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Long-Term Care: Options in an Era of Health Reform. Joshua M. Wiener, Ph.D. RTI International. Why Long-Term Care?. Large projected growth in the number of people with disabilities Federal and state governments spend over $200 billion on long-term care

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long term care options in an era of health reform

Long-Term Care:Options in an Era of Health Reform

Joshua M. Wiener, Ph.D.

RTI International

why long term care
Why Long-Term Care?
  • Large projected growth in the number of people with disabilities
  • Federal and state governments spend over $200 billion on long-term care
  • People with long-term care needs have high physician, hospital, prescription drug and other acute care costs
  • Current long-term care system is broken
long range options for reform financing
Long-Range Options for Reform: Financing
  • Political divide over role of government programs vs. private sector initiatives
  • Key issue is fiscal sustainability for the future
  • Private insurance and reverse mortgages
  • Social Insurance, Medicare and Medicaid expansion, and increases in Older Americans Act and other appropriated programs
  • Major changes (including private insurance) will require large increases in direct government spending or expensive tax incentives
long range options for reform service delivery
Long-Range Options for Reform:Service Delivery
  • Broad, bipartisan, liberal/conservative consensus to promote a more balanced long-term care system and more consumer control
  • Participant-directed home care, money follows the person, expansion of assisted living
  • States may lack the will or the wallet, but already have the legal authority
  • More direct government service funds (e.g., Medicare, Medicaid or Older Americans Act, or other appropriated programs) or infrastructure grants
long range options workforce
Long-Range Options: Workforce
  • Long-term care is provided primarily by people not machines
  • Long-term care workforce shortages, problems of recruitment and retention, understaffed facilities, inadequate training and career ladders, low salaries and fringe benefits
  • Overlap with quality issues
  • Increasing staffing in nursing homes, wages, and fringe benefits potentially expensive
  • Grant programs for workforce initiatives, such as worker registries, training, and culture change
long range options quality
Long-Range Options: Quality
  • Quality an ongoing issue in long-term care
  • Reform options include:
    • Increase mandatory requirements, such staffing levels in nursing homes, minimum training for direct care workers
    • Voluntary approaches that are external to providers, such as Nursing Home Compare, increase funding for AoA Ombudsman program, reform payment system
    • Voluntary strategies that are internal to providers, such as practice guidelines and change organizational culture
  • Some options, such as increasing staffing levels, will increase costs to Medicare and Medicaid
  • Create new grant programs to states, providers and others to improve workforce
starting the conversation
Starting the Conversation
  • Bipartisan consensus “low-cost” recommendations
  • Focus more on service delivery system, workforce, and quality rather than financing reform
  • Assume availability of couple of billion dollars maximum
  • What can be done at the federal level?
  • Way too timid or way too bold?
starting the conversation options cont
Starting the Conversation: Options (cont.)
  • Educating the American people
  • National Commission on Long-Term Care
  • Relatively minor changes to Medicaid program, such as medically needy, personal needs allowance, and spousal impoverishment
  • Increase funding for direct service programs, such as Older Americans Act and other appropriated programs
  • Establish grants to states and others for infrastructure development (e.g., Aging and Disability Resource Centers and participant-directed services)
starting the conversation options cont1
Starting the Conversation: Options (cont.)
  • Establish workforce grant program to promote culture change, worker registries, and training programs
  • Increase financial support for relatively low-cost quality initiatives, such as AoA Ombudsman program, Medicaid pay-for-performance demonstrations, and strengthen federal requirements that states monitor quality of home and community-based services
  • Increase funding for research and development, including demonstrations that address chronic illness, disability, and long-term care
conclusions
Conclusions
  • Long-term care is not the centerpiece of health reform, but it can and should play a role
  • Our day will come
  • Comprehensive reform will cost money, but low-cost options can make contribution
  • The “window” for health reform