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Table 6.

Percentage and Number of Medicare Beneficiaries in High- and
Low-Cost Spending Groups with Selected Chronic Conditions, 2001

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Source: Congressional Budget Office based on data from the Centers for Medicare and Medicaid Services.

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Illustrative Criteria for Targeting Future Medicare Beneficiaries in High-Cost Spending Groups

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Source: Congressional Budget Office based on data from the Centers for Medicare and Medicaid Services.
Notes: A chronic condition is a diagnosis of asthma, chronic obstructive pulmonary disease, chronic renal failure, congestive heart failure,

coronary artery disease, diabetes, or senility in at least one month. Multiple chronic conditions comprise two or more of those seven
conditions. Spending is reported in 2005 dollars.
n.a.= not applicable.

Senator KOHL. We will now call our second panel. The first witness on the second panel is from Arkansas, and so we would like to recognize Senator Lincoln to introduce her constituent.

Senator LINCOLN. Well, thank you, Mr. Chairman, and as our panelists are taking their seats, I have a real pleasure today to introduce Dr. William J. Evans, who is director of the Nutrition, Metabolism, and Exercise Laboratory in the Donald W. Reynolds Institute on Aging at the University of Arkansas for Medical Sciences, UAMS, where he is also a professor of geriatric medicine, physiology, and nutrition.

Dr. Evans, I just have to say I routinely bring up the Don Reynolds Institute on Aging and ỦAMS in this Committee and in the Finance Committee, so I am so pleased that I now have a representative from there who can speak to the tremendous work that's going on in terms of the dealings with multiple disease diagnosis and coordination of care.

Dr. Evans is also a research scientist in the Geriatric Research, Education, and Clinical Center in the Central Arkansas Veterans' Health Care System. He is author or co-author of more than 190 publications and scientific journals. His research has examined the powerful interaction between diet and exercise in elderly people. Along with Dr. Erwin Rosenberg, Evans is the author of Biomarkers: The Ten Determinants of Aging That You Can Control, and the author of Astrofit.

His work has been featured in numerous newspapers, including the New York Times, the Boston Globe, the Chicago Tribune, as well as the CBS Evening News, CBS Morning Show, 20/20, CNN, and the PBS Series, the Infinite Voyage.

His landmark studies have demonstrated the ability of older men and women to improve strength, fitness, and health through exercise, which we all want information for, even into the 10th decade of life. I am not sure that he has met my husband's grandmother, who is 108 this year, living out in Parkway Village, Dr. Evans, so she is a great one to consult.

Dr. Evans receives grant support from the National Institute of Health, the Veterans Administration, NASA, private industry, and other sources. He is a fellow of the American College of Sports Medicine, and the American College of Nutrition, and an honorary member of the American Dietetic Association.

I am enormously proud to be here to introduce you to Dr. Evans and to share your wealth of knowledge with this Committee and I thank the Chairman and the two Senators here, Chairman Smith and Chairman Kohl.

Dr. Evans. Thank you Senator Lincoln. It is a real honor and pleasure Senator Kohl. Thank you, and we will just go through it, and then we will get to your testimony.

Senator LINCOLN. Oh, good.

Senator KOHL. Our next will be Bill Herman who is vice president of Human Resources at High Smith in Fort Atkins in Wisconsin.

Highsmith has been nationally recognized for its innovative employee wellness programs, and so we are pleased that Mr. Herman is here today to share the keys to the success of his company. Thank you so much for being here.

Senator Smith, would you like to welcome your guest?

The CHAIRMAN. Thank you, Mr. Chairman. It is my privilege to welcome our next witness as well, Mr. Stephen J. Brown, president and CEO of Health Hero Network, founded in 1988. His company is a recognized leader in the development and implementation of innovative technologies used to monitor or manage traditionally high-cost patients.

Their technology is currently being used by a number of institutional health care providers, including the Veterans' Administration, to more efficiently manage patients with heart failure, pulmonary cardiovascular disease, diabetes, asthma, post acute care, mental health, and many other chronic conditions.

Additionally, Health Hero Network and Bend Memorial Clinic in Bend, OR, are partnering to see how this technology can be used to coach and monitor Medicare patients with severe chronic illness and prevent them from going to the hospital and developing further complications.

So we thank you, Stephen for being here, and I look forward to hearing more about your technologies.

Senator KOHL. Our final witness on this panel will be Dr. Steven Woolf, professor of the Departments of Family Medicine, Epidemiology, and Community Health at Virginia Commonwealth University.

Ďr. Woolf's career has focused on preventive medicine, and he is a senior advisor to the Partnership for Prevention.

We welcome you all, and Mr. Evans we will start with your testimony. STATEMENT OF DR. WILLIAM EVANS, DIRECTOR OF NUTRI

Dr. EVANS. Thank you very much. It is a real honor to be here.

I am in only the second department of geriatrics in the United States, which is an indication of the relative lack of attention toward geriatrics in this country, and it is only now changing, and so we are very fortunate to be in this wonderful new center.

As we know, attitudes toward aging have been around a very long time. As Shakespeare describes the ages of man, he says the second childishness and mere oblivion, sans teeth, sans eyes, sans tastes, sans everything.

This attitude toward aging I think is now beginning to change. I think we are at the beginning of a revolution in how we think about aging, because for the first time, we can actually separate what is biological aging from how we go about living our lives, as we have just talked about.

One of the features of aging we know is a loss of muscle. We think that that is critical. These are data from the Baltimore Longitudinal Study on Aging. The yellow line happens to be loss of muscle. This is a lifelong process. We have coined a term for it. We call it sarcopenia, and that simply means the age-related loss of skeletal muscle mass.

We think that this is an enormous problem. It leads to reduced protein reserves, the decreased ability of elderly people to respond

to stress, decrease strength and functional capacity, leading to frailty and falls, reduced aerobic capacity, and reduced needs for calories.

Recently, health care costs directly attributed to sarcopenia have been estimated. There is enormous prevalence of this problem: greater than 20 percent of people over the age of 65 suffer from sarcopenia. In the year 2000, sarcopenia could be attributed to more than $18.5 billion, which is 15 percent of total health care expenditures. That translates to an excess of $860 for each sarcopenic man and $933 for each sarcopenic woman.

A 10 percent reduction in sarcopenia prevalence would save $1.1 billion (dollars adjusted to 2000 rates) per year in U.S. healthcare costs.

This is what sacropenia looks like. These are the cross sections of the thighs of two women, a 21-year-old woman and 63-year-old woman. You can see the astonishing and remarkable change in body composition, with an impressive decrease in muscle and an equally as impressive increase in fatness.

Do elderly people respond to exercise? This is a study we did some time ago where we asked the question. We trained young and old people with bike exercise. Our older subjects gained more than 20 percent of their aerobic capacity in 12 weeks. They had regained in 12 weeks what they had lost in 15 years. But the biggest problem we think in older people is weakness. These are data from the Framingham Study showing that for women between 75 and 85, 65 percent report that they cannot lift 10 pounds, and 35 percent of men. That translates directly into reduced independence, decreased dependence on social services and other issues.

So can we get older people stronger? The answer to the question is yes. The first study we did was in older men, doing just weightlifting 12 weeks. We were able to triple their muscle strength in just 12 weeks so that many of these men who were in their mid-60's were not only stronger than most men of their age, they were stronger than they had ever been in their lives.

We were able to show the size of their muscle increased dramatically, at 15 percent. We next looked at the ability of older women to respond to this type of exercise. We know that one in two women and one in eight men aged 50 and over will have an osteoporoticrelated fracture in their lifetime. The costs of osteoporosis are tremendous and rising.

We did a simple study, again funded by the National Institutes of Health. We took post-menopausal women. We randomized them to an exercise group two days a week of weight lifting exercise versus a control group. This is what their bone density looked like. So the exercising women showed no age-related loss in bone in that year; in fact, an increase in bone density. The control group lost bone. If you look at the evidence of the new generation of antiosteoporosis drugs that are so expensive, none of them have an effect like this. They don't affect other factors related to falls related to fracture. So this one simple intervention increased strength, increased muscle, improved balance, and increased their levels of physical activity. In totality, this simple exercise program has far greater effects of reducing risk of above fracture than any medication.

Then the final studies I wanted to show you was the ability of very, very old people to respond to exercise. The first study that we did we reported in JAMA and we got a lot of press. This is a cartoon that appeared in Sports Illustrated of all places when they did a report on our study.

We did that. In another study we published in the New England Journal of Medicine that I am going to highlight. In this study, our subjects range in age between 72 and 98; 69 percent were over the age of 85. This is a population with multiple chronic disease. These were nursing home patients.

At least half of them were somewhat demented. Half of them had arthritis. Forty-four percent had pulmonary disease. Forty-four percent had a previous osteporotic fracture. Thirty-five percent were hypertensive. Twenty-four percent had a diagnosis of cancer. Sixteen percent were diabetic, and 13 percent had a myocardial infarction. They were all allowed into the study. We showed that we could triple their strength. We improved their balance, decreased the risk of falling. Their walking speed improved. Their ability to climb stairs improved. They were able to get up and move around a lot more. They told us that they didn't need to ring for a nurse in the middle of the night anymore to use the toilet. They told us that they could get up and move around and get their meals. So not only can we improve their independence, but we can improve the quality and dignity of their life.

Importantly, there was a significant decrease in depression in the group that exercised.

. So it is possible. They are quite responsive. We have a number of different very, very positive effects of this type of exercise that is enormously important and powerful. I just wanted to show a couple of statewide exercise programs that I designed. One was in Massachusetts, where I was a faculty member at Tufts University for 15 years. I designed a program for the state called Keep Moving, and every year we had an event called the Governor's Cup for Seniors, and this was the line for two of the races; lots of grey hair in there. They love these programs. We also designed a program at—when I was at Penn State, called PEPPI, Peer Exercise Program Promotes Independence, which we are now implementing in Arkansas. It says we trained community-based peer leaders using the Triple A's in Pennsylvania—very inexpensive, very effective. This is one of the groups in Altoona, PA. This is a newspaper that somebody sent me with all of the PEPPI programs that are in their community. Currently, there are 250 groups, with a total participation of more than 5,000.

A recent survey of this program showed that 82 percent say they can walk better. Ninety-five percent are better able just to get up from a seated position. Seventy-eight percent say they can climb stairs more easily. Many of them have improved balance.

Even more importantly, 99 percent of the participants state that their health has improved and 87 percent say they are more independent.

So we hope that this will be the future of nursing homes. Finally, I was privileged to be at a joint press conference with Senator Glenn after his space flight to talk about similarities between space flight and aging and found a wonderful quotation that described

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