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Determining the Future of Long-Term Care
Dr. Stefanacci served as a CMS Health Policy Scholar for 2003-2004, is an associate professor of health policy, University of the Sciences, and a Mercy LIFE physician, Philadelphia, PA; and is chief medical officer, The Access Group, Berkeley Heights, NJ
Dr. Spivack is the founder of the Connecticut Geriatrics Society, and is on the medical staff of Greenwich Hospital, Greenwich, CT.
How will long-term care (LTC) be financed and delivered in the future? This important question was presented to the Commission on Long-Term Care upon its establishment under Section 643 of the American Taxpayer Relief Act of 2012, which was signed into law on January 2, 2013.1 The Commission was tasked with developing a plan for the establishment, implementation, and financing of a system to ensure the availability of long-term services and supports (LTSS) for individuals such as elderly persons, those with substantial cognitive or functional limitations, those who require assistance to perform activities of daily living, and those who wish to plan for future LTC needs. The Commission on Long-Term Care, which comprises 15 members appointed by the President of the United States, the majority leader of the Senate, the minority leader of the Senate, the Speaker of the House of Representatives, and the minority leader of the House of Representatives, was given only months to answer this vital question for frail older adults and all of us involved in the delivery and funding of LTC. The Commission submitted its final report to Congress on September 30, 2013, which highlights its recommendations for addressing the challenges with delivering and financing LTSS.2
Beyond the 1.8 million persons residing in US skilled nursing facilities (SNFs) are over 12 million Americans of all ages with functional impairments who rely on personal assistance and other LTSS provided in their home, their community, or an institution (eg, SNFs, assisted living facilities, adult day care centers, etc) to help them perform daily activities, and maintain quality of life, and, when possible, independence.3 Most of these individuals receive services and supports from dedicated formal and informal caregivers who enable them to cope with their cognitive or physical limitations with dignity.
The number of older Americans with physical and cognitive limitations will grow as baby boomers advance in age. At the same time, fewer family caregivers combined with more limited personal financial resources to pay for caregiving due to declines in savings rates, retirement asset accumulation, and private insurance purchases will place increasing pressure on the Medicaid program and the federal and state budgets that fund it. Currently, more than 60% of LTC funding comes from Medicaid, and this funding is expected to increase with the expansion of Medicaid under the Patient Protection and Affordable Care Act.2
The dollar value of family caregiving exceeds that of all spending on LTSS. Family caregiving had an estimated economic value of $450 billion in 20094 as compared with $220 billion spent on LTSS in 2012.5 In addition, the cost to US businesses due to lost productivity from full-time family caregiver employees (eg, reduced hours, replacement of employees, absenteeism, distractions) was estimated at approximately $34 billion in 2004.4
Private LTC insurance has been sold in the United States for more than 30 years, but only 10% of the potential market of Americans older than 50 years is insured.2 Therefore, any hope of it serving a large percentage of the population has not been realized. In fact, the rate of issuing new policies has declined, and a significant number of insurers have left the private LTC insurance market and closed blocks of policies for several reasons, including low interest rates that have affected the products’ financial performance and unexpectedly low forfeiture rates. The policies that remain have been forced recently to substantially increase their premiums.
Today, there is no comprehensive approach to care coordination for these individuals and caregivers, although there are models, such as the Program for All-Inclusive Care (PACE) in which nursing home–eligible older adults are cared for by an interdisciplinary team focused on care coordination and supportive services. Outside of PACE, the fragmentation and lack of coordination of the LTSS delivery system is due in part to the misalignment of benefit structures, conflicting rules, and separate funding streams of Medicare, Medicaid, and other public and private programs.
Recommendations for Addressing Challenges With Delivering and Financing LTSS
The Commission set forth several specific recommendations in its final report to Congress within the areas of service delivery and workforce, and offered two approaches for financing LTSS. A summary of the specific components of this vision is outlined below. For more detailed recommendations, refer to the full text of the Commission’s 138-page report to Congress.2
Service Delivery
The Commission described its vision for service delivery as “a more responsive, integrated, person-centered, and fiscally sustainable LTSS delivery system that ensures people can access quality services in settings they choose.”2 Its multifaceted plan for executing this vision includes incentivizing states to provide care in the patients’ setting of choice; integrating care across settings; creating a single, uniform assessment tool across settings; improving consumer access to information; improving quality of home- and community-based care; and shifting the focus of payment models.
Rebalancing. The Commission recommends promotion of services for individuals with functional limitations to reside in the least restrictive setting possible according to an objective assessment of needs. The Commission advises incentivizing state provisions of care that would take into account the individuals’ needs, values, and preferences, and provide options for people who would prefer to reside in the community. Achieving this goal entails patient and family access to information for informed decision-making and streamlining Medicaid waiver processing, among other provisions.
Care integration. There are four major recommendations outlined under the vision of providing better integration across settings of care:
1. Create a single point of contact within the medical care team for facilitating LTSS for individuals with cognitive and functional limitations. This contact can be a personal navigator, case manager, or care coordinator.
2. The Centers for Medicare & Medicaid Services (CMS), states, patients, and communities should work together to improve the integration of LTSS with healthcare services using a person- and family-centered approach.
3. Technology should be used more effectively to mobilize and integrate community resources and to share information such as patient health records among providers, individuals, and caregivers across the settings of care.
4. Livable communities and support programs for aging in place should be created and sustained. Voluntary community efforts, small start-up funds, and technical assistance can help build upon new models of care that improve access to services and LTSS coordination.
Uniform assessment. The Commission recommends development of a simpler and more usable standardized mechanism to assess one’s cognitive and functional capacity; this tool should be implemented across acute, post-acute, and LTC settings to produce a single care plan, and it should be informative of all LTSS choices, inclusive of all providers and caregivers, and responsive to the individual needs of residents.
Consumer access/assistance. Three major recommendations were included in the goal of improving access to and understanding of LTSS information.
1. The “No Wrong Door” approach, which assists consumers in identifying and qualifying for the appropriate services no matter where they enter the system, should be expanded via the ongoing Enhanced Aging and Disability Resource Centers Options Counseling Program. This approach for helping consumers navigate LTSS information should become effective on a national level with the help of the Administration for Community Living and CMS to ensure best practices. The program should look to states that currently use the “No Wrong Door” approach for creating a national model.
2. Provide information and assistance on discharge planning and care transitions to consumers and family caregivers before patients are moved from one setting to another (ie, before discharge). This would potentially avoid unnecessary hospital admissions, readmissions, or institutionalization that can occur as a result of inadequately prepared and supported transitions. This information should be available on admission or after a precipitating event, as well as after hours.
3. Improve access to information technology for patients and caregivers that would provide them with additional information and resources.
Quality. Quality improvement efforts have traditionally focused on institutions, with little attention paid to home- and community-based services. The Commission advises that the quality across settings of home- and community-based LTSS should be improved by increasing resources and accelerating the time frame for activities, establishing a system to publish quality measures, developing payment incentives, and developing quality-based provider accreditation/certification.
Payment reform. The Commission is pushing for a shift in public payment models in which payment for post-acute care and LTSS is based on service and not setting. This can be accomplished via regulatory or legislative changes that adjust Medicare payment rates for post-acute services and by testing person- and family-centered payment models to include LTSS.
Workforce
The Commission’s vision for workforce is as follows: “An LTSS system that is able to support family caregivers and attract and retain a competent, adequately-sized workforce capable of providing high quality, person- and family-centered services and supports to individuals across all LTSS settings.”2
Family caregiving. The Commission outlined four major goals of enhancing the role of family caregivers within the LTSS system:
1. Family caregivers and their needs should be included in the assessment and care planning processes, as they provide most LTSS for those with disabilities. This can be accomplished in several ways, such as requiring the Department of Health and Human Services (HHS) to develop a national strategy to support caregivers.
2. Family caregivers should be included as members of the patient’s care team, and their input and recommendations should be included in the patient’s records.
3. Family caregivers should have access to relevant information to provide care through technology. HHS should create a resource for family caregivers to find information on new caregiving technologies and best practices for caregivers.
4. Caregiver interventions, including options for respite care, should be encouraged as a means of caregiver support. Caregivers should also be encouraged to participate in volunteer efforts.
Paid workforce. The Commission set forth two major recommendations for improving the quality of care provided by professional and direct care workers within LTSS.
1. To improve workers’ job satisfaction, the scope of practice should be expanded to allow for additional opportunities for professional and direct care workers with demonstrated competency. This can be accomplished by permitting nurses to be in charge of delegating tasks to direct care workers and providing supervision.
2. The federal government should work with individual states to allow for the performance of national criminal background checks for all members of the LTSS workforce to improve safety.
Direct care workforce. The Commission outlined four additional workforce recommendations for the direct care team.
1. Career ladders and lattices should be established to give direct care workers access to career advancement opportunities and improved compensation.
2. Direct care workers should be integrated into care teams to improve consumer outcomes and to improve the information relayed to the care team regarding day-to-day delivery and adherence.
3. The appropriate federal agency, such as the CMS, Health Resources and Services Administration, or Bureau of Labor Statistics, should collect detailed data on the LTSS workforce.
4. States should improve the standards for home care workers. As part of this initiative a certification process should be established.
Finance
The Commission envisions the creation of a sustainable balance of public and private funding for LTSS that enables individuals to remain in the workforce or in the care setting of their choice. The Commission did not agree on a financing approach and therefore did not make any formal recommendations in its final report. It did, however, offer two suggestions for financing approaches to demonstrate ways in which LTSS financing could be restructured.2
Approach A. This approach for strengthening LTSS would entail financing through private options for financial protection. It would require providing new market incentives, such as a tax preference for LTC policies through retirement and health accounts, among others, as well as educating the public about the options/incentives for private financial protection.
Approach B. This approach for strengthening LTSS financing would emphasize social insurance by creating a comprehensive Medicare benefit for LTSS or a basic LTSS benefit within Medicare.
Commission on Long-Term Care Minority Report Recommendations
Five members of the Commission released a separate minority report incorporating their viewpoints on how to establish and finance a high-quality LTSS system with an emphasis on comprehensiveness.6 “We are convinced that no real improvements to the current insufficient, disjointed array of LTSS and financing can be expected without committing significant resources, instituting federal requirements, and developing social insurance financing,” the report stated. Accordingly, this group made three key recommendations, which are summarized below.
Its first recommendation was to establish an easily understood and navigated public social insurance program to accomplish the following: broadly spread the risk for the costs of LTSS; provide benefits to individuals of all ages who need them; and enable patients and families to meet their responsibilities. This would not eliminate the roles of private insurance or of family financing/caregiving, but rather would make them more manageable. The group believes that including a comprehensive LTSS benefit in Medicare Part A or a more limited benefit within Medicare or in a new public program are ways to develop social insurance for LTSS. This social insurance program was thought to be needed in the face of failures of voluntary private and public programs, such as the CLASS Act, the LTC program initially proposed under the Affordable Care Act. Health Services Administration officials calculated that, because of the limited enrollment of a significant number of healthy people signing up during their working years for this voluntary program, the needs of disabled beneficiaries would drive premiums so high that they would destabilize the program.7
Its second recommendation was to pay direct care workers a living wage, and that by law, they must be well trained and have opportunities for career advancement. This will ensure high-quality services for patients and their families in all service settings, the report advised.
Its third recommendation was to ensure that public programs providing services to LTSS beneficiaries appropriately engage family caregivers and address their needs to successfully integrate caregivers into a comprehensive LTSS system. They should be included in all needs assessment and care planning processes. In addition, the assessment and care plan should include not only the needs of the patient, but also the needs of the family when the family is providing the care.
While the country moves toward a comprehensive system for LTSS, and to supplement it as necessary, this group recognized that improvements are needed in current programs. The minority report made three specific suggestions in this area:
1. The current Medicare program must be updated to reduce counterproductive, outdated, and unreasonable barriers to outpatient therapies, home health care, and SNF care to successfully meet the needs of individuals who qualify for Medicare. This refers to the 3-day inpatient hospital qualifying stay to meet the criteria to receive SNF admission, among other requirements.
2. To strengthen and improve Medicaid and to make it easier to rebalance Medicaid LTSS, current financial incentives to states for quality home- and community-based services should be extended and streamlined. Medicaid’s benefits must be improved for those who rely on Medicaid’s services. This includes the requirement of covering home- and community-based services in Medicaid and broadening access to LTSS in the community.
3. Tax-preferred savings accounts must be provided for individuals and their families who are not currently receiving LTSS through the Medicaid program; the Medicaid buy-in program for workers with modest earnings must be expanded; and a new program for workers with significant disabilities with higher earnings must be created. These would all provide new means of accessing LTSS for those with disabilities.
Take-Home Message
So, what can geriatric providers take away from these recommendations? While it is unlikely that the federal government will be able to implement many of these suggestions because of funding and legislative barriers, many of these recommendations will find their way into state and private LTSS offerings. As such, LTSS providers will be well served to continue to monitor advances in LTSS delivery outside of the beltway. Programs such as PACE and state-managed care programs focused on dually eligible beneficiaries in need of LTSS will likely continue to advance. Within those programs—and others that will likely be offered—providers who are able to deliver LTSS in an efficient, effective manner and tap into these emerging sources for support are likely to create tremendous opportunities to care for the growing population in need of LTSS.
Achieving the delivery of LTSS in an efficient and effective manner requires a well functioning interdisciplinary care team, innovative delivery systems, and carefully coordinated care. This cannot be done alone, but will sometimes require a strong strategic partner. Finally, it’s not only the “who” to partner with that is important, but the “when” that is critical to achieving successful outcomes in LTSS. This process requires a clear understanding of where the federal government will focus its resources through funding and regulations. This process starts with an understanding of how LTSS will be supported going forward given the explosive demand generated from aging baby boomers in the face of ever-limiting resources. Understanding these reports is certainly a starting point.
References
1. American Taxpayer Relief Act of 2012, HR 8, 112th Congress (2012).
2. Commission on Long-Term Care. Report to Congress. www.gpo.gov/fdsys/pkg/GPO-LTCCOMMISSION/pdf/GPO-LTCCOMMISSION.pdf. Published September 30, 2013. Accessed April 28, 2014.
3. Brault MW. Americans with disabilities: 2010. Washington, DC: US Census Bureau; July 2012. www.census.gov/prod/2012pubs/p70-131.pdf. Accessed April 28, 2014.
4. Feinberg L, Reinhard SC, Houser A, Choula R. Valuing the invaluable: 2011 update the growing contributions and costs of family caregiving. https://assets.aarp.org/rgcenter/ppi/ltc/i51-caregiving.pdf. Accessed April 16, 2014.
5. O’Shaughnessy CV; National Health Policy Forum. National Spending for Long-Term Services and Supports (LTSS), 2012. Basics_LTSS_03-27-14.pdf. Accessed February 1, 2013.
6. Long-Term Care Commission. A comprehensive approach to long-term services and supports. Published September 23, 2013. Accessed April 28, 2014.
7. Stefanacci RG. Moving into 2013: major issues facing geriatric care providers. Annals of Long-Term Care. 2013;21(2):16-19.
