September 2010 Archives

Medicaid, which funds more long-term care supports and services than any other payer--$115 billion in 2008--is about to crash. Like a head-on train wreck, we can see it coming. The question is: What are we going to do about it?

The Kaiser Family Foundation, in an extensive new survey of all 50 state Medicaid programs, tells the grim story. Medicaid is actually two programs: acute health care for young mothers and their kids, and long-term care for frail seniors and younger people with disabilities. According to Kaiser, enrollment rose a staggering 8.5 percent in fiscal year 2010, mostly because high unemployment drove young families to Medicaid for their acute care.

Even as enrollment rose, state spending on Medicaid fell for the second year in a row. Combined, the two years of cuts mean that states that spent $1.00 on Medicaid in 2008, spent only 83 cents in 2010--even though enrollment rose in both years.

Medicaid was kept from cratering thanks only to a huge slug of extra federal aid included in the big stimulus Congress passed last year. That federal help, according to Kaiser, more than made up for cuts in the state share of the program.

Still, 20 states cut benefits in 2010, twice the number in 2009. It would surely have been worse except that extra federal aid came with some strings, including a requirement that states not reduce their eligibility standards.

The problem is that federal help is drying up, and unemployment is not falling. Facing a bigger financial squeeze in the coming year, it is very likely that even more states will cut Medicaid services, both for acute and long-term care.

That will make the future of Medicaid long-term care services grim. It will be especially tough for those home and community based services that most seniors want. The reason: States must provide long-term care in nursing homes, but there is no such obligation for home care. As a result, states will cut where they can--in the home care program. 

The other victims: providers such as nursing homes. While states must provide skilled nursing benefits to those who are both medically and financially-needy, they are not obligated to pay those facilities that provide such care any minimum amount. In the coming year, while 22 states expect to increase rates for nursing homes, 29 will cut them. And I suspect that those that do raise them, will do so by very small amounts.

Consumers should care because these continued reductions in Medicaid payments are likely to drive some providers out of the long-term care business. And that will be bad news for those seniors who need care in a nursing facility, either because of their health status or because they have no one at home to care for them. 

The new health reform law makes matters even more complicated. It provides states with new incentives to improve Medicaid long-term care, but it also will add 16 million new low-income acute care patients to the Medicaid roles. Washington will provide states with some temporary financial assistance to help pay for those extra beneficiaries, but that aid won't last long. As long as Medicaid must provide both acute and long-term care out of the same pot, low-income seniors will never get the services they need.

In an important new study, Lynne P. Snyder and Christopher Baker show the importance of energy assistance for elders living at home. The paper, Affordable Home Energy and Health: Making the Connections, was published by AARP. It is another example of why it is not enough for states to provide Medicaid waiver programs to help people receive long-term care at home. Without additional supports, such as energy assistance, the dream of aging in place can easily become a nightmare.

The problem is that rising energy costs put low-income seniors at serious physical risk. About 900 older adults suffer either heat-related or cold-related deaths each year. But those killed directly by extreme weather are only a fraction of those who die as a result of their inability to manage very high or very low temperatrues.

Seniors are at greater risk for death from respiratory or cardiovascular disease in the high heat of summer and from heart disease in the cold of winter. Not surprisingly, those with access to central heat and air conditioning are far less likely to die than those who do not.

Snyder and Baker report that 80 percent of housholds receiving federal energy assistance through the program known as LIHEAP have at least one member who suffers from a disease that puts them at risk of extreme temperature.

This study is yet another example of why states must do a far better job of managing all the needs of low-income elders who require long-term services. These people need more than a Medicaid-paid home health aide. They need an accessible home, transportation, good nutrition, companionship, and, as this study shows, assistance with energy bills. Without a full package of assistance--and without the ability to find and access that help--aging in place is doomed to fail, despite our wishes.

Some of this help, such as transportation and companionship, can be provided by neighbors helping one another. But other services very likely will have to come from government. And unfortunately, Medicaid dollars can normally not be used for supports such as energy assistance. The Snyder-Baker paper is more evidence of why policymakers must think outside of their narrow silos if they are going to do their part to keep frail elders safe at home.     

Among the great challenges we all face as we age is where to live. We may be a bit too frail to stay in our suburban colonial, but are not nearly ready for assisted living, to say nothing of a nursing home. We could move to a traditional large retirement community such as a Leisure World, but that would mean moving to a gated community where we'd be surrounded by thousands of other seniors. No kids except for visitors. No real neighborhood beyond the clubhouse, the pool. and the shuffleboard court.

So how about this: Imagine sharing a residential home with about 10 others. The homes are located in urban or suburban neighborhoods. Each resident gets her own studio apartment with a private bath, and shares a communal den and dining room. The building is acccessible for both people with disabilities and the frail elderly, with grab bars, ramps, railings and elevators. While it is designed for those who can still live independently, it is fully staffed and you have access to a local community health center for both medical care and supportive services. The home is also set up for convalescent care, should you need it. And the cost for a typical resident: less than $2,000 per month, including meals.

The houses are private, and are not operated by the government. They can be started by non-profits such as service clubs, churches, or community groups. 

What's remarkable is that the idea of these homes is not new. Called Abbeyfield Houses, they have been operating in England since the 1950s and there are now more than 900 worldwide.

So where do I sign? Well, there are 27 in Canada, including the Parkdale House in Ottowa. But Beth Baker, who told me about Abbeyfield, says that as far as she knows, there are none in the U.S. Beth, author of the terrific senior housing book Old Age in New Age, would know.

It would be great if a local non-profit opened one. Imagine, for example, if it was linked to a senior village (a community group started by seniors to help one another) perhaps with a partnership with a local hospital or community health center. Imagine if the model became so well established that groups of friends could use the template to create small communities of their own as they aged.

We have similar models here. Small group assisted living homes and co-housing come to mind. But none quite fit the niche that Abeyfield does. If someone builds it, we will come. 

Instead of admitting patients, hospitals are increasingly keeping them under "observation status." This decision results in lower Medicare payments to the hospitals and more out-of- pocket costs for patients. But it also means that Medicare is no longer paying for some admissions to nursing homes, and is instead shifting those expenses to residents and their families. 

What's going on? It is complicated. But here is the story: In the past, if a physician felt it was appropriate, a patient was admitted to a hospital for care. However, hospitals, which are under increasing pressure from Medicare to reduce costs, are becoming more cautious about formally admitting people who may not meet government criteria for in-patient care but are too sick to go home. 

These days, this decision is often not made by a doctor, but by a computer program called InterQual.Why InterQual? Because it is the software used by the Medicare inspectors, hospitals rely on it as well. Hospitals do this because if they do admit a patient and Medicare determines later that she should have been kept under observation, the hospital must return part of its Medicare payment to the government.  

The consequences of this situation reach far beyond hospitals, however. Medicare provides limited payments for nursing home care, and in fact is the biggest payer of post-hospitalization skilled nursing care. But it will pay only after a person has been in the hospital for at least three days. And time under observation does not count towards those three days. As a result, nursing homes are not being reimbursed by Medicare for these stays, and patients are being billed for their care, sometimes without advance notice.

A few weeks ago, Medicare held a meeting about all of this and got an earful--from hospitals, physicians, nursing homes, patients, and advocacy groups. Most agreed that time spent in a hospital under observation status should count against the three day rule.

This issue begs for clarification from Medicare. The agency needs to better explain the rules for admission and observation. It should rethink a system that relies on commerical software to make these determinations. And it should require nursing homes and hospitals to explain to patients in plain language who is paying for their stay, and why.    

I spent yesterday with more than a hundred elder care professionals at the Seven Acres senior care campus in Houston. For a while they listened to me, but for much of the time I had the opportunity to listen to them. And what I heard was striking, and an important addition to the HSC Foundation's recently published study based on listening to family caregivers.

We had a wide range of professionals at this program, the 24th annual Lou Lewis Symposium in Gerontology: executives from nursing homes, assisted living facilites, and home health agencies; case managers, social workers, nurses, and maybe even a physician or two. Early in the program I asked how many had also been caregivers for their own family members. At least 80 percent raised their hands.

After I spoke, the participants broke up into a dozen small groups to come up with their own ideas for improving today's long-term care system. Not surprisingly, there were many suggestions. But there was also a striking consensus on a few broad themes.

Participants were tremendously frustrated at how poorly the system works today. Their biggest frustration may have been over the lack of communication between families and professionals and the absence of care coordination within the health system itself.

A word I heard over and over again was education. These professionals felt passionately that family members, aides, doctors, and--yes--politicians need to learn much more about how elder care works, not at a broad policy level but for individuals. The resources out there today, such as Area Agencies on Aging and Aging and Disability Resource Centers, help. But the participants thought they need to do much more. 

We talked about the need for better training for all caregivers, both family members and aides.

The participants felt strongly that community groups, local businesses and, especially, faith-based organizations need to play a greater role in caring for the frail elderly. We talked about the village movement, where seniors join together to form community non-profits to help one another. But many participants felt that churces, synagogues and other religious institutions could do much more to aid their own congregants. This assistance could come from volunteer committees who help arrange rides, friendly visits, and phone calls.

We also discused the importance of financing long-term care. This group, at least, was skeptical about whether young people would enroll in the voluntary CLASS Act. Even though this was Texas, some even felt the country would do better with a social insurance design for long-term care. But, once again, they felt that better education is the key to encouraging people to begin preparing for future long-term care needs.

I learned a lot yesterday, and I hope the participants follow up on some of their teriffic ideas.