Mr. Chairman and members of the Subcommittee, thank you for inviting me to testify today on the important topic of preventive benefits offered under the Medicare program.  I am Dr. Chris Himes, primary care physician and Director of Geriatrics for Group Health Cooperative, based in Seattle, Washington.  I also am a member of the Group Health Permanente Medical Group, which with 1,217 physicians, is among the largest medical groups in the state of Washington.  Group Health Permanente contracts exclusively with Group Health Cooperative. 

Founded in 1947, Group Health is a not-for-profit and with nearly 600,000 members, is the nation's largest consumer-governed health care organization.  Group Health has a long-standing commitment to serving Medicare beneficiaries.  Shortly after Medicare's creation, we began working with the government to design a program that would allow Medicare to work with prepaid health care organizations like Group Health.  In 1976, we were the first organization to partner with the government under what was then referred to as the Medicare risk program.  At present, we serve nearly 60,000 Washington state beneficiaries under Medicare+Choice. 

Since our founding, Group Health has focused on preventive care programs to help people stay healthy, while at the same time making sure people receive the comprehensive care they need when they are ill.  Pre-payment has been fundamental to our ability to pursue both of these objectives simultaneously.  Pre-payment allows us to direct resources to areas of greatest need and to be creative and innovative in designing programs.  Simply stated, when you are not paid on an encounter-by-encounter or procedure-by-procedure basis, you can shift your focus to include longer-term improvement in health outcomes.

 Group Health has developed programs related to chronic illnesses common in the elderly including depression, diabetes, and heart disease.  We also have initiatives in prevention and acute care for conditions such as breast, cervical, and colorectal cancer. At present, work is underway to unify these initiatives with other special needs of seniors, such as fall prevention.  Although the programs span a wide spectrum of health care conditions and approaches, they all reflect the collaborative relationships between an organization, patients, clinicians, and other providers.  

II.        Promoting Healthy Aging: Preventive Care Model

Today, I'd like to focus on the concept of "healthy aging" - a topic that has long been a passion of mine.  The concept of 'healthy aging' is not a magical or fanciful quest for the 'fountain of youth', but rather a clearly attainable road to being the 'best we can be' -- physically, mentally and spiritually.  Healthy aging is not dependent on high cost medical technology - although certainly, technology can sometimes extend the length of life, improve functional ability and overall quality of life. 

To achieve healthy aging, individual relationships between patients and their providers must take center stage; providers need to understand fully their patients needs, desires and things that most impact their ability to live their lives well.  Patients need to have confidence that their providers will listen and partner with them to make the best choices for their own lives and circumstances.   

With the baby boomers aging and individuals over age 85 becoming our nation's fastest growing population segment, the definition of good preventive health care models are changing and expanding.  In addition to disease prevention, the focus is gradually shifting to include a greater emphasis on helping people live with chronic illness and maintaining and improving functional abilities and quality of life.  

Helping our providers keep up with changes and the best approaches to care - including ways to promote healthy aging - is one of the most important contributions of Group Health's care delivery model.  Our focus on evidence-based medicine - a systematic approach to collecting and critically evaluating available scientific evidence on treatment options - seeks to offer practitioners and patients the information they need to make informed decisions about treatment options.  It also helps ensure that health care dollars are being spent on treatments that have proven benefits. 

For today's - and tomorrow's - Medicare beneficiaries, the growing body of geriatric literature clearly points the way.  In achieving healthy aging, studies point to the need for regular geriatric assessments and evidence-based interventions in areas known to threaten functional ability, commonly called the 'geriatric syndromes' (e.g., physical inactivity, depression, urinary incontinence, falls, cognitive impairment, medication-related complications and poor nutrition).  For the most part, these interventions are low cost and do not involve advanced technologies.  Yet, studies have clearly shown that assessments, certain interventions and close follow-up of these syndromes can help avoid deterioration in health and costly complications, while dramatically improving the quality of life for seniors in six to twelve months.  From a medical perspective that is a relatively fast timeframe for improvement, especially when considering that beneficiaries often experience geriatric syndromes for lengthy periods of time. 

IV.       Group Health's Work to Improve Beneficiaries' Health and Well-Being Through Exercise

Today, I want to focus on perhaps one of the best examples of a low-cost, low-technology intervention that can have a dramatic impact on seniors' health and well-being: Group Health's simple, but pioneering research and resulting strategies in promoting senior fitness. 

Group Health not only has focused on learning from the geriatric literature, but also has made significant contributions to it over the last twenty-five years.  In the 1980s, researchers from Group Health's Center for Health Studies and their colleagues at the University of Washington examined key determinants of overall health outcomes for seniors.  The results were quite clear. There are only two statistically significant predictors: social isolation has a negative impact on health, while regular physical activity had a very positive effect on health.  In assessing the types of physical activity, the researchers found - and many others have since validated - that in addition to endurance activity, such as walking, gardening, swimming, muscle strengthening and flexibility exercises are also important, especially for seniors with functional deficits or balance problems as they age.    

The joint Group Health-University of Washington work led to the development of an exercise program known as Lifetime Fitness, offered by Group Health at local senior centers through a community partnership with Senior Services of Seattle-King County.  Group Health paid the start-up costs for the weights used for muscle strengthening and the training and salaries for the exercise instructors.  Senior centers provided the space and logistics for the classes, which were offered to all comers in the community, three times a week in five-week sessions.   

Each class has segments that focus on improving balance, flexibility, and aerobic capacity.  Participants perform exercises both standing up, holding the back of a chair for balance, as well seated in chairs.  In addition to the actual exercise components, the class offers participants a chance to socialize - they talk about their weekends, their grandchildren, and visits with their families.  Couples exercise together; group lunches are occasionally arranged after class.   

Based on the positive response from participants, Group Health soon expanded the availability of classes throughout our entire service area by partnering not only with community senior centers, but also with YMCA's.  Lifetime Fitness is now offered in 34 locations.  

To further contribute to the evidence-base in healthy aging, the same Group Health Cooperative-University of Washington research team, in partnership with Senior Services of Seattle-King County Health Enhancement Project, developed and tested a model of geriatric assessment with accompanying interventions and follow-up by a nurse practitioner.  Over the study period, a nurse practitioner stationed in a senior center that offered Lifetime Fitness classes performed regular assessments on patients 70 years and older from Group Health and Pacific Medical Center who participated in Lifetime Fitness.  The improvements in health and well-being were dramatic as evidenced by reductions in "geriatric syndrome visits."  The nurse practitioner, along with a social worker, was able to demonstrate significant cost and utilization savings - a 72 percent reduction in six to twelve months.  

It became clear that regular exercise was key to the intervention's success.  The study's positive findings with respect to avoided deteriorations in health and costly complications served as a catalyst for Group Health to move regular assessment and intervention support into all primary care settings.  Senior Services, a local not-for-profit organization, also expanded the Health Enhancement Program to senior centers around the country. 

IV.              Integrating Fitness into Group Health's Medicare+Choice Plan

Once we understood that increasing physical activity for all seniors was the most important key to healthy aging, Group Health began to develop a "full spectrum" of exercise opportunities that could be individualized according to patient preference and ability.  Whether robust and healthy or frail, living independently or in nursing homes, Group Health is working to bring the benefits of exercise to all our Medicare members.  Today, in addition to Lifetime Fitness, Group Health offers Medicare+Choice enrollees a benefit called "Silver Sneakers" which enables them to join local health clubs and YMCA's at which they can take senior-focused fitness classes.  At present, 1,300 Medicare beneficiaries participate in Lifetime Fitness, of whom 1,000 are Group Health Medicare+Choice members.  Nearly 10,500 Group Health Medicare+Choice members have participated in Silver Sneakers.  In April alone, 3,748 Group Health Medicare beneficiaries - 6.3 percent of our membership - used their Silver Sneakers benefit.  

In addition, Group Health is 'rolling out' our new geriatric assessment protocol to all primary care clinics.  Physicians will be asked to write 'exercise prescriptions' for all of their senior patients and to conduct regular follow-up on their progress.  We have developed a set of tools and supports, as well as planned training for all practitioners in addressing and monitoring geriatric syndromes.  The key message in this training is that recommending exercise is among the most important prescriptions to write, individualize, and assure compliance. 

While these two exercise programs have been overwhelmingly successful in improving quality of life, they are beyond the ability of many seniors with disabilities and multiple chronic diseases.  These seniors, however, often have the most to gain from increasing physical activity.  Virtually all guidelines and care coordination programs for conditions such as diabetes, heart disease, chronic obstructive pulmonary disease, hypertension, depression, osteoporosis, arthritis, to name a few, call out exercise as a central strategy to improve health.  

Let me give you a few examples of why this can be so effective and life changing for the most frail among us.  Group Health currently has an exercise program beginning at our nursing home, Kelsey Creek, and has started our first program in a retirement community next to one of our clinics.  For several years in my own practice, I have written exercise prescriptions based on individual needs and preferences for all senior patients, promoting the value of regular exercise in managing virtually every medical condition and disability.  In doing so, there was a particular group of patients who caught my attention - my patients who visited me often with various ailments and complaints that did not have a specific etiology.  Simply stated, they were in 'downward spirals'. 

As I did with all my patients, I encouraged them to exercise and get out socially but they just couldn't.  They lacked the motivation and will, and they had real obstacles -- chronic pain, significant medical diseases and functional deficits, depression, social isolation, lack of transportation; the list goes on.  Perhaps most importantly each of these people was facing huge losses - death of their spouse, a move from their life long home to a retirement apartment.  They felt like they were simply burdens on their families and friends.  They most common word they used to describe themselves was 'useless'. 

I knew that these were the very people who would benefit most from an exercise regimen so I decided to start a muscle strengthening and flexibility program at Group Health's Northgate Medical Center, where I practice, tailored specifically to their needs and disabilities.  I asked this group to commit to coming to class three times a week for four and a half months, stay for lunch together once a week after class, and participate in a community performance at the end to share with their families and community all I knew they would accomplish.  Within weeks I could see them getting stronger, becoming an incredible support group for each other, and perhaps most importantly, truly embracing and enjoying life again. 

It's been two and a half years since the first class, and they are still coming.  Some have died, they are old and frail.  But at their funerals, each of their families talked about how much better their mom's last year of life had been as a result of the 'dancing ladies and their few good men' program.  As for the rest, I don't see them as much for these 'unspecified ailments', though I regularly see them at the lunches and in class where we talk about a whole range of healthy aging issues.  With sponsorship from Group Health, the group recently made an exercise video of this class to be used as an inspiration and entry-level in-home exercise option for our frail populations. 

IV.       Updating Medicare To Include Benefits that Promote Healthy Aging

Limited health care resources mandate that physicians, health plans and payers alike identify new and innovative ways to improve the overall health outcomes for the Medicare population and control costs.  Care coordination programs for high-risk, high-cost conditions have and continue to promote cost-effective delivery of services and avoid deteriorations in health.  That said, we as a nation must persist in looking 'upstream' for additional strategies.  In my view, one such strategy is the promotion of healthy aging. 

Regular geriatric assessments and follow-up of geriatric syndromes are key to healthy aging.  The most important of these follow-up activities is increasing regular physical activity for all patients, whether they are healthy or frail.  We know that fitness can make a difference not only in terms of beneficiaries' physical and mental well-being, but also in terms of expenditures.  A recent controlled analysis of health cost and utilization of 1,124 Group Health Medicare+Choice members enrolled in Lifetime Fitness who were compared to 3,342 age and gender "matched" control beneficiaries.  The baseline per year expenditures on members of the control group and individuals who participated in more than 120 Lifetime Fitness Classes were virtually the same: $3,932 and $3,940 respectively.  However, the change in the subsequent year's expenditures differed dramatically: costs for individuals who did not participate in Lifetime Fitness increased by $1,175, while costs for Lifetime Fitness participants decreased by $71.  The study also showed that costs for members who increased their participation by just one time a week decreased by 14 percent, while the annualized number of inpatient days fell by half a day.  

Writing and assuring compliance with exercise prescriptions is the single most important intervention physicians can do for their patients.  Health plans need to continue to develop a full spectrum of exercise opportunities for their members and their communities, in partnership with community, private and governmental organizations.  Toward this end a national effort, cosponsored by the Center for Disease Control and the Robert Wood Johnson Foundation, is currently underway bringing health plans, government agencies, seniors themselves and community organizations together in support of the 'National Blueprint on Increasing Physical Activity Among Adults Age 50 and Older'.  The Blueprint work will continue to support the development of the exercise and behavior change literature base, as well as broadly 'spreading the word'.  Group Health, as well as many others like us, fully embrace and support this work, understanding its central importance to the health of the health, our members, and ourselves.  

IV.       Updating Medicare To Include Benefits that Promote Healthy Aging

There is no doubt that the Medicare benefits package needs to be updated.  As a practitioner, I applaud Congress' work in recent years to improve the availability of important preventive benefits for our nation's Medicare beneficiaries.  But as I have presented here today, prevention of illness or deterioration in health does not always result from a screening test, but rather it can result from even more simpler, fundamental, low cost approaches like fitness programs.  As Congress continues its work in this important area, I urge you to continue to think creatively and to take a broader perspective on seniors' health.  

Our Medicare members have told us loudly and clearly that they want to live life fully with dignity and grace.  Group Health is committed to fulfilling their request.  As you can tell, we are proud of our accomplishments, but we know that more can and must be done to ensure that all Medicare beneficiaries achieve 'healthy aging.'  We again want to thank you for the opportunity to share our work in this area and to contribute to the Subcommittee's deliberations on this important issue.