More than three-quarters of surveyed healthcare experts favor adding a long-term-care benefit to Medicare, and most agree that ensuring adequate financing and a workforce able to meet the needs of the nation’s aging population top the list of long-term-care policy challenges.
The future of the nation’s long-term-care system was the focus of the latest Commonwealth Fund/
Modern Healthcare Opinion Leaders Survey, which gathered the perspectives of experts in academia, healthcare delivery, healthcare-related business and government.
Commenting on the results, Commonwealth Fund President Karen Davis compared long-term-care policy to an iceberg.
“People have the tip, they’re a little bit aware of it, but underneath it there’s a huge concern about long-term care,” she says. “It seems far away on the horizon, but it’s really a huge issue, and that’s perceived by healthcare leaders.”
Some 82% of the 196 healthcare leaders who responded to the survey thought that developing a large enough and skilled enough workforce to meet the nation’s long-term-care needs was either very urgent or urgent. This response reflects similar concerns to those raised by a report the Institute of Medicine published in April.
Len Fishman
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That study,
Retooling for an Aging America: Building the Health Care Workforce, stated that the number of older Americans will almost double between 2005 and 2030, as the baby boomers start to turn 65 in 2011. At the same time, the IOM report says, very few physicians or other caregivers are being trained with an expertise in geriatrics. The report concludes that we need to train our healthcare workforce better in geriatrics, improve recruitment into the field and explore new models of care.
“The needs are so great that the residents, patients and their families and the community at large are really going to have to bone up and get very sophisticated about being able to help provide the care because there simply won’t be the workforce to do it,” says Sarah Greene Burger, a survey respondent, gerontological nurse, advocate for the elderly and former executive director of the National Citizens’ Coalition for Nursing Home Reform.
Penny Feldman, another respondent, is the vice president for research and evaluation at the Visiting Nurse Service of New York and director of its Center for Home Care Policy and Research. She calls the workforce training issue “urgent and immediate.”
The average age of a nurse in home care is about 46, she says, and many of these nurses did not receive training in geriatrics. “The really critical issue is we need to retool our existing workforce and really give them the additional knowledge and skills and support to deal with this aging population,” she says.
Financing the system is another enormous challenge, according to Feldman and other survey respondents, especially because the public has not, by and large, come to grips with the implications of the so-called “gray tsunami.”
Many, if not most, Americans wrongly assume Medicare will pay for their long-term care, and many are simply not aware of the high probability that they will need long-term care before they die.
In fact, Feldman cited AARP data showing that only 35% of people 65 or older think they will need long-term care in the future, while research shows that 69% of people who are 65 today will need some kind of support services at some point.
Len Fishman, a survey respondent and the president and chief executive officer of Hebrew SeniorLife, a senior housing and healthcare system based in Boston, says that the financing system should move away from the current welfare model, with Medicaid paying for long-term care for the indigent (in many instances people who have become impoverished by paying for long-term care) toward more of a disability model.
Adding a long-term-care benefit to Medicare would be less politically feasible, Fishman suggests, than other alternatives that might carry a lower price tag. Specifically, he favors a bill introduced a year ago in the Senate by Sens. Edward Kennedy (D-Mass.) and Tom Harkin (D-Iowa) and in the House by Reps. John Dingell (D-Mich.) and Frank Pallone (D-N.J.). Under the bill, workers would contribute $30 in monthly premiums through a payroll deduction for at least five years and would then be eligible for benefits under a two-tiered structure if they became disabled. People would be allowed to opt out of the program altogether, and the benefit levels would not cover the entire cost of nursing home care and therefore would split funding between public and private sources.
Maintaining such a public-private balance is in line with what survey respondents favored. Some 55% said individuals and the government should share long-term-care costs, while only 8% thought such costs should be paid mostly by the government.
By offering payment vouchers, the Kennedy legislation would allow disabled people to remain independent and receive care in their homes instead of forcing people prematurely into institutions, as the current system often does by sending dollars directly to nursing homes.
“In the current system, there are more people going into nursing homes than would be the case if people had a cash benefit to make other arrangements,” Fishman says. This kind of legislation might also “unleash a great amount of incentive to offer care to even frail elders in their homes instead of nursing homes,” he says.
Another organization that supports the Kennedy bill is the National Council on Aging. Howard Bedlin, the council’s vice president for public policy and advocacy, says that in his 20 years of working on long-term-care policy in Washington for various organizations, this is the first time he has been encouraged about the possibility of forging a consensus around an approach to improving it.
Bruce Bullen
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“Medicare is very much a medical model,” Bedlin says. The Kennedy plan “is more of a disability insurance model; it generates a cash payment.” The key, he says, would be to determine whether it would attract enough participants to pay for itself, which is the intent of its sponsors.
While 79% of survey respondents said that they would favor or strongly favor adding a long-term-care benefit to Medicare, financed by a premium, 64% favored or strongly favored providing tax incentives for individuals to purchase private long-term-care insurance, and 63% favored or strongly favored transferring the responsibility for Medicaid long-term care from the states to the federal government.
On the quality front, 74% of survey respondents favored using payment incentives to promote quality in long-term care, and more than half thought quality would improve with a full-time physician or nurse practitioner on-site at nursing homes. Some 38% said that they were familiar or very familiar with the concept of “resident-centered care,” a movement to deinstitutionalize nursing homes by giving seniors greater control over their daily lives and living spaces. Of those who were familiar with the concept, 66% said that it has been effective in improving nursing home quality.
“I think we’re heading into a time where the vast majority of seniors will need different services,” says Bruce Bullen, chief operating officer of Harvard Pilgrim Health Care and a survey respondent. “I think we’ll see, with the baby boomers, what they’ll want is the right residential setting, 24-hour support, but it’s not going to be medically focused for the most part.”
Barbara Kirchheimer, a former Modern Healthcare
news editor and reporter, is a freelance writer based in Highland Park, Ill. Reach her at bkirchh@sbcglobal.net.
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