Response to Howard Gleckman’s article in Forbes Online: Long-Term Care a Forgotten Issue in the Presidential Campaign

 Posted by on October 25, 2012  No Responses »  Tagged with: , , ,
Oct 252012
 

by Judith Peres, LCSW

Howard Gleckman in Forbes online (http://www.forbes.com/sites/howardgleckman/2012/10/24/long-term-care-a-forgotten-issue-in-the-presidential-campaign/) rightly states that long-term care and the needs of citizens with serious chronic conditions and functional limitations are not part of our current Presidential debate.

There are an estimated 10 million Americans with long-term care needs. The amount and quality of long-term care/palliative care/hospice received through their illness trajectories varies tremendously, as do their unmet needs near the end of life.  Studies consistently demonstrate that patients with advanced illness and functional decline experience untreated pain and other symptoms; lengthy hospitalizations involving unwanted, often low-yield and costly medical treatments; and low overall family satisfaction.

The current national dialogue about the need to reform the health care “system” includes recognition that the population is aging, a changing trajectory of illness for Medicare beneficiaries, advancements in high-tech life support systems, limitations in health care resources and issues surrounding patient autonomy and the right to a dignified death. However, for the most part, the development of the new chronic condition models tend to overmedicalize the services delivered and do not acknowledge the knowledge base developed over three decades of  long-term care and palliative care research on how to manage this population.

Recent studies suggest that medical care for patients with serious illness is characterized by inadequately treated physical distress; fragmented care systems; poor communication between doctors, patients, and families; and enormous strains on family caregiver and support systems.  Although most of the years after age 65 are a time of good health, independence, and integration of a life’s work and experience, eventually, most adults will develop one or more chronic illnesses with which they will live for years before death.  These years are characterized by physical and psychological symptom distress; progressive functional dependence and frailty; and high family support needs.

What, exactly, do we need? More than anything, we need programs that support family caregivers, those individuals who provide an estimated $450 billion dollars worth of care for older adults. We need hospice-like wraparound services that would help people from the time they are seriously ill or disabled, and that offer home care services, respite for our caregivers, and supports for what we can no longer manage or cope with on our own. We need social structures and public policies that support families as they live through years in which they simply cannot piece it together on their own.

As a country, we’ve done a remarkable job of creating a health care system that does well at treating acute problems and curing much of what ails us. But that system, with all its fragmentation and problems, is simply not one that is going to be able to serve our aging population. At Altarum Institute Center for Elder Care and Advanced Illness, we believe that doing so will require fundamental changes in how we see and care for these individuals–and that it will require sweeping changes in how we organize and manage that care. It will require a real blending of social supports and medical services. It will require comprehensive care plans, and an array of services ranging from transportation to home health to hospice. It will require local levels of management, with the authority to channel resources to meet locally identified needs and priorities. It will, indeed, take the whole village to solve this problem.

 

key words:  presidential election, Medicare, older adults, public policy

Family Caregivers Doing More Than Ever: Results from New UHF/AARP Study Shed Light

 Posted by on October 1, 2012  No Responses »  Tagged with: , , ,
Oct 012012
 

from the United Hospital  Fund

A report based on the first population-based survey of its type shows that 46 percent of family caregivers in the U.S. perform medical and nursing tasks. Three out of four provide medication management – including administering IVs and injections – for a family member with multiple chronic physical and cognitive conditions.  More than a third of these caregivers providing medical and nursing tasks reported doing wound care.  Other tasks include operating specialized medical equipment and monitors.

These and other findings are included in the new report published by the United Hospital Fund and the AARP Public Policy Institute.  The report is based on a national survey of 1,677 family caregivers who were asked about the medical and nursing tasks they perform and what they find difficult about performing them.

The report Home Alone: Family Caregivers Providing Complex Chronic Care recommends actions to assist the more than 42 million family caregivers in the U.S., including: encouraging health care professionals and providers to reassess the way they interact with caregivers, ensuring that caregivers are well trained and prepared to perform difficult tasks, revising how caregiving tasks are labeled and identified, and addressing family caregivers’ needs in the development of new models of care.

The results of this study challenge the common perception of family caregiving as a set of personal care and household chores that most adults already do or can easily master.  The full report is available at http://www.uhfnyc.org/publications/880853.

 

Key words: family caregivers, medication management, AARP, United Hospital Fund

PBS Broadcast, Money and Medicine, Offers Opportunity for Insight

 Posted by on September 24, 2012  No Responses »  Tagged with: , , , , ,
Sep 242012
 
MoneyMedicine

I was talking about the long-term effects my father’s chemotherapy and radiation were taking on him; to be sure, the treatments had probably given him as yet uncounted years of life, but they have come at a price.  My girlfriend, who had cared for both of her parents during their struggles with cancer, agreed: The burdens and costs of treatments were greater than patients often understood.

And, she told me, she and her husband had developed an entirely different sort of treatment plan. When their time came, she said, they were going to broach their health insurance plans with a deal: They would forego $100,000 in treatments for a one-time payout of $50,000. And, check in hand, they would ride off into the sunset on their ultrafast street production motorcycles, wind in their faces, sun at their backs. “Dream on,” I told her.

But after watching a pre-release version of “Money and Medicine,” a new documentary by Roger Weisberg, my girlfriend’s preferences seem almost worth thinking about. The program, which will premiere Tuesday, September 25, at 8 p.m. ET, on PBS stations nationwide, talks honestly about the incentive of profit in health care while juxtaposing the actual financial costs of various treatments and procedures with the profound and troubling human costs of undergoing those treatments. (Watch a trailer here: http://www.youtube.com/watch?v=a9oEtRwoVxs) It follows several patients being cared for by the vastly different systems available to them at the University of California-Los Angeles Medical System and at Intermountain Health Care, based in Utah.

There are heart-wrenching scenes in the UCLA ICU, where we watch a young African American man, convinced his comatose mother will one day recover, as he struggles to understand the hospital having decided that it would be “futile” to try resuscitation if (and when) her heart stopped.  The hospital was continuing all other support, keeping her in a limbo of unresponsive survival.

“I call it a medical execution,” he says, as he explains that the hospital will offer his mother comfort measures only. The mother, who has been in the ICU for 10 months, has run up millions of dollars in costs to Medicare; there is no indication that she could ever recover. The son, devoted and loving, spends hours with her, showing her old photos and talking to her.

Another poignant scene, again an African American family, shows the desperate family gathered around the patient’s bedside; the husband/father is tethered to life support. Although an ICU physician has explained in clinical terms that the patient is never likely to return to any semblance of fulfilling life, the family is determined at first that he undergo any and all possible procedures.  His wife sobs, “Life is so unfair.”  This family eventually acquiesces in the clinical team’s plan to deal with any symptoms but to accept stopping treatment and allowing the dying that is in store.

The film underscores these personal tragedies with the larger social issues of how much we are willing to pay for endless medical tests and treatments–and how much those tests will cost us in the future, as the price of medical care becomes something our society will no longer be able to afford. The program uses several common conditions and treatment options–Cesarean-section rates, and breast cancer and prostate cancer screenings–to bring home its points: We have tremendously powerful prevention and detection procedures available to us. But each is very costly to administer, each exacts a psychological toll on patients and families, and each is imprecise in targeting exactly who can benefit from it. As one of the many experts interviewed for the program explains, “One person’s story does not tell you the whole story.” At a population level, certain tests have tremendously high rates of false positives. But at an individual level, patients are often willing to play that lottery.

All of this makes for an interesting contrast to our work in improving care transitions. Some medical situations run up tremendous bills with modest justifications, bringing into question the professionalism of those ordering the tests and treatments. In contrast, until now, care transitions improvement efforts have been largely  rooted in improving patient experiences and reducing patient suffering, with no real chance of improving the bottom line. The new penalties on hospitals with high readmission rates and the payments to community-based organizations in the Community-Based Care Transitions program and to physicians in the proposed Medicare physician payment rule may allow good practices to show modest gains.

The money at stake in the diagnoses and treatments in Money and Medicine are huge – often more than $100,000 for an uncomplicated patient.   The care transitions work, however, relies on far less expensive interventions–indeed, many of the interventions involve virtually no-cost changes in patient and provider communication, in medication management, and in patient activation. These changes are not the stuff of drama at the fringes of technological innovation and medical research magic, but they are innovative and important. In our experience, the most sustaining impetus for improving care transitions has been  professionals’ realization that patients suffer when transitions go badly–and that patients do better when transitions go well. Doctors, nurses, and everyone else prefer to work in systems that work for patients.

Improving care transitions may prove to be a cornerstone for what we need to do to improve care generally. As communities around the country are discovering, it truly takes a village to improve transitions. It takes a community-wide (and deep) commitment to improving care, to working together, to coordinating services, and to focusing on patient experience. Improving care transitions provides a base for achieving broader “MediCaring” reforms for care of older Americans: recognizing the special needs of the period of frailty that most people have in the last years of life; developing and implementing care plans that go with these patients across time, setting, and provider; and developing a local coalition that integrates, monitors, and assesses that process. To learn more about our ideas in this arena, check out our recent blog on the Altarum Health Policy Forum at http://altarum.org/forum/post/call-action-boomers-we-grow-old

In the meantime, we hope you’ll watch “Medicine and Money” on Tuesday, September 25, and that you’ll respond here for a discussion of the issues and ideas in the program.

 

key words: overtreatment, health disparities, Money and Medicine, PBS, health care spending, cost curve

 

Time to Comment on Care Transitions Provisions in New CMS Physician Payment Rules

 Posted by on August 27, 2012  No Responses »  Tagged with: , , , , ,
Aug 272012
 

Each year, Medicare releases a schedule of physician payment rules, which set the amounts doctors are paid for Medicare beneficiaries. The public is always invited to comment on those rules. This year, for the first time, Medicare is considering allowing physicians to bill for services rendered in the course of managing hospital discharge. For those new to this world, now is an opportunity to comment on those rules—and to let the Centers for Medicare and Medicaid hear your voice. Comments can be positive or negative—but every comment counts. Don’t be intimidated or put off by the bureaucracy of the effort. Medicaring is here to help you through!

The rule can be found in Section H of the “Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, DME Face to Face Encounters, Elimination of the Requirement for Termination of Non-Random Prepayment Complex Medical Review and Other Revisions to Part B for CY2013 [CMS-1590-P]”. It proposes to pay doctors to coordinate care for beneficiaries following a discharge from a hospital or nursing facility.

This would be the first time Medicare would explicitly pay physicians for the care required to help a beneficiary transition back to the community following a discharge from a hospital or nursing facility.

This “postdischarge transitional care management” code would be added to the fee schedule.  The service would include telephone or electronic communication with a beneficiary within two business days of discharge, medical decision-making of moderate or high-complexity, and face-to-face visit with the beneficiary 30 days prior to the transition of care or 14 business days following the transition.

The rule compares the new service to hospital discharge and high-level evaluation and management care that is currently covered.  The fee for the new services would be approximately $95 using current rates for 2013.

MediCaring suggests that folks comment on a few key provisions of the rule, especially on:

  1. 1.     The post-discharge transitional care management section,  for which: CMS seeks comment about the best ways to ensure that all the activities of the discharge day management codes for hospital and nursing facility discharge, including the care coordination activities, are understood and furnished by the physicians or qualified nonphysician practitioners who bill these services, noting that potential ways could include physician education or MEDLEARN articles.

 

  1. 2.     Whether and how the visit needs to be face-to-face, for which: CMS seeks comment about whether it should require a face-to-face visit when billing for the post-discharge transitional care management services, and how it might incorporate such a required visit into the payment for the proposed G-code.

 

CMS must receive comments on for before September 4, 2012. Full text of the Regulation, along with information on how to comment, can be found at: http://www.gpo.gov/fdsys/search/pagedetails.action?granuleId=2012-16814&packageId=FR-2012-07-30&acCode=FR Here’s how and where to submit comments:

Comments must be received by CMS on for before September 4, 2012. In commenting refer to file code CMS-1590-P. Comments may be submitted to CMS in the following ways:

  • · Electronically. You may submit electronic comments on this regulation to http://www.regulations.gov. Follow the instructions for “submitting a comment.”
  • · By regular mail. You may mail written comments to the following address ONLY:

Centers for Medicare & Medicaid Services

Department of Health and Human Services

Attention: CMS-1590-P

P.O. Box 8013

Baltimore, MD 21244-8013

  • · By express or overnight mail. You may send written comments to the following address ONLY:

Centers for Medicare & Medicaid Services

Department of Health and Human Services

Attention: CMS-1590-P

Mail Stop C4-26-05

7500 Security Boulevard,

Baltimore, MD 21244-1850

 

If you’d like a hand preparing your comment for submission, feel free to contact us at [email protected].

 

 

 

Key words: care transitions, CMS, Centers for Medicare and Medicaid, Physician Payment Rules, comment period

 

 

Where I’d Put the Money: Quality of Life Investments for Frail and Disabled Elders

 Posted by on May 22, 2012  No Responses »  Tagged with: , , ,
May 222012
 
Portrait of Dr. Joanne Lynn
By Joanne Lynn, M.D.

Readers of this blog are familiar with—and mostly supportive of—these two claims: (1) that social and environmental factors are stronger than health care services in shaping the population’s health, but (2) those factors are weaker than health care services in securing funding and public attention. Most of us are convinced that sending more funds and public support toward healthy food and exercise would do more to improve health than sending those funds toward high-cost medications or surgeries.

My question here is whether we can usefully apply the same perspective to the care needed for frail and disabled elders. Some will want to stop and contend that prevention of disability would still be the priority, and that argument has merit, of course. But “prevention” of disability associated with aging is really mostly delay, and most of us will have a period of serious disability before dying, no matter how well we eat and exercise.

As we age and accumulate illnesses and disabilities, we ordinarily need more and more support to get through the day, and we become less and less able to travel to get what we need. Furthermore, what we most need has to be local—no one travels to a referral medical center for spoon feeding or bed baths! So, we come to be tied to our communities, and to the housing, transportation, service supply and service coordination that our local system offers.

A community that has encouraged substantial new building with universal design and substantial retro-fitting of old buildings will have more elders able to stay at home longer, in comparison with one that is inattentive to making its housing stock elder-friendly. Some communities provide substantial non-medical services such as counseling for personal and financial planning, in-home nutrition and caregiver support, and keeping caregivers and elders in relationship with others. Those communities will have less reliance on nursing homes and hospitals, which is generally what aging persons strongly prefer. Senior-friendly housing and transportation are absolutely essential to the well-being of frail elders.

These claims appear to me to parallel the arguments for attention to social and environmental determinants of health generally. Indeed, the call for an “integrator” function to set priorities and manage systems to achieve population health locally seems also to be the right direction for elder care. If anything, elder care even more urgently needs integration across social services, housing, long-term-care services and health care services. A great deal of public and private funding goes into the uncoordinated cacophony of programs that aim to provide support and health care to frail elders, using probably about half of our lifetime expenditures on illness and disability and yielding remarkable waste, gaps, inefficiency and frustration. We need that integrator—and the integrator needs tools and authority.

In some other countries, care of the disabled and elderly is part of the public health system, alongside maternal-infant health and infectious disease. In the United States, however, services for the disabled and elderly have been outside of the scope of public health practitioners, who generally seem to lose interest when primary prevention fails (as it must). Indeed, at least for the elderly, the U.S. has mostly split the medical services into a quite separate category from the social supports. We fund health care with an open checkbook and we measure quality mostly as if each person faced at most one health challenge. In contrast, we primarily fund social services as poverty programs and rarely measure their quality at all.

From my perspective, engendering a way to manage the local system for elder care across medical and social issues is key to achieving “Triple Aim” goals. Can those advocating for attention to social and environmental determinants of health come to include frail elders and disabled persons in their scope? Well-being while living with serious and even fatal disabling conditions counts. Most of us will live for multiple years in this state—and some of us for much longer. Can’t we come to count improved well-being while ill as part of population health, and employ the tools, perspectives and personnel that now advocate for healthy built environments?

About this post:

This week,  Joanne Lynn, M.D., Director for the Altarum Center for Eldercare and Advanced Illness, blogs on Improving Population Health. A few months ago, David Kindig asked readers, “Where Would You Put the Money?” Dr. Lynn responded with a provocative comment, which she expands on here. This is reposted with permission of IPH, and is cross-posted on Altarum Institute’s blog, Health Policy Forum).

Key words: population health, frail elders, local integrator function, public health

Speak Up! Detroit Roundtable To Focus on Aging, Caregiving, and End of Life

 Posted by on May 6, 2012  No Responses »  Tagged with: , , , , , ,
May 062012
 
Cheryl Woodson and Muriel Gillick at Altarum Roundtable (April 13, 2012)

On June 5, 2012, Altarum Institute will sponsor a roundtable, “Speak Up! Infuential Women Give Voice to the Challenges of Eldercare.” Moderated by Eleanor Clift, the panel will include physicians Muriel Gillick, Cheryl Woodson, and Joanne Lynn, along with policymaker and caregiver advocate, Lynn Alexander. The session, to be held in the Detroit studios of Detroit Public Television, will be recorded and will form the basis of an hour-long documentary. The program runs for a full day, with the roundtable discussion in the morning, and breakout discussion groups in the afternoon. Those not able to journey to Michigan for the event are invited to join the streaming webcast. For details on how to sign up, watch the following video and follow the links at the end.

This video includes outtakes from an April 13 Roundtable held in Washington, DC, and features several of the authors slated for the June program.

 

http://www.youtube.com/watch?v=nBaYNFHT07A

 

Key words: Altarum Institute, policy roundtable, Eleanor Clift, Muriel Gillick, Lynn Alexander, Joanne Lynn, end of life, caregiving, aging, writing

 

Video from “The Last Word” Author Roundtable Now on YouTube

 Posted by on April 27, 2012  No Responses »  Tagged with: , , , ,
Apr 272012
 
portrait of Cheryl Woodson

On April 13, Altarum Institute and the Center for Elder Care and Advanced Illness, cosponsored a special event: The Last Word: Influential Women Discuss What Matters When Loved Ones Face Aging.” Moderated by Pulitzer-Prize winning columnist Ellen Goodman, the program featured panelists Cheryl Woodson, Muriel Gillick, Susan Jacoby, Francine Russo, and Joanne Lynn. The group discussed experiences as family caregivers, interactions with patients and families, and myths about what it means to grow old in America. Their conversation sparked lots of enthusiasm and interest, and a similar program will be held in June in Detroit, Michigan.

To watch the entire program, follow this link:

 

http://www.youtube.com/watch?v=wMDO1RE1vbY&feature=youtu.be

Key words:  Ellen Goodman, Susan Jacoby, Francine Russo, Cheryl Woodson, Muriel Gillick, Joanne Lynn, Janice Lynch Schuster, Altarum Institute, end of life, public policy, aging, caregiving

The Case for Identifying Family Caregivers on Medical Records

 Posted by on February 21, 2012  1 Response »  Tagged with: , , ,
Feb 212012
 

By Suzanne Mintz President and CEO, National Family Caregivers Association

 www.nfcacares.org

Across the chronic care continuum there are only two people who are consistently present, a patient and that person’s family caregiver. Family caregivers are acknowledged as the nation’s primary providers of long-term care, but they are not equally acknowledged as primary providers of their loved one’s non-acute healthcare needs. Family caregivers are like undocumented aliens, they have no official status and there is no official record of their existence. There is significant research about the impact that family caregiving has on the health and wellbeing of family caregivers, but there is very little on the impact that family caregivers make in the lives of their care recipients or on the healthcare system as a whole. We know that:

 Persons with multiple chronic conditions are the most vulnerable and medically expensive members of society. Their care consumes approximately 75% of all healthcare dollars.

 Family caregivers provide 80% of the care for this cohort of the population, most of who reside in the community.

 Family caregivers are ill prepared for their “job” as homecare aide, nurse, advocate, physical therapist, etc. There is no organized mechanism for providing the education, training and support family caregivers need.

Medical records are the official documents of the healthcare system. They provide the information on which care plans are developed, insurers pay claims, and the course of an illness is tracked. Yet nowhere on medical records is there a place to record the name of a person’s family caregiver or the fact that someone is a family caregiver. There is a serious disconnect between the day-to-day reality of chronic illness care and traditional healthcare practice and payments.

Until there is a place on medical records to identify who is and who has a family caregiver:

 American healthcare will not be able to truly alter the way it provides care for those with chronic conditions.

 Family caregivers will continue to be relegated to the category of nuisance rather than taking their rightful place on their care recipient’s health care team, one who has intimate knowledge of the patient that is not available to any other team member.

 There will be no mandate for providing family caregivers with the education, training, and support they need to both be a more confident and capable care provider and also a responsible steward of their own health.

 There will be the lost opportunity for research on the impact family caregivers have on their loved one’s health and wellbeing, healthcare costs, the value of different educational and supportive interventions, and caregivers’ own health behaviors.

As we move toward the implementation of electronic medical records and coordinated care it is more important than ever that we address this issue. It is imperative that going forward medical intake forms and official records capture information on who is a family caregiver and who has a family caregiver. Without recognition of the chronic care dyad the treatment of those with long-term chronic conditions cannot be as effective and efficient as possible, and equally important, family caregivers will not regularly be evaluated for the healthcare risks to which they are prone. For all the reasons stated above it is time for family caregivers to be given official recognition as full-fledged citizens in chronic illness care.

 

Key Words: family caregivers, care plan, public policy, patient activation

After CLASS: A Proposed Long-Term Care Insurance System

 Posted by on January 24, 2012  No Responses »  Tagged with: , , ,
Jan 242012
 

By Gloria Eldridge, PhD and Joanne Lynn, MD, MA, MS

The announcement by U.S. Health and Human Services Secretary Kathleen Sebelius that the Community Living Services and Supports (CLASS) Act will not be implemented drew a call for Congressional hearings to account for dollars spent on CLASS preparation since the March 2010 Affordable Care Act (ACA) made the measure law. What additional hearings might be in planning stages remain to be seen.

Opinions are as numerous as they are varied as to whether the CLASS Act was ill-conceived and ill-fated from the start, or a critical and feasible first step in addressing the longer-term care issue in America. In the meantime, media reports are that President Barack Obama has issued a veto threat for any legislative attempt to formally repeal the measure. All of this is taking place in a political environment charged with presidential politics.

Unfortunately – and some might say, “once again” – our political leadership is losing sight of the facts that matter most: We need a long-term care financing solution, and we need it quickly. We need fiscal solutions that encourage the middle class to save for the future costs of aging and its disability, and not to assume that Medicaid will cover these supports.

Going a step further, we need a long-term care financing solution that saves the federal and state government budgets by replacing Medicaid long-term care expenditures with personal savings. We need to concentrate on generating ideas about how to solve the long-term care financing problem. If we stay within a rubric that the initiative should be self sustaining and fiscally sound, then a public long-term care financing model is part of the deficit puzzle solution.

So, what are possible solutions to the long-term care financing conundrum and what have we learned from attempts to implement (and repeal) the CLASS Act? We propose a long-term care financing system here that will apply much of what we have learned so far.

Before outlining the components of the proposed plan for the long-term care insurance portion of the system, we note that there are two pieces of the overall long-term care financing system that, while difficult to accept, may be necessary for the system to properly function. First, we may want to allow individuals to buy into the Medicaid program at the age of 65. This option is for the portion of the population that determines they probably will eventually spend-down to Medicaid. At the beginning of their retirement, these individuals could select to buy into the Medicaid program, keeping some assets and income while immediately becoming a dual beneficiary. For some Boomers who waited too long to purchase long-term care insurance, buying into Medicaid at the age of 65 may be their best option.

Second, we would need another option for people who already are functionally disabled or have an illness that is expected to lead to functional disability. For individuals in this situation, insuring against the risk of long-term care insurance is no longer an issue – and so including this group in the risk pool for a long-term care insurance system at its genesis would not make sense.

The proposed long-term care insurance part of the system includes several components based on what we have learned so far about financing these costs. The components include:

Overall Infrastructure. In terms of the overall infrastructure, we could either create a national long-term care insurance exchange, or we could leverage state medical insurance exchanges that are currently in development. At the moment, Utah and Massachusetts have Affordable Insurance Exchanges and more than 20 others are in the process of developing them. Private products and a public product insuring for long-term care would be offered in the exchange(s).

While the medical exchanges are covering essential health benefits for medical care, one would purchase a long-term care insurance product to “marry” with the medical benefit in order to be covered for long-term services and supports. However, purchasing long-term care insurance would be optional. The private marketplace would develop products to supplement the basic coverage offered in the exchanges.

All employers would be required to offer at least one of the private long-term care insurance products in the exchange, as well as the public product, so that all workers would have easy access to two long-term care insurance options through their employer. However, individuals would have the choice of whether to participate, with incentives built-in to purchase earlier in one’s working years. Individuals would also be able to purchase exchange products of their own choosing outside of the workplace environment.

Participating Plan Requirements. For all long-term care insurance products that are offered, certain minimum protections are essential, including premium increase protections and caps. However, the national or state exchange model would allow some underwriting by the private long-term care insurance carriers competing in the exchange environment.

Public long-term care insurance would contain broad bands that distinguish premium rates according to rough risk categories. For example, differences in premiums by age would be allowed. There must be some differential in premium payments based on some criteria. Also, there would be some type of penalty for waiting to buy into the system during one’s working years.

Combination products that paired long-term care insurance and life insurance could be offered, as could products that paired disability insurance and long-term care insurance. Long-term care annuities would not be included.

Payment Options. Individuals would pay for the product either through deductions from their paychecks or additions to their Social Security tax.

Budget Rules. In the future, if a public long-term care insurance initiative is projected to save Medicaid money, it would help if it was “given credit” for these savings in budget processes. In other words, let’s not consider a public long-term care initiative to be deficit producing if it costs $60 billion but saves the Medicaid program $100 billion. The statutory language would amend budget rules and processes so that the public long-term care insurance option was considered budget neutral if it cost the same amount as it saved the Medicaid program.

Public Long-Term Care Insurance Caveat. This design requires that we carefully weigh any populations that are provided subsidies for participation. In CLASS, $5 premiums were offered to individuals living below the federal poverty level (FPL) and full-time students. This contributed to the program’s non-sustainable structure. The Medicaid program was intended for individuals who come to live below the FPL. The challenge is in providing fair and just incentives for the middle class to insure for their future long-term care costs instead of assuming that they will rely on spending down to the Medicaid program.

The options for future public long-term care insurance models and the lessons from the CLASS Act experience do not stop here. We have learned a great deal from the CLASS Act experience about the development of long-term care insurance and, after the dust settles, those involved will be able to provide more details. The point is that we are facing the type of big league problem that requires leadership. Let’s not capitalize on or mourn the loss of CLASS for too long. We have work to do – and we do not have the luxury of time before forging ahead.

This blog first appeared on November 17, 2011, on the Health Affairs blog at http://healthaffairs.org/blog/2011/11/17/after-class-a-proposed-long-term-care-insurance-system/

Copyright ©2010 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.

 

Key Words: CLASS Act, long-term care insurance, social insurance, public policy

New AARP Factsheet Summarizes Health Care Reform Opportunities that Support Family Caregivers

 Posted by on October 19, 2011  No Responses »  Tagged with: , , , ,
Oct 192011
 

In a just-released factsheet from AARP’s Public Policy Institute, Lynn Feinberg and Allison M. Reamy  detail how provisions of the Affordable Care Act (ACA) will lead to better recognition of and support for family or informal caregivers. An estimated 40 million Americans are family caregivers, and provide everything from help with transportation to assistance with daily living. As boomers age, the need for caregivers will grow tremendously—but their numbers will note. It is essential that we have public policies that address the social, financial, and health care realities of people who are family caregivers. The ACA takes a step in that direction.

Noting that the ACA explicitly mentions the term “caregiver” 46 times, and “family caregiver” 11 times, the authors are hopeful in their analysis of how caregivers might benefit from programs and policies enacted under various sections of the Act. In particular, they note that progress will be made in four critical areas: engaging individuals and families in shared decision making and addressing family experience of care; recognizing caregivers as part of the care team in new models of care;  improving education and training not only of the health care workforce, but of family caregivers; and improving support for services at home and in the community.

Of special note is the effect Section 3026, the Community-Based Care Transitions Program, will affect the lives of caregivers.  Under that program, grantees will have to carry out at least one transitional care intervention, which could include any of several scenarios, with a focus on engaging beneficiaries and their caregivers. Topics might include discharge education, help to ensure timely follow-up appointments  with post-hospital and outpatient providers, self-management education, and help with comprehensive medication review and management.

The entire factsheet is available free and online at: http://assets.aarp.org/rgcenter/ppi/ltc/fs239.pdf

 

Key Words: care transitions, Section 3026, public policy, health care reform, ACA, family caregivers