November 2010 Archives

For seniors trying to manage multiple chronic disease, moving from one care setting to another can literally be a matter of life and death. That's why it is so important that health providers--doctors, nursing homes, hospitals, assisted living facilities, and home care agencies--work together to make sure that those moves happen safely.

Too often in our poorly coordinated health and long-term care systems, those transitions fail: Somebody loses track of a medical record, fails to correctly administer an important medicine, or repeats an unnecessary, costly and uncomfortable test. Transitions even within hospitals are notoriously dangerous. When they require cooperation of different providers, the risks are even greater.

Transitional care was the subject of the Gerontological Society of America's annual meeting this week in New Orleans. Just the fact that physicians, social workers, nurses, and academic researchers spent five days talking about this topic was hugely important. It is evidence that the issue is finally getting the attention is deserves.

Even better news: There are transitional care models that both improve patient health and save money. New training programs are making doctors, nurses, and aides aware of the importance of careful transitions and teaching them how to better accomplish them. Other programs work with families to help make them strong advocates for patients during these challenging moves. And models such as those developed by Eric Coleman at the University of Colorado, Mary Naylor at the University of Pennsylvania, and Chad Boult at Johns Hopkins University, have all redesigned the systems we use during transitions.

At the same time, old models are being improved. Palliative care programs do a great job combining medical treatment with social and spiritual care as well as symptom management to improve outcomes for patients. But now they are being better integrated into hospitals and physician practices--a key element to their success.   

On the other hand, it was clear how far we have to go, especially in our wildly inefficient fee-for-service health system. Discharge planning in both hospitals and nursing homes continues to be a broken link in the chain of care. Too often, patients are sent home or to a nursing facility without an appropriate care plan in place. Discharge planners are overworked and ill-prepared, and too often the focus is on a quick discharge rather than a good plan. 

In addition, while many creative experiments are sprouting up all over the country, it was clear from listening to researchers that we have a lot to learn before we know which will work and which will disappoint. 

On December 13 and 14, I'll be participating in an important conference in St. Louis on ways to better integrate care for chronically ill seniors. Sponsored by the Catholic Health Assn., the program will bring together health providers to share successful ideas and help work though some of the financial and medical challenges to better coordinating care.   

It is a tough time to try to sell long-term care insurance.  The private market was stunned on Nov. 11 when MetLife, one of the nation's biggest carriers with insurance on 600,000 lives, announced it would stop selling new policies. At the same time, surveys by two of the nation's most respected long-term care researchers suggest why it will continue to be very difficult both for private companies to sell coverage and for the federal government to succeed in its new national long-term care insurance program--the CLASS Act.

CLASS is the national, voluntary, government-sponsored long-term care insurance program that was passed as part of health reform. It would provide people who need personal assistance with an average minimum daily cash benefit of $50 for life.  

At a conference on Tuesday, Josh Weiner of the research firm RTI International reported that a new survey of potential consumers showed very little interest in a CLASS-like product. The survey, taken in Hawaii last summer, found that 60 percent of respondents said they favored the public insurance program. But only one-fifth thought they'd buy coverage. A quarter said they would not, and more than half didn't know--not surprising for a product that was so new and unfamiliar.

But Josh also asked how much people were willing to pay for coverage. And those responses were far more ominous for the future of the program. Twenty-three percent said they would not enroll. Nearly 60 percent said they'd pay no more than $40 a month, and 17 percent said they'd pay no more than $80. Only 1.5 percent said they'd pay between $80 and $120, and the same number would be willing to spend more than $120.

This is very bad news since most independent analysts figure CLASS premiums will average at least $120-a-month.  It does not mean that only 1.5 percent of potential buyers will purchase, but it shows what a tough selling job the government will have to convince people to buy--a marketing campaign that private insurance has so far failed to pull off for its own long-term care products.

Btw, Josh also asked what people thought of mandating private long-term care insurance--an idea I strongly support. One quarter agreed, 20 percent didn't know, and almost 60 percent opposed the idea. Honestly, I thought it would be worse.

The second survey was done by Marc Cohen of the consulting firm Lifeplans on behalf of the insurance industry. This national survey asked about long-term care insurance in general, not just CLASS

While Marc found that price matters, he also learned that attitudes may be just as important. He concluded that buyers shared several key attributes that non-buyers did not. They were more likely to believe they'd need care at some point in their lives, had a much better idea what it would cost, realized they or their family would have to pay these costs, and were "planners" who felt the need to prepare for future care needs.  His conclusion: People are willing to buy, but only if they perceive value.

The co-chairs of President Obama's bipartisan deficit commision have proposed a far-reaching plan to reduce the nation's massive deficit. It includes big changes for both current and future seniors. Among them: higher Social Security taxes and reforms in the design of benefits, reduced payments to Medicare providers and greater cost sharing by Medicare beneficiaries, and, perhaps most dramatic, a fundamental change in federal payments for Medicaid long-term care.

The chairs, Erskine Bowles--who was chief of staff to President Clinton, and Alan Simpson--a former Republican senator from Wyoming--released their draft plan today. Their proposal still must win the support of 14 of the 18 members of the bipartisan commission, which will be an uphill battle. If the group can reach a consensus, the panel's plan would be presented to Congress in early December.

The Bowles-Simpson plan makes cuts throughout government, including defense and most domestic spending programs. It also includes $750 billion in tax increases over 10 years. While much of what the co-chairs proposed will be hugely controversial, their plan shows what it will take to put the nation back on a firm fiscal footing.

In such an environment, long-term care services can't expect to be immune from cuts. Their biggest proposed change: capping the federal contribution for Medicaid long-term care.

Today, the federal government must automatically pay its share of the cost of these services, no matter how fast they rise. The feds contribute an average of about 60 percent of the cost of Medicaid, although the share varies from state to state. Bowles and Simpson would, for the first time, place a ceiling on the federal match for this joint state/federal program, reducing the federal contribution by about $90 billion from 2012 to 2020.

This would place a tremendous increased burden on states and likely result in both lower payments to nursing homes and home health agencies, and tougher eligibility standards and lower benefits for frail seniors and younger people with disabilities.

No doubt these proposals are harsh, but, like them or not, changes such as these are inevitable. They are a big reason why we must find a way to replace Medicaid long-term care with an insurance program.        

There is lots of quiet speculation in Washington about the fate of the CLASS Act in the wake of the huge Republican 2010 election day victory. Will CLASS be repealed? Will it be changed in any major way?

My best guess is that CLASS--the national voluntary long-term care insurance program passed as part of the 2010 health reform law--will neither be repealed nor fundamentally changed, despite the GOP threat to roll back the entire health law. 

That is not to say conservatives won't try. Activists at the Heritage Foundation and elsewhere have called for repeal of CLASS, which they fear will turn into a new unfunded entitlement program. Sen. Lindsey Graham (R-S.C.) has already introduced a bill to repeal the law.

Worse for CLASS backers, the law has no real advocate in Congress. No Democrat has stepped up to take ownership of the idea since its primary sponsor, the late Sen. Edward Kennedy, died last year. Indeed, about a half-dozen Democratic senators opposed the provision when it was added to the health law.

There is a good chance the soon-to-be GOP-controled House will pass a repeal bill early next year. It would fit with the Republican vow to wipe out the entire health law and their special dislike of federal long-term care insurance. But even with strengthened GOP ranks in the Senate and the support of those Democrats, CLASS opponents remain far short of the 60 votes they'd need to repeal the law. And they''d need even more-- 67 votes-- to override a veto by President Obama. As one insurance lobbyist told me today, "CLASS isn't going to disappear."

Similarly, there is little chance Congress will gut the bill. Unfortunately, the new political environment also makes it extremely unlikely that Congress will improve those elements of CLASS that need to be fixed. As I have written before, there is a real question about how many people will buy CLASS policies, which are likely to cost an average of $100 or more per month.

Some changes in premium design and eligibility could help bring those premiums down. But given the hostility to the law on Capitol Hill, there is no chance the White House will ask Congress to make repairs. Those backers of CLASS who pushed to pass the law, flaws and all, in the expectation that they could fix it down the road are now stuck with the measure, flaws and all.