Washington Update - June 2005

AMERICAN GERIATRICS SOCIETY CHAIR, MEGHAN GERETY, MD, TESTIFIES BEFORE CONGRESS ON NEED FOR MORE COHERENT, EFFECTIVE, AND COST-EFFECTIVE LONG-TERM CARE

An estimated 10 million Americans—two-thirds of them elderly—need long-term care. And while many getting such care rely primarily on unpaid help from relatives and friends, spending on long-term care totaled more than $150 billion in 2003.

Medicaid outlays made up the largest portion of that total, exceeding $60 billion, and Medicare spending (to cover limited skilled nursing facility and home health care benefits) totaled about $27 billion. Individuals’ out-of-pocket payments came to about $38 billion, and private insurance expenditures, $15 billion, according to the Kaiser Commission on Medicaid and the Uninsured.

Not surprisingly, proposed government spending cutbacks (Medicaid alone is slated for $10 billion in cuts over the next five years under the budget blueprint Congress recently endorsed) are intensifying the debate over long-term care financing. And so of course there are concerns about unprecedented growth in future needs for long-term care. Demand for care is expected to jump dramatically between now and 2030, when the youngest of the nation’s 76 million baby boomers reach retirement age.

“We must find new and innovative ways to encourage individuals to prepare for their long-term care needs,” Congresswoman and House Ways and Means Health Subcommittee Chair Nancy L. Johnson (R-CT) noted in calling for the subcommittee Hearing on Long-Term Care that took place in Washington, DC, on April 19.

Policymakers are already looking at certain private sector proposals, such as encouraging more people to buy long-term care insurance by increasing incentives, such as tax credits. But tax incentives for private long-term care insurance will primarily benefit higher-income individuals, as Dr. Meghan Gerety, Chair of the American Geriatrics Society, testified at the subcommittee meeting.

The insurance is just too costly to be viable for everyone, explained Dr. Gerety, Associate Chief of Staff at South Texas Veterans Health Care System, and Professor of Medicine at the University of Texas Health Science Center at San Antonio. “Additionally…long-term care insurance premiums often increase dramatically as individuals age, meaning that people drop their policies just when they need them most,” she added. “In fact, as a baby boomer and a geriatrician, I have neglected to purchase a long-term care policy because it is of limited value.”

A better approach, Dr. Gerety argued, would be to institute changes that would make long-term care more comprehensive and consistent, and thereby cut waste, help contain costs, and improve quality. As things stand, care is often allocated based on eligibility requirements, rather than a comprehensive plan for a patient. To make her point, Dr. Gerety offered an example of what might happen to a hypothetical 88-year-old woman who lives at home, falls, and breaks her hip:

She is sent to the hospital where Medicare covers her care. Following her surgery, she is sent to a nursing home for rehabilitation, also covered by Medicare. However, when her therapy is completed, she is less independent and therefore cannot return to her home. She qualifies for Medicaid coverage in the nursing facility, but not for enhanced services that would allow her to return safely home. After several months at the nursing home, she develops a urinary tract infection and needs antibiotics and IV therapy. Unfortunately, Medicaid will not cover this service in the nursing home, but Medicare will cover it in the hospital. The woman is transferred back to the hospital.

It’s an all-too-common scenario, one illustrating how the current system can be inefficient and costly, and lead to poor outcomes. Such a lack of coordination among settings and care providers, Dr. Gerety pointed out, can result in incomplete information sharing, inadequate patient assessment, poor care during transitions from one setting to the next, and both under- and overutilization of medication and other services.

One model for more coherent, and more cost-effective, care—advocated by the American Geriatrics Society—is based on a comprehensive geriatric assessment. Following this model, an integrated team of geriatrics providers evaluates the patient, and after consulting with the patient and his or her caregivers, develops an overarching plan of care. This care might occur over various settings, including the home. Research has shown that many therapies and treatments can be just as effectively—and more economically and comfortably—provided at home and in other community settings as in hospitals and nursing homes (though government financing and long-term care insurance continue to favor institutional care settings).

Dr. Gerety ended her speech by calling for a “paradigm change” in policy and financing, providing for more comprehensive, more thoughtfully allocated care, in a wider range of settings. We think that’s wise. It’s a call, we believe, policymakers should heed.