After seeing long-term care rise and fall as a priority in this year's healthcare reform debate, provider groups and advocates for senior citizens are lowering their expectations for 1995.
A year ago, the Clinton administration handed Congress a proposal for an $80 billion home- and community-based-care entitlement as part of a healthcare reform package. Now provider and seniors groups may be reduced to lobbying for bills that aim to increase long-term-care insurance coverage or finance demonstrations of integrated acute and chronic care.
Because Congress' focus is trimming the federal deficit, long-term-care providers also may be fighting cuts in Medicaid or Medicare long-term-care coverage.
"Nobody is going to be rushing to the hopper with comprehensive healthcare reform (bills) next year," said Joanne Elden Beale, government liaison with the Catholic Health Association. "So we'll probably be dealing with incremental pieces."
At least one senior citizens organization, however, holds out hope that Congress will pass legislation to pay for some home- and community-
based long-term care, perhaps through spending restraints elsewhere in Medicare or Medicaid.
"The prospects for something happening are not bad, in large part because some consideration will be given to Medicare reductions," said Howard Bedlin, legislative representative for the American Association of Retired Persons. "We would encourage them to strengthen the program at the same time they take away from it."
More conservative.But the coming Congress is expected to take on a more Republican and conservative flavor, meaning it probably won't be as generous as the current body.
As a result, long-term-care providers may have to fight efforts to reduce payments for post-acute skilled-nursing care. HCFA's estimate for fiscal 1995 Medicare spending on skilled-nursing benefits is $6.6 billion. Medicare accounts for about 5.6% of payments to skilled-nursing facilities.
Routine cost limits, now 112% of the national mean cost for a given service, are set to expire Oct. 1, 1995. Because Congress will be looking at ways of limiting increases in Medicare costs, members may consider lowering the cap to 100% of the national average. Such a move was proposed as part of the Clinton administration's reform plan last year and would cost skilled-nursing facilities $830 million between fiscal 1996 and fiscal 2000.
About 26% of long-term-care providers' costs are above routine cost limits for services to their Medicare patients, said David Kyllo, spokesman for the American Health Care Association, which represents nursing homes, residential care and subacute providers. But about 44% will exceed the routine cost limit if it's dropped to 100% of the national mean, Mr. Kyllo said.
Alternate plan.As an alternative to such cuts, Mr. Kyllo said his association favors a prospective payment system for Medicare and Medicaid that matches the severity of patients' conditions. That proposal was part of its "Quality Care for Life" plan, which Sen. Orrin Hatch (R-Utah) sponsored in the last session of Congress.
Mr. Kyllo said the AHCA once again will lobby for that proposal, which also includes provisions that aim to increase long-term-care insurance coverage. Those provisions include making long-term-care premiums tax deductible-even as an employer-paid fringe benefit-and establishing national consumer protection standards.
Although such insurance-related provisions had been introduced in bills long before any comprehensive healthcare reform proposal, they failed as part of comprehensive reform in the last session of Congress. But observers give those provisions better odds of passing next year.
"Assuming we don't have the singular attention to comprehensive healthcare reform, there's a strong likelihood that advocates for federal standards for long-term-care policies and tax clarification will take this up again," said Valerie Wilbur, government affairs director in the Washington office of the law firm Katten, Muchin & Zavis and a lobbyist for a coalition of insurance carriers, providers and academics.
Mr. Bedlin added that he sees the long-term-care-insurance standards "hopefully as a fait accompli."
Demonstration projects.Others are setting their sights on federal funding of projects to demonstrate integration of acute and long-term care, as well as bundling Medicare, Medicaid and Medigap insurance payments in a capitated system.
The National Chronic Care Consortium, a group of providers and health networks, probably will seek federal financing for 25 seven-year demonstration projects.
Although the consortium advocates a comprehensive healthcare reform proposal that includes universal coverage for acute and long-term care, its members are hoping that Congress will at a minimum support research into better coordination of chronic care.
"Give them at least a chance to show that an integrated, coordinated system of care can work," said Deborah Paone, the consortium's vice president for member services.
And although those projects would cost $57 million a year, such a sum might sail past congressional budget analysts, escaping cuts, said Ms. Wilbur, who works for the consortium in Washington.