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Long-Term Care and Medicare PolicyCan We Improve the Continuity of Care?
Broookings Institution PressCopyright © 2003 National Academy of Social Insurance
All right reserved.
Cristina Boccuti, Marilyn Moon, David Blumenthal, and Mark Warshawsky
The fourteenth annual conference of the National Academy of Social Insurance, held in January 2002, took on a tough challenge: to motivate attendees to be concerned about an issue of unmet need in a time of declining government revenues and economic prosperity. The baby boomers are aging, and a considerable share of them will need long-term care, as their parents do now. The conference participants addressed ways to increase both the provision and the quality of long-term care to meet these current and absolutely predictable needs and also explored Medicare's role in smoothing the transitions between acute and long-term care.
The two-day conference, entitled Long-Term Care and Medicare Policy: Can We Improve the Continuity of Care?, grappled with these issues, considering a variety of funding options in addition to Medicare. The conference chairs, David Blumenthal, Marilyn Moon, and Mark Warshawsky, asked participants to consider the impact of acute-care policies on long-term and chronic care. Their goal was to draw attention to how the segmentation of health-care provision (by setting and by payment sources, for example) can force disruptions in patient care, creating both inefficiencies and unhelpful complexities for patients and families-often during health crises. Participants provided insight into the barriers to access and affordability between stages of disease and proposed some solutions. Even the speakers, however, often found it difficult to make linkages across the varying policy and research communities.
This volume presents papers by most of the conference participants. The material is divided into five parts, organized around the conference's panel session topics. An epilogue presents official remarks from national policymakers who were keynote speakers at the conference. The authors of these papers comprise a broad range of researchers, policy analysts, and policymakers who have had a long-standing interest in the area of long-term care. In many ways the issues raised are similar to those they have expressed over the past twenty years. Little progress has been made in resolving these issues, however, although in some areas greater awareness and consensus has evolved.
First, there is a recognition that long-term care, which provides supportive services to help infirm individuals with their basic functioning, cannot and should not be thought of as fully separate from the care provided to those with chronic conditions. Both raise issues concerning acute medical care. Good chronic care can reduce long-term-care needs, and long-term care may be an essential part of treatment for those with severe chronic conditions. These areas are often separated, however, by sources of financing, by experts in each area who inadequately communicate with one another, and by attitudes regarding acute versus long-term care. Indeed, although the conference sought to bring these issues together, this proved to be a difficult task for most participants.
Second, caregiving is raised as a major theme by many of the authors, who stress the need to incorporate the wishes of the patient and his or her family or other caregivers. Third, the limitations of Medicaid in meeting the long-term-care needs of Americans are well understood. An insurance approach would not only guarantee that people would receive good care when they need it but would allow them to maintain financial security, as well.
However, the next step, consensus on how to achieve protection for persons in need of long-term care, is still beyond our grasp. The biggest divide is over whether to rely on the public or the private sector for both the resources and structure for an improved long-term-care system. Unlike the debate in the 1980s over long-term-care approaches, expectations for major public resources to help support individuals have been scaled back considerably. Proposed solutions seem to be limited to incremental approaches, even from those who believe that personal responsibility can never fully fill in the gaps.
Chronic and Long-Term Care: What Are the Needs?
Part 1 of this volume provides a description of the needs of long-term-care recipients and the methods by which they receive services. The authors also present a number of aspects of chronic and long-term care that need attention and improvement, particularly with respect to individuals' access to care and provider reimbursement. Quickly evident in this section (and throughout the book) is the range of definitions applied to the term long-term care.
Christine Bishop, of the Schneider Institute for Health Policy, presents her understanding of critical definitions: what is long-term care, who needs and uses it, and who supplies it. Bishop writes that an important theme in chronic and long-term care is its principal reliance on basic human intervention rather than on technology and medicine. That is, people who need long-term care are defined by their dependence on human assistance to accomplish everyday activities. Bishop notes that though rates of disability increase with age (approximately 35 percent of people age 85 and older live with a disability), about 20 percent of the disabled adult population is under the age of 65. Furthermore, recent research has shown a decline in disability rates attributable, in part, to advances in acute care.
Bishop raises a crucial point, echoed throughout the conference: the most important providers of long-term care are the patient's family and friends, but policy concerns tend to focus instead on the most expensive provider, the nursing home. Indeed, the majority of adults with long-term-care needs reside not in nursing homes but in their communities, though tracking more precisely the time and dollars expended for indirect and unpaid caregiving is difficult with the survey tools currently available.
Offering additional insight into the realities of long-term care in the United States is Robyn Stone, from the Institute on the Future of Aging Services. Stone notes that, despite the high statistical likelihood that policymakers will be touched by the issue of long-term care, either directly or indirectly, there is a strong disconnection between the public financing necessary to help defray those costs and the incentives it creates. Out-of-pocket expenses for long-term-care, for example, are high-accounting for one-third of the national long-term-are bill, not including the value of unpaid work provided by family members. Furthermore, federal barriers to integrating Medicare and Medicaid impede a cohesive delivery system, except in a few exemplary cases. Private long-term-care insurance covers only a small proportion of our long-term-care expenditures. Stone asserts that this market remains largely unavailable because few individuals can afford the products.
In contrast with acute care, where medical cure is the focus, patients and their families want long-term care to focus on quality of life. Therefore, Stone suggests, adequate consumer information on nursing-home quality requires further development and commitment from the Centers for Medicare and Medicaid Services. Public information campaigns should also encourage consumers to learn more about long-term-care options before they experience health crises-a difficult charge, considering the unwillingness of many to anticipate living with a chronic, debilitating illness.
Robert Friedland, of the Center on an Aging Society, raises concerns about the quality of care that can be provided when payment for services along the continuum of illness is divided into discrete units. Comparing long-term-care coverage to a jigsaw puzzle, Friedland comments that though different incentives and eligibility criteria, when combined, make for a collection of pieces that can help, they have not yet been sorted into a coherent package of affordable long-term-care options. Family caregiving currently fills in much of the gap.
It is because of this family support that many people needing long-term care can live at home and, depending on where they live, find community-based services, turning to nursing homes only as a last resort. Friedland outlines some of the other long-term-care settings (for example, group homes and assisted-living facilities), reinforcing the observation that long-term care has a broad definition. Furthermore, options for anticipating the financial risk consist mostly of saving, moving into an insured continuing-care retirement community, and purchasing long-term-care insurance.
These options can be expensive, as acknowledged by Maribeth Bersani, from Sunrise Assisted Living. Speaking from the provider community, Bersani notes that innovations in assisted living are seen primarily in private-pay markets that serve wealthier consumers. In line with Stone's call for more consumer choice and facility accountability, Bersani stresses that in her organization active ombudsmen, representing residents, challenge their facilities to find a balance between patient freedom and patient safety.
Ingrid McDonald, from the Service Employees International Union, provides insight into the work-force crisis occurring in facilities like those Bersani represents and, even more so, in nursing homes. McDonald cautions against accepting shortsighted solutions that perpetuate the already high turnover rates in staff. McDonald states that primary considerations for increasing worker retention should address three essential aspects: wages, workload, and work environment. In light of Bishop's and Stone's characterization that patients' chronic- and long-term-care needs depend most heavily on human assistance, improving the situation of workers in the long-term-care industry is especially relevant to achieving quality care.
Paul Yakoboski, from the American Council of Life Insurers, writes that the relatively low level of participation in the long-term-care insurance market is a function of its youth, having been in existence for only fifteen years. He suggests that to increase participation, consumers need to be informed that long-term-care insurance is primarily an issue of individual retirement-income security: in 2000, the average yearly cost of staying in a nursing home was $55,000. Furthermore, in research conducted by the American Council of Life Insurers over the past year, 98 percent of insured individuals said that preparing for long-term-care expenses is an important part of their retirement planning. This interest, therefore, suggests that, as Robyn Stone also notes, consumer education is critical, especially with the aging of the baby boomers around the corner.
Although these authors approach long-term care from different points of view, on some issues they all agree. For example, all comment that workforce issues need further attention, especially considering the importance of valuing and quantifying home-care needs. Several authors also note that public financing can be inadequate in many cases and that targeted increases in reimbursement could be helpful. Most agree that the expansion of private insurance products could benefit the industry of long-term care as well as the beneficiaries of that care.
Care for the Elderly and Disabled under the American Social Contract
Although this book's title juxtaposes "Medicare" and "long-term care," Medicare does not specifically cover long-term care. Through postacute care benefits (that is, home health care and skilled-nursing-facility services), Medicare covers some of the same services needed by long-term- and chronic-care patients. This overlap, however, has never been an explicit commitment to financing long-term care. To open part 2, Theodore Marmor, a professor at Yale University, offers an explanation for why long-term care is absent from Medicare's operational and political agendas, relying primarily on historical decisions and events. Marmor posits that Medicare was designed as the first step toward universal health insurance against the costs of acute episodes of illness or injury, and thus its scope was narrow from its inception. He argues further that the role of Medicaid as a means-tested program covering room and board, as well as specific services, for low-income nursing-home residents has effectively prevented Medicare from expanding into long-term-care coverage. In this respect, Medicaid offers both social and medical benefits. However, Medicaid, by design, does not provide the social effect of income protection-a benefit that is currently available only in the private market. Moreover, Marmor asserts, there has been steadily growing support for market-based initiatives, under the premise that governments do not work. Marmor notes an important distinction between private insurance and social insurance: whereas private insurance links the premium costs to beneficiary risk, under social insurance an individual's financing contributions are not proportional to his or her expected health-care use. Social insurance disconnects experience from premiums. In Medicare, for example, people contribute a proportion of their wages; under private insurance, members are charged a premium based on an actuary's estimation of their likely use of medical care. In this regard, Marmor argues, long-term care is an ideal candidate for social insurance, whereby people of all incomes, ethnicities, and medical conditions can contribute a small share of their incomes against the possibility of needing extremely expensive services.
In addition to the elderly, Medicare's social contract includes people with disabilities under the age of 65-a segment of the Medicare population often overlooked in popular press accounts. Among the many chronic conditions that render individuals disabled enough to qualify for Medicare is HIV/AIDS. Indeed, notes Chris Collins, of the health policy consulting company Progressive Health Partners, almost one-quarter of federal spending on health care for HIV/AIDS comes from the Medicare program. Collins presents findings from field research he conducted with June Eichner, of the National Academy of Social Insurance, investigating the role of Medicare in financing HIV/AIDS services. They observe several problems that are not unique to the disabled population but are particularly troublesome for those with HIV/AIDS (such as the twenty-nine-month waiting period and the absence of prescription drug coverage). Collins and Eichner report that the Medicare application process has been an entrance barrier to the Medicare program, as is declining physician participation. When disability can be linked to medical conditions, Medicare can play a substantial role.
Excerpted from Long-Term Care and Medicare Policy Copyright © 2003 by National Academy of Social Insurance
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