Discussion Board
© 2010 Jones and Bartlett Publishers, LLC
© 2010 Jones and Bartlett Publishers, LLC
Chapter 2
Long-Term Care Policy: Past, Present, and Future
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Introduction - 1
- Public policy deals with issues that the government thinks must be addressed
- Health policy falls within the broader domain of public policy
- It affects various entities – people and organizations
- The Affordable Care Act is a recent example of a major health policy
- Policy may be made at the national, state, or local level of government
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Introduction - 2
- The term “policy” also applies to private policy – strategic decisions that senior managers make to better serve their markets
- However, public policy is an important consideration in strategic decisions
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Types of Policy
- Policies made by legislative bodies are the most common – e.g., the US Congress
- Administrative agencies interpret legislations and craft rules and regulations to implement the laws – e.g., the CMS
- Certain decisions rendered by the courts and the president’s executive orders also form policies
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Examples of Health Policy
- Legislative policy: PPS required by the BBA, 1997
- Regulatory policy: PPS payment methodology developed by the HCFA
- Judicial policy: Olmstead v. L.C.; the U.S. Supreme Court upheld part of the ACA to be constitutional
- Executive policy: Executive orders have provided incentives for the adoption of HIT
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Historical Perspectives in LTC Policy
- Healthcare policymaking has followed an ad hoc approach of incrementalism
- LTC policy had 3 major effects:
- Government became the largest payer for nursing home care; it promoted a private nursing home industry
- Nursing home regulations followed
- At first, policies promoted institutionalization; later, rising costs shifted policies that promoted community-based care
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Historical Perspectives in LTC Policy
Welfare policies
Poorhouses, and later, mental asylums
Old Age Assistance, as part of the Social Security Act of 1935, prohibited payments to residents of poorhouses
The policy resulted in ending the poorhouse system, and spawned a private for-profit nursing home industry
The Hill-Burton Act indirectly led to the conversion of old hospitals to nursing homes
1950 Social Security amendments authorized payments directly to nursing homes
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Historical Perspectives in LTC Policy
Financing and Growth of Nursing Homes - 1
Two major programs of public financing, Medicare and Medicaid, were created in 1965
The federal and state governments became the largest payers for LTC services
The nursing home industry came to by dominated by multifacility chains
Financing favored care in nursing homes as opposed to community-based care which was difficult to regulate
Nursing home utilization and government expenditures exploded
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Historical Perspectives in LTC Policy
Financing and Growth of Nursing Homes - 2
Nursing homes began to be held accountable for complying with the conditions of participation
Federal laws had required states to license nursing homes; in 1967, states were mandated to license nursing home administrators (because of public outcry over substandard care)
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Historical Perspectives in LTC Policy
Policies Favoring Community-Based Services
Title 20, created under the Social Security Amendment of 1975, had the goal of reducing inappropriate institutional care
Creation of single block grants in 1981 (Social Services Block Grants) reduced funding to the states
On the other hand, 1915(c) waivers (Home- and Community-Based Services – HCBS – waivers) allowed states to offer LTC services to Medicaid recipients
The waiver program has been quite successful
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Historical Perspectives in LTC Policy
Deregulation Averted
In the 1980s, nursing home regulations came under a broader sweep of deregulation
It was rumored that the Reagan administration was trying to do away with some key standards governing nursing homes
Interest group politics played a key role in lobbying Congress against deregulating the industry
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Historical Perspectives in LTC Policy
Legislation to Address Quality Issues
- The Nursing Home Reform Act (OBRA-87) was heavily influenced by a study by the Institute of Medicine
- Consensus positions by interest groups were presented to Congress
- Also, a possible role of Estate of Smith v. Heckler in Colorado
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Historical Perspectives in LTC Policy
Main areas of emphasis in OBRA -87 (1)
- Emphasis on both quality of life and quality of care
- Expectations to improve ADL function
- Care plans to be driven by assessment
- Training and testing of nursing assistants
- Right to remain in the nursing home barring unusual circumstances
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Historical Perspectives in LTC Policy
Main areas of emphasis in OBRA -87 (2)
- Address the needs of residents with MR (ID) and mental illness
- Right to have personal funds managed
- Right to return to the nursing home after brief absence
- Right to choose one’s physician and access one’s medical records
- Right to organize resident and family councils
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Historical Perspectives in LTC Policy
Main areas of emphasis in OBRA -87 (3)
- Access to an ombudsman
- Right to be free of unnecessary physical or chemical restraints
- Remedies against nursing homes that fail to meet federal standards
- Change in inspection procedures to include interviews with residents and family, and observation of dining and med pass
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Historical Perspectives in LTC Policy
Policies to Regulate Other Services (1)
Assisted living
Not regulated by federal regulations
- Because no federal reimbursement
- All states require licensing of facilities
Adult day care
Medicaid-funded ADCs must meet state licensing standards, minimum staff-to-participant ratios, and undergo inspections if required by the state
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Historical Perspectives in LTC Policy
Policies to Regulate Other Services (2)
Home Health Services
The Balanced Budget Act of 1997 mandated a prospective payment system (PPS) for reimbursement (implemented in October 2000)
[Skilled nursing facilities also came under PPS reimbursement]
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Historical Perspectives in LTC Policy
Policies to Regulate Other Services (3)
Money Follows the Person program
A 5-year demonstration program (2007-2011) showed that people could be successfully moved out of nursing homes into the community if the funds that previously paid for nursing home care are transferred to community-based care
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Current State of LTC Policy
Financing (1)
- There are multiple sources of financing LTC services
- Hence, access and utilization become uneven
- People face obstacles to pay for services
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Current State of LTC Policy
Financing (2)
- Medicaid is the largest source of financing LTC services
- Financing has shifted from nursing homes to community-based care
- All states provide 1915(c) waiver services
- 44 states and DC participate in Money Follows the Person – however, this has been far less effective due to a shortage of affordable housing
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Current State of LTC Policy
Financing (3)
- The Affordable Care Act authorizes Money Follows the Person through 2016
- The law also created a new program called Community First Choice (home and community-based attendant services)
- States that implement this program get additional federal funding under Medicaid
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Current State of LTC Policy
Financing (4)
- Reimbursement is inadequate according to both nursing home operators and independent experts
- Government has been concerned about rising expenditures
- Public is averse to paying higher taxes
- Few options are available to cut costs in a labor-intensive industry
- Pay for performance does not result in consistent improvements in quality
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Current State of LTC Policy
Financing (5)
- Only 7% of those 50 and above have private LTC insurance
- For many, high premiums are a deterrent
- Younger groups show little interest
- Public policy has created few incentives to purchase LTC insurance
- Partnership for Long-Term Care has been adopted by about 40 states
- Community Living Assistance Services and Supports (CLASS) was dropped from the ACA
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Current State of LTC Policy
Utilization - 1
- Number of nursing homes and beds as well as utilization have declined
- Occupancy rates have declined since 2005
- See Table 2-1
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Current State of LTC Policy
Utilization – 2
Reasons for utilization decline:
1. Policies have emphasized a shift toward community-based care (5 to 12% of nursing home residents require low levels of care)
2. Private-pay patients are spending their money in residential and assisted-living facilities, and later apply for Medicaid when the need for skilled care arises
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Current State of LTC Policy
Quality
- OBRA-87 has been largely successful, but it also remains controversial
- Improvements have reached a plateau
- Inconsistent application of regulations
- Do not primarily focus on high-quality care
- Punitive rather than a remedial tone
- Nursing Home Compare quality reports have resulted in improvements in quality measures
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Policies for the Future
Demographic challenges call for policy initiatives:
- IOM projections forecast doubling of older adults with disabilities between 2007 and 2030
- A growing population of older fragile adults poses challenges for informal care
- The demographic imperative
- Increasing prevalence of dementia – this population could more than double between 2013 and 2050
- There is a looming global epidemic of dementia
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Policies for the Future
- Future challenges will depend on critical factors such as:
- Health status
- Birth and mortality rates
- Strong economy (education, innovations, quality of immigration)
- Availability of financial resources and how their use will be prioritized
- Infrastructure of care delivery
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Policies for the Future
- Prevention: Despite the ACA’s emphasis on preventive care and wellness, much of disease prevention requires changes in person behavior as well as policy interventions that promote physical activity, safety, crime prevention, leisure, diet, fall prevention, etc.
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Policies for the Future
- Financing: A real challenge is how to make LTC insurance more affordable without putting additional tax burden on younger Americans
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Policies for the Future
Workforce:
- Experts say that workforce issues are at par with the aging of the population, yet it remains a neglected policy concern. Even the ACA does not touch upon this issue.
- Training deficits in geriatrics need to be addressed
- Recruitment and retention of NHAs is also a growing national problem
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Policies for the Future
Health Information Technology:
LTC needs to be represented in future interoperable electronic health records
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Policies for the Future
Mental Health:
- LTC patients are not always receiving mental health care they need
- Also common are inappropriate or unnecessary mental health services
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Policies for the Future
Evidence-Based Practices:
No policy initiatives have emerged to provide incentives for their use
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Policies for the Future
Innovations in Care Delivery:
Regulators need to incorporate person-centered care and culture change into oversight policies and practices
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