The economic case for integrated care for older people

Population aging is likely associated with greater health and long-term care costs. Rationale use of available resources poses a significant challenge for policymakers. Unfortunately, there are sparse data about the economic evaluation of old-age health care. There is a misconception that people become sick or dependent after reaching some predefined age. On the contrary, the older population is quite heterogeneous. Healthy and active older people continue to provide paid or unpaid work and make a positive economic and societal contribution. The value of unpaid work provided by older people is considerable but challenging to monetize. Further, even if not in paid employment, older people continue to pay consumption and other nonlabor taxes, thus contributing to public sector revenues. Older people may help support economic activity through their consumption patterns and a general tendency to spend down savings. Older people can give necessary inputs into caring for other older people. The dependence and diseases in old age can be averted by policies promoting healthy aging through adequate physical activity, proper nutrition, early detection and management of chronic diseases, vaccination, and societal connectedness. In addition, policies to promote cost-effective health and long-term care interventions include using technology, integrating health and long-term care, and other models of care delivery and supporting better treatment and care choices near the end of life. However, policymakers require high-quality information to make informed decisions and develop policies concerning older people. Health economics is a sub-discipline of economics, principally concerned with issues related to scarcity in allocating resources for health-care expenditures to promote health. An economic evaluation of health, social, and aged care services for older people will improve efficiency by targeting scarce resources toward interventions that promote health, independence, and well-being. Economic evaluations are of four main types: cost minimization, cost-effectiveness, cost–utility, and cost–benefit analyses. The most widely applied technique of economic evaluation is cost–utility analysis.[1] Health measurement and valuation have become essential components of economic evaluation in health care. The cost–utility analysis compares the costs of alternative health-care programs with their utility, usually measured in terms of quality-adjusted life years (QALYs). QALYs combine the quality and length of life changes into a single measure of value. QALYs are easy to calculate and help to compare desperate health interventions. Direct or indirect valuation of health could be used for economic evaluation. In practice, examples of the direct valuation of health, like time trade-off, are less commonly found in economic evaluations within geriatrics and other medical specialties. Indirect valuation through the utilization of generic preference-based measures of physical and mental health such as the Assessment of Quality of Life, the EuroQol-5 Dimension, and the SF-6D has become the most popular mechanisms for the estimation of QALYs for cost–utility analyses in older people. In older people, self-completion of these evaluation instruments may not be possible, requiring interviewer administration or proxy responses, particularly in cognitively impaired or frail older people.[2] In older people, the benefits of health care extend beyond health, particularly to the quality of life. The recently developed Index of Capability for Older People evaluation tool adopts a capability approach to measure and value the benefits of health and social care interventions in aged care.[3] It comprises five attributes (attachment, role, enjoyment, security, and control) and has demonstrated relationships between health, disability, hope, and capability. These tools need validation in various health-care systems. Health economists have recognized that besides the outcome of the services, the “process” by which geriatric services are provided is also vital for older people and their families. Consumer satisfaction surveys offer one method for consumer engagement which has been and continues to be widely used. An alternative approach for systematically engaging older people and their families to elicit their preferences about the process of geriatric service delivery is to employ the discrete choice experiment (DCE) methodology.[4] DCE is an economic technique based on stated preference designed to establish the relative importance and impact of individual attributes, or characteristics, upon the overall utility of a good or service. Health professionals engaged in the care of older people need to know about health economic techniques for assessing the costs and benefits of new and existing health-care technologies and modes of aged care service delivery. In addition, they need to work with health economists to generate data to facilitate policymakers to decide on efficient and responsive health-care interventions and delivery systems. The World Health Organization has recently proposed the Integrated Care for Older Persons (ICOPE) approach for health delivery for older people, with functional ability at the center of the theme. Initial implementation studies have shown that older adults had positive attitudes toward the ICOPE approach, agreeing that integrated care is vital for a better aging process.[5] Furthermore, Chen et al. have found integrated health care cost-effective in the Taiwanese geriatric population.[6] However, there is a need for well-designed, reliable economic evaluation research across the WHO regions for the ICOPE approach to support decision-making on the implementation and dissemination. The challenge will be to have cross-national comparable studies from different geographical regions with varying systems of health-care and social values. This effort will develop an economic argument for accepting and implementing the ICOPE approach in the member states.