required to evaluate the effectiveness of interventions that promote shared decision-making. To date, the Physicians’ Orders for Life Sustaining Treatment (POLST) paradigm has attempted to address these concerns, yet faces legal and political barriers to implementation in many states.12 12 National POLST Paradigm Task Force, POLST Legislative Guide, Approved February 28, 2014, available from: content/uploads/2014/02/2014-02-20-POLST-Legislative-Guide-FINAL.pdf 13Centers for Disease Control, Chronic Disease Overview, available from:, Chronic Care: Making the Case for Ongoing Care, Robert Wood Johnson Foundation and Johns Hopkins University Bloomberg School of Public Health Report, 2010, available from: 3 Incentivizing Patient Self-Care and Self-Management Patients with chronic disease account for a huge portion of healthcare spending in the US. Among older adults, 80 percent have at least one chronic condition.13 99 perecnt of Medicare spending is attributable to individuals with at least one chronic condition, and 79 percent is attributable to individuals with 5 or more chronic conditions.14 Better management of chronic disease could help patients with complex, co-morbid conditions avoid unnecessary interactions with the healthcare system, such as costly trips to the emergency room. Patient self-care and self-management initiatives encourage patients to work with their providers to maintain their health status and minimize avoidable complications. These initiatives utilize strategies, such as patient education, to encourage healthy decisions and behaviors. Patient Self-Care and Self-Management Interventions Behavioral Adherence Contracts: Behavioral contracts are often used to achieve patient adherence to medications or treatment plans by identifying motivations or positive reinforcements, problems and barriers that interfere with adherence, social supports to assist in adherence, reminder strategies, and identification of the consequences for non-adherence. These contracts have been effective in improving adherence among renal transplant recipients undergoing immunosuppressant therapy. Addressing the Health Needs of an Aging America | 26 15Bipartisan Policy Center, What is Driving U.S. Health Care Spending? America’s Unsustainable Health Care Cost Growth, 2012 Report, available from: -care-spending-americas-unsustainable-healthcare-cost-growth/ 16Agency for Healthcare Research and Quality, Patient Safety and Medical Liability Initiative, Summary of Findings, June 2014, available from: -resources/resources/liability/liability_initiative.html Numerous policy proposals related to the health of the aging lack a foundation in rigorous evidence. For a variety of reasons, including the difficulty of systematically evaluating or modeling agerelated health policies, policymakers will continue to face obstacles to evidence-based decision-making. Researchers of this study found this to be particularly true for proposals related to malpractice and the financing of long-term care. In these areas, researchers and policymakers alike should support efforts to conduct systematic research and rigorous evaluation of pilot interventions at the local, state, and federal levels. Malpractice Reform: Can It Safely Eliminate the Costs of Defensive Medicine? Defensive medicine – a practice in which physicians order excessive or unnecessary tests and treatments out of fear of a potential lawsuit – leads to somewhere between $45.6 to $650 billion per year in healthcare system spending. Proposals to reform malpractice often focus on creating evidencebased standards of care that would limit the liability of doctors who adhere to these standards.15 A cost effective, high-value healthcare system would ideally eliminate wasteful and unnecessary care associated with the practice of defensive medicine. However, there are considerable gaps in the evidence base on the potential consequences of malpractice reform on the costs and quality of care. To address this problem, some organizations have suggested expanding demonstration and incentive programs to test alternative medical liability systems following the Patient Protection and Affordable Care Act authorization of $50