View Research by Author - Brenda Spillman

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Relatively little is know about the implications for Medicare spending of downward trends in old age disability in the United States between the mid-1980s and the end of the century. This is in part because uncertainty persists about the extent to which the aggregate disability declines reflect improvements in health versus improvements in the technology, service, and physical environment. This study examines Medicare spending and utilization that occurred over the period of declining disability between 1984 and 1999 and how it differed from what might have been expected had disability not changed and discusses implications for the relationship between disability, Medicare spending, and health. Projections are developed under various assumptions about how disability and spending are likely to change over the over the next several years.

One of the most intriguing aspects of recent declines in old age disability is the concurrent increases in use of assistive devices among older persons with disability, and in particularly in use of devices for all disabilities without human assistance. This study updates information on trends in assistive device use and characteristics of device users; examines differences in the hours of care received by persons who do not use devices and those who use devices with and without help; and discusses implications for multivariate modeling of the relationship between device use and hours of help and other outcomes. Data are from the 1984 through 1999 rounds of the National Long Term Care Survey (NLTCS), which has been the key source of earlier information on trends in equipment use.

This review of existing estimates confirms an upward trend in the number of facilities, beds, and residents in residential care alternatives to nursing homes, often collectively referred to as "assisted living." Estimates vary substantially, however, depending on the methodology and the type of data used. Key sources of differences are population included (i.e. aged, all ages); definition used to identify assisted living, and for population-based surveys that include both community and facility settings, survey-specific definitions of "facilities" and whether settings identified as assisted living are limited to those meeting the survey-specific facility definition. Greater disagreement exists with respect to trends in the number of nursing homes and users, even between estimates from the same data source.

Older adults with disabilities increasingly are entering residential care alternatives to nursing homes. This study used Medicare Current Beneficiary Survey data for 1992-1998 to compare the characteristics of nursing home and alternative facilities and residents. The proportion of elders in alternative residential care settings increased from 0.8% in 1992 to 1.3% in 1998, and characteristics of facilities and their residents suggest that alternative settings are caring for a more disabled clientele over time. Blacks, long under-represented in nursing homes, increased as a proportion of nursing home residents, but growth in alternative settings was disproportionately among whites and others. Further research is needed to understand the implications of these trends.

Considerable evidence suggests that disability prevalence among older Americans has fallen, but less is known about how to promote further declines. This report develops and begins to demonstrate a framework for comparing population-level effects of interventions. We reviewed the literature for seven interventions and conducted simple modeling exercises. Evidence is strongest for exercise programs that increase strength, balance, and physical activity; depression screening with referral and feedback and therapy with pharmacologic treatment; and multi-factor fall prevention programs. Little evidence exists about the long-term effects of such interventions. Both short and long-term effects are critical when evaluating the population-level impact of such interventions.

Although the prevalence of late-life disability has been declining, how to promote further reductions has been unclear. We developed an analytical framework that compares the effects of different interventions on the prevalence of late-life disability. We considered three potentially high-impact intervention strategies: physical activity programs, depression screening and treatment, and fall prevention. We conclude that in the short run multi-component fall-prevention efforts have the greatest impact. At present, longer-term impacts cannot be assessed based on the current literature and may differ from short-run conclusions, since increases in longevity may temper the effect intervention strategies have on prevalence of late-life disabilities. (Milbank Quarterly 84(3): 493-520, 2006.)

This article attempts to resolve previously published inconsistencies across national surveys in trends in activity limitations among the elderly. The authors prepared estimates from five national surveys from 1982-2001, and investigated sources of the inconsistencies. The panel found consistent declines of 1%-2.5% per year for two commonly used disability measures: difficulty with, and help with daily activities. Mixed evidence was found for the use of help or equipment. The panel found that the period, definition of disability, treatment of the institutionalized population, and age standardizing of results affected results. The implications of the findings for policy, national survey efforts, and further research are discussed. (Freedman, VA, E Crimmins, RF Schoeni, B Spillman, H Aykan, K Land, J Lubitz, K Manton, L Martin, D Shinberg, T Waidmann. 2004. "Resolving Discrepancies in Old-Age Disability Trends Across National Surveys: Report From a Technical Working Group." Demography 41(3):417-441.)

Recent research indicating a downward trend in age-adjusted chronic disability among older Americans has caused some to speculate that the declines will moderate future health costs. This study examines the trend's underlying components using data from the 1984–1999 National Long-Term Care Surveys to better understand the declines and potential implications for acute and long-term care costs. The reductions occurred primarily for activities like financial management and shopping. Assistance with personal care activities associated with greater frailty fell less, and independence with assistive devices rose. Institutional residence was stable. More needs to be known about the extent to which disability declines reflect environmental improvements allowing greater independence at any level of health, rather than improvements in health, before concluding that the declines will mean lower costs. (The Milbank Quarterly 82(1): 157–94, 2004.)

Using data from the 1997 National Survey of America's Families and county-level data on local safety net conditions, the authors find little variation in utilization and access among low-income adults by local safety net conditions, but very large differences by insurance status, after controlling for individual demographic characteristics and health care market characteristics. This suggests that expanding insurance coverage would be a more effective tool for increasing health care use and access among low-income adults than expanding the safety net.

This study explores the properties of an integrated income and disability annuity as an alternative framework for long-term care financing, demonstrating that pooling disability and mortality risks can reduce the need for medical underwriting, and discussing private and public implications. Specifically, a simulation indicates that pooling these competing risks can reduce the costs of both the income annuity and the disability coverage and expand the medically eligible population to 98 percent of 65-year-olds. Combining income and disability protection may be able to expand private markets for long-term care financing beyond what appears possible in the conventional long-term care insurance market, and is only one of multiple models that could be considered for long-term care financing. Public policy should foster innovation in financing mechanisms and avoid the distortion of choices created by exclusive policy focus on a conventional insurance model. (Journal of Aging and Health 15(1): 45–73, 2003.)

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