Health Affairs Examines Long-Term Services And Supports
January 5th, 2010
by
Chris Fleming
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Congress is now debating whether to include in health reform a new program to help people pay for long-term care services and supports. At this propitious time, leading experts explore critical policy issues related to long-term care in a series of articles in the January 2010 edition of Health Affairs. (As of this issue, Health Affairs also moves from a bimonthly to a monthly publication in a substantially redesigned format.)
The articles suggest that providing affordable, high-quality long-term care to the elderly and disabled continues to present formidable challenges to policymakers. This issue is funded by the SCAN Foundation and was released at a briefing on January 5 at the National Press Club in Washington, DC.
The Community Living Assistance Services and Supports (CLASS) Act is one of the topics addressed in this edition. Through the CLASS Act, incorporated into both the House and Senate health reform bills, people who agree to have a new monthly premium deducted from their paychecks would be eligible after five years for a daily cash benefit to purchase nonmedical services and supports if they become disabled or need long-term care assistance. Supporters say that it will provide much needed assistance, while opponents worry about the creation of a potentially costly new federal program. At this juncture, the fate of the CLASS Act in health reform remains unclear.
This Health Affairs issue examines other issues related to long-term care. For example, ensuring the availability of a competent, paid workforce to deliver needed services and supports is essential. In one article, Robyn Stone, executive director of the American Association of Homes and Services for the Aging, and Mary Harahan, senior adviser for the Institute for the Future of Aging Services, argue that specific issues in the marketplace, low compensation and prestige, and limited career opportunities and planning are serious obstacles to workforce development. They urge policymakers and stakeholders to create financial incentives to help expand the supply of personnel entering the field, to invest in workforce education, and to increase pay for long-term care workers.
Assisted living facilities. In another article, David Stevenson and David Grabowski of Harvard Medical School report that assisted living facilities are disproportionately located in areas where people have higher levels of income and education and where home values are higher. According to their study, the first nationwide county-level analysis of supportive housing, low-income people, minorities, and people living in rural areas have relatively little access to this housing and long-term care option
Other articles assess the following:
- Family caregivers are the bedrock of long-term care, yet they can get scant attention from policymakers. The Institute of Medicine has called for a new policy approach to family caregivers that recognizes them as part of the health care workforce. In response, Carol Levine, director of the Families and Health Care Project at the United Hospital Fund, and coauthors, recommend a series of measures. These include developing more comprehensive information on family caregivers from new surveys and report cards. They also suggest formally training clinicians on how to develop strong relations with and provide support for family caregivers. And they call for building measures of provider responsiveness to the needs and roles of family caregivers into pay-for-performance and other bundling payment models.
- End-of-life issues affect employers and their workers in significant ways, yet they typically are unaddressed by employers. J. Brent Pawlecki, corporate medical director at Pitney Bowes, urges employers to recognize the extent to which end-of-life issues affect workforce productivity and address them as a specific workforce management challenge. By implementing corporate wellness and benefit programs that meet end-of-life needs, employers can reduce the tremendous challenges that employees face as caregivers, as well as the impact on their own businesses, Pawlecki says.
- Should financing for long-term care be primarily a public or a private responsibility, or a shared one? According to David Stevenson of Harvard Medical School, and several colleagues, neither approach on its own can meet the long-term care needs of all Americans. In the view of Stevenson and his coauthors, public and private long-term coverage ideally should play complementary roles. They suggest that public policy focus on a coordinated public-private financing approach to long-term care in order to achieve the most efficient and equitable outcomes.
- Two articles argue that high-quality palliative care should be made more available to elderly people living in nursing homes. Currently, Medicare’s hospice benefit is the primary source of palliative care coverage for the elderly. Yet Haiden Huskamp, David Stevenson, Michael Chernew, and Joseph Newhouse, all of Harvard Medical School and Harvard University, contend that the hospice benefit is a poor fit with nursing home settings because it requires physicians to certify their patients’ prognosis – in effect, as likely to die within six months — and it requires patients to forgo curative care in order to receive the benefit. The authors support a new Medicare end-of-life benefit for nursing home residents with neither of those requirements.
- Going a step further, Diane Meier, professor of geriatrics at Mount Sinai School of Medicine, asserts that palliative care should be the standard of practice for all elderly dementia patients in nursing homes, regardless of their prognosis. Although Meier supports the idea of a new end-of-life benefit for nursing home residents, implementation, she says, would be challenging. Better to make palliative care the de facto standard for dementia patients in nursing homes, she continues, and ensure appropriate, resident-centered care.
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