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Thursday, December 9, 2010

How Do We Provide Affordable Care For Millions Of People, Preserving Their Independence, Without Breaking Their Pocketbooks Or Bankrupting The Taxpayers?

Bob Rosenblatt
Senior Fellow, National Academy of Social Insurance

Each summer, NASI’s Somers Aging and Long-Term Care Research Internship program selects 5-7 graduate students to spend 12 weeks receiving high-quality training in policy research skills on challenging issues facing the diverse aging population of the United States.

This year’s interns wrestled with the reality of cost, care, and service when they visited two dramatically different programs in and outside of Baltimore. The first one, PACE – the Program of All-inclusive Care for the Elderly, is funded by the federal government for low-income persons over 55 who need help to remain at home. The second program, Collington is a private continuing care retirement community (CCRC), at which the relatively affluent have chosen to live in a senior community where they can get all levels of care.
 
The interns’ wrote follow-up essays on how to provide affordable care for millions of people while preserving their independence without breaking their pocketbooks or bankrupting taxpayers.   Here are some of their insights:
 
Choices Are Uncertain.
Elizabeth Cullar, Master’s student in social work, University of Baltimore
 
Research shows “seniors at CCRCs are more likely to be happier and healthier individuals than those who live in their own homes.” On the other hand, “There may be substantial argument that seniors involved in the PACE model may be as happy and healthy because they are surrounded by loved ones and others who by choice support their chosen lifestyles.”
 
The Big Middle Class Is Left Out.
Allessia P. Owens, Doctoral student in social work, Howard University
 
“Both models are committed to the   long-term support of adults but they are on either extreme of the services and supports continuum. PACE is a service utilized by low income elders who want to remain in their family home while seniors that are more affluent use CCRC’s   and the sale [of a] personal home to live in a senior community.”

Let’s Combine The Best Of Both.
April Wong, Masters student in health policy, Columbia University.
 
There should be “a care coordination system in CCRC settings. In this new model, an interdisciplinary team similar to that of PACE would decide on a care plan that uses the residents’ Medicare funds the most effectively and the most cost-effectively.”  

They Are No Universal Solutions.
Laura Darlak, recent Bachelors graduate in Aging Studies, Ithaca College.
 
The programs “can be described as boutique models, not scalable or capable of meeting the demands of our aging population. The exclusivity of both models contributes to the boutique critique. ElderPlus and Collington, when viewed as mechanisms part of a larger healthcare system, fail to include middle class America.”
 
You Need More Than Medicine.
Jessica Moss, recent Bachelors graduate in psychology and public health, Brandies University.

“The structure of PACE allows for the care team to decide how best to use the money they have to keep patients healthy. The strength of PACE is that PACE has the freedom to use the capitations it receives for anything that benefits the health and well-being of enrollees. This could be something as simple as installing an air conditioning unit in an enrollee’s home.”
 
Money Makes The Difference And Provides The Risk.
Terrell D. Brown, Doctoral student in social work at Howard University.

“Given the ALL INCLUSIVE nature of the PACE program, not much is missing except their ability to impact a greater number of those in need of services, which is a policy/funding issue that needs to be addressed. Because of the hefty contractual financial obligation CCRCs require, what sometimes goes overlooked is the financial risks and/or safeguards for older adults taking and receive for taking such a risk.”

Strengths and Flaws in Each Approach.
Sadie Rubin, Masters student in social work, Columbia University

“The PACE and CCRC models of service each have strengths, while demonstrating weaknesses as well. As the PACE plan provides health care to those who may not be able to afford higher levels of care, they also run up against the weakness of their “boutique model” from a policy perspective. Similarly, as the CCRCs provide older adults with the security of knowing they are taken care of for the rest of their lives, they also run up against the weakness of their high costs and therefore limited accessibility to a broader population.”
 
What do YOU think?   Did these students get the essence of the solution? How DO we provide affordable care for millions of people, preserving their independence, without breaking their pocketbooks or bankrupting the taxpayers?
Posted on December 9, 2010  |  Add your comment
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Affordable Care is simple. The solution is not complex. Take a couple of economics classes. First: To make something affordable you must reduce the expenses behind it. Caring for a senior cannot be done by someone via a phone in India so you must increase the supply of nurses and physicians in this country so that the supply way out does the demand. Imagine a world where physicians are unemployment for six months along with nurses because there are too many of them. Now the equation is simple a nurse would be paid far less than they are now and physicians rate would be lower through competition. We do not need to nationalize anything. So how do you increase the supply of health care workers, simple the government should spend billions over the next 5-10 years opening free medical colleges. Instead of paying for welfare put people through medical education then in ten years you will have a supply that will not deplete because the next wave of a small generation the current middle school kids is tiny compared to the current baby boomers. Who would this plan piss off? The Unions, The democrats and of course the current nurses and doctors who would see there future rate severely drop. Why has this not been done because education is controlled by the unions and the current nurses who keep program growth tight.
I was pleased to see the good article on PACE in the Washington Post yesterday. Health reporter Susan Jaffee wrote about the ElderPlus program at Johns Hopkins in Baltimore that the NASI Somers interns visited this last summer. http://www.washingtonpost.com/wp-dyn/content/article/2010/12/20/AR201012...

I was glad I'd accompanied them, as it helped me see firsthand how person-centered care and the pooling of funds from Medicare and Medicaid can make sense for frail elders and their families when the incentives are right. Karen Armacost, the ElderPlus director, vividly described a multi-disciplinary care team meeting, too. These student essays show that she made a lasting impression!
Thanks NASI for facilitating a good discussion, as always.

I think Elizabeth Cullar's point about choice is an interesting one. To the extent that PACE and CCRC's recruit a self-selecting pool of seniors who prefer community living situations, the residents are more likely to be happy in these environments? As these models scale up across the country to a larger pool of seniors with different beliefs, it will be interesting to see the extent to which the same gains can be realized...
The interns who commented on the provision of LTC by CCRCs did not distinguish between type A, B and C communities. Type C offers higher levels of care such as assisted living and skilled nursing home care, but only on a fee for service basis. Charlestown in Baltimore is an example of a type C community. In effect residents are not prefunding their need for higher levels of care, and so residency is not a substitute for LTC insurance.
The students have accurately identified the limitations of each model and their failure to cover the vast majority of middle income Americans. What is missing, I think, is a sense that there other programs that offer long term supportive services (LTSS) to seniors who need them. In particular, many HUD-subsidized senior housing communities provide LTSS, in addition to housing, to a large number of low and moderate income seniors.

Unfortunately, our nation lacks a coherent, coordinated policy for providing LTSS to seniors (and people of all ages with disabilities). Consequently, we have a patchwork of programs for these populations and many empty spaces where needs are going unmet. CCRCs and PACE are 2 of the patches, so to speak; federally-subsidized (and tax-credit enabled) senior housing serve more seniors than those 2 programs combined.

Our organization operates 2 market-rate CCRCs and 5 subsidized housing communities for low and moderate income seniors (most of whom were middle class during their earning years). Subsidized senior housing is a cost-effective platform for providing LTSS to frail elders and keeping them in the community. We also operate LTC and assisted living communities and know that many of our housing residents would need these more intensive settings were it not for the LTSS provided to them in our housing communities.

In sum, it's important for the students to realize that CCRCs and PACE are important vehicles, but by no means the only ones, for providing LTSS to seniors. and, it would be a good idea to expose students to the possibilites of subsidized senior housing as a model for extending LTSS to a large number of community-dwelling seniors, many of are quite frail.
How DO we provide affordable care for millions of people, preserving their independence, without breaking their pocketbooks or bankrupting the taxpayers?

First define "we". Is it our government or is it individuals and families?

This can be (and is) an unsolvable social problem for our country, or it can become a way of motivating "families" to return to their original function of caring for members at all generational levels. Tax incentives and community support programs that truly create an incentive for people to care for the elderly would be a step in the right direction.
You mean I don't have to pay for expert advice like this anymroe?!
I actlualy found this more entertaining than James Joyce.
It is a very difficult task to plan a strategy to provide affordable health care to millions of people. Most of the countries have tried a lot of ways but nothing turned out well and everything ended up in making the people poor because of the over expenses. EMR software companies

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