DCHS. Issue Brief: Supervisory Care: Key costs, trends, and strategic implications. Deloitte Center for Health Solutions

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1 Issue Brief: Supervisory Care: Key costs, trends, and strategic implications Foreword Nine million individuals in the United States receive long-term care services and daily living support, or supervisory care, from family members and friends, at an estimated cost of $199 billion annually. 1 (This cost is not included in most industry and government reports; it occurs outside of the official national health expenditure accounts). Up to 66 million U.S. caregivers provide supervisory care. 2 On average, care recipients over the age of 50 receive 28 hours of supervisory care per week. 3 Most individuals needing long-term care and support prefer home-based care to institutional care. 4 Supervisory care seeks to assist care recipients with their daily living activities, but may also include clinical services and treatment planning with doctors, nurses, nutritionists, psychologists, and others. Supervisory care is a strategic element of the health of the public. However, based on our understanding, it is neither wellunderstood by consumers, providers, and policy-makers, nor optimally integrated into health programs sponsored by the government, private health plans, health systems, and employers. As the U.S. population ages and individuals face financial hardships (e.g., limited workforce participation due to medical conditions), demand for supervisory care is expected to soar. Innovation in tools to assist in-home recipients, and better integration of supervisory care into the scheme of local health delivery, will be necessary to improve the effectiveness of these services and reduce the negative impact on caregivers. Paul H. Keckley, Ph.D. Executive Director Deloitte Center for Health Solutions DCHS Deloitte Center for Health Solutions Produced by the Deloitte Center for Health Solutions

2 Overview of supervisory care Supervisory or informal care is unpaid care at home provided by a family member or friend to someone limited in their capacity to self-care due to illness, advancing years, or disability. 5 Supervisory care provides for all or some of the essential long-term care and support that enables care recipients to stay at home, the desired care setting of individuals, 6 and to avoid or delay institutional care. 7 Individuals can be cared for in home and community settings without sacrificing quality and with an increase in beneficiary satisfaction. 8 Supervisory caregivers (referred to as caregivers in this issue brief) can play a critical role in providing home-based care. 9 Highlights of caregiver characteristics Two-thirds of caregivers are female. More than eight in ten caregivers provide care for a relative or friend aged 50 and over. Majority of caregivers are active members of the labor force. On average, caregivers have been providing support for 4.6 years, and most are assisting with long-term physical conditions. Source: Caregiving in the U.S., Bethesda, MD: National Alliance for Caregiving, Fourteen percent of all respondents in the Deloitte 2011 Survey of Health Care Consumers in the United States 10 had one or more family members requiring supervisory care (age of care recipients is almost evenly dispersed among age categories); of this 14 percent, the majority (83 percent) had one family member in the household requiring supervisory care 11 (Figure 1). Figure 1: Supervisory care for a family member Number of family members in household requiring constant care (Percent of total caregivers) One 83% 14% of all U.S. health care consumers report having one or more family members who require constant care Two or more 17% Source: Keckley PH, et al Survey of Health Care Consumers in the United States: Key Findings, Strategic Implications. Washington, DC: Deloitte Center for Health Solutions Supervisory care might be positive and deeply meaningful for many caregivers, but some of them may encounter economic, social, interpersonal, and health-related difficulties that make it difficult to sustain services. The potential strain to caregivers balancing work and caregiving responsibilities, or those with personal health problems, might be overwhelming and detrimental to their well-being. The financial implications of supervisory care are substantial for employers and consumers. A 2006 study estimated $33.6 billion of cost to employers of lost productivity for all full-time, employed caregivers (average cost of $2,110 per employee). 12 The same study found that employed caregivers made some work-related adjustments (60 percent), reduced their hours from full-time to part-time (10 percent), took early retirement (3 percent), or left work entirely (6 percent). Also, supervisory care exceeding 20 hours per week results in lost income for employed caregivers. 13 The Deloitte 2011 Survey of Health Care Consumers in the United States found a significant impact on one or more family members ability to earn an income due to caregiving. Households providing supervisory care for more than two years and households with an income of $25,000 or less reported the greatest impact on earning ability 14 (Figure 2). 2

3 Figure 2: Household insights about supervisory care* (Percent of total caregivers) Length of time care has been provided Impact on ability of one or more family members to earn an income due to supervisory care Major impact Moderate impact Minor impact No impact Statistically different by impact Less than 1 month 10% 5% 24% 10% P < months 5% 14% 3% 10% 3-6 months 7% 11% 6% 1% 6-12 months 8% 9% 10% 6% 1-2 years 10% 9% 7% 2% More than 2 years 48% 37% 27% 27% Not sure 13% 15% 23% 44% Family/household income level Less than $25,000 41% 20% 21% 15% P <.0001 $25,000-$49,999 18% 30% 21% 25% $50,000-$74,999 17% 20% 19% 15% $75,000-$99,999 10% 8% 14% 10% $100,000+ 9% 18% 22% 27% Prefer not to say 5% 4% 3% 7% Employment status Self-employed, full-time 9% 11% 10% 11% P=.0008 Self-employed, part-time 8% 6% 12% 4% Employed by organization or corporation, full-time 29% 44% 39% 38% Employed by organization or corporation, part-time 5% 7% 16% 6% Not working - At home/homemaker, not looking for work 9% 14% 4% 19% P=.001 Not working - Looking for work 22% 16% 20% 14% Not working - Caring for another 34% 15% 4% 5% Not working - In training/education 10% 21% 15% 17% Not working - Retired 25% 34% 57% 45% Source: Keckley PH, et al Survey of Health Care Consumers in the United States: Key Findings, Strategic Implications. Washington, DC: Deloitte Center for Health Solutions *Respondents were able to select more than one care recipient. Supervisory Care: Key costs, trends, and strategic implications 3

4 Nature and extent of supervisory care The true extent of supervisory care is unknown, as it occurs outside of the official national health spending captured in most industry and government reports. The estimated number of caregivers in the U.S. ranges from 28 million 15 to 66 million 16 (adjusted to 2009 values). Supervisory caregiver duties include clinical, social, and physical responsibilities, 17 and vary in intensity and time required based on the patient s functional ability, medical status, age, and co-residency. Supervisory care may include a wide variety of daily living services 18 (Figure 3). Increasingly, these caregivers are performing medical services such as catheter changes and infection control. Levels in caregiving intensity Levels 1-2: lower levels in caregiving intensity; caregivers provide, on average, fewer than 10 hours of care per week of less intense tasks, such as taking someone to a doctor s appointment or doing housework Levels 3-5: higher levels in caregiving intensity; caregivers provide, on average, 12 to 87 hours of care per week of more intense tasks, such as bathing or dressing Figure 3: Long-term care and support duties most often provided by caregivers Basic self-care tasks Area Activities of daily living (ADLs) Details Bathing Dressing Moving around indoors Transferring from bed to chair Using the toilet Eating Household chores Instrumental activities of daily living (IADLs) Light housekeeping Meal preparation Grocery shopping Laundry Taking medications Managing money Telephoning Outdoor mobility Transportation Source: Informal Caregiving: Compassion in Action. Washington, DC: U.S. Department of Health and Human Services Most caregivers provide low-intensity care services 19 (Figure 4). The Level of Burden Index was derived from activities of daily living (ADLs), instrumental activities of daily living (IADLs), and the amount of time devoted to caregiving in order to classify intensity. 20 4

5 Figure 4: Caregiving intensity Most informal caregivers provide low-intensity care Percent of informal caregivers Most caregivers provide less than 10 hours of care per week Some provide close to 20 hours of care per week A minority of caregivers provide full-time, high-intensity care Intensity of care: Depends on ADL and IADL need requirements, the types of medical conditions present, whether or not the caregiver is the primary caregiver, whether or not the caregiver lives with the care recipient, the amount of care provided per week, and the length of the caregiving episode Source: Draganova A. Paying for Unpaid Care, The Costs and Benefits of Informal Care to Caregivers and the Federal Government. Charlottesville, VA: University of Virginia The Affordable Care Act (ACA) of 2010 does not contain provisions that directly support supervisory care. ACA does include some programs that aim to provide care in the home and community to better assist care recipients, such as the Community First Choice Option for Medicaid (which provides community-based support to care recipients) and the Money Follows the Person program (which helps care recipients move from institutional care to community-based care) (Figure 5). Figure 5: Affordable Care Act (ACA) provisions that support care in the home and community ACA provision Sec Community First Choice Option Sec Removal of barriers to providing home- and community-based services Sec Money Follows the Person Rebalancing Demonstration Sec Funding to expand state aging and disability resource centers Sec Incentives for states to offer home- and community-based services as a long-term care alternative to nursing homes Summary Establishes an optional Medicaid benefit through which states could offer community-based attendant services and supports to Medicaid beneficiaries with disabilities otherwise requiring institutional care Removes barriers to providing home- and community-based services by giving states the option to provide more types of home- and community-based services through a state plan amendment to individuals with higher levels of need, rather than through a waiver, and to extend full Medicaid benefits to individuals receiving home- and community-based services under a state plan amendment Extends through 9/30/2016 the Money Follows the Person Rebalancing Demonstration program to assist states in rebalancing their long-term care systems and help Medicaid enrollees transition from institutions to the community. Also changes the eligibility rules for individuals to participate in the demonstration project by requiring that individuals reside in an inpatient facility for no less than 90 consecutive days Direct appropriation for $2.25 billion to extend the program Funding available for fiscal years 2011 through 2016 The Aging and Disability Resource Centers program provides states with funding to streamline access to long-term care services Direct appropriation for $10 million annually Funding available for each fiscal year 2010 through 2014 Adds a new policy that creates financial incentives for states to shift Medicaid beneficiaries out of nursing homes and into home- and community-based services. The provision provides Federal Medical Assistance Percentage (FMAP) increases to states to rebalance their spending between nursing homes and home- and community-based services States spending less than 25 percent of total long-term care and support expenditures on home- and community-based services receive a 5 percent increase; states with percent receive a 2 percent increase Source: Patient Protection and Affordable Care Act (P.L ): Potential Funding Opportunities for States. Washington, DC: National Governor s Association Legislation has been proposed to improve programs for seniors and caregivers. In November 2011, the Strengthening Services for America's Seniors Act legislation was introduced to improve existing Older Americans Act (OAA) programs by helping to ensure that caregivers receive the support and services they need, strengthening the long-term care ombudsman program, and creating better referral and reporting systems for legal assistance programs. Supervisory Care: Key costs, trends, and strategic implications 5

6 Cost of supervisory care services in the U.S. Supervisory care has considerable, but unrecognized, costs because they are not systematically captured. 21 The Deloitte study, The hidden costs of U.S. health care for consumers: A comprehensive analysis, 22 estimated a U.S. supervisory care imputed cost in 2009 of $199 billion ($ per capita) or 31 percent of 2009 U.S. total discretionary spending for health care 23 (Figure 6). The 2009 costs associated with supervisory care 24 ($199 billion) were higher than 2009 spending on home- and community-based care ($191 billion) and nursing home care ($137 billion) (Figure 7). Estimates were made for the imputed cost of supervisory care using data from both the Health and Retirement Study (HRS) 25 and the Medical Expenditure Panel Survey (MEPS). 26 This study found that approximately 9 million at-home care recipients over the age of 50 received 28 hours of care per week, while 16.5 percent of all supervisory care days were provided to persons under the age of Figure 6: 2009 U.S. total discretionary spending* for health care (billions) Direct costs Direct costs Indirect costs (imputed) Total costs Categories NHEA Additional to NHEA Total Hospital care $23.38 $0.00 $0.00 $23.38 Professional $ $60.59 $0.00 $ Long-term care $43.89 $45.00 $0.00 $88.89 Retail $53.28 $59.14 $0.00 $ Prescription drugs $49.01 $0.00 $0.00 $49.01 Supervisory care (imputed) $0.00 $0.00 $ $ Subtotal $ $ $ Total $ Source: Keckley PH, Freeman A. The hidden costs of U.S. health care for consumers: A comprehensive analysis. Washington, DC: Deloitte Center for Health Solutions *Includes direct costs (out-of-pocket: co-pays, deductibles, premiums, and direct purchases) and imputed indirect costs for supervisory care (replacement costs). Figure 7: Comparison of long-term care support services Component Supervisory care Home- and community-based care Nursing home care Number of care recipients 9 million a 1.5 million b Number of care providers million unpaid family members and friends c 1.7 million paid home health aides and personal/home care aides d 0.9 million paid registered nurses, licensed practical nurses, certified nursing assistants, nurse s aides, and orderlies e Annual cost $199 billion f $191 billion g $137 billion h Sources: a 28, U.S. estimated number of care recipients. b 30, U.S. nursing home current residents. c 2009 U.S. estimated number of caregivers: ranges from 28 million 32 to 66 million. 33 d 2010 U.S. paid home-care workforce: home health aides (occupation code ), 0.98 million, and personal care aides (occupation code ), 0.69 million. 34 Between 2008 and 2018, home health aides are projected to grow by 460,900 (rate of 50.0 percent) and personal and home care aides are projected to grow by 375,800 (rate of 46.0 percent). 35 e 2009 U.S. nursing home workers: a total of 936,000 persons (registered nurses, licensed practical nurses, certified nursing assistants, nurse s aides, and orderlies) provided nursing care to nursing home residents. Certified nursing assistants (600,800) represented the majority of all nursing staff employed in nursing homes. 36 f 2009 U.S. supervisory care imputed cost. 37 g 2009 U.S. other health, residential, and personal care and home health care 39 cost. 40 h 2009 U.S. nursing care facilities and continuing care retirement communities 41 cost. 42 6

7 Stakeholder considerations Demand for supervisory care in the United States is expected to climb as the population ages and individuals face financial hardships. The projected population in 2050 of individuals age 65 and above is 88.5 million or 20 percent of the total population at that time, an increase of 49.6 million from 2008 (38.9 million or 13 percent of the total population). 43 "The aging population is expected to drive a substantial increase in the number of cases of chronic disease, 44 such as heart disease, stroke, cancer, diabetes, hypertension, asthma, and arthritis, because the risk of developing most chronic diseases increases with age. 45 Many chronic conditions, such as arthritis (currently the most common cause of disability) 46, can result in one or more daily activity limitations. 47 Ensuring the integrity and sustainability of supervisory care requires caregiver integration into post-discharge care planning, health care decision-making, and the service delivery system. New care assistance products and services for caregivers are also needed (Figure 8). Figure 8: Supervisory care considerations by stakeholder group Stakeholder Caregivers Employers Health providers Government Health plans Considerations Learn care provision skills and techniques specific to the care recipient s condition Actively participate in the care recipient s health care decisions Follow hospital discharge guidelines/checklists Learn coping techniques to alleviate caregiver strain and burden, such as focusing on managing time and emotional reactions Join caregiver support groups to discuss feelings, problems, and successes in caregiving Learn about available community care programs Learn the laws surrounding long-term care, surrogate decision-making, guardianship, Social Security, elder abuse, Medicare, and Medicaid Learn about caregiver rights, such as job-protected family medical leave for care provision Access and use employer-sponsored elder care resources (if available) Develop flexible workforce policies that balance caregivers workplace and caregiving responsibilities in order to retain or attract talent Provide flexible work arrangements to caregivers to reduce company costs associated with productivity loss due to work impairment, specifically absenteeism (i.e., productivity loss because of absence from work) and presenteeism (i.e., productivity loss while at work) Provide paid leave at the outset of a new caregiving episode to prevent employees from quitting or switching to part-time work Provide comprehensive, interactive care resources to assist employee caregivers, such as emergency backup dependent day care, telephone counseling for caregiver stress, and telephone nurse medical advice Implement workplace wellness programs that address caregiver health issues, including depression and fatigue Incorporate caregivers as a key part of the patient-centered team, including case management and post-discharge planning coordination and communication Provide caregiver training and ongoing support in management of such things as medical devices, monitoring and communications equipment, medication management, and other activities of daily living Incorporate technology-enabled care and support programs and services into discharge planning and ongoing monitoring of chronic conditions Teach caregivers to monitor themselves for burden and strain and employ strategies to manage it Implement innovative care coordination programs for home-based care and smooth transitions from hospital to home, to promote patient self-management, and to educate and support caregivers Checklists could be used to plan for safe transitions between sites of care to prevent avoidable 30 day re-admissions Sponsor development of service models that integrate multiple health care settings, home health providers, caregivers, and consumers, to focus on care transitions and a sustainable at-home care relationship Include caregivers as key members in new service delivery models in the hospital-to-home transition designed to reduce avoidable hospital re-admissions and to improve patient safety post-discharge, such as Partnership for Patients and Care Transitions Develop innovative respite care programs that extend opportunities for care recipients and provide caregiver relief Improve or increase the organizational capacity, structure, and operations of the service delivery system to support the integrity and sustainability of caregiving arrangements Key areas of improvement include individualized and responsive services; workforce planning and development; increased community awareness, inclusion and valuing of diversity; community strengthening through partnerships and collaboration; and continuous quality improvement Provide consumer education and training on long-term care and support planning (assessing current needs and preparing for future care needs) Facilitate or enable an environment that supports transition strategies to support individuals wishing to move out of nursing facilities to home- and community-based services programs Introduce care transitions coaches to support care recipients; this may include specific tools and self-management strategies to ensure that the patient s needs are met during the transition from the acute care setting to home Sponsor innovative care coordination programs designed to maintain the at-home care relationship and reduce hospital re-admissions Design incentives/reimbursements to health providers to facilitate the education of caregivers about care delivery, provide counseling and training, provide access to respite services, and design interventions to assist care recipients (increase reciprocity and decrease dependency) Provide technologies that can facilitate caregiving Supervisory Care: Key costs, trends, and strategic implications 7

8 Summary Supervisory care is a critical extension of the formal U.S. health care system that covers nine million individuals at an estimated cost of $199 billion annually. Up to 66 million caregivers in the U.S. provide supervisory care; demand is expected to increase due to an aging population and increased consumer financial hardships. Studies show that long-term care and support provided in the home is preferred by most care recipients. Home and community-based care often increases care recipient satisfaction and deters or delays institutional care without sacrificing quality. Consumer-directed, long-term care and support requires supervisory care. However, innovation is necessary to facilitate improved supervisory care effectiveness and help reduce the negative impact on caregivers. Stakeholders should integrate caregivers into post-discharge care planning, health care decision-making, and the service delivery system, as well as develop new care assistance products and services (Figure 9). Figure 9: Supporting and sustaining caregivers Incorporate into postdischarge care planning Involve in health care decision-making Supervisory caregivers Make a critical member of the service delivery system Develop new care assistance products and services 8

9 References 1 Keckley PH, Freeman A. The hidden costs of U.S. health care for consumers: A comprehensive analysis. Washington, DC: Deloitte Center for Health Solutions Caregiving in the U.S.. Bethesda, MD: National Alliance for Caregiving Keckley PH, Freeman A. The hidden costs of U.S. health care for consumers: A comprehensive analysis. Washington, DC: Deloitte Center for Health Solutions State Options That Expand Access to Medicaid Home and Community-Based Services. Washington, DC: The Henry J. Kaiser Family Foundation Saltman RB, et al. "The Impact Of Aging On Long-Term Care In Europe And Some Potential Policy Responses," International Journal of Health Services. 2006;36(4): The 1999 U.S. Supreme Court ruling in Olmstead v. L.C. upheld that individuals with limited self-care capacity have the right to live at home or in the community if they are able and do not oppose doing so versus being institutionalized (State Options That Expand Access to Medicaid Home and Community-Based Services. Washington, DC: The Henry J. Kaiser Family Foundation. 2011). 7 Most care recipients with three or more ADL disabilities are able to avoid nursing home admission and continue residing in the community because they do not live alone and are able to obtain most of the help they require on an unpaid basis (Informal Caregiving: Compassion in Action. Washington, DC: U.S. Department of Health and Human Services. 1998). 8 Keckley PH, Frink B. Medicaid Long-term Care: The ticking time bomb. Washington, DC: Deloitte Center for Health Solutions Who Cares...? Report on the Inquiry into Better Support for Carers. Canberra, Australia: The Parliament of the Commonwealth of Australia A nationally representative sample of 4,000 American adults, aged 18 and older, reflective of the U.S. census with respect to age, gender, race/ ethnicity, and income, conducted online April Keckley PH, et al Survey of Health Care Consumers in the United States: Key Findings, Strategic Implications. Washington, DC: Deloitte Center for Health Solutions The MetLife Caregiving Cost Study: Productivity Losses to U.S. Business. Westport, CT: MetLife Mature Market Institute Lilly MB, et al. "Labor market work and home care's unpaid caregivers: a systematic review of labor force participation rates, predictors of labor market withdrawal, and hours of work." Milbank Quarterly, 2007;85(4): Keckley PH, et al Survey of Health Care Consumers in the United States: Key Findings, Strategic Implications. Washington, DC: Deloitte Center for Health Solutions Arno P, et al. "The Economic Value of Informal Caregiving." Health Affairs, 1999;18(2): Caregiving in the U.S.. Bethesda, MD: National Alliance for Caregiving Saltman RB, et al. "The Impact Of Aging On Long-Term Care In Europe And Some Potential Policy Responses." International Journal of Health Services, 2006;36(4): Informal Caregiving: Compassion in Action. Washington, DC: U.S. Department of Health and Human Services Draganova A. Paying for Unpaid Care, The Costs and Benefits of Informal Care to Caregivers and the Federal Government. Charlottesville, VA: University of Virginia Caregiving in the U.S.: Findings from a National Survey. Bethesda, MD: National Alliance for Caregiving Arno P, et al. "The Economic Value of Informal Caregiving," Health Affairs. 1999;18(2): The hidden costs of U.S. health care for consumers: A comprehensive analysis was commissioned research undertaken on behalf of Deloitte by Oxford Economics in Keckley PH, Freeman A. The hidden costs of U.S. health care for consumers: A comprehensive analysis. Washington, DC: Deloitte Center for Health Solutions The cost of replacing, or replacement cost, all supervisory care (approximately 9 million at-home care recipients over the age of 50 received 28 hours of care per week, while 16.5 percent of all supervisory care days were provided to persons under the age of 50) with paid home health care was the method used to impute the cost of supervisory care. The value applied to the replacement cost method calculation was $12.60 per hour which was equal to the mid-point of the average hourly wage of home health workers and the Federal minimum wage in 2009 (Analysis of the size of the US health sector. A report for Deloitte. London, England: Oxford Economics. 2010). 25 Data from the 2006 Health and Retirement Study (HRS) was used to estimate the total hours of supervisory care received by those aged 50 and over. This 2006 estimate was then projected to 2009 by applying population growth between these two years by age band. 26 To account for supervisory care provided to those under the age of 50, this study utilized data from the Medical Expenditure Panel Survey (MEPS) on days of supervisory care received by age. The relevant share of total supervisory care days for each age band was used to scale up the value of supervisory care. It was assumed that those under the age of 50 received the same amount of care as those aged 50 and over. 27 This study used data on care recipients versus data on caregivers. As such, the study may be identifying far fewer caregivers with much bigger time commitments by capturing a minority of care recipients receiving a significant amount of care and not capturing the majority of caregivers who provide less than 10 hours of care per week. Average hours and cost of care per day were assumed to be the same for all ages of care recipients. 28 Keckley PH, Freeman A. The hidden costs of U.S. health care for consumers: A comprehensive analysis. Washington, DC: Deloitte Center for Health Solutions Medicaid and Long-Term Care Services and Supports. Washington, DC: The Henry J. Kaiser Family Foundation The National Nursing Home Survey: 2004 Overview. Atlanta, GA: U.S. Centers for Disease Control and Prevention Medicaid and Long-Term Care Services and Supports. Washington, DC: The Henry J. Kaiser Family Foundation Arno P, et al. "The Economic Value of Informal Caregiving," Health Affairs. 1999;18(2):

10 33 Caregiving in the U.S.. Bethesda, MD: National Alliance for Caregiving Occupational Employment Statistics (April 6, 2011 last modified date). Washington, DC: U.S. Bureau of Labor Statistics. Retrieved from: gov/oes/current/oes_nat.htm. 35 The Complexities of National Health Care Workforce Planning. Washington, DC: Bipartisan Policy Center The National Nursing Home Survey: 2004 Overview. Atlanta, GA: U.S. Centers for Disease Control and Prevention Keckley PH, Freeman A. The hidden costs of U.S. health care for consumers: A comprehensive analysis. Washington, DC: Deloitte Center for Health Solutions Includes spending for residential care facilities (North American Industry Classification Codes [NAICS] and ), ambulance providers (NAICS ), medical care delivered in nontraditional settings (such as community centers, senior citizens centers, schools, and military field stations), and expenditures for Home and Community Waiver programs under Medicaid (Keehan SP, et al. "National Health Spending Projections Through 2020: Economic Recovery And Reform Drive Faster Spending Growth." Health Affairs. 2011;30(8): ). 39 Includes freestanding facilities only. Additional services of this type provided in hospital-based facilities are counted as hospital care (Keehan SP, et al. "National Health Spending Projections Through 2020: Economic Recovery And Reform Drive Faster Spending Growth," Health Affairs. 2011;30(8): ). 40 Keehan SP, et al. "National Health Spending Projections Through 2020: Economic Recovery And Reform Drive Faster Spending Growth," Health Affairs. 2011;30(8): Includes care provided in nursing care facilities (NAICS 6231), continuing care retirement communities (623311), state and local government nursing facilities, and nursing facilities operated by the Department of Veterans Affairs (Keehan SP, et al. "National Health Spending Projections Through 2020: Economic Recovery And Reform Drive Faster Spending Growth," Health Affairs. 2011;30(8): ). 42 Keehan SP, et al. "National Health Spending Projections Through 2020: Economic Recovery And Reform Drive Faster Spending Growth," Health Affairs. 2011;30(8): Profile America Facts for Features (March 2, 2010 publication date). Washington, DC: U.S. Census Bureau. Retrieved from: gov/newsroom/releases/archives/facts_for_features_special_editions/cb10-ff06.html. 44 The increase in cases occurs even if other risk factors remain unchanged (DeVol R, Bedroussian A. An Unhealthy America: The Economic Burden of Chronic Disease Charting a New Course to Save Lives and Increase Productivity and Economic Growth. Santa Monica, CA: Milken Institute. 2007). 45 DeVol R, Bedroussian A. An Unhealthy America: The Economic Burden of Chronic Disease Charting a New Course to Save Lives and Increase Productivity and Economic Growth. Santa Monica, CA: Milken Institute U.S. Centers for Disease Control and Prevention. "Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation United States, ," Morbidity and Mortality Weekly Report. 2006;55: Anderson G. Chronic conditions: making the case for ongoing care. Baltimore, MD: John Hopkins University Supervisory Care: Key costs, trends, and strategic implications 10

11 Authors Paul H. Keckley, PhD Executive Director Deloitte Center for Health Solutions Deloitte LLP Sheryl Coughlin, PhD, MHA Head of Research Deloitte Center for Health Solutions Deloitte LLP Elizabeth L. Stanley, MPH Research Manager Deloitte Center for Health Solutions Deloitte LLP Contributors Anna Draganova Consultant Deloitte LLP Acknowledgments We wish to thank Jennifer Bohn, Anna Brewster, Isabel Ortiz, and the many others who contributed their ideas and insights to this project. Contact Information To learn more about the Deloitte Center for Health Solutions, its projects and events, please visit centerforhealthsolutions. Deloitte Center for Health Solutions 1001 G Street N.W. Suite 1200 Washington, DC Phone Fax Toll free healthsolutions@deloitte.com Web 11

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