A National Long- term Care Program for the United States; A Caring Vision. Reprinted from JAMA. The Journal of the American Medical Association December 4, 1.
Volume 2. 66 Copyright 1. American Medical Association. The financing and delivery of long- term care (LTC) need substantial reform. Many cannot afford essential services; age restrictions often arbitrarily limit access for the nonelderly, although more than a third of those needing care are under 6. Medicaid, the principal third- party payer for LTC, is biased toward nursing home care and discourages independent living; informal care provided by relatives and friends, the only assistance used by 7. LTC, is neither supported nor encouraged; and insurance coverage often excludes critically important services that fall outside narrow definitions of medically necessary care. We describe an LTC program designed as an integral component of the national health program advanced by Physicians for a National Health Program. Everyone would be covered for all medically and socially necessary services under a single public plan, federally mandated and funded but administered locally. An LTC payment board in each state would contract directly with providers through a network of local public agencies responsible for eligibility determination and care coordination. Nursing homes, home care agencies, and other institutional providers would be paid a global budget to cover all operating costs and would not bill on a per- patient basis. Alternatively, integrated provider organizations could receive a capitation fee to cover a broad range of LTC and acute care services. Individual practitioners could continue to be paid on a fee- for- service basis or could receive salaries from institutional providers. Support for innovation, training of LTC personnel, and monitoring of the quality of care would be greatly augmented. For- profit providers would be compensated for past investments and phased out. Our program would add between $1. LTC. Polls indicate that a majority of Americans want such a program and are willing to pay earmarked taxes to support it. AMERICAN medicine often cures but too rarely cares. Technical sophistication in therapy for acute illnesses coexists with neglect for many of the disabled. ![]() County Address Phone; Alameda: Alameda County LTC Ombudsman Program 6955 Foothill Boulevard, Suite 300 Oakland, CA 94605 (510) 638-6878 Fax (510) 577. ![]() New hospitals that lie one- third empty house thousands of chronic- care patients because even the shabbiest nursing homes remain constantly full. If the fabric of our acute care is marred by the stain of the uninsured and underinsured, the cloth of our long- term care (LTC) is a threadbare and tattered renmant. For millions with disabilities, the assistance that would enable independent living is unobtainable. ![]() ![]() Long-Term Care Reimbursement AB 1629. The Long-Term Care System Development Unit establishes the Medi-Cal reimbursement rates for Freestanding Skilled. Long-Term Care Ombudsman Program. Ombudsmen are independent, trained and certified advocates for residents living in long-term care facilities. ![]() Nursing homes offered as alternatives to the fortunate few with Medicaid or savings are often little more than warehouses. In the home, relatives and friends labor unaided, uncompensated and without respite. Geriatric training is woefully underfunded and carries little prestige. Hence, too few physicians are well equipped to address remediable medical problems that contribute to disability ,3,4 while many are called on to assume responsibility for care that has more to do with personal maintenance and hygiene than with more familiar medical terrain; even when they know what should be done, the needed resources are often unavailable. The experts in providing care- nurses, homemakers, social workers, and the like are locked in a hierarchy inappropriate for caring. With the aging of the population and improved survival of disabled people of all ages, the need for a cogent LTC policy will become even more pressing. Yet policymakers have neglected LTC, for a number of reasons. The United States has a complicated and overlapping array of financing and service programs for LTC. Financing for LTC is largely independent of financing for acute care and varies depending on whether the need is intermittent or continuous, short or long term, posthospital or unrelated to hospitalization. Private insurance companies have made only tentative efforts to market LTC insurance and currently insure less than 1% of Americans. Insurance for LTC is unaffordable to most who need it and rarely covers all necessary services. Thus, about half of LTC expenses are paid out- of- pocket, with most of the remainder paid by Medicaid. Presently the elderly spend 1. Social Security payments. Medical expenses cost the average elder 4. Social Security checks. The financial burden for LTC falls most heavily on disabled people without Medicaid coverage. To qualify for Medicaid, families must either be destitute or . Furthermore, Medicaid is institutionally biased, funding nursing home care far more extensively than home - and community - based services. Age restrictions on many LTC programs arbitrarily limit access, since about a third of the LTC population is not elderly. Seventy- eight percent of the disabled who receive Social security disability benefits, 1. Children constitute 5% of the severely disabled, yet generally are not eligible for LTC under public programs unless they are poor. Informal services are vital to millions but are neither supported nor encouraged by current programs. More than 7. 0% of those receiving LTC (3. Almost 2. 2% use both formal and informal care, while 5% use only formal care. Of the more than 7 million informal care givers, three fourths are women, 3. Such personal devotion can never be replaced by the assistance of even the kindest of strangers. It must be valued and supported, not supplanted by formal care. We believe that a government- financed program will be required in order to ensure adequate LTC for most Americans. At most 4. 0%, and perhaps as few as 6%, of older Americans could afford private LTC insurance. The average nursing home costs of $2. Americans within 3 years. There is growing recognition that the crisis in LTC, as in acute care, calls for bold and fundamental change. We pro- pose the incorporation of LTC into a publicly funded national health program (NHP). We borrow from the experience in the Canadian provinces of Manitoba and British Columbia,2. LTC is part of the basic health care entitlement regardless of age or income. Case managers and specialists in needs assessment (largely nonphysicians) evaluate the need for LTC and authorize payment for services. This mechanism for directing appropriate services to those in need has allowed broad access to nursing home and community- based services without runaway inflation. We also incorporate elements from several recent LTC proposals for the United States. Most of these, however, have three important flaws: (1) they focus primarily on the aged and would exclude the 4. LTC but are under the age of 6. Medicare, they would provide a major role for private insurers, perpetuating fragmented and inefficient financing mechanisms; and (3) they exclude nurses and social workers from certifying and prescribing nonmedical LTC services, inappropriately burdening physicians with responsibilities that are often outside their areas of interest and expertise. Our proposal is designed as a major component of the NHP proposed by Physicians for a National Health Program. The NHP would provide universal coverage for preventive, acute, and LTC services for all age groups through a public insurance program, pooling funds in existing public programs with new federal revenues raised through progressive taxation. This approach would improve access to the acute care that could ameliorate much disability, eliminate the costly substitution of acute care for LTC, prevent unnecessary nursing home placements, and provide a genuine safety net, both medical and financial, for people of all ages. GOALS FOR LTC Nine principles are central to our proposal: Long- term care should be a right of all Americans, not a commodity available only to the wealthy and the destitute. Coverage should be universal, with access to services based on need rather than age, cause of disability, or income. Long- term care should provide a continuum of social and medical services aimed at maximizing functional independence. Medically and socially oriented LTC should be coordinated with acute inpatient and ambulatory care. The program should encourage the development of accessible, efficient, and innovative systems of health care delivery. The program should promote high- quality services and appropriate utilization, in the least restrictive environment possible. The financial risk should be spread across the entire population using a progressive financing system rather than compounding the misfortune of disability with the specter of financial ruin. The importance of . Consumers should have a range of choices and options for LTC that are culturally appropriate. COVERAGEEveryone would be covered for all medically and socially necessary services under a single public plan. Home- and community- based benefits would include nursing, therapy services, case management, meals, information and referral, in- home support (homemaker and attendant) services, respite, transportation services, adult day health, social day care, psychiatric day care, hospice, community mental health, and other related services. Residential services would include foster care, board and care, assisted living, and residential care facilities. Institutional care would include nursing homes, chronic care hospitals, and rehabilitation facilities. Drug and alcohol treatment, outpatient rehabilitation, and independent living programs would also be covered. In special circumstances, other services might be covered such as supported employment and training, financial management, legal services, protective services, senior companions, and payment for informal caregivers. Preventive services would be covered in an effort to minimize avoidable deterioration in physical and mental functioning. The reluctance of some individuals to seek such preventive services requires sensitive outreach programs.
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