Recently, the Department of Health and Hospitals announced
the formation of a group to advise in this area of policy, with a planned
implementation date in 2015. Currently, the state pays $2.4 billion a year, or
about a tenth of its budget, for long term care to about 70,000 individuals, or
an average cost of almost $35,000 a year. The concept is to move administration
of these services to a managed care concept that would better match needs to
services, which probably would save taxpayers money as well, but with a primary
goal of expanding access.
If there is one area of health policy that just begs for increased
coordination, this is it. Basically, the elderly indigent qualify to have the
state pay for their care, and the disabled also may receive services with a
higher ceiling on assets and income to qualify. Until about 15 years ago, this
garnered a single state response: chuck them in a nursing home and reimburse these
providers day after day.
But given court
cases that mandated that states had to provide services in the least
restrictive settings if they were to provide that service, given the cost
effectiveness of that service provision, this meant that some portion of the
his population had to be served in homes and in the communities, through what
are called “waiver” programs. As long the overall aggregate cost of the waiver
programs did not exceed the same cost for institutionalizations, and there was
not some medical appropriateness to place individuals in an institution that
could not be replicated outside of one on a case by case basis, as many as
possible were to be placed in home and community settings.
The implementation of this unfortunately spawned a confusing
and inefficient intake and processing bureaucracy. Multiple waiver programs
popped up doing different things where individuals could qualify for several,
creating waiting lists filled with many of the same people that slowed down
assignment of services. Procedures were such that in instances of immediate
need few could get these services – if they even knew about them – meaning the
only alternative was nursing home placement even if that provision far exceeded
the actual need in many cases, and probably the cost. But it was
administratively far simpler and offered the path of least resistance.
It also was desired intensely by the nursing home industry, which had
predicated its future on an ever-flowing spigot of dollars – an inefficient
utilization that Louisiana policy had encouraged –to pay for long term care
for a disproportionately aged population. When that began to change, it found
itself overbuilt, whereupon it used its political clout to work out favorable
deals for protection and taxpayer subsidies of empty
beds and reimbursement
rates.
Yet this reform is the most serious shot across its bow to date encountered.
Explicitly, the plan is to shift dollars and service provision away from
nursing homes, and even if cost reductions are not planned and do not come
about, to enable more to receive more services inevitably means a reduction in
nursing home populations and revenues. This is a big deal to institutions because
in Louisiana in any given year somewhere around 85 percent of all revenues come
from government, mostly Medicaid.
At this point they are putting a brave face on it, but if long term
care is headed in the direction of managed care – such as in the Bayou Health program
that serves three-quarters of the state’s Medicaid population where third-party
administrators determine on what services dollars are spent and saved
over $135 million in its initial year of operation – they know these
organizations will place fewer cases into nursing homes. The current
inefficient system serves nursing homes’ interests, so expect that any move to
improve will be fought by them, not just through the advisory panel, but also
at the Capitol.
1 comment:
A few thousands of Americans can sustain health care from personal funds alone but these are the wealthy group of people who can do without long term care (LTC) and simply rely on out-of-pocket coverage. This specific group is just 1% of the total population. Roughly 2% can survive health care by shelling out from their savings. 80% can barely afford care. Looking at these numbers makes you want to think about considering long term care ins.
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