Before the Deluge: What Changing Demographics Mean for Imaging

Age catches up with us all at some point. For the Baby Boomers, that point is arriving year after year, with 10,000 Americans turning 65 every day from now until 2030. It’s no secret our elderly population will grow to levels never before seen in the U.S. Meanwhile, the obesity epidemic rages on and other macroeconomic forces, such as the recovering economy and widespread health policy reforms, also promise to change the equation in healthcare. Are we prepared?

It’s a story best told by the numbers. In 2010, the number of Americans aged 65 or older was 40.5 million. By 2050, that number will more than double to 89 million—making up about a quarter of the U.S. population. And, since medical advances are now helping Americans to live longer, 5.8 million of those seniors are projected to be older than 85.

This all means a lot of birthday candles, but it also means a growing strain on the healthcare system. More than 92 percent of elderly individuals reported having one or more chronic diseases in 2008, according a 2013 report by healthcare analysts from business intelligence firm IHS, published in Health Affairs.

Concordia University recently broke it down like this: the average American over 65 has multiple chronic conditions such as hypertension (72 percent), arthritis (51 percent), heart disease (31 percent), cancer (24 percent) and diabetes (20 percent). These account for one third of all healthcare spending in America.

All the numbers add up. “You’re not just talking about more people over 65,” notes Frank J. Lexa, MD, MBA, professor in the Department of Radiologic Sciences at Drexel University College of Medicine in Philadelphia, “you’re talking about more people over 75, more people over 85, than we’ve historically had in the U.S.”

It becomes a supply and demand issue, says Lexa, with the Medicare-aged population growing, creating more financial strain on those still working and paying into the system.

And what will they be paying for? That same Health Affairs analysis also projected future demand for healthcare services, and broke it down by specialty. Radiology was among the fastest growing, with demand for radiology services expected to rise 18 percent by 2025. This is in line with the growth projections for neurological surgery and general surgery. The services with the highest projected demand growth were vascular surgery at 31 percent and cardiology at 20 percent, according to the report.

A big concern for radiologists is the impact on reimbursement, especially since about a dozen various reimbursement cuts have been levied against imaging services since the Deficit Reduction Act of 2005. But Lexa notes that one of the largely unspoken worries is that while cuts may target the cost of individual services, it’s hard to imagine aggregate healthcare spending going down given the macroeconomic forces in play. This will have varying impacts depending on the type of condition.

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Growing burden of Alzheimer’s

As baby boomers reach the age of greatest risk for Alzheimer’s disease (AD), what is currently one of the nation’s most serious health threats will only intensify. According to the Alzheimer’s Association’s 2014 Alzheimer’s Disease Facts and Figures report, 5.2 million Americans are living with AD, but by 2050, that number will spike to as many as 16 million people aged 65 and older with the disease.

The emotional toll exacted by AD is tremendous by itself, but it is also a huge financial burden. The cost of caring for AD patients and others with dementia will reach $214 billion this year, and that doesn’t include unpaid caregiving time and effort from family and friends, itself valued at more than $220 billion a year, according to the Alzheimer’s Association. Medicare reportedly spends almost $1 in every $5 on people with Alzheimer’s or other dementias, and that’s just the current situation. If no major breakthroughs are made in the near future, changing demographics will push national costs past $1 trillion by 2050 (not adjusted for inflation), including a 500 percent increase in combined Medicare and Medicaid spending.

Given the looming challenge, there’s a lot of effort being put into finding a method for identifying those at risk for developing AD before they become symptomatic. This is not all that different from how researchers approach many other diseases, explains Jennifer Weuve, ScD, of the Rush Institute for Healthy Aging in Chicago, but with AD it’s becoming more apparent that any interventions will have to take place early in disease development. Early identification of those at risk also will help researchers who are looking for treatments and ways to prevent the disease, says Weuve.

Imaging could play a pivotal role here, and there are now three FDA-approved diagnostic imaging agents aimed at helping rule out AD by identifying plaques made of beta-amyloid proteins that are one of the hallmarks of AD. In March, the FDA approved the use of F-18 florbetaben (Neuraceq) for this purpose. It joins other agents F-18 florbetapir (Amyvid), approved in 2012, and F-18 flutemetamol (Vizamyl), approved in 2013.

But AD imaging did suffer a setback late in 2013 when the Centers for Medicare and Medicaid Services (CMS) issued a final coverage decision on beta-amyloid PET imaging and required coverage with evidence development (CED). Under CED, CMS will cover just one PET scan to exclude AD, but only for patients participating in specific clinical studies.

Dean M. Hartley, PhD, director of science initiatives at the Alzheimer’s Association, says the organization was disappointed in the decision, and felt the data supports CMS coverage of a limited set of neurological indications for amyloid PET imaging. Hartley was part of the Amyloid Imaging Task Force, a joint effort from the Alzheimer’s Association and the Society of Nuclear Medicine and Molecular Imaging to review the literature and develop specific indications for amyloid imaging. The appropriate use criteria developed by the task force outlined situations in which to consider this type of  imaging, including:

Patients with persistent or progressive unexplained, but objectively confirmed, mild cognitive impairment;

Patients satisfying core clinical criteria for possible AD, however because of unclear clinical presentation, show an atypical clinical course or a mixed presentation suggesting different causes; and

Patients with progressive dementia at an atypically early age of onset, generally considered to be 65 years old or younger.

“We thought the appropriate use criteria gave expert and helpful guidance,” says Hartley. “Not everybody should have this test; it’s very expensive and is not for somebody who just has a memory issue. The individual needs to have a full neurologic workup and the memory impairment needs to be documented by a neurologist or a dementia expert.”

Hartley says experts are now working to determine which trials could convince CMS to provide coverage for these indications, and he thinks it will be a totally different picture once more AD treatments are developed. Those will likely be more effective at an earlier age, and imaging could help in determining who’s most at risk.

Although dementia experts can make a highly certain diagnosis of AD, it is estimated to be misdiagnosed in 10 to 30 percent of cases. Additionally, it is estimated that 50 percent of individuals with AD go undiagnosed. Advanced dementia in general also presents a patient management challenge, one that needs to be addressed before the system is overwhelmed by a growing population of seniors. A 2011 study published in the New England Journal of Medicine found that one-in-five nursing home residents with advanced dementia experienced a burdensome transition in their last 90 days of life, including repeat hospitalization and movement between facilities in the final three days of life. The Brown University researchers who conducted the study said this indicated inefficiency in the healthcare system and could be a side effect of misaligned incentives under Medicare and Medicaid.

An expansion of AD research initiatives could address some of the issues. Currently, the National Institutes of Health spends $6 billion a year on cancer research, $4 billion on heart disease research and $3 billion on HIV/AIDS research. In contrast, only about $500 million per year is devoted to AD, according to the Alzheimer’s Association. Weuve notes that while we’ve made great strides in improving cancer survival and reducing cardiovascular disease rates, the number of AD patients continues to grow. “It’s hard to think that was random, research had something to do with it,” she says. “We have not made near the same investment with respect to Alzheimer’s disease, we’re still at a fraction of where we have been for cancers and cardiovascular disease.”

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Matters of the heart

AD is not the only condition that becomes a greater risk as people age; cardiovascular disease (CVD) is already the leading cause of death in the U.S. and responsible for 17 percent of national health expenditures. These costs will only increase at the population ages.

“Much of heart disease, particularly heart failure, is a disease of the elderly,” says Paul A. Heidenreich, MD, MS, FAHA, professor of medicine at Stanford University School of Medicine.

In 2011, the American Heart Association (AHA) issued a policy statement, chaired by Heidenreich, which forecasted the future of CVD in the U.S. The statement looked at future costs of care for hypertension, coronary heart disease, heart failure, stroke and all other CVD through 2030. The projections assumed no change in healthcare policy, but did account for changing demographics over time.

According to the AHA statement, 40.5 percent of the U.S. population will have some form of CVD by 2030. Total direct medical costs of CVD will rise to $818 billion (in 2008 dollars) by 2030, approximately triple the cost from 2010. Real indirect costs due to lost productivity will jump to $276 billion in 2030, a 61 percent increase.

While AHA didn’t look specifically at the impact on imaging, Heidenreich says imaging spending will parallel the overall trends. “Much of the imaging will be related to heart failure and coronary disease, and both of those, as the elderly population increases, will be going up.”

On the positive side, AHA’s statement noted that greater life expectancy has accompanied the growth in costs, suggesting the increased spending was of some value. Heidenreich is also careful not to play Chicken Little. The numbers are alarming, but 30 years ago the concern was that healthcare spending couldn’t surpass 10 percent of GDP, but its proportion today is north of 17 percent and the entire system hasn’t collapsed.

Still, spending can’t continue to grow at this pace and more must be done to control costs, though Heidenreich says totally halting increased spending will be impossible. “It should make us very concerned that we need to think about what can be done to prevent this—prevent heart disease, prevent heart failure,” he says, noting that a two-fold increase in CVD spending by 2030 rather than a three-fold increase would be a major achievement.

There’s only so much providers can do in terms of reducing costs. Appropriateness criteria from the American College of Cardiology (ACC) can recommend which imaging is likely appropriate or inappropriate in a given situation, and Heidenreich says that the ACC and AHA are considering adding cost considerations to current guidelines.

However, potential savings from encouraging appropriate care on the provider side pale in comparison to what can be achieved by population prevention initiatives. Americans have already made a dent in their smoking habit. Since 1964, smoking rates have fallen from 42 percent to 18 percent, according to the American Association for Cancer Research. Limiting diabetes, controlling blood pressure and other prevention activities are all ways to reduce the burden of CVD. The AHA says that if everyone followed all recommended prevention activities, myocardial infarctions and strokes would be reduced by 63 percent and 31 percent, respectively, in the next 30 years. Full participation is a mighty high bar to set, but even if a more feasible level of prevention adherence was achieved, myocardial infarctions and strokes could be cut by 36 percent and 20 percent, respectively.

“To the extent we can come up with population interventions, somehow slowly adjust the culture, I think that would have a big effect,” says Heidenreich.

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Obesity’s toll

Americans aren’t just getting older, they are getting larger. One-third of the U.S. population is obese, and that rate is projected to grow to nearly 50 percent by 2030, according to the Centers for Disease Control and Prevention. The issue starts early; 43 million preschool children are overweight or obese, a 60 percent increase since 1990. Obesity increases risks for a number of conditions, including heart disease, stroke, type 2 diabetes and some cancers, and the estimated annual medical cost of obesity in the U.S. is around $147 billion. Some two in five baby boomers are said to be obese.

Since old age and obesity are both risk factors for cancer, research into how these factors intersect is of particular interest given the demographic shifts in the U.S. One such study comes from the National Institute on Aging in Bethesda, Md. Rachel A. Murphy, PhD, and colleagues noted that while body mass index (BMI) has been investigated for its correlation to cancer risk, the role of BMI is controversial in older patients because BMI is limited as a proxy for adiposity. Associations between adipose tissue in certain body regions may be useful for examining cancer risk.

Murphy and colleagues looked at a dataset featuring more than 2,500 individuals who had more precise measures of total adipose tissue acquired using dual-energy x-ray absorptiometry and CT, and these individuals were followed for incident cancers for 13 years. They found that total adipose tissue was associated with obesity-related cancer risk among women, and that visceral adipose tissue and abdominal fat was positively associated with cancer risk among men, a finding that remained consistent even when controlling for BMI.

“Our results really illustrate the long-term health risks of greater fat and importance of maintaining a healthy body weight in old age,” says Murphy.

She adds that more research needs to be conducted to determine the cumulative effect of a lifetime of obesity because the population is aging and more people are going to be obese for a longer period of time. 

While obesity increases risks for a number of conditions, providers must be careful not to succumb to the “obesity paradox”—a phenomenon in which obese patients in the hospital setting actually have fewer significant diagnoses after testing because physicians have a lower threshold for ordering those tests for obese patients.

An example of this paradox was demonstrated by Jeffrey A. Kline, MD, of Indiana University School of Medicine in Indianapolis, and colleagues. In March, they published a study online in Circulation: Cardiovascular Quality and Outcomes that looked at the impact of BMI in patients with chest complaints presenting to the emergency department (ED).

Kline and colleagues’ prospective, four-center study found that costs for overweight patients were 22 percent higher than for normal weight patients, 28 percent higher for obese patients and 41 percent higher for morbidly obese patients. Morbidly obese patients also had longer hospital stays than normal weight patients regardless of whether they underwent CT scanning. Despite the extra costs, morbidly obese patients has the highest proportion (87 percent) of no significant cardiopulmonary diagnosis for 90 days after CT pulmonary angiography.

“[Obese patients] come in with symptoms that mimic coronary syndromes and PE [pulmonary embolism] that are really just a state or part of the disease process of obesity, with the overlap of sleep disorder breathing and deconditioning that makes physicians think about coronary syndrome and PE,” says Kline. “They also have the perception that obese patients are at higher risk for these conditions because of the population data and they end up overtesting them.”

Kline suggests that physicians are not doing enough to limit this overtesting, and are hiding behind issues such as malpractice liability, patient satisfaction and administrative pressure when they order more testing than is needed. A structured approach, such as decision rules in computerized ordering systems, could help significantly reduce the imaging ordered in obese patients.

Moreover, Kline says research should be done to measure uncompensated activity in the care of obese patients. This patient population is more time- and resource-consuming, and billing codes don’t capture things like the additional staff needed to help transport some patients or if an IV needs to be restarted. “Obese patients are taking an unfair share of healthcare resources from other patients,” he says.

Silver linings

Despite the sobering projections for healthcare as a result of changing demographics, there is an awareness of the problem and efforts are already being made to control costs. Lexa admits that he doesn’t imagine costs will every really go down, but there has already been a bending of the cost curve. “Growth since 2010 as a percentage of GDP looks like it is trying to flatten,” he says, though he admits this could be associated with lingering effects from the recession.

More providers, medical associations and policy makers are focused on value-based care, represented by the increase in the number of accountable care organizations. Clinical decision support to limit unnecessary services is trendy politics in Washington, D.C., and there’s evidence that more dollars can be saved by transferring some services normally performed by physicians or under physician supervision to nonphysicians, when appropriate.

Even if all the solutions haven’t been worked out, there’s at least more attention being paid to these concerns. Within radiology, Lexa says he’s noticed more interest in economic issues among imaging professionals. When he was training, neither he nor his fellow residents would have understood how payment works or how costs were changing over time. “Not only would we not have known, many of our attendings wouldn’t have known, because it wasn’t something we’d pay a lot of attention to.”

Now, people stay late at conferences to hear lectures on leadership issues and reform, and Lexa is encouraged by the engagement of residents, fellows and young professionals. It may still be a minority containing less than 20 percent of physicians, but those who care are dedicated to fixing the issues. “The people who are interested are very interested.”