May 312016

By Joanne Lynn

Medicare fee-for-service (FFS) beneficiaries with advanced illnesses and worsening disabilities, and the clinicians who focus on serving them, could wind up becoming big losers if MACRA (Medicare Access and CHIP Reauthorization Act of 2015) is implemented without sufficient attention to the realities of caring for these vulnerable populations. But there are ways in which we just might thread the needle and come out with sustainable excellence. Our future will depend a great deal on sustained activism by consumer advocates, clinicians, and caregivers, along with a heavy dose of thoughtful model-building.

MACRA is the payment scheme that replaces Congress’ annual drama of delaying implementation of the “Sustainable Growth Rate” payment system, which would have adjusted FFS reimbursements for physicians downward each year since 2002. MACRA directly affects only Medicare Part B payments. These are mostly payments to physicians but will also affect other provider reimbursements as well. The statute is complicated, and the proposed regulations run almost 1000 pages, but the potential impact upon the care of frail and disabled elderly people and their clinicians is easy to trace.

Physicians (and most others who are paid under Part B, such as nurse practitioners,) will automatically be in the “MIPS” (Merit-based Incentive Payment System) of MACRA. That looks to be very challenging for clinicians who focus on serving very sick and disabled elders. Each physician’s payment will be adjusted by a score that depends upon four factors: quality, cost, information technology (IT) use, and improvement activities. Quality measures Medicare now uses are mostly irrelevant to this population (e.g., cholesterol and lipid management and cancer screening) and some are even harmful (e.g., conventional diabetes and hypertension control). A few calamities give rise to relevant quality measures, such as onset of pressure ulcers or falls with injury, but these are rare events, even in high-risk populations, and most physicians won’t have many. Furthermore, our eldercare patients are costly, often in ways that are not captured in risk adjustment, such as having inadequate family caregivers or displaying very difficult behavioral problems. And nursing homes, assisted living centers, hospice programs, and home care have never received the federal funding and technical assistance needed to launch and integrate information technology, so performing well on IT use is going to be difficult.

Therefore, practitioners focused on frail and sick elderly people are sure to lose in MIPS, which has to stay revenue neutral: the model is designed such that every physician who “wins” in MIPS has to have a counterbalancing physician who “loses.” How badly geriatricians will lose will depend upon who they are compared with, but there’s no comparison group in which we can “win.” Since it is already very difficult to justify working in geriatrics, where clinician incomes are lower than other primary care, this will be a severe blow. We should rally to improve the metrics in MIPS, but that will take time and might never work adequately.

But there is another part of MACRA, called APMs, for Advanced Payment Models. Being qualified to be paid under an APM will earn the clinician a 5% bonus, without the downside risk of MIPS, as described above, and with a much better update in the fee schedule over time. The requirements for APMs are not settled yet, but some form of patient-centered medical home and accountable care organizations will count (as required by statute). Medicare’s new Comprehensive Primary Care Plus (CPC+) will qualify. Basically, an APM has to aim to improve care and reduce costs, and to have the clinical service provider take on more than nominal risk. Clinical specialty societies of every stripe are jumping on board with working parties around particular procedures or diagnostic categories—creating dozens of potential APMs.

However, our elders with frailty, disability, or advanced illness can’t effectively be carved up into procedures and single diagnoses. When we are old and sick, we need comprehensive care planning, reliability across time and settings, attention to the burdens on family and the costs, comfort, respect, and meaningfulness, and, finally, life closure. These are fundamentally not episodic or time-limited, nor restricted to one domain of specialization. Arranging home-delivered food may be more important than managing diabetes. Indeed, what matters is radically up to the elder and family—no one set of conventional quality measures could address the variety of situations, preferences, and possibilities. The quality measures that will matter most will include alignment with the elder’s goals, and ongoing evaluation of the performance of care plans. Of course, understanding that alignment requires having come to know the patient and family situation, values, preferences, and goals—a knowledge set that is remarkably absent from most modern medicine and virtually all health records.

So, the APM that geriatrics needs will look very different from those of most other “specialties,” precisely because it will be comprehensive, enduring, and allegiant to the elder’s priorities. I am not sure what will work. Ideally, a geriatrics APM might include showing that the clinical provider stays with patients across time and settings; provides 24/7 on-call responsiveness with a comprehensive care plan in hand; engages with one or more community boards that have authority to monitor the elderly population’s well-being and to have a hand in managing the local eldercare delivery system; and has a high rate of patient/caregiver reports of good care planning. Such a provider might still bill the conventional FFS, but perhaps the chronic care management fee would be a more substantial part of the payment package, and the patient would be protected from co-payment (as it is in CPC+).

Although the details of MACRA and proposing an APM are daunting, the advocates for the frail and disabled elders need to work together to make their voices heard and propose one or more APMs. At a meeting of the recent technical advisory committee (the PTAC) that will advise Medicare as to the acceptability of proposed APMs, person after person representing specialty societies and major health care funders made their interests known while I was the only representative of geriatric clinicians and families. Medicare pays most of the bills for elders in decline, and Medicaid pays another large proportion. Families pay most of the rest. More than any other patient group, this group is the heart of Medicare. Yet, this phase of life is at risk of being left out of the planning altogether, for lack of strategic advocacy.

Of course, our clinicians have overwhelming responsibilities and low incomes, and our professional societies are much less well-financed than most other specialties. We have not been able, in general, to support centers that can handle registries, claims analysis, and policy modeling. Furthermore, our patient advocates are likewise limited, with the larger ones focused upon earlier, healthier, stages of aging, though we have important but small, focused advocacy organizations around particularly troubling issues like nursing home abuses and legal rights under federal programs. While cancer and heart disease have strong research, consumer, and clinician organizations, geriatrics and palliative care populations and those who serve these populations have few such resources.

What is the better course? First, all who care about their futures as elderly persons, or as caregivers, or as clinicians and service providers should quickly plan and strategize, and we should all get behind one or more comprehensive models. A worthwhile model needs to be more comprehensive than the research-supported models like home-based primary care, or GRACE, or INTERACT. It also needs to be sustainable from the start. MACRA’s PTAC has proposed a process that would enable them to devote some funds to developing models. We should advocate that this support go especially to the otherwise disadvantaged field of eldercare. We could build a collaborative effort by a wide variety of provider and consumer groups. None of these groups has the funding, the skills, and the will to put together a winning APM on its own, and half-formed competing models would reduce our effectiveness. Together, we could aggregate resources and get behind a useful model or a few—and win!

Rather than having only MIPS, which is likely to disadvantage geriatrics and palliative care, or APMs established to advantage fragmentation, we could end up with a good payment model that supports elders, their families, and their service providers. It still might be true that this phase of life should generally be paid in a capitated or salaried system. However, for now, most Medicare patients are still in FFS arrangements. Clinicians who are willing and able to serve this difficult population must be able to make a living providing the right services. Otherwise, care for elders living with frailty, disability, and advanced illnesses will fare badly, and all of us will suffer when it comes our turn.

For more information:
Administration takes first step to implement legislation modernizing how Medicare pays physicians for quality (HHS)

MACRA Quality Payment Program (CMS)

To push this agenda, write to [email protected] and talk with your consumer and professional groups about participating in formulating a plan, and then getting behind it.

Feb 222016

By Anne Montgomery

A tremendously positive legislative achievement occurred on November 5, 2015, when the PACE Innovation Act (P.L. 114-85) was signed into law. Although it has received little notice, what this five-line statute does is provide the Centers for Medicare & Medicaid Services (CMS) with the authority to loosen the rigidity of the best, most established service delivery model for a geriatric population wishing to “age in place” at home: the Program of All-Inclusive Care for the Elderly. Some of the most salient possibilities for evolution of the PACE model are wrapped up in a potential PACE Expansion.

PACE already has a solid reputation as a comprehensive program tailored to dually eligible beneficiaries who need a mix of medical care and long-term services and supports (LTSS). Yet it has a small footprint across the country, serving about 35,000 adults age 55 and older. With the additional flexibility provided by the new law, PACE is now in the ambit of CMS’ Center for Medicare & Medicaid Innovation (CMMI). For the first time, the program can be readily adapted and tweaked to serve Medicare-only beneficiaries who have a need for some LTSS but are not yet functionally at the nursing home level of care (which varies between states) and have incomes above their state’s Medicaid financial eligibility threshold. During the height of the Baby Boomer-driven “age wave” a little more than a decade from now, when tens of millions of seniors living into their 80s and beyond will be seeking reliable, affordable assistance to remain in their homes, many might welcome a flexible, comprehensive program that offers both ongoing medical care and tailored LTSS.

Here is how an adapted PACE model might work: Medicare-only beneficiaries would be empowered to buy into PACE for their LTSS services with private dollars, whether in the form of tiered bundles of services, on a menu-driven basis, or a combination of both approaches. These at-risk beneficiaries would be appropriately motivated and incentivized to buy just the amount of LTSS that they actually require, which would be determined based on a comprehensive assessment and a corresponding comprehensive care plan. The amount they would pay would be far less than what has long been required for Medicare-only PACE enrollees, who, by regulation, are now forced to pay the full Medicaid capitation rate. Because the Medicaid capitation rate is a blended rate to cover the needs of those who are eligible for nursing homes and to stay with them to the end of their lives, the fee is typically several thousand dollars a month. Vanishingly few Medicare-only elders think that they will need this level of service, so there are very few Medicare-only PACE enrollees today. If, instead, Medicare beneficiaries could secure tailored LTSS at much more reasonable premiums, this would stretch and conserve their retirement savings. From the vantage point of states that are struggling to plan for substantially larger Medicaid LTSS populations, this could have a positive impact on slowing spend-down rates.

In addition, it may be possible to consider whether the out-of-pocket payments made in such an arrangement could be made through a revised, more affordable private long-term care insurance (LTCI) market. Some initial promising ideas for improving LTCI have recently been announced by the Bipartisan Policy Center.

More importantly in the near term, the overall state of readiness of the Aging Network (AN), which is still not well-understood within the health care industry, must be enhanced. For an expanded PACE program or any other health care provider to succeed in serving a significantly larger population of Medicare beneficiaries with varying needs for LTSS, which are delivered in the home, will require much more focused attention to the AN by policymakers and stakeholders in the health care sector. Composed of thousands of small, locally administered Area Agencies on Aging (AAAs) and related community-based organizations across the country, the AN is charged with arranging for and providing social services and supports (e.g., home-delivered nutrition services, respite care and flexible, adapted transportation systems) to all older citizens who are deemed to be in need in any given community. In practice, the ability of the AN to deliver on this promise is compromised by an inadequate financing base. Although the AN is moving as quickly as possible to transition to partnering with health care partners, some of the key infrastructure required (e.g., data systems to collect, report, and analyze performance metrics that are compatible with what health care providers are asked to submit) is poorly developed. This suggests that more focused attention, as well as well-targeted financial investments, must be made in order to create a reliable, comprehensive, cost-effective service system that spans the health and social services sectors.

To date, investments by the health care agencies in the federal government to link the AN’s service delivery system with the health care system have been miniscule. Along with chronic underfunding through the appropriations process despite steadily rising need among aging seniors in communities across the country, underinvestment in the AN’s infrastructure is arguably stymieing further development of this sector. Questions about how an expanded PACE program (and similar evolving initiatives) can be positioned to work with the AN most cost-effectively are probably best answered through prudent investments in research, pilots, and demonstrations, along with ongoing monitoring and quality improvement efforts. Without such investments, LTSS services for millions of community-dwelling Medicare beneficiaries could become increasingly unreliable or perhaps even completely unavailable. If this happens, the likely outcome will be that health care costs for a rapidly growing population of older adults who need LTSS services but cannot secure them will continue to rise quickly.

On the other hand, an expanded PACE model approach offers the possibility of connecting an already established, high-quality, interdisciplinary health care model with an existing, though still loosely organized, community-anchored social services sector. It is a possible and exciting adaptation of the best that our current care system has to offer. To make it a reality will require timely, concerted action on the part of CMS and interested stakeholders. Also needed are local leaders and community and aging services advocates who recognize that there is an opportunity at hand to create a strong foundation for a more comprehensive system of care—one that explicitly includes supports that address the social determinants of health.

Click here to view a slide deck on the Frail Elder Expanded PACE Program.

Dec 162014

by Stephen F. Jencks, M.D., M.P.H.

[Also see companion post by Joanne Lynn, M.D.]


The Medicare Readmission Reduction Program (MRRP) encourages hospitals to reduce readmissions within 30 days of discharge by imposing substantial financial penalties on hospitals with more readmissions than would be expected if the same patients were discharged from an average hospital.[1] But some hospitals and communities have succeeded too well and reduced discharges even more than readmissions so that their readmission rates, as currently calculated, do not improve much, which puts them at higher risk for penalties. There are two underlying problems:

First, there are two ways of thinking about, and therefore measuring, the rate of readmissions; and they often lead to quite different results and quite different decisions on penalties. One is discharge-based; the other, population-based. The relationship between the two is simple: (readmissions/discharges) X (discharges/(beneficiary population (1,000s) ) ) = readmissions / (beneficiary population (1,000s))

Patients who are admitted but die during hospitalization or are transferred to another hospital are not counted as discharges from the first hospital.

Second, effective interventions to reduce 30-day readmissions have an effect on admissions that extends far beyond 30-days after discharge and they reduce a lot of other admissions, especially if implemented in partnership with community providers and services.

When Congress created the MRRP, many stakeholders had become aware (and dismayed) that 20% of people enrolled in Medicare fee-for-service and discharged from a hospital were readmitted within 30 days of hospital discharge. Clinical trials had shown that improved processes around hospital discharges could prevent many of these readmissions. The aim of establishing accountability also made a hospital focus desirable. In this view, readmission is a burden resulting from poor hospital discharge processes, whether clinically premature or poorly executed. With that emphasis on discharge processes as cause and cure for readmissions, it was natural for the Centers for Medicare & Medicaid Services (CMS) to choose to estimate each hospital’s expected readmissions as the number of patients whom the hospital discharged and who would be expected to be readmitted after discharge from an average hospital. Most readmission reduction initiatives use this discharge-based readmission rate to measure performance. This discharge-based perspective effectively defines the readmission rate as the percentage of discharges that are followed by a readmission. In this way of thinking, the number of hospital discharges is simply a fact of life, much like the fact that a year has 365.24 days. This view does not see that hospital actions might reduce the number of patients they discharge, and this blind spot causes trouble.

Hospitals actually have a great deal of influence on how many patients they admit and discharge because so many of their discharges are admitted through their emergency department or by hospital-affiliated physicians and because they can collaborate with community services and providers who can forestall patients even coming to the hospital. Population-based hospital discharge rates vary substantially across regions, and they can change over time.

Some policy makers worried that the discharge-based rate could behave in unexpected ways if hospitals took steps that reduced total discharges by more than the reduction in 30-day readmissions. As a result, several programs, such as the Partnership for Patients and the Quality Improvement Organizations’ (QIOs) Care Transitions Program, were designed using a population-based readmission rate or converted to such a rate after evaluating early findings. The population-based rate is the number of readmissions for every 1,000 fee-for-service Medicare beneficiaries in the hospital’s service area. This view sees readmissions as a community health problem, a burden on a population of beneficiaries and the Medicare trust funds that is associated with that population’s use of hospitals just as hospital-acquired infections are associated with use of hospitals. From this perspective, preventing hospitalizations, improving discharge transitions, and improving post-discharge care are equally valid ways to reduce readmissions. Whether the hospital reduced hospitalizations in order to reduce readmissions is less important than being sure that we do not penalize hospitals for taking such steps. Population-based rates are closely aligned with the three-part aim of the National Quality Strategy (individual care, population health, and affordability), not only because they are population-based but also because they reflect the close relationship between care in the community and a hospital’s apparent performance.

Thus, a program can reduce burdens on beneficiaries and Medicare through significant reductions in the population-based discharge and readmission rates but see much smaller reductions in the discharge-based readmission rate. In a companion blog to this piece, Joanne Lynn presents evidence that this attenuation of changes in discharge-based rates has happened repeatedly in community-based readmissions programs. We do not know, at this point, whether attenuation of changes translate into financial penalties but it seems very likely to increase a hospital’s risk.

We also do yet fully understand what specific changes produce these decreases in the population-based discharge rate, but the most parsimonious explanation is that the causes are pretty much the causes of reduced readmissions: Provide urgent care with support for keeping the patient in the community, and you are likely to reduce all admissions, not just readmissions. Enroll more patients in medical homes, and the benefits will not disappear 30 days after hospital discharge. Improve nursing home communications with emergency rooms, and the benefits will not be limited to patients within 30 days after hospital discharge.

What we can foresee is that hospitals, already wary of readmissions reduction because it directly reduces revenue, will become doubly wary if they conclude that reducing discharges may also cause or increase the MRRP penalty. If CMS is penalizing hospitals and communities for succeeding at improving care and reducing costs, the reaction may threaten a very successful set of initiatives. The examples we report are for community-based efforts to reduce readmissions. Hospital-level calculations are generally beyond our capability. CMS can, however, easily determine whether, all else being equal, penalties are more likely or larger in areas where the population-based hospital discharge rate is declining substantially than elsewhere. That information is urgently needed.

What to do.

The purpose of the MRRP is to reduce the burden of readmissions on Medicare beneficiaries and the Medicare trust funds, so the important indicator of progress is the number of readmissions, not the percentage of discharged patients that are readmitted.

Healthcare quality measurement needs to catch up with the National Quality Strategy and add measures of the impact of care on the health of the population that will complement measures of the quality of individual episodes of care such as hospitalizations. In the case of readmission measurement for the MRRP, this need is substantially more urgent because there is good reason to fear that a hospital that engages with its community and does exactly what the MRRP hopes for is more liable to financial penalties under the current, discharge-based measure than it would be under a population-based measure.

The first step is to assess the degree of urgency by examining national evidence on actual penalties. If unreasonable penalties are at all frequent then the problem is far more urgent. This will be complex, because Epstein has already shown in cross-sectional studies that population-based hospitalization rates and readmission rates are positively correlated.[2] At the same time it will be important to develop population-based measures of readmissions and compare their impact on penalties with the impact of discharge-based measures. The obstacles are bureaucratic, technical, and political.

Bureaucratically, the most important obstacle has been a widespread belief that the Patient Protection and Affordable Care Act requires calculating discharge-based rates. In fact, the Act says only that penalties are to be determined from the ratio of observed to expected numbers of readmissions and is silent on how the expected number is to be calculated. The other bureaucratic problem is less tractable: Under current procedures, the steps laid out for implementing a new measure, both at CMS and at the National Quality Forum (NQF) would likely take several years. The process should be expedited if the analysis of current penalties indicates that hospitals are being penalized for success in reducing admissions.

The technical challenges of creating a population-based readmission measure for hospitals are substantial. First, the procedure must find a way to measure each hospital’s population-based hospitalization rate. Second, a method of risk adjustment must be developed and applied so that population-based readmission rates for each hospital and community can be compared. Although these methods are still evolving, adjustments for factors such as neighborhood deprivation[3] are actually easier at the population level. These are difficult tasks, but a first step good enough to improve on the existing model should be possible within a year.

Politically, hospitals will be concerned about accountability for the community hospitalization rate. They will recognize that if hospitals in areas with low hospitalization rates are protected, then hospitals in areas with high hospitalization rates will be more vulnerable.

Some have hoped that traditional risk adjustment could solve this problem, because the most likely scenario is that average risk of readmission increases as the number of discharges decreases. That prospect is not promising, because the most assiduous work on risk adjustment has produced tools of only moderate power. The prospects for solving this problem with improved risk adjustment are not promising.[4],[5]

When you find yourself in a hole you should stop digging. It seems prudent for NQF to suspend endorsement of the pending discharge-based readmission measures and for CMS to delay implementing discharge-based measures if NQF endorses them until CMS has studied and reported the extent to which readmission penalties punish hospitals that are actually reducing both admissions and readmissions and has laid out an approach to any problems found. Finally, the problem identified here underlines the importance of placing a population-based foundation under at least some measures of health care system performance.


[1] Centers for Medicare and Medicaid Services. Readmission reduction program. Retrieved from

[2] Epstein, A. M., Jha, A. K., & Orav, J. E. (2011 December 15). The relationship between hospital admission rates and rehospitalizations. New England Journal of Medicine 365(24).

[3] Kind, A. J. H., Jencks, S., Brock, J., Yu, M., Bartels, C., Ehlenbach, W., & Smith, M. (2014 December 2). Neighborhood socioeconomic disadvantage and 30-day rehospitalization: a retrospective cohort study. Annals of Internal Medicine 161(11) 765-775.

[4] Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation. (2014, July). 2014 measure updates and specifications: Hospital-wide all-cause unplanned readmission – version 3.0. Retrieved from

[5] Kansagara, D., Englander, H., Salanitro, A., Kagen, D., Theobald, C., Freeman, M., & Kripalani, S. (2011 October 19). Risk prediction models for hospital readmission: A systematic review. Journal of the American Medical Association 306(15) 1688-1698.

Dec 082014
Dr. Joanne Lynn Portrait

By Joanne Lynn M.D.

[Also see companion post by Stephen F. Jencks, M.D., M.P.H.]

Care transitions improvement programs have been effective in helping the health care system both become more effective in serving people living with serious chronic conditions and reduce costs. However, the key metric used to measure performance is seriously malfunctioning in at least some hospitals and communities, leading to penalties and adverse publicity for providers and communities that are actually performing well and continuing to improve performance. In this post we provide supporting data, and a companion blog article provides a thoughtful discussion of the conceptual issues underlying this troubling malfunction. For our earlier blog post about this problem see:

Very simply, this problem arises because the metric used is some variant of readmissions (within 30 days) divided by discharges (from a particular hospital) within a particular period. Thus, the usual metric is something like “20% of Medicare fee-for-service (FFS) hospitalizations are followed by a readmission within 30 days.” This metric works well if the denominator, namely the number of hospitalizations, is not affected by the improvements that reduce the risk of readmission. If the denominator declines along with the numerator, the metric will not reflect the degree of improvement that was actually achieved. The data below show that this happens in real situations.

We are here showing the data from San Diego County, a very large county with about 250,000 Medicare FFS beneficiaries, who had about 60,000 Medicare FFS admissions to hospitals per year and about 10,000 readmissions per year in 2010, when almost all of the hospitals and the county’s Aging & Independence Services (functioning as the Community-based Care Transitions Program partner agency/Area Agency on Aging/Aging and Disability Resource Center) started working together to improve care transitions and reduce readmissions under the San Diego Care Transitions Program, one of the Community-based Care Transitions Programs initiated by Section 3026 of the Patient Protection and Affordable Care Act. The application year was 2012 and the start-up year was 2013. The table below shows an initial summary of their results, provided through their Quality Improvement Organization.

Exhibit 1: San Diego County: Relative Improvement by Metric, 30-day Readmissions

Exhibit 1: San Diego County: Relative Improvement by Metric, 30-day Readmissions

Readmissions of county Medicare FFS residents fell by 15% in 2013, compared with 2010. San Diego County reduced hospitalizations by 11%. However, when the numerator and denominator go down at nearly the same rate, the fraction moves just 4.3%, which falls far short of the 20% reduction goal that Medicare has set.

What follows are the quarterly data from San Diego. The first graph, Exhibit 2, shows the quarterly rate of admissions per 1,000 Medicare FFS beneficiaries in San Diego County. We have adjusted these data for the effects of seasons on admissions (since there are usually more admissions in the winter). The shaded portion shows the “control limits,” an area which represents the expected range of variation demonstrated in the first 3 years of the data (2010-2012). Data that fall outside of the range or that consistently run on one side of the midline indicate that something has changed in how the system is functioning. Clearly, admissions are falling.

San Diego Seasonally Adjusted Admissions

Exhibit 2: San Diego Seasonally Adjusted Admissions

The second graph, Exhibit 3, shows the readmissions rate in the same framework – quarterly rate of readmissions per 1,000 Medicare FFS beneficiaries in San Diego County, adjusted for seasonality. The control limits again show change. Readmissions are falling.

Exhibit 3: Seasonally Adjusted Readmissions

Exhibit 3: Seasonally Adjusted Readmissions

The third graph, Exhibit 4, shows the metric in the conventional form, readmissions divided by discharges. The graph does eventually show a decline, but only a modest one. The fact that the denominator was falling attenuated the impact of the falling number of readmissions.

Exhibit 4: Seasonally Adjusted Percent Discharges with 30-day Readmissions for San Diego County, by quarter

Exhibit 4: Seasonally Adjusted Percent Discharges with 30-day Readmissions for San Diego County, by quarter

The next three exhibits show the comparison of the San Diego measures with the national rates for the same metrics. Exhibit 5 shows that San Diego County is dramatically less likely to have Medicare FFS beneficiaries in the hospital than the nation as a whole: 56 per 1,000 per quarter in San Diego, compared with 69 per 1,000 per quarter nationwide. Exhibit 6 shows that San Diego is also much lower in readmissions than the national average: 10 per 1,000 per quarter in San Diego, compared with 12 per 1,000 per quarter nationwide. In both cases, the declining use is reasonably parallel between San Diego and the nation. This would imply that improvement strategies are still being effective at this lower range, and thus the lower range is not yet a limit on improvement opportunities. Exhibit 7 shows that San Diego County’s conventional metric of readmissions divided by discharges simply tracks the national average. Clearly, the metric is not functioning in a way that reliably separates good practices from wasteful ones. That readmissions over discharges metric does not convey the fact that San Diego is much less likely to hospitalize and to rehospitalize. Indeed, 10 of the 14 San Diego hospitals eligible for penalties for high readmission rates are being penalized next year. Since the calculations that go into determining the hospital penalty focus on particular diagnoses in three past years, it is possible that these hospitals manage to do badly with those diagnoses in those years, but it seems quite unlikely. More plausibly, the metric used is of the readmission divided by discharge form, so the shrinking denominator will affect this calculation.

Exhibit 5: Seasonally Adjusted Quarterly Admissions, National and San Diego County

Exhibit 5: Seasonally Adjusted Quarterly Admissions, National and San Diego County

Exhibit 6: Seasonally Adjusted Quarterly Readmissions, National and San Diego County

Exhibit 6: Seasonally Adjusted Quarterly Readmissions, National and San Diego County

Exhibit 7: Percentage of Quarterly Discharges Readmitted, National and San Diego County

Exhibit 7: Percentage of Quarterly Discharges Readmitted, National and San Diego County

Without access to and analysis of much more data, one cannot know how widespread this problem is. We do know that San Francisco had an admission rate of just 50 per 1,000 per quarter in 2013 and a readmission rate of just 8 per 1,000 per quarter, which are rates much lower than San Diego. Yet 8 of San Francisco’s 10 eligible hospitals will be penalized for excessive readmissions in 2015. Furthermore, we know that the initial Medicare foray into this work, published in the Journal of the American Medical Association in January 2013 (link: “Association Between Quality Improvement for Care Transitions in Communities and Rehospitalizations Among Medicare Beneficiaries”, see “Outcome Measures”), involved 14 smaller communities, and that project had to change from using the discharge-based metric to using the population-based metric when it became clear that the shrinking denominator was making the project monitoring unreliable.

Hospitals, other providers, and communities that believe they may be adversely affected by the malfunctioning metrics should have access to the data needed to investigate and CMS should welcome reconsideration of those situations. NQF should suspend endorsement of new readmission/discharge metrics and re-examing existing ones. CMS has multiple contractors working on readmissions, and some have substantial experience and skills in the technical details of these metrics. CMS should quickly modify their contracts to require them to investigate the extent of this problem, to identify steps to ameliorate adverse impacts of the current readmissions/discharges metrics, and to build the metrics that can guide care transitions work into the future. Certainly, the time has come to sort this out and develop metrics that reliably separate exemplary from persistently inefficient practices.

Want to know more?

“Protecting Hospitals that Improve Population Health” by Stephen F. Jencks.

“Senior Alert: A Swedish National Dashboard for Preventitive Care for the Elderly” by Elizabeth Rolf.

Apr 302014

Medicare coverage for services shortly after hospitalization includes a great deal of waste, low-value care, and services that stretch Medicare coverage rules. If reforms save a great deal of money in “post-acute” care, where should those savings go?

A recent Institute of Medicine (IOM) report showed tremendous variation in “post-acute” care, and the U.S. Department of Veterans Affairs and a score of small projects have shown that hospitalization and after-hospital costs can be cut. Various initiatives are hustling to scale up such approaches, aiming to save millions of dollars, too. Mostly, these endeavors improve care and deserve support on that score, but one should also pay attention to what happens to the savings. When private companies contract to manage a population through the post-hospital period, the managed care or Accountable Care Organization (ACO) giving the contract and their efficiency contractor share the savings, with a little also going back to the Medicare Trust Fund from ACOs. What if policy were changed to ensure that some of the savings will pay for the social services and supports that elderly people require if they are to live (and flourish) at home, cared for by family and friends?

The questions we have been asking at the Center here — as old people in training, as people who love old people, and as advocates for better policies — are whether and how the public can rally to act in its own best interests? It is not enough to insist that we save money. We also need to decide what to do with what we save.

Where Will the Elders Go? And the Money?

One likely effect of dramatically trimming services available to elders after hospitalization will be to increase the demands on families. We will expect them to provide ever more care to people who would once have still been in the hospital or nursing home. Most just-discharged elders will have ongoing needs for supplemental services at home. Since many will not meet current Medicare requirements for such care, they and their families will have to pay even more out of pocket. They will spend down to Medicaid more quickly.

Also, the effective arrangements for follow-up that many hospital-based practitioners have had will be disrupted. The orthopedist who could count on the skilled nursing facility or inpatient rehabilitation facility to implement shared protocols will now have patients going home more quickly and to family caregivers who cannot reliably follow instructions or report issues.

Many very old people will not have homes and families able to take them in or to drop everything to provide care. Many of the essential services (e.g., personal care, housing, food, transportation, caregiver support and training) will have to be paid for privately or by Medicaid. If, in the end, Medicaid pays more and families are more depleted, have we really saved money? Did we get what we really wanted?

Investing Shared Savings to Build Medicare 2030

What if we invested much of the projected savings to support frail elders better in their communities? Doing so would slow the rate of spending to Medicaid and buttress family caregiving by providing, for example, stipends, respite care, and training. Very old people could feel more confident and avoid being plagued by fears of burdening families, going without food, or living in inadequate or overly expensive housing.

For now, we could allow the efficiency contractors to implement the changes broadly enough to create irrevocable change and then build a new system on their success, or we could aim to build the new system that generates the efficiencies and reinvests the savings from the start. Both strategies would keep public funds working in the public interest, at least eventually.

What’s your role in all of this? Write to your elected officials or talk with them when they hold a forum. Express your concerns as an old person in training and as a citizen. We are building the system into which our parents, our spouses, and we ourselves will age. Surely, in protecting our own future, we can craft a better one for us all.

Make a comment below and let us know how you see things.

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May 302013

by Anne Montgomery

There’s a reason why the nation has convened a White House Conference on Aging (WHCOA) once a decade, and it’s this:  Historically, these seminal events – which involve thousands of people feeding in ideas from communities across the country – have spurred creative consensus at a national level about how apparently intractable current challenges can be practically approached, even as strategies for making promising opportunities a reality over time are also mapped out.

The United States is now in Year 3 of its “Age Wave,” and it’s become clear to policymakers and stakeholders alike that much work remains to be done to build sufficient capacity for delivering the comprehensive array of services that our aging society demands, in the form of policy frameworks that align financial incentives and position a broad array of mostly non-coordinated providers to be accountable for delivery of consistently good-quality services.  So how can we get from where we are today to meeting these goals? What policies and strategies will get us there?

This is where the WHCOA comes in.

The first Conference was held in January 1961 at the directive of Congress, which established it in legislation that was enacted in 1958 (Public Law 85-908).  In addition, in 1959, a Senate Subcommittee on Problems of the Aged and Aging was established, and three years later, this panel was elevated to become the Special Committee on Aging.  In the words of then-Aging Committee chair Sen. Pat McNamara, the convening Conference was dedicated to “bringing to national attention the problems, potentials – and challenges – of an aging population.”

For perspective on what McNamara and other framers had in mind for the WHCOA, here is how the aspirations of an aging society were framed in the Aging Committee’s foreword, which accompanied the first Conference’s final report:

“Today the life expectancy is around 70 years.  In 1900, it was less than 50 years.  In the lifetime of today’s younger generation, without any further progress in medical science, an average life expectancy of 80-85 will be typical….Our traditional approaches to the ‘aged’ require reappraisal in the light of hard facts. For one thing, past approaches were characterized by a tendency to look at the problem involved – if indeed, problems were recognized – in a fragmented way.  A systematic, coordinated outlook and action policy [emphasis added] are increasingly called for as we become more and more conscious of the impact of the aging trend in our society upon the lives of the total population and even upon the policies relating to matters not otherwise considered as directly affected by the emergence of the ‘problems of the aged.’”

More than 50 years later, these prognostications have turned out to be remarkably accurate. According to the Social Security Administration, a man reaching the age of 65 today can expect to live, on average, until 83. A woman turning 65 today can expect to live on, average, until the age of 85.  Equally or perhaps more important, one out of four 65-year olds will live to be 90 years of age or older, and one out of 10 will live beyond age 95.

The WHCOA framers could not know which, if any, of the many ideas and recommendations that were suggested and debated in 1959, 1960 and 1961 – the first Conference was held after 2 ½ years of public meetings and deliberations–would be adopted.  Many focused on health care and income. Today, looking back with the benefit of hindsight, we know that in 1965, Congress enacted legislation establishing Medicare, Medicaid and the Older Americans Act.  These statutes and programs have grown in scope and importance over the years, and they are widely acknowledged to be essential for meeting the challenges of our nation’s quickly accelerating “age wave.”  The issues being debated at present are whether these and other public programs, along with private-sector options, have adapted sufficiently to meet the challenges of the 21st century. Many are arguing that further reforms are warranted.

Yet looking ahead, the policy picture is far from clear. The current state of discussion about Medicare and Medicaid is vigorous – but divided.  No firm consensus has emerged on the specific nature of what changes are essential.  Moreover, the Older Americans Act, which is overdue for reauthorization, has been overshadowed by a range of other issues that are deemed to be more pressing.  At the same time, the number of Americans turning 65 each day grows by about 10,000.

This situation suggests that a national conversation in the form of a WHCOA, to be held in 2015, and accompanied by a process of meetings and conversations – both in-person and online – to solicit input and ideas from thousands of citizens across the country would be a sound civic investment – just as it was more than five decades ago.

All WHCOAs have resulted in subsequent adoption of signature initiatives.  For example, the 1971 WHCOA is given credit for creation of the Supplemental Social Insurance program and establishing the National Institute on Aging within the federal government’s biomedical research establishment, the National Institutes of Health.  In 1995, the WHCOA called for establishing a program to recognize and assist the nation’s millions of family caregivers – which led to enactment of the National Family Caregiver Support Program. This WHCOA also highlighted a pressing need to develop strategies for detecting, addressing and preventing elder abuse, along with improved opportunities for retraining and assisting older workers.  Notably, it rejected the notion of pitting programs for older adults against those that serve cohorts of younger adults, adolescents and children.

Most recently, the 2005 Conference provided momentum for reauthorizing the Older Americans Act in 2006, which strengthened the role of Aging Disability Resource Centers (ADRCs).  Discussions of elder abuse generated widespread attention and interest, and were transformed into a discussion on elder justice, which in turn helped to prompt Congress to enact the Elder Justice Act in 2010.  Significantly, the 2005 Conference flagged the issue of coverage and support for long-term care as a critical and emerging issue—one that is awaiting further action.

To forecast what the next WHCOA might be able to help develop in one key area, it is useful to review some of what the delegates considered when they assembled more than 2,500 delegates in Washington, D.C. in 1961.  The four-day meeting resulted in a report that covered 20 areas of emphasis. Among these was a section titled “Local Community Organization,” which declared, in part:

“To put total emphasis on the care of the aged, as opposed to developing a community in which one can age with dignity and independence, would poorly serve the coming generations of Americans. We must not create the continual crisis of ‘problems.’ A total program of local community awareness and individual responsibility can develop the great opportunity which we presently have in the lengthened lifespan of Americans….To create this activity in the local community, where the individual must live and function, it is recommended that local communities immediately create a Committee on Aging through which planning may be done for the good life that can be achieved by and for its elder citizens.”

With the subsequent establishment of 50 State Units on Aging as part of the Older Americans Act, and more than 600 local Area Agencies on Aging and their close cousins, ADRCs – which aim to be potential portals for long-term care services and supports – the concept of building stronger networks of cohesive, locally-rooted initiatives that can support frail elders and individuals with disabilities in their own communities is one that has the potential to create a series of lively and productive discussions at the next WHCOA.

In this and many other areas, there is a lot left to do – so if you or your organization would like to lend support to the idea of convening a WHCOA in 2015, please take a moment to read the “Letter to the President” (supported by more than 40 organizations including AARP and the National Council on Aging) and then send in your own request.

[Update: The White House Conference on Aging was held in 2015. Read the “Final Report of the 2015 White House Conference on Aging”.]

Anne Montgomery is a Visiting Scholar at the National Academy of Social Insurance and a Senior Policy Analyst at the Altarum Institute. She worked for the Senate Special Committee on Aging from 2007 until early 2013. This article originally ran on the NASI website ( on May 13, and is reprinted here with Anne’s persmission.



Key words:  White House Conference on Aging, National Academy of Social Insurance, Anne Montgomery, age wave, aging, elder care, frail elders

May 222012

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 (May 2012),  Joanne Lynn, M.D., Director for the Altarum Center for Eldercare and Advanced Illness, blogs on Improving Population Health. A few months ago (February 2012), 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

Apr 272012

On April 13, 2012, 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.

To watch the entire program, follow this link:

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

Feb 212012

By Suzanne Mintz President and CEO, National Family Caregivers Association

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

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

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