That's just a tiny fraction of the nearly 1 million people who are eligible, and only about one-quarter of the 35,000 the participating states initially hoped to move. And of the 8,500 who have enrolled in the program, one-third lived in just one state--Texas. By contrast, California has signed up only 186 people since MFP began, and New York only 165, according to the study done by Mathematica Policy Research Inc.
The concept makes great sense. Move people out of nursing homes, where most don't want to live and where the costs to Medicaid are extremely high, and help them get back to their homes or other community residences. Unfortunately, states have struggled to turn this concept into reality.
Most troubling for the frail elderly, it turns out that while three out of every four people eligible for the program are age 65 or older, only one-quarter of participants are seniors. Money Follows the Person has been far more successful for younger adults with physical and developmental disabilities than for the frail elderly.
Mathematica identified several reasons why so few frail elders participate. The biggest may be that they have no home to return to. In the original design, MFP participants had to have been nursing home residents for at least six months. Because many elderly people sold their homes or given up their apartments when they moved into a nursing facility, it was not possible for them to return to their communities. In addition, in many states participants were not allowed to move into assisted living facilities.
Just as troubling, many states don't have enough subsidized rental housing or funding for necessary home and community based services, such as personal aides or transportation. Unfortunately, the growing wave of state budget cuts is likely to make that problem even worse.
Still, there is some good news. The 2010 health reform law (the Affordable Care Act) allows people to use the program after only 90 days in a nursing facility, instead of six months. That will make another 112,000 people eligible to participate. The health law also promised an additional $1.75 billion in funding, gives states new flexibility in providing community-based services, and continued MFP experiment until 2014.
Long-term care experts and top government officials have had high hopes for Money Follows the Person. They see it as key to helping both the frail elderly and younger people with disabilities receive the supports and services they need at home and not in nursing facilities. But as the Mathematica study suggests, MFP has so far fallen far short of those expectations.
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This plan would turn Medicaid from a federal entitlement into a block grant. Over time, states would be responsible for paying a growing share of the program costs but in exchange would have broad flexibility over who to cover and what benefits they'd receive. In such an environment, chances are good that fewer aged and disabled would be eligible for benefits and they'd receive less assistance than they do today. At the same time, providers such as nursing homes and home health agencies would likely get lower Medicaid payments even though the program reimbursements are already at dangerously low levels.
Today, the federal government pays about 57 percent of Medicaid costs (the actual amount varies from state to state and ranges from 50 percent to about 80 percent). While the elderly and disabled account for only 25 percent of the 50 million Medicaid enrollees, the program spends two out of every three of its dollars on this population. More than one-third of the total Medicaid budget, or $125 billion, went to long-term care supports and services alone in 2009, according to a new study by the Kaiser Family Foundation.
Under the current arrangement, the federal government pays its share no matter how quickly Medicaid costs rise. Thus, because Medicaid rose by 7.7 percent in 2009 (mostly because the recession drove many newly-unemployed into the program), the federal contribution increased to keep up. In fact, Washington's share actually grew even more thanks to the much-reviled 2009 stimulus law.
By contrast, under a block grant the federal share would increase only up to a cap, say equal to the growth rate of the economy plus one percent. In 2009, this would have resulted in no increase in federal payments for the program. As a result, states would have had to scale back their Medicaid programs, including their long-term care services.
Over time, the federal contribution would fall significantly, leaving the states with more and more responsibility for the program and less and less assistance to pay the bills. Governors who support a block grant insist it would drive greater efficiencies.And it might, for instance, make it easier for states to expand their home and community based long-term care programs.
But it is also likely to generate major cuts in both benefits and reimbursements. In addition, without minimum federal standards, the differences among state long-term care benefits, already dramatic, would only grow.As a result, residents of one state may receive much better long-term care than residents of a neighboring jurisdiction.
Despite these risks, GOP governors came to Cngress today to demand the changes. Mississippi Governor Haley Barbour, who is mulling a presidential bid--told a congressional committee that states should not have to "kow-tow" to the federal government and insisted the program be turned into a block grant. Mississippi, as it happens, recieves a greater federal Medicaid payment than any other state.
Even more troubling, these Medicaid cuts would come on top of what are likely to be freezes or cuts in non-Medicaid benefits for the frail elderly, such as nutrition, energy assistance,and housing.
My guess is that much of this call for a Medicaid block grant is political posturing. It is hard to believe that many governors would turn their backs on hundreds of billions of dollars in federal aid at a time when they are struggling to balance thier budgets. I suspect what Barbour and his colleagues really want is the money with less regulation. But given federal budget pressures, their GOP friends on Capitol Hill may give them both.
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The reason, of course: money. States pay the insurance plans a fixed amount to care for these patients. And the private insurers say they can provide quality care for less cost through their use of care coordinators and by keeping many people at home.
Tennessee, for instance, pays private insurers an average of $4,400 per patient per month to provide Medicaid long-term care services. Under this system, if the insurer can provide care for less, it makes a profit. If its costs are higher, the insurer is at risk for the difference. This is a big incentive to create a care plan built around home care, which for many beneficiaries can be far less costly than a skilled nursing facility.
USA Today reported that one Tennessee insurer, Amerigroup, spent about $3,000 per month to care for one patient at home. The cost for this patient in a nursing facility would have been almost $4,600 per month and a money-loser for the insurer.
Medicaid managed care isn't new. States have been using it for acute care beneficiaires (mostly low income mothers and kids) for years. But long-term care patients are a very different challenge.
One one hand, more than any other population, the frail elderly need to have their care coordinated. They have complex medical needs, often suffer from multiple chronic diseases, and frequently take many medications. If a mix of care managers, personal assistance, nursing, and other services and supports can help them get the care they need at home for less money, that is great.
This flat fee, or capitated, payment model works well with programs such as hospice and PACE, for instance.
On the other hand, many insurance companies badly damaged their reputations in the 1980s and '90s with managed care plans that seemed more intent on maximizing profits than care. It will be important to put protections in place to be sure that the frail elderly, who are often unable to advocate for themselves, are getting the care they require.
The other problem with Medicaid managed care is that these beneficiaries often receive their physician and hospital care through Medicare, not Medicaid. Because these two programs are so poorly coordinated, seniors who transition from, say, home to hospital to rehab and back to home may not get proper care as they cross settings.
This lack of coordination between Medicare and Medicaid also creates some perverse and dangerous incentives. If, for instance, a Mediciad managed care patient winds up in the hospital as a result of poor care, neither Medicaid nor the managed care firm is on the hook. The bill, instead, is paid by Medicare.
If managed care is going to work well, there will have to be much closer delivery and financial relationships between these two payers, as there is with successful programs such as PACE or through provider-based managed care mechanisms such as Accountable Care Organizations.
]]>There is some good news for seniors in Obama's fiscal plan. For instance, he has asked for a modest increase in home and community-based supportive services. However, the budgets for many other key programs, including Meals on Wheels and other nutrition programs, would be frozen. Respite care remains grossly underfunded, even though it received a modest budget increase.
On the other hand, Obama proposed cutting the major subsidized senior housing program (called Section 202) by $68 million from the 2010 budget and low-income energy assistance for those living at home by $2.5 billion. The community services block grant program would be funded at $350 million, just half its 2010 level. These are grants for local non-profits that provide housing, nutrition, and other supportive services for very low-income people, including seniors. Overall, Obama would cut the Administration on Aging budget by almost $181 million, or about 8 percent, from 2010 levels.
Keep in mind, though, that once Obama and Congress agree to a final compromise budget (probably sometime next fall) cuts will be deeper than Obama has proposed. Also remember that these cuts so far largely exclude changes in Medicare and Medicaid, which are exempt from the annual budget process but face enormous financial and political pressures of their own.
Worse, as federal budget pressures grow, these cuts are likely to be only one step in a long and painful process of scaling back government assistance for the elderly. As I have suggested in the past, in such an environment, it will be critically important for state and local governments, senior service providers, non-profits, and advocacy groups to rethink their own future roles in caing for our parents.
]]>There is some good news for seniors in Obama's fiscal plan. For instance, he has asked for a modest increase in home and community-based supportive services. However, the budgets for many other key programs, including Meals on Wheels and other nutrition programs, would be frozen. Respite care remains grossly underfunded, even though it received a modest budget increase.
On the other hand, Obama proposed cutting the major subsidized senior housing program (called Section 202) by $68 million from the 2010 budget and low-income energy assistance for those living at home by $2.5 billion. The community services block grant program would be funded at $350 million, just half its 2010 level. These are grants for local non-profits that provide housing, nutrition, and other supportive services for very low-income people, including seniors. Overall, Obama would cut the Administration on Aging budget by almost $181 million, or about 8 percent, from 2010 levels.
Keep in mind, though, that once Obama and Congress agree to a final compromise budget (probably sometime next fall) cuts will be deeper than Obama has proposed. Also remember that these cuts so far largely exclude changes in Medicare and Medicaid, which are exempt from the annual budget process but face enormous financial and political pressures of their own.
Worse, as federal budget pressures grow, these cuts are likely to be only one step in a long and painful process of scaling back government assistance for the elderly. As I have suggested in the past, in such an environment, it will be critically important for state and local governments, senior service providers, non-profits, and advocacy groups to rethink their own future roles in caing for our parents.
]]>"The program must be able to pay for benefits over the long-term with the premiums it takes in,' she told the Kaiser Family Foundation. "No taxpayer dollars will be used to pay for CLASS benefits.This is non-negotiable."
At the same time, however, Sebelius said she was open to major changes to the program and acknowledged that the national, voluntary long-term care insurance system that was included in the 2010 health reform law "is not perfect." And, in an apparent nod to critics, said "it would be irresponsible to ignore the concerns about the CLASS program's long-term sustainability in its current form."
To respond to those fears, she suggested that HHS has broad authority to restructure key provisions of the law. Sebelius said that, besides sustainability, CLASS contains only two other "key principles." The first is that consumers must have the ability to direct their own services--a reference to CLASS' cash benefit. The other is that there should be no traditional underwriting for health status such as is included in private long-term care policies.
However, she explicitly opened the door to other highly controversial changes to the law. These include tightening its "at work" requirement, changing its premium structure, and assisting employers who offer CLASS benefits to their workers.
The biggest change would make it tougher for some people with disabilities to enroll in the program. The law allows anyone 18 and older to sign up for CLASS as long as they earn just $1,100 a year, which makes it possible for many working people with disabilities to buy coverage. This is an extremely important change for them, but such a flexible standard has been sharply criticized by industry actuaries.
The problem is that this design may mean that those buying CLASS insurance will be more likely than average to claim benefits under the program. If that happens, the government will have to increase premiums to pay those claims which in turn will discourage healthy consumers from buying coverage. This will eventually lead to a "death spiral" that will destroy the program.
Sebelius said her office is reviewing that at-work requirement, although it is unclear how much flexibility she has to change it without an amendment to the law.
Other changes she is considering include:
Replacing a flat premium with one that increases annually with inflation. This postive change would allow for relatively low initial premiums, especially for young buyers.
Imposing anti-gaming rules. These would prevent consumers from going in-and-out of coverage during their lives without paying penalties.
Easing the burden on employers that offer CLASS insurance. This could be another key change. The law automatically enrolls workers in CLASS, but only if they get coverage through their job. Currently, however, the law includes no incentives for employers to participate.
Creating an aggressive marketing campaign for long-term care insurance. This change could attract broad insurance industry support. But coming up with the funding will be a huge challenge, especially given severe budget pressures and the strong opposition to CLASS from congressional Republicans.
Tailoring benefits to individual needs. The law appears to require Sebelius to approve only a single policy. But today she suggsted she might have the flexibility to approve multiple coverage options. This could be another key change.
Sebelius' speech today was a major acknowledgement that CLASS as currently designed is in deep trouble--both politically and as an insurance program. By recognizing the flaws that some of us have been noting for more than a year, she has taken the first steps towards making CLASS successful. The question now is whether it is not too late given the broad opposition to the program that has been building for months on Capitol Hill.
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The analysis, by center director Alicia Munnell and co-author Josh Hurwitz, projects an average monthly CLASS premium of $194--a rate that falls within the wide range of earlier estimates by both government and private analysts. For instance, the Congressional Budget Office projected monthly premiums for a CLASS-like policy would cost an average of $123, while the office of the Medicare actuary projected a premium twice as high.
To estimate premiums, Munnell and Hurwitz built a basic economic model to project premiums for both CLASS and several variations of the insurance program. The authors conclude that premiums could be cut significantly with some major changes to the basic CLASS framework. However, they found that the deepest premium cuts would only come if the insurance were made mandatory--an outcome favored by many economists but quite unlikely in the current political climate.
They concluded that only a mandatory program could drive premiums below $100 per month.
As I have noted at Caring for Our Parents in the past, the big problem with the CLASS design is that coverage is available to all, including working people who already have disabilities. This is good for them, but their high level of likely claims threatens to make premiums unaffordable for healthy buyers.
To ease that problem, Munnell and Hurwitz propose a couple of changes to the CLASS design that would mimic the medical underwriting that private insurers use to hold down premiums. They'd require both a tougher work requirement for buyers and a 10-15 year waiting period before they can collect benefits. The current waiting period is five years.
Unfotunately, while these changes may make good actuarial sense, they'd drive a wedge between the political coalition of aging and disabilities groups that backed CLASS in the first place.
The authors also suggest a more practical change that I have also proposed. They'd index premiums for inflation instead of setting them at a fixed level for life. This one adjustment could cut average premiums by one-third to about $120, Munnell and Hurwitz estimate.
Finally, they urge a major marketing campaign to teach prospective buyers the importance of planning for long-term care needs. As they note, however, such an effort will be costly for the government. While some private foundations and advocacy groups have commited to help fund such a campaign, it is hard to imagine the current Congress allocating any new funds for the effort.
The Munnell and Hurwitz paper is more evidence that while CLASS is based on a good idea, it faces huge challneges if it is going to succeed in the real world.
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In his State of the Union address last evening, President Obama called for a five-year freeze on a narrow slice of the federal budget. Unfortunately, programs subject to the freeze would include many that are critically important to the frail elderly and younger people with disabilities--especially those living in the community.
This is only the beginning of what will be a very difficult period. Yet it is an opportunity for communities to pull together to provide services that government may no longer offer.
The freeze would not include Medicare or Medicaid, although Medicaid long-term care benefits are already being cut at the state level. However, it is very likely that programs such as meals-on-wheels, adult day care, transportation, housing, aging and disability resource centers, and Area Agencies on Aging would all be hit by this freeze.
It is not clear exactly how the freeze would work. It could be an across-the-board cut in all so-called domestic discetionary programs. These are programs that are subject to annual congressional review, but exclude entitlements such as Medicare, Medicaid, and Social Security. Alternatively, Congress could pick and choose which programs to cut, as long as the total amount of all domestic non-entitlement spending did not rise from year to year.
Either way, a freeze will inevitably result in fewer services since demand for this assistance is growing as the population ages and the cost of services rises.
Congressional Republicans are already criticizing Obama's plan as too weak and vow to cut even more deeply into these programs. Some would return spending to 2008 levels, others to 2006 funding. However it finally works out, there is little doubt that many of the long-term care supports and services that seniors now rely upon are in line for major cuts.
With a national debt of $14 trillion and annual deficits of more than $1 trillion, there is no doubt that government spending is going to be trimmed--perhaps quite substantially.It is also likely that sooner or later, federal payments for Medicaid services will also be slashed. One can hope that an eventual budget deal will eventually include tax increases as well, which would help soften the spending blow. But in the current political environment, that is not likely--at least until after the next presidential election.
So what do families and advocates do? I believe we need to begin to look for community, non-government solutions. If transportation services are cut, we should pull together to create volunteer ride programs. Senior villages are one way to build such an infrastructure. So are more informal groups organized around neighborhoods, churches, synagogues, or fraternal organizations.
If budgets for government-funded resource centers are slashed, we should support private non-profits that pick up the slack.(Full disclosure: I serve on the board of one of these--the Jewish Council for the Aging of Greater Washington--and as an adviser to another--Caring from a Distance).
As needs grow and government services shrink, we all face a huge challenge. But it is also an opportunity to rethink our obligations to, not only our own parents, but to our neighbors and friends. I hope we will be creative enough to take up this challenge.
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The latest evidence comes from two new reports. Following an extensive survey of state officials, AARP reports that 31 states cut their non-Medicaid long-term care services programs in Fiscal Year 2010 and at least 28 expect to slash them in the coming budget year. These essential programs include home-delivered meals, transportation, adult day care, housing, and foster care.
At the same time, a report by the American Health Care Association--which represents mostly for-profit nursing homes-- concludes that skilled nursing facilites are losing increasing amounts of money on their Medicaid long-term care beds. It concludes that nursing facilities are paid $17 per day less for long-term care than it costs them to provide these services. It is easy to criticize these results as self-serving, but the general trend is hard to dispute. And it could result in dramatic cuts in these long-term care resources. While this may not be a short-term problem in communities with an oversupply of nursing homes, this trend may already be curbing services in low-income areas.
The AARP study reported that only a handful of states cut Medicaid benefits last year, but that was because the federal government, as part of its stimulus effort, increased its share of program payments. In addition, states that took the extra federal money were barred from cutting Medicaid benefits--although they could trim or freeze provider payments. Normally, the federal government pays about 60 percent of the cost of Medicaid while the states pay the rest (the amount varies from state to state).
However, this additional federal Medicaid funding is already winding down, and will disappear completely on July 1. Even more troubling, AARP found many states built the higher federal payments into this year's budgets, a decison that will force even deeper cuts in state programs as those dollars dry up. Just this week, lawmakers in Texas and Ohio proposed major cuts in Medicaid.
AARP also asked state officials whether they intended to pursue additional federal funding for home and community based services that's been promised under the 2010 health reform law. Despite their serious financial shortfalls and the growing interest among policy analysts and advocates in expanding community services, state officials were remarkably cautious about whether they'd embrace these initiatives.
I'll have more to say about these studies soon, but they are both worth reading.
]]>But the Archives study by Zhanlian Feng and coauthors also raised some serious concerns. The report concluded that many of these closures occured in minority and low-income communities, the same areas where other care alternatives may be unavailable.
Other studies have shown that relatively few assisted living facilities--which are overwhelmingly private pay--are located in these neighborhoods. In addition, while data are scarce, it appears that many low-income and minority serniors may have limited access to high-quality home care. In other words, for one segment of the population, good care may increasingly be unavailable.
A study published last year in Health Affairs, David Stevenson and David Grabowski of the Harvard Medical School found that larger assisted living facilities (those with 25 beds or more) were far more likely to be located in higher income counties than in poor jurisdictions.
As a result, low-income seniors who are unable to live at home--perhaps because there may be no one to care for them or because their home may not be suitable for someone with disabilities--have very few options. Many may move to small board-and-care homes--often a room they rent in a local home where assistance is provided by an unlicensed caregiver. Others may get no care at all.
From the perspctive of the long-term care industry, the Archives paper reflects another troubling trend. Most long-term care in SNFs is paid by Medicaid, and reimbursements for these patients are often lower than the cost of providing care. By contrast, Medicare, which pays for post-acute and rehabilitation services, is far more generous. Medicare typically pays $500 or more per day for these services while Medicaid may pay just $125 for a long-term care bed (these payments vary by state and Medicare payments are adjusted to reflect patient needs).
The result: Growing industry consolidation and an increasing shift away from long-term care and towards more lucrative post-acute services. These choices make perfect economic sense. And they are often praised by advocates for the elderly, who argue that aging services should be provided in the community. However, for some seniors, including some with dementia or those with no family members to help provide care, nursing homes or assisted living facilities may be their only alternatives. Sadly, for many, those options are increasingly unavailable.
]]>In late November, the government adopted new rules that included discussion of advance directives as one of many services physicians could provide during routine annual physicals for their Medicare patients. But The New York Times reported this morning that the White House has now overruled the Department of Health and Human Services and withdrawn the provision.
The decision echoes the decision by the White House and congressional Democrats who dropped a similar provision from the 2010 health reform law in the face of pressure from the political right. During that congressional debate, Sarah Palin and others made the absurd claim that Medicare payments to doctors for discussing advance directives was akin to creating "death panels" where government officials would withhold care from some patients. Democrats were so slow to respond to these charges that even recent polls reported many seniors still believe the death panel canard.
Obama's decision is a tragedy for patients. The rule would have done nothing more than pay doctors for the time they took to discuss advance directives during annual Medicare "wellness visits." Patients could have refused this service if they chose. And nothing in the rule would have in any way constrained end-of-life choices by patients. They could have written living wills however they wanted, or not prepared such a document at all.
The Times quoted new House speaker John Boehner (R-OH) as saying the provision "could be a step down a treacherous path toward government-encouraged euthanasia." Nothing could be further from the truth. In fact, frank talk about end-of-life choices achieves exactly the opposite result. Advance directives give patients more control over medical decisions, not less. It allows them to make their own choices based on their own moral, ethical, and religious views.
As a society, we struggle to confront death. Patients struggle, and so do many physicians. This modest Medicare rule would have provided a small incentive for doctors to take a more active role in helping their patients think about end of life care. And perhaps it might have encouraged better training for those physicians who are not prepared to discuss these issues.
Now, thanks to a toxic mix of conservative ideology, Obama's lack of political courage, and more than a little political cynacism, patients and doctors are left with only confusion and uncertainty. They and their families deserve so much more.
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The new rules are an important first step. Doctors absolutely should be paid for the time it takes to have these difficult conversations. But compensation alone is not nearly enough.
Here's why: Early one morning in a hospital intensive care unit, I was shadowing a care team on their rounds. A patient in her 90s had been admitted from a nursing home with severe breathing problems.She had Stage IV lung cancer and congestive heart failure. A doctor, nurse, and social worker explained to her that she was very ill and gave her two options: They would stop aggressive treatment but make her comfortable. And she would likely die in a day or two. Or they could hook her up to a ventilator. They explained that the device would probably keep her alive for a few months, but also described how uncomfortable she would be.
The woman, who seemed surprised by her prognosis, chose the ventilator. And I could not help but wonder: Why did nobody talk to her about these choices long before this crisis? How could the system have failed her so badly?
If physicians are going to counsel patients on end-of-life choices, they first need to learn how to talk about these issues with their patients. They not only have to be trained in how to use the right words and body language, many need to fundamentally rethink their own attitudes about treatment and death. Today, too many physicians equate the death of a patient as failure. As a result, they and their patients suffer.
Dr. Dan Sulmasy, who is both a physician and a Franciscan friar, has written powerfully about the intersection of medicine, faith, and death. In one article, he says that doctors "have three great attachments: The need to be in control. The need to be effective. And the need to be right."
Death confounds all three.
But giving patients the information they need to confront the end of life will take more than just retraining doctors. It will also require hospitals, nursing homes, and other health facilities to change they way they approach the dying. For instance, once a patient is admitted to a hospital, it is too easy to become sucked into the powerful and seemingly inexorable cycle of treatment and diagnostic tests. The pressure is always to "do more" and it is reinforced by both a perverse payment system and, often, the demands of family members.
We know how to break that cycle. For example, well-designed palliative care programs can increase the comfort of chronically-ill patients. And while terminally-ill palliative care patients often request less treatment, they also live longer.
But palliative or hospice care remain an after-thought in too many hospitals. These programs are not given the resources they need. They are not well-integrated into the hospital's practice of care. And attending physicians often wait too long before requesting palliative care consults and then ignore their advice.
Conservative critics are still opposed to these end-of-life dicussions. Robert Pear's New York Times piece that first reported the new rules quoted Elizabeth D. Wickham of a group called LifeTree as saying that end-of-life counseling would encourage patients to forgo or curtail care, thus hastening death. "Patients will lose the ability to control treatments at the end of life," she told The Times.
Of course, Wickham has it exactly backwards. Good physician-patient discussions will give patients more control over their treatment at the end of the life, not less. But only if health providers are fully prepared to have these conversations.
]]>The League's white paper, called "Moving Beyond Medicaid: Long-Term Care for the Elderly as a Life Quality and Fiscal Imperative" makes three basic recommendations--all aimed at increasing the role of personal responsibility for long-term care while maintaining a safety net for the most needy.
The group would restructure Medicaid, encourage innovative financial products to help families pay for long-term care, and begin a broad education campaign through civic organizations and employers.Their goal is for half of Minnesotans to have some financial planning in place for long-term care by 2015.
Here is a brief summary of each proposal:
Medicaid: The state/federal insurance program would remain a safety net for the very poor, but middle-class families would be expected to self-finance some of their long-term care costs. While Medicaid would supplement coverage, families would either rely on savings, private long-term care insurance, or home equity to pay their share. They could also buy coverage through the the CLASS Act, the new voluntary national long-term care insurance program that was included in the 2010 health reform law.
New Financing Tools: These include a program to offer prizes to low- and middle-income households who open new savings accounts, a design modeled on an existing program in Michigan. My favorite idea, however, is a new hybrid home equity/reverse mortage product that would provide a low-fee way for people to tap into the equity in their homes for long-term care needs. Today, reverse mortgages can serve that purpose but their fees are too high.
In the League model, Minnesota could create a new low-cost product. I've written about a similar model where the state itself could lend money to those who need long-term care and, get, in return, a lien on the recipient's home. After the person getting care and their spouse died, the loan would be repaid with interest. Such a design would give people broad flexibility in designing their own care, an advantage not available with Medicaid.
Education: Finally, the League, which has close ties to the local business community, urged companies to play a larger role in encourgaing workers to plan for their long-term care needs.It calls on business to encourage workers to increase both savings and consider home equity or insurance projects to prepare for care in old age.
This would be a major change. Today, only one in seven workers has access to long-term care insurance through their workplace, according to the SCAN Foundation. And while the CLASS Act is built on workers buying government long-term care insurance through their job, there is little evidence that employers will be willing to offer the coverage as part of their benefit packages.
The League has built a sturdy foundation for long-term care reform--education, better savings vehicles, and a broad reform of Medicaid. Minnesota's state-funded long-term care program is, like most states, under tremendous financial pressure these days. I hope the state gives some of the League suggestions a try.
]]>CHA asked me to write a paper for this conference and gave me the opportunity to visit providers around the country who are leading the effort to meet this challenge. And the conference allowed about 100 of the nation's top faith-based care providers to get together and exchange ideas. To read my paper, and to see presentations of other participants, go here.
The idea of integrated care is simple to describe: Ideally, it is a seamless system that provides seniors with medical treatment for chronic and acute disease even as it meets their personal care, social, and spiritual needs. The description may fit on a (long) bumper sticker, but it is not easy to implement. Building such a system requires hospitals, doctors, nursing facilities, home health agencies, assisted living facilities, care managers, families, and communites to work together. And for many reasons, including a perverse payment and regulatory system and the inability of health providers to talk to one another, this rarely happens today.
But some providers are making it work. In researching this paper I learned about projects such as:
The Congregational Health Network: Methodist LeBonheur Health Care in Memphis--a 7 hospital, 1,000-bed system-- is working with 250 churches to improve care for chronically-ill congregants. The keys to this program: hospital-based patient navigators and church-based volunteer liaisons who work together to help patients while they are hospitalized and build a care plan and follow-up after they are discharged.
Schervier Nursing Center's Cardio-Pulmonary Program: Schervier, a Bronx (N.Y.) skilled nursing facility operated by the Bon Secours health system, has dedictated a 39-bed unit to providing sub-acute and post-acute care to patients who have undergone major heart surgery at local hospitals. Rather than recovering in the hospital, where care is extremely expensive and risks of infection and delerium are high for elderly patients, they can recover and undergo rehab at Schervier.
Guided Care at Kaiser Permanente focuses on elderly patients at high-risk of hospitalization. Designed by Dr. Chad Boult at Johns Hopkins University, the Guided Care model is built around an RN who is fully integrated into primary care practices. She visits patients at home, reponds to their telephone calls, and works with families, physicians, and patients to build an easy-to-follow care plan. Kaiser is now deciding whether to make this experimental program a regular part of its healh delivery system.
Making these creative solutions work today is a huge challenge. But the new health law includes some important incentives, such as accountable care organizations, that mayl encourage more providers to find innovative ways to deliver integrated care.
After spending two days with CHA's health system members, I am optimistic. I was really impressed with their commitment to turn the concept of integrated care into a reality that can both improve the health of chronically ill seniors and be financially sustainable for providers.
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]]>Frank, a highly respected professor of health policy at Harvard Medical School, is Deputy Assistant Secretary for Policy and Evaluation at HHS. He told a group of long-term care industry representatives, researchers, and elder advocates today that while HHS faces major challenges, the agency can design a workable insurance program under the controversial law,
Although a deficit reduction commission appointed by Obama recommended last week that CLASS be either repealed or reformed, Frank says he is squarely in the reform camp. And, while he acknowledges it will be a major challenge to create policies that consumers will be willing to buy, he thinks that goal can be reached without changes to the law. CLASS, Richard says, "is designed to change the terms under which we buy and sell long-term supports and services in this country." And, he adds, "it has a great deal of potential."
I agree. But I worry that a real insurance market may never develop under CLASS. The problems are many: CLASS is a voluntary program for both consumers and their employers. The government is barred from refusing coverage to anyone over 18 who works even part-time, no matter what their health status. Anyone who makes more than $1,100 a year is eligible to participate, and low-income workers may buy insurance for only $5-per-month. This arrangement will encourage many working people with disabilities to buy, but also threatens to drive premiums so high that others will be discouraged from purchasing.
Richard acknowledges the problem, and says he assumes initial participation rates will be quite low--likely well below 10 percent. He also says HHS is wrestling with a number of technical issues, such as how to encourage employers to participate in the program, how CLASS will work for those who are also using home care services under Medicaid, how to manage the risk of rapidly-rising long-term care costs, and how to deermine eligibility, especially for those with mental illness. The mentally ill are not usually covered by long-term care insurance but some will be eligible for CLASS benefits.
Making CLASS work will be a huge challenge, but at least today, two years before HHS is due to begin selling policies, Frank still thinks the agency can pull it off. I hope he's right.
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