Cost, Coverage and More Drive Hearing Aid Inequality

Elderly woman in a hospital room being fitted with a hearing aid by a young woman.

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Hearing loss seems like one of the great equalizers of old age, striking people of all kinds as their ears gradually lose the ability to pick out sounds or hear certain pitches. But a new national study reveals major gaps in whether Americans over age 55 get help for their hearing loss – gaps that vary greatly with age, race, education and income.

In all, just over a third of older adults who say they have hearing loss are using a hearing aid to correct it, the study finds. But those who are non-Hispanic white, college-educated or have incomes in the top 25 percent were about twice as likely as those of other races, education levels or income ranges to have a hearing aid.

The cost of hearing aids is most to blame, say the researchers from the University of Michigan who published the study in The Gerontologist, and presented it this week at the annual research meeting of AcademyHealth, professional society for healthcare researchers.

They can cost thousands of dollars out of a patient’s pocket, since most health insurance programs, including Medicare, don’t cover them.

In fact, the study finds that the only factor that leveled the playing field for hearing aid use was having insurance through the Veterans Administration, which covers hearing aids in many cases. Hearing-impaired veterans ages 55 to 64 were more than twice as likely as their non-veteran peers to use a hearing aid, even after the researchers corrected for other differences. The gap between veterans and non-veterans was also significant for those over age 65.

But the detailed interviews conducted for the study also show that personal concerns about hearing aid use, and lack of engagement with health providers, play a role.

“Hearing aids are not easy for many to obtain due to their costs,” says Michael McKee, M.D., M.P.H., the U-M family medicine physician and assistant professor who led the analysis. “However, there are a number of additional issues that place at-risk groups at an even larger disadvantage to achieving good hearing health. Many of these issues are beyond the financial aspects, including racial/ethnicity and sociocultural elements, for instance stigma and vanity.”

National survey and local interviews

McKee, who uses a cochlear implant to overcome his own hearing loss, worked on the study with Helen Levy, Ph.D., a health economist and professor at the U-M Institute for Social Research, and other colleagues. The authors are members of the U-M Institute for Healthcare Policy and Innovation.

They used survey data from the nationally representative Health and Retirement Study, which is based on interviews conducted by ISR with funding from the National Institutes of Health.

The analysis included data from more than 35,500 people nationwide over age 55 who said they had hearing loss. In addition, McKee and colleagues conducted in-depth interviews with 21 other older adults with hearing loss in the communities surrounding the University.

The authors conclude that the Centers for Medicare and Medicaid Services should consider covering hearing aids for Medicare participants, and those in Medicaid plans for lower-income adults of any age. Some state Medicaid plans do cover hearing aids but it is not required.

“Many people may not realize that Medicare does not cover hearing aids,” says Levy. “But it doesn’t, so cost can be a significant obstacle preventing older adults with hearing loss from getting the help that they need.”

More Findings from the Study

  • The percentage of older adults with hearing loss who used a hearing aid rose with age, from about 15 percent of those in their late 50s to more than 57 percent of those in their late 80s.
  • Forty percent of non-Hispanic white adults with hearing loss used a hearing aid, compared with 18.4 percent of non-Hispanic Black and 21.1 percent of Hispanic adults with hearing loss.
  • Nearly 46 percent of hearing-impaired older adults who had gone to college reporting that they used a hearing aid, compared with just under 29 percent of those who hadn’t graduated from high school.
  • Nearly half of those with incomes in the top 25 percent wore a hearing aid, compared with about one-quarter of those in the bottom 25 percent.
  • There were no significant differences in hearing aid use based on the size of the community where the person lived, nor their level of health literacy as measured on a standard test.
  • Interviews showed that cost, lack of insurance coverage (or knowledge about insurance coverage), vanity and stigma were common reasons for not using hearing aids. Participants also cited a lack of attention to hearing loss by their primary care provider, or worries about finding an audiologist they could trust.
  • Many interview participants who used a hearing aid mentioned efforts that hearing-related professionals made to connect them to discounts and insurance programs.

More about Hearing Loss

Estimates of hearing loss incidence place it at 29 percent of people in their 50s, 45 percent of those in their 60s, 68 percent of those in their 70s and 89 percent of those in their 80s.
Previous studies have shown that untreated hearing loss reduces older adults’ ability to carry out everyday tasks, reduces their quality of life, and is linked to social isolation, lower income, reduced cognitive function and poorer physical and psychological health.

A recent study led by McKee’s colleague Elham Mahmoudi, M.D., found that having a hearing aid was associated with a lower chance of being hospitalized or visiting an emergency room in the past year. That study focused on individuals over age 65 who had severe hearing loss, and used data from a federal database.
McKee leads the Health Info Lab, which is carrying out research on health information use and literacy among deaf and hard-of-hearing individuals.

Contact

Kara Gavin, kegavin@umich.edu

As retirement age creeps up, health of those close to retirement is getting worse

Older couple looking at a piece of paper, possibly a bill.

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ANN ARBOR—Ten years from now, Americans born in 1960 will be able to start collecting their full Social Security retirement check, at the age of 67. That’s two years later than their parents, because of a change in the federal retirement age enacted in 1983.

But a new study shows that today’s pre-retirement generation already has more health issues and health-related limits on their lives than prior generations did when they were in their late 50s. The new findings, made by a University of Michigan team using data from long-term health studies and funding from the Alfred P. Sloan Foundation, are published in the new issue of Health Affairs.

The study suggests that today’s older workers will face more challenges than their predecessors as they continue to work, seek work, apply for Social Security disability payments, or try to retire on other income over the next decade. But the researchers also say their findings have implications for any proposals to change the Social Security retirement age, pushing it higher for people now in their 50s and below in order to stretch the federal budget.

“Other research has found similar trends in the health of Americans who are now in the 50s and 60s, but this is the first study to look specifically at groups, or cohorts, of Americans by Social Security retirement age, which has specific policy implications,” said HwaJung Choi, lead author of the new study and an economist and demographer at the U-M Medical School.

“We found that younger cohorts are facing more burdensome health issues, even as they have to wait until an older age to retire, so they will have to do so in poorer health,” said Robert Schoeni, an economist and demographer at the U-M and co-author of the new paper.

Long-term look at five birth cohorts

Choi and Schoeni are both members of the U-M Institute for Healthcare Policy and Innovation. Last year, they published a paper looking at health-related limitations among people who were in their late 50s and 60s from 1998 to 2012, and found that trends were stable but that those with less education and more economic issues related to the Great Recession had worse health.

The new paper used data from the Health and Retirement Study, funded by the National Institute on Aging and based at ISR, and from the National Health Interview Survey run by the Centers for Disease Control and Prevention.

Both studies go back decades, and provide in-depth data from people of different ages—making it possible to see how different age cohorts were doing at different times.

For this study, the researchers grouped older Americans into five birth cohorts: those who could receive their full Social Security benefits at 65 because they were born in 1937 or earlier, those born during 1938-1942 who could claim benefits sometimes during the year they turned 65, those born between 1943 and 1954 who could claim at age 66, those born between 1955 and 1959 who can claim full benefits somewhere between ages 66 and 67, and those born in 1960 to 1962, who are the first group to have to wait until age 67 to collect their full Social Security benefit.

They found:

  • Those born later, who have to wait longer to receive their full Social Security benefits, tended to have higher rates of poor cognition, such as memory and thinking ability, in their 50s than the earlier cohort groups had at a similar age.
  • When people in the latest-born birth cohort was asked at around age 50 to rate their own health, more of them said it was fair or poor—compared with lower percentages in the middle three birth cohorts when they were around 50.
  • The later-born groups had higher percentages of people who had at least one limitation on their ability to perform a basic daily living task by themselves, such as shopping for groceries, taking medications or getting out of bed.
  • There weren’t strong differences between the groups in physical function, such as being able to climb a flight of stairs without resting, lifting 10 pounds or walking several blocks.
  • Stark differences in health between people with different levels of education were seen—echoing what other studies have shown. For instance, about 25 percent of people who had to wait until age 66 to claim full benefits and had less than 12 years of education reported at least one health-related life limitation when they were in their mid-50s. But among those who had more than 12 years of education and were in the same claiming group (age 66), only about 7 percent had at least one such limitation. Those whose education had stopped at high school graduation were in the middle.
These graphs show the percentage of people in each Social Security retirement age cohort who had at least one health-related limitation on their ability to carry out everyday activities. In addition to differences by level of education, the data show more issues among younger cohorts. Credit: Health Affairs

These graphs show the percentage of people in each Social Security retirement age cohort who had at least one health-related limitation on their ability to carry out everyday activities. In addition to differences by level of education, the data show more issues among younger cohorts. Credit: Health Affairs

Yesterday, today and tomorrow

The authors note that Social Security retirement age changes were made when the people who are now in their 50s and 60s were only in their 20s and 30s. At that time, demographers predicted that they were likely to live longer on average than their parents’ generations.

“They were focusing on life expectancy, not morbidity, and implicitly assuming that improvements in mortality would be accompanied by similar improvements in health or morbidity,” Choi said.

“Now they are retiring and we know what their health is like—and it’s not better. In fact, some aspects of their health are worse than for the people who came before them,” Schoeni said. “As policymakers talk of making the retirement age even later, these findings suggest that to fully understand the benefits and costs of such a policy, we must realize that raising the retirement age may further exacerbate the inequality between cohorts born only a few years apart, because the younger ones may find it more challenging to work beyond age 67.”

The authors note that among those who rely on Social Security for most or all of their retirement income, education levels tend to be lower, and their pre-retirement occupations tend to involve more physical demands, making it more difficulty to work to an older age. Applications for Social Security disability benefits may also rise among this group, putting even more demands on the overall Social Security budget.

Health can also make a major difference in individuals’ decisions to actually stop working once they reach their Social Security retirement age. Many people want or need to keep working for pay after they start collecting Social Security, and some studies have suggested that working can be beneficial for health. But if their health is poor they may not be able to.

Choi is a research assistant professor in the Division of General Medicine in the U-M Department of Internal Medicine. Schoeni holds appointments in the Institute for Social Research, the Department of Economics in the College of Literature, Science, and the Arts, and the Ford School of Public Policy.

Contact

Kara Gavin: kegavin@umich.edu, 734-764-2220

Dementia on the downslide, especially among people with more education, study finds

Positive brain health trend may cushion blow on society, but doesn’t lessen impact on individual patients and caregivers, U-M researchers say

ANN ARBOR, MI — In a hopeful sign for the health of the nation’s brains, the percentage of American seniors with dementia is dropping, a new study finds.

The downward trend has emerged despite something else the study shows: a rising tide of three factors that are thought to raise dementia risk by interfering with brain blood flow, namely diabetes, high blood pressure and obesity.

Those with the most years of education had the lowest chances of developing dementia, according to the findings published in JAMA Internal Medicine by a team from the University of Michigan. This may help explain the larger trend, because today’s seniors are more likely to have at least a high school diploma than those in the same age range a decade ago.

With the largest generation in American history now entering the prime years for dementia onset, the new results add to a growing number of recent studies in the United States and other countries that suggest a downward trend in dementia prevalence. These findings may help policy-makers and economic forecasters adjust their predictions for the total impact of Alzheimer’s disease and other conditions.

“Our results, based on in-depth interviews with seniors and their caregivers, add to a growing body of evidence that this decline in dementia risk is a real phenomenon, and that the expected future growth in the burden of dementia may not be as extensive as once thought,” says lead author Kenneth Langa, M.D., Ph.D., a professor in the U-M Medical School, Institute for Social Research and School of Public Health, and a research investigator at the VA Ann Arbor Healthcare System.

“A change in the overall dementia forecast can have a major economic impact,” he adds. “But it does nothing to lessen the impact that each case has on patients and caregivers. This is still going to be a top priority issue for families, and for health policy, now and in the coming decades.”

Nearly three-point drop

Langa and colleagues used data and cognitive test results from ISR’s long-term Health and Retirement Study to evaluate trends from 2000 to 2012 among a nationally representative sample of more than 21,000 people age 65 or over.

In all, 11.6 percent of those interviewed in 2000 met the criteria for dementia, while in 2012, only 8.8 percent did. Over that time, the average number of years of education a senior had rose by nearly an entire year, from 12 to 13.

“It does seem that the investments this country made in education after the Second World War are paying off now in better brain health among older adults,” says David R. Weir, Ph.D., senior author of the paper and director of the Health and Retirement Study. “But the number of older adults is growing so rapidly that the overall burden of dementia is still going up.”

Even as these new results come out, the Health and Retirement Study team is in the middle of another large study of dementia in the U.S. that will help refine the techniques for better understanding who has dementia in the American population, and allow them to be used in other countries around the world where HRS “sister studies” are also collecting data.

Langa, who is the Sturgis Professor of Internal Medicine and a member of the U-M Institute for Healthcare Policy and Innovation, notes that the differences in dementia risk according to education level mark an important health disparity now, and likely into the future.

“More Baby Boomers have completed some higher education than any previous generation, but the trend toward more education appears to be leveling off in the U.S. And there are clear disparities in educational attainment according to wealth and ethnicity,” he says. “These differences in education and wealth may actually be creating disparities in brain health and, by extension, the likelihood of being able to work and be independent in our older years.”

Years of formal education was the only marker tracked among the study participants. But, says Langa, it is likely that the other ways that people challenge and use their brains throughout life—reading, social interactions, what occupation they have, and how long they work — may also have an impact on dementia risk in later life.

All of these pursuits can help build up a person’s “cognitive reserve” of brain pathways that can survive the assault of the physical factors that lead to dementia.

Next steps

Researchers hope to learn much more about the cognitive reserve concept with new funding from recent federal initiatives that aim to increase dementia-related research and discovery.

Continued focus on reducing cardiovascular risk — through increased physical activity and controlling hypertension and diabetes in younger and middle-aged people — may also help reduce future dementia rates.

Growing evidence has shown that dementia in older adults is usually due to multiple causes, including Alzheimer’s disease, which is characterized by a buildup of abnormal proteins in the brain, as well as vascular dementia, which results from brain tissue not receiving enough blood due to blockages and leaks in the brain’s blood vessels.

For those who do develop dementia, Langa notes, the challenge for America going forward will be to address the need for long-term care at home and in institutions, in the face of smaller families with fewer members to act as caregivers.

Even if the slide in dementia incidence continues, the Baby Boom generation’s sheer size will mean challenges for those who fund care or provide it.

In addition to Langa and Weir, the study’s authors are Eric B. Larson, M.D., M.P.H. of the Group Health Research Institute, Eileen M. Crimmins, Ph.D. of the University of Southern California, and University of Michigan researchers Jessica D. Faul, Ph.D., Deborah A. Levine, M.D., M.P.H., and Mohammed Kabeto, M.S. The study was funded by the National Institute on Aging of the National Institutes of Health (AG00974, AG040278, AG053760, AG024824)

Reference: JAMA Internal Medicine, 2017:177(1):1-9. Doi:10.1001/jamainternmed.2016.6807.

Contact

Kara Gavin, kegavin@umich.edu, 734-764-2220

What makes a patient more likely to end up back in the hospital? Study finds surprising role for social factors

Social determinants of health and disability raise readmission risk differently for the three conditions Medicare focuses on for hospital payment

 

MeddingsANN ARBOR—No patient who just got out of the hospital wants to end up there again soon. Whoever’s paying their hospital bills doesn’t want that either.

That’s why the Medicare system has started penalizing hospitals with the highest readmission rates for certain conditions. But a new study suggests that unlike hospital gowns, such penalties should not be one-size-fits-all.

In fact, the study shows, certain social, economic, disability and personal-care factors can make a major difference in the readmission risk of people who were recently hospitalized for heart failure, pneumonia or a heart attack.

And the factors that make the most difference vary greatly from condition to condition, and are largely not something a hospital can change through treatment.

For instance, pneumonia patients who already had trouble with multiple tasks like getting dressed or cooking food, or who needed paid help at home, before their hospital stay were the most likely of all pneumonia patients to be readmitted in the first 30 days after a hospitalization, the study shows.

But for patients with heart failure, that kind of functional difficulty didn’t matter as much as money, family and race. Those who had a higher wealth level or adult children had a much lower chance of readmission – while simply being African American increased the risk of another hospital stay.

And for heart attack survivors, the most important factors boosting their chance of readmission were whether they had been in a nursing home before their hospital stay, and whether their hospital cared for a high percentage of minority patients.

The results, published in the Journal of General Internal Medicine, come from a team from the University of Michigan Medical School and Institute for Healthcare Policy and Innovation, and the VA Ann Arbor Healthcare System. They used data from the Health and Retirement Study, based at the U-M Institute for Social Research (ISR), and from Medicare, and looked at 10 measures of disability and what are called “social determinants of health.”

A model to inform change

The resulting model of readmission risk they developed could be used to predict a patient’s chances of readmission, and prompt hospitals to offer extra support such as transportation and home visits. At the same time, it could give the agency that runs Medicare a new tool for determining which hospitals truly have high readmission rates given the patients they treat.

Currently, Medicare adjusts its penalties based only on how sick a hospital’s patients are; the more severely ill, the lower the penalty. The research team started with the existing Medicare adjustments and then added the patient’s social determinants of health to assess their incremental value.

Headshot of Jennifer Meddings

Jennifer Meddings, M.D., M.Sc.

But the new study looks at factors that the hospital can’t control, such as patients’ race, education, income, social and family support, difficulty taking care of themselves, and what environment they return to after a hospital stay. Such factors have emerged in other research as crucial to a patient’s overall chance of a good outcome. But they’ve never been studied for how their impact upon readmission risk may vary among people with the same reason for their initial hospitalization.

“The relationship between socioeconomic status, functional status and use of health care is not a simple or straightforward as people might think,” says Jennifer Meddings, M.D., M.Sc., first author of the new paper and an assistant professor of internal medicine at U-M. “The impact is different depending on condition. We hope these findings will inform future adjustments in the models for readmission.”

Penalize or reward?

Meddings notes that the Centers for Medicare and Medicaid Services (CMS), which runs Medicare and pays for the care of tens of millions of seniors and seriously disabled people, has opened the door for socioeconomic status to be considered in its programs. The National Academy of Sciences has convened a committee to evaluate evidence on the topic, and present it to CMS.

“In many ways, hospitals these days are being held accountable for the failures of the social safety net, as policies have been developed and implemented to evaluate the performance of hospitals and tie payment to that,” says Meddings. “As these programs are refined, understanding the impact of social determinants of health will be crucial.”

Accounting for the social determinants of health that could be helping or hurting a hospital’s specific patient population could go two ways, she notes. Factoring these issues in to reduce or increase penalties is one way. But another would be to provide additional payment for the services that hospitals don’t typically get paid for, such as hiring social workers to connect patients with social services and resources that can help them avoid another hospital stay.

Patients who are “dual eligible” – old or disabled enough for Medicare, and poor enough for Medicaid – present a special challenge. The new study looked at Medicaid status but the sample size wasn’t large enough to determine if it played a role in readmission risk.

Meddings sees hope for using social determinants of health and disability level in health care payment, based on the fact that many of these measures are now captured in electronic medical records when a person arrives at a hospital or when they’re being prepared to leave. CMS has traditionally used Medicare claims data – how much the hospital billed the system – but mining EHR data could prove fruitful if it can be done in a standard way, Meddings says.

But, she notes, just knowing that a patient has a spouse or adult children doesn’t show how helpful those family members will be to the patient.

Meddings and her colleagues have started studying this same issue in Medicare patients who have had a joint replacement, since CMS has begun penalizing hospitals for high readmissions after a hip or knee replacement operation.

In addition to Meddings, the study’s authors are Heidi Reichert, M.A., Shawna N. Smith, Ph.D., Theodore Iwashyna, M.D., Ph.D., Kenneth Langa, M.D., Ph.D., Timothy Hofer, M.D., M.Sc., and senior author Laurence McMahon, Jr., M.D., MPH, the chief of the Division of General Medicine in the U-M Department of Internal Medicine who also holds an appointment in the Department of Health Management and Policy in the School of Public Health. Meddings also holds an appointment in the U-M Department of Pediatrics, and Smith, Iwashyna and Langa hold appointments at ISR.

The study was funded by the Agency for Healthcare Research and Quality (HS018334, HS019767) and the HRS is funded by the National Institute on Aging (AG009740).
Reference: J. Gen Internal Med DOI: 10.1007/s11606-016-3869-x  

Contacts

Kara Gavin, kegavin@umich.edu, 734-764-2220
Kory Zhao, koryzhao@umich.edu, 734-647-9069

A ‘purpose in life’ lowers risk of stroke for older adults

Senior couple on cycle ride (Photo by Thinkstock)

Photo by Thinkstock

ANN ARBOR—Among older American adults, a greater purpose in life is linked with a lower risk of stroke, a new University of Michigan study found.

Diseases like stroke can cause severe social, financial and personal burden. Therefore, recent studies have sought to uncover links between psychological factors and stroke in order to identify innovative prevention and treatment efforts.

U-M researchers used data from the Health and Retirement Study, a national survey of American adults over the age of 50. Nearly 6,800 adults who were stroke-free prior to the study were examined. The Health and Retirement Study is conducted by the U-M Institute for Social Research (ISR) and funded by the National Institute on Aging (NIA), part of the National Institutes of Health, and by the Social Security Administration.

To assess the odds of stroke incidence over a four-year period, the researchers used psychological and other data collected in 2006, along with occurrences of stroke reported in 2006-10 and during exit interviews.

Some factors analyzed included gender, race/ethnicity, education level, health behaviors (smoking, exercise, alcohol use), biological factors (hypertension, diabetes, blood pressure, BMI), negative psychological factors (depression, anxiety, hostility) and positive psychological factors (optimism positive emotions, social participation).

Participants rated their responses to a half-dozen questions, including: “I enjoy making plans for the future and working to make them a reality,” “My daily activities often seem trivial and unimportant to me,” and “I live life one day at a time and don’t really think about the future.”

“Even after adjusting for several risk factors that have been linked with stroke, the effects of purpose remained significant in all models, implying that purpose displays a protective effect against stroke above and beyond the effects of the factors we tested,” said Eric Kim, the study’s lead author and a U-M doctoral student in clinical psychology.

The study’s other authors include U-M graduate student Jennifer Sun and Nansook Park, U-M professor of psychology.

The findings appear in the current online issue of the Journal of Psychosomatic Research.

 

Contact: Jared Wadley, (734) 936-7819, jwadley@umich.edu

 

U-M’s Toni Antonucci to receive Distinguished Career Award

Toni AntonucciANN ARBOR, Mich.—University of Michigan psychologist Toni Antonucci will receive the 2012 Distinguished Career Contribution to Gerontology Award from The Gerontological Society of America, the nation’s largest interdisciplinary organization devoted to the field of aging.

Antonucci is the associate vice president for research, social sciences and humanities, at U-M, the Elizabeth M. Douvan Collegiate Professor of Psychology, and a research professor at the U-M Institute for Social Research (ISR).  She also chairs Society 2030, an innovative consortium bringing together U-M researchers and corporate leaders to prepare for society’s changing age structure. Continue reading

Why retire later? U-M experts show how to encourage longer careers

Work vs. Retirement (Image by Thinkstock)ANN ARBOR, Mich.—What if every U.S. worker got an automatic 10 percent pay raise at age 55?  According to a new University of Michigan study, most people would work quite a bit longer before they retired, to enjoy the extra income.

By eliminating social security payroll taxes starting when workers are 55-years-old, the study shows that people’s take-home pay would jump by 10.6 percent and they would work 1.5 years longer on average, paying more income taxes and helping to reduce the Federal deficit.

“People are living longer, healthier lives, and so far have opted to take most of that extra time as additional retirement rather than work,” says U-M economist John Laitner, who conducted the analysis with U-M economist Dan Silverman.   “We are proposing a way of responding to this situation through targeted tax-rate changes that would reward older workers for staying on the job and also benefit the economy as a whole.” Continue reading