Lack of communication results in waste and health risks, but other models show promise
By Howard Gleckman for Next Avenue(Next Avenue invited all our 2016 Influencers in Aging to write essays about the one thing they would like to change about aging in America. This is one of the essays.)
Imagine an 85-year-old woman who suffers from heart failure, arthritis and has some dementia. She is still living at home, but needs help. Doctors treat her medical conditions. Her daughter and a home health aide provide personal assistance such as cooking, help getting dressed in the morning and bathing. And she gets care that falls in a gray area in between, including help giving her pills and checking her weight to be sure her heart condition is well-controlled.
She needs this suite of services to help maintain the best possible quality of life. But this care is rarely coordinated and, indeed, is often separated by impenetrable walls that waste billions of dollars and put older adults at risk.
Payment for Some Health Services, Not Others
Largely due to the way the U.S. pays for health care and long-term care, these services are delivered under wildly different rules and by people who almost never talk to one another. For example, Medicare will pay for her heart failure drugs, but not for the aide who helps her get dressed. Her long-term care insurance or Medicaid may pay for her aide, but not for her health care. And, except in limited circumstances, no one will pay to install grab bars to prevent her from falling in the bathroom.
Worse, her cardiologist may not even know she has a rheumatologist, much less communicate with him or her. And neither doctor may ever talk to her home health aide.
We need to break down these artificial and dangerous barriers between medical treatment and the personal and social care that most of us need as we age. Nearly all older adults live with chronic illness that often can be best managed with social, non-medical supports. Thus, we need to refocus our health system to better organize personal care with medical treatment, and develop a sustainable way to finance those supports and services.
There are a few models out there. PACE (the federal Program for All-Inclusive Care for the Elderly) combines Medicare’s health services and Medicaid’s personal services into a single package. The Commonwealth Care Alliance Senior Care Options program in Massachusetts is a Medicare special needs plan that also integrates medical and personal care. In some states, managed care insurance companies operate demonstration programs for those who are eligible for Medicare and Medicaid (known as the dual eligibles) that also combine medical treatment with personal care.
The most common example of an integrated health and services program is hospice but, of course, you need to be dying to participate.
All of these programs work very differently than traditional fee-for-service Medicare. They are built on a model where the government pays the operators a fixed monthly rate for each participant. In exchange, some provide the full range of medical and personal care. They are at financial risk if their costs exceed the government payment, but can reap additional profits if they can keep costs down.
These programs also use limited networks of doctors and other providers in an effort to control costs and maintain quality.
Imperfect, But Necessary
This design makes these types of programs controversial. Some advocacy groups fear that managed care companies will skimp on care to save money. But we’ve learned that it is difficult, if not impossible, to integrate medical and personal care in fee-for-service Medicare.
For the sake of the older adults who need both medical and personal care, and their families, we must do better. Consumer groups, providers, insurance companies and government should work together to create a model that fully, and successfully, integrates care in a way that can save money and meet quality standards.