Jul 302014

by Janice Lynch Schuster

Age-related issues, including family caregiving, must become integral to the domestic policy agenda. Until now, they have received lip service. But here’s our opening to push for real conversation: The Obama Administration has declared a domestic policy focus on improving the lives of working families. At a June White House Summit on Working Families, cosponsored by the Department of Labor and the Center for American Progress, I was struck by an array of political, media, and business superstars—and their failure to focus on the fact that workers age and become and need family caregivers. In a workforce teeming with family caregivers, one thing is for sure: The work is unpaid, but it has real costs.

For now, programs that help family caregivers are few, often limited in time and scope. At the federal level, the Family Medical Leave Act provides 12 weeks of unpaid leave; but in a world in which caregiving may require years, not weeks, that is simply not enough. Working families cannot afford a week, much less 3 months, with no income. Time away from work means lost Social Security contributions; lost retirement; and, for some, a loss of skills. Aging workers are themselves challenged by illness, disability, and ageism in the workplace.

Those of us aiming to build a better future for elders (and ourselves) must push for a conversation that includes family caregivers. Whenever we can, we need to remind our opinion leaders and policymakers that family caregivers are working families. Policies that help pregnant and new moms and dads are fantastic, but so are policies that help families support loved ones who are old or frail or have disabilities.

The well-documented yet unsolved problem is creating public policies that support family caregivers—not just in name, and not just with lip service, but with real, meaningful financial, social, and physical help for the challenges that we all may face eventually. Throughout the day at the White House Summit, people talked about what working families need, but as if those needs ended with paid maternity leave, high-quality daycare, or an onsite lactation room.

The fact of the matter is that we will spend more years as caregivers to adults than we spend parenting children from birth to age 18, and those years will have a profound effect on our income and our economic security.

Private industry leading the way for working families?

At the White House Summit, several business leaders described what their organizations have been doing to improve life for their workers and, by extension, their families. Several had exceeded the minimum wage, offering what is known as a living wage, which, even at $15/hour, is far from what a family of four needs to thrive. Employers like Seattle-based Moz have implemented “no-meeting Fridays” and flexible commuting and worksite policies that encourage telecommuting and flex schedules.

Executives from companies large and small shared their strategies for helping employees balance work life and family life. A restaurant owner from Washington State described the consequences of providing paid sick leave to her staff of 52; the cost was offset by an increase in business from a community that admires her commitment. Mark Weinberger, CEO and Global Chair of EY (formerly Ernst Young), noted his efforts to lead by example—to demonstrate for his employees that family obligations and opportunities should always come first—flying home from his own first-ever keynote address in China, he said, to get to a family event.

When government and business work to develop effective policies for families, Weinberger cautioned, employers should remember that “women don’t want to be singled out and men don’t want to be left out.”

Breakout issue, not just breakout rooms

Yet caregivers are regularly left out of policy discussions. Even at a major event focused on working families, family caregiver issues were mostly in the breakout rooms. Important as it was to have Ai-jen Poo of National Domestic Workers Alliance and Gail Hunt of the National Alliance for Caregiving on the agenda, neither was featured in the plenary, with its standing-room-only, high-profile program.

The voices of older adults must be center stage, not just in the breakout rooms or as afterthoughts, but as central to what helps working families.

Congressional leadership for working families

Recent actions on Capitol Hill offer hope. The challenge for proposed policies and programs is to generate will and awareness, despite the possibility of an increased payroll tax. Examples follow:

  • Rep. Rosa DeLauro (D-CT) and Sen. Kirsten Gillibrand (D-NY) have introduced [and reintroduced in 2019] the FAMILY Act, about which DeLauro has written, “The FAMILY Act would create an independent trust fund within the Social Security Administration to collect fees and provide benefits. This trust would be funded by employee and employer contributions of 0.2% of wages each, creating a self-sufficient program that would not add to the federal budget. The expected cost to the average worker would be similar to the expense of one tall latte a week.” When needed, benefits would be paid out to cover about 66% of a worker’s wages for some period of time.
  • Rep. Nita M. Lowey (D-NY) and colleagues in the House have introduced the Social Security Caregiver Credit Act of 2014, which would allow family caregivers to continue to accrue credits necessary to earn Social Security benefits, even when they leave the workforce temporarily to care for another. Supporters can find out how to lend their voice via a website from the Center for Community Change.
  • U.S. Senator Robert P. Casey, Jr. (D-PA) has announced his plans to introduce legislation to create a national Caregiver Corps, an idea first launched as a grassroots movement to address workforce shortages, build intergenerational support, and promote opportunities for adults of all ages interested in community volunteerism.

Progress is not inevitable

While all these great ideas would make useful laws, we need to do more to advocate and be sure that our issues and aspirations are not lost in the ongoing debates over domestic policy. At the White House Summit, Labor Secretary Tom Perez spoke movingly of what it means not just to “put food on the table but to have time to eat at the table.” He also noted, “Progress does not roll in on the wheels of inevitability.”
Progress occurs because we make it occur. If we simply wait to react to the “age wave,” we will be swamped.

When it comes to an aging America, denying the numbers and science cannot change the future: If cancer does not kill us in our 60s and heart disease spares us in our 70s, dementia and frailty will come for us in our 80s and 90s. It is not just death and taxes that are inevitable: Aging, after all, is the only path to a long life.

key words: Medicaring, Working Families, White House Summit, family caregivers

Jul 092014

by Anne H. Montgomery and Joanne Lynn, MD, MA, MS

Congress is gearing up to put a legislative glide path in place that is intended to culminate in major reform of Medicare’s post-acute care (PAC) payment system. Following several months of soliciting and reviewing comments on a discussion draft, the “Improve Medicare Post-Acute Care Transformation Act” (H.R. 4994/S. 2553) was introduced on June 26. Sponsored by Sens. Ron Wyden (D-OR) and Orrin Hatch (R-UT), together with Reps. Dave Camp (R-MI) and Sander Levin (D-MI), the IMPACT proposal (https://www.congress.gov/bill/113th-congress/senate-bill/2553) is believed to have good odds of being enacted during the 113th congressional session.

One of IMPACT’s primary goals is to establish a system of uniform assessment in the PAC sector (or perhaps more accurately the “after- hospital” sector) along with improved quality measurement. This information, which would be transmitted to CMS and available for analysis and research, would be used to help redesign payments across skilled nursing facilities, inpatient rehabilitation facilities, long-term care hospitals and home health agencies, with recommendations due from CMS and the Medicare Payment Advisory Commission by 2022.

“Without comparable information across PAC settings, policymakers and providers cannot determine whether patients treated and the care provided in different settings is, in fact, the same or whether one PAC setting is more appropriate,” a summary of the bill notes.

“Absent this information, it is difficult to move forward with PAC payment reforms.”

This is true enough: Clinicians and thoughtful experts knowledgeable about the care of older adults have advocated a uniform assessment for several decades, and having a high-quality, standardized tool in hand would enable better prognostication and decision support.

But there are other factors that could heavily influence the way that PAC reform played out. One is the “Bundling and Coordinating Post-Acute care Act of 2014” (BACPAC) bill (https://www.congress.gov/bill/113th-congress/house-bill/4673) introduced on May 19 by Rep. McKinley (R-WV) and Tom Price (R-GA). As proposed, the policy would give control of PAC services to a PAC coordinator – which could be a hospital, health insurance issuer, third-party benefit manager or PAC provider; no government entities or locally-managed coalition efforts are envisioned. PAC coordinators would be given full authority to authorize, deny and coordinate all PAC services for 90 days post-discharge. These services are defined as post-hospital extended care services, home health services, inpatient services provided in a rehabilitation facility, inpatient hospital services provided by a long-term care hospital, durable medical equipment, outpatient prescription drugs and biologicals, and skilled nursing facility services. Physician services and hospice are not included. Standardized assessment is called for, but there is no mention of the information being transmitted to CMS.

Starting in January 2016, PAC coordinators receiving a single payment from the HHS Secretary for PAC services would manage PAC services within a designated “PAC area” (no standardized geographic definition of these areas is provided), and would reimburse “PAC providers” (providers or suppliers furnishing PAC services) at current rates.

After January 2019, PAC coordinators would be empowered to negotiate rates and savings targets with PAC providers. Under the terms of these negotiated agreements, PAC coordinators would keep up to 70% of any savings realized, with 10% or more to PAC providers, 10% or more to the PAC physician, and 10% or more to the discharging hospital. Although unlikely to be enacted in this Congress, BACPAC will probably be reintroduced in the 114th session. And while it may be financially attractive for certain providers, beneficiaries would not see financial gains, and the benefits from better “navigation” of services are not well established. Nonetheless, unless careful attention is paid to the implications of the bill, it is even possible that some of the proposed reforms could be implemented administratively.

But the most interesting issue is where PAC dollars that are saved will go before any of the proposed legislative reforms culminate in a rebased PAC financing system. In the IMPACT bill, financing reforms are more than seven years away. This provides a window of opportunity for capturing large savings in this sector, now that research and private companies has established that substantial efficencies in the PAC sector are feasible.

This raises two related questions: Are there models already in use that are capturing PAC savings, and if so, where are the savings going? The answers are “yes” and “to private investors.” More specifically, evidence-based proprietary protocols are now being used by some risk-bearing contractors and managed care plans to significantly reduce PAC expenditures (http://healthaffairs.org/blog/author/jlynn/). Under these arrangements, savings from taxpayer-financed PAC services are not being reinvested in further improvements, but rather are being funneled via contractual agreements directly into private pockets.

Business as usual, you say? Classic American capitalism? Certainly. But for policymakers and other guardians of the public purse and the public welfare, the merits of this approach may best be examined in a larger framework: the future of the U.S. health and long-term care systems after 2020, when the largest generation of older adults in U.S. history will rapidly drive up demand for a mix of services that are aimed at controlling chronic conditions and mitigating the impact of functional disability. Since evidence suggests that about 45% of the roughly 23% of total Medicare dollars that are spent on PAC services can be harvested
(http://healthforum.brandeis.edu/meetings/materials/2014-18 march/naviHealth.Scully.pdf), this represents an important opportunity to have a robust policy discussion about whether PAC savings — or a portion of them – could be set aside to re-engineer the health, PAC and post-PAC (i.e., long-term care) systems into better-organized integrated care systems.

The sheer size of the possible PAC savings that are available to possibly be captured over the next seven to 10 years – roughly 10% of all Medicare spending – makes this a particularly important case to debate thoroughly – rather than merely standing by and letting the money quietly disappear.

The reality is that today, we are still billions of dollars away from having the necessary infrastructure to grow our modestly-sized coordinated care and shared savings models into the stable integrated care system that will be needed for tomorrow’s large cohort of older adults. For American health care to have become so chaotic and poorly designed that private companies can design ways to pull about 10% of Medicare spending out of services and mostly into profits points out just how poorly we have built our care system for complex chronic conditions.

Some private gain using public dollars may be necessary to catalyze reforms of the PAC sector. However, the size of the looming potential loss for the Medicare Trust Fund is stunningly large, especially when the services provided are primarily decision support and navigation. If, instead, the strategy can be shifted to reinvesting a hefty portion of realized savings in care systems that are deliberately designed to deliver consistent and reliable supports for frail elders and their families, while also reducing their overall health care costs, our future will look very different.

One such comprehensive and community-focused system, the MediCaring model, has been developed by Altarum’s Center for Elder Care and Advanced Illness [now Program to Improve Eldercare]. Others may emerge from the dual eligibles demonstration and ongoing research efforts, while smaller-scale plans such as PACE may devise successful expansion strategies. These models spring from efforts to serve the target population, rather than opportunistically attending only to the happenstance period after hospitalization.

Making these and other high-quality comprehensive models larger and economically viable and sustainable – capable of both driving down unnecessary utilization while improving outcomes — will take ingenuity and innovation, significantly more efficient deployment of services and workforce, and greater flexibility in how existing financial resources are used. Given the likelihood that Congress will not want to make substantial resources for further reforms available in the form of new programs and large grants, this is an important time to think carefully about how greater efficiencies in the PAC sector can both be reliably achieved and how any resulting savings can be best leveraged to build the care system we need to handle the demands of the “age boom.”


key words: Joanne Lynn, IMPACT, BACPAC, MediCaring model, congress