Geriatric Medicine Training and Practice in the United States at the ...

Table 4.5 Leading Causes of Death and Numbers of Deaths, Age 65 Years and Over:
United States, 1980 and 1999
1 LRD – Lower respiratory disease
2 COPD – Chronic obstructive pulmonary disease
3 Renal Disease – Nephritis, nephrotic syndrome, and nephrosis
*Source: Centers for Disease Control and Prevention,
National Center for Health Statistics, 1980
**Source: Hoyert, Smith, Arias et al., 2001
Utilization of Services
The trends in the number of aged Medicare enrollees and federal
Medicare expenditures for the aged over the past 20 years are shown
in Tables 4.6 and 4.7. Federal efforts to control the rate of growth of
these expenditures has centered on complex formulas that control
payments to providers and the less successful application of managed
care principles to Medicare. Medicaid payments to older adults have
also risen significantly during the past 20 years (Table 4.8). The VHA,
charged with caring for the nation’s veterans,
is the largest health system in the
United States with more than 6 million
patients. The median age of veterans is 58.3
years; 36.8% of male veterans are over the
age of 65 and 1.5% are over the age of 85
(www.va/opa/vetpopbook). The VHA medical
care budget in 2001 was over $22 billion
(US Department of Veterans Affairs, 2002).
In 1999, 25% of office visits to physicians
in the U.S. were made by adults age
65 or over (192.2 million visits). This represented
592 visits per 100 persons age 65 or
older, as compared to 283 visits per 100
1980* 1999**
Cause of Death Deaths Cause of Death Deaths
Diseases of the Heart 595,406 Diseases of the Heart 607,265
Malignant Neoplasms 258,389 Malignant Neoplasms 390,122
Cerebrovascular Diseases 146,417 Cerebrovascular Diseases 148,599
Pneumonia and Influenza 45,512 Chronic LRD 1 108,112
COPD 2 43,587 Pneumonia and Influenza 57,282
Atherosclerosis 28,081 Diabetes mellitus 51,843
Diabetes mellitus 25,216 Alzheimer’s disease 44,020
Unintentional injuries 24,844 Unintentional injuries 32,219
Renal Disease 3 12,968 Renal Disease 3 29,938
Chronic liver disease 9,519 Septicemia 24,636
Table 4.6 Aged Medicare Enrollees: 1980-1999
Year (as of July 1st)
Millions of People
1980 25.5
1985 28.2
1990 30.9
1995 33.1
1996 33.4
1997 33.6
1998 33.8
1999 33.9
Source: U.S. Centers for Medicare & Medicaid Services, 2000
persons of all ages (CDC, 2001:281).
Forty-six percent of office visits made by
older adults were to family physicians or
general internists; 54% were made to other
medical specialists (CDC, 2001:285). Over
the past decade, the trend has been for
an increasing percentage of ambulatory
office visits to occur in non-primary care
specialists’ offices. Table 4.9 lists the
percentage of ambulatory visits accounted
for by older adults to various specialties in
1999. During 1999, hospitalization rates
were 120 hospital discharges per 1000
persons of all ages. As compared to the
overall population, the hospitalization rate
was 1.9 times higher for adults age 65-74,
and 2.7 times higher for adults age 75 and
over (CDC, 2001: 291).
In 1999, in the U.S., more than 1.9
million nursing home beds were available,
and the occupancy rate was 83%. The
rates of nursing home utilization varied from 11/1000 people age
65-74 to 183/1000 people age 85 or over (CDC, 2001: 306). During
1998, 1.82 million people utilized some type of home health care
service, for an overall rate of 70 patients/10,000 people. This rate
increased to 407/10,000 people age 75-84 and 885/10,000 for
people age 85 or over (CDC, 2001:289). Tables 4.10 and 4.11 show
trends in skilled nursing facility utilization and the growth of nursing
homes. Table 4.12 lists the number of proprietary, voluntary
non-profit, and government owned nursing homes.
The majority of nursing home beds are occupied by older adults
(Table 4.13). Among older adults in nursing homes, one-half are age
85 or older, 75% are women, and 88% are white. In 1997, Medicare
and Medicaid combined were the source of payment for 68% of
institutional care (US Center for Health Statistics, 2000). In addition,
the VHA operates 137 nursing homes and in 2001 provided treatment
to 87,000 nursing home patients (www.va.gov).
During the past decade there has been a nationwide rapid growth
of assisted living facilities. While definitions of assisted living vary
across states, it was estimated in 1998 that 600,000 residents were
living in 25,000-30,000 assisted living facilities. The typical assisted
living resident is an 83-year-old female requiring assistance with 3
Table 4.7 Medicare Disbursements for the Aged: 1980-2000
Year Hospital Insurance – Part A 1 Medical Insurance – Part B 1
(ending Sept. 30th) (millions of dollars) (millions of dollars)
1980 20,951 8,497
1990 58,503 36,837
1995 100,107 54,830
1996 109,379 57,807
1997 120,239 60,989
1998 118,467 65,118
1999 113,321 67,996
2000 110,142 76,507
1 Beginning in 1998, home health agency transfers were shifted from Part B to Part A.
Source: U.S. Centers for Medicare & Medicaid Services, unpublished data, 2001
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