval. The FDA has acknowledged it’s not clear whether the medication will actually slow the progression of Alzheimer’s disease or by how much.
“This drug raises all kinds of questions about how we think about health and our priorities,” said Dr. Kenneth Covinsky, a geriatrician and professor of medicine at the University of California, San Francisco.
Since most Alzheimer’s patients are older and on Medicare, the medication would become a significant financial burden on the federal government and beneficiaries. Some experts warn that this could drive up Medicare premiums and raise out-of-pocket expenses.
And if Medicare and Medicaid must absorb drug spending of this magnitude, other improvements in care are less likely to receive attention.
Here, experts — geriatricians, economists, health policy specialists — share how they would spend an extra $56 billion a year. Their answers highlight significant gaps in care for older adults.
>> Make Medicare more affordable. High out-of-pocket expenses are a growing burden and discourage many from seeking care. “I’d cut Medicare copayments and deductibles. I think that would go a long way toward improving access to care and health outcomes,” said Dr. David Himmelstein, a professor of urban public health at Hunter College in New York City.
>> Support family caregivers. Nearly 42 million people provide assistance — help with shopping, cooking, paying bills and physical care — to older adults trying to age in place at home. Yet these unpaid caregivers receive little support.
Dr. Sharon Inouye, a geriatrician and professor of medicine at Harvard Medical School, suggests investing in paid services in the home to lessen the burden on unpaid caregivers, especially those tending to people with dementia. She would fund more respite care programs as well as adult day centers. Also, she recommends more caregiver training and support and paying caregivers stipends. For the most part, Medicare doesn’t cover those services.
>> Strengthen long-term care. Shortages of direct- care workers — aides who care for older adults at home and in assisted living facilities, nursing homes, residential facilities and other settings — are a growing problem. PHI, a research organization that studies the direct-care workforce, has estimated that millions of direct-care jobs will need to be filled as baby boomers age.
“We could greatly improve the long-term care workforce by paying these workers better and training them better,” said Dr. Joanne Lynn, a geriatrician and policy analyst at Altarum, a research and consulting organization.
>> Help people age in place. Most older adults want to age in place, but many need assistance over time. Will they be able to climb the stairs? Cook for themselves? Do the laundry? Take a shower?
Simple solutions can help, including installing handrails on staircases, grab bars in bathrooms and better lighting, and purchasing devices such as raised toilet seats, shower stools or scooters. But Medicare doesn’t pay for many of these.
Covinsky of UCSF would make the program CAPABLE (Community Aging In Place — Advancing Better Living for Elders) a Medicare benefit. It combines at-home visits from an occupational therapist and a registered nurse, with up to $1,300 in services from a handyman.
Evidence shows it helps seniors stay out of nursing homes. The total cost: $3,000 per person. “For less than one infusion of (Aduhelm), you can greatly improve someone’s quality of life and well-being,” Covinsky said.
>> Find out what older adults need. Sarah Szanton, director of the Center for Innovative Care in Aging at the Johns Hopkins School of Nursing, developed CAPABLE. She would use $56 billion to assess every older adult annually to “figure out what they need to be able to live comfortably and independently. From that, I would generate a list of tailored interventions.”
>> Focus on prevention. A growing body of evidence suggests that dementia could be prevented — perhaps up to 40% of the time — if people didn’t drink excessive amounts of alcohol, controlled blood pressure and obesity, managed depression, used hearing aids, stopped smoking, exercised regularly, socialized and engaged in cognitively stimulating activities, among other strategies.
“If I had $56 billion to spend, I’d focus on prevention,” said Laura Gitlin, a dementia expert and dean of Drexel University’s College of Nursing and Health Professions.
>> Invest in social determinants of health. The health of older adults is shaped by the environments in which they live, their interactions with other people and how easy it is to fulfill basic needs.
Dr. Anthony Joseph Viera, a professor of family medicine and community health at Duke University School of Medicine, said he would invest in “transportation for the elderly. Safe housing. Food. Programs that reduce social isolation. Those would end up helping a lot more people.”
Kaiser Health News is a national newsroom that produces in-depth journalism about health issues.