Discussion Topic- Quality Initiatives

Chapter 11 Long-Term Care

Reimbursement

Learning Objectives

1. Understand how long-term care services are reimbursed

2. Identify and define public sources of reimbursement

3. Identify and define private sources of reimbursement

Learning Objectives (continued)

4. Understand how managed care works and its impact on long-term care

5. Understand the trends affecting long-term care reimbursement

Long-Term Care System Development

Little government involvement until welfare (Social Security) in 1935

Major involvement with Medicare and Medicaid in 1965

Has evolved since then

Current Reimbursement Options Government (public) sources:

• Medicare • Medicaid • Other

Private sources: • Out-of-pocket payments • Private long-term care insurance • Managed care organizations

Public/private partnerships

Medicare

Title XVIII of the Social Security Act Covers elderly and some disabled No means test Covers (with some limitations):

• Skilled nursing in nursing facilities and subacute care

• Home health care • Hospice

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Medicaid Title XIX of the Social Security Act Covers “medically indigent” Funded partly by federal and partly by state

governments Run by the states under federal guidelines Covers (depending on the state’s program):

• Nursing care facilities • Assisted living • Home health care

Medicaid (continued)

State efforts to reduce costs: • Divert funds to less expensive forms

of care (community-based) • “Spend-down” requirements • May be greatly expanded by the

Affordable Care Act

Other Public Funding Sources

Supplemental Security Income program Department of Veterans Affairs Older Americans Act Others

Private Reimbursement Sources

Out-of-pocket payments Private long-term care insurance Public/private partnership programs Managed care

Public/Private Partnerships

Robert Wood Johnson Foundation demonstration projects

Provide incentives for consumers to provide some long-term care coverage in return for asset protection

2006 legislation to create nationwide program

Managed Care

• Impact on long-term care • Types of MCO/provider arrangements • Making the transition to managed care • Managed care’s tarnished image

Trends in Reimbursement

• Growth of private managed care • Growth of public managed care • Prospective payment • Emphasis on community-based care • Incentives for purchase of private • LTC insurance • Liability costs and tort reform

Financing Reform

Much talk, not much action until 2010 • Passing of the ACA

Long-term care is not a high priority • Hard to define • Would be very expensive

Summary

Long-term care provider organizations are

reimbursed by a combination of public and

private organizations and agencies.

Reimbursement is fragmented and varies by

type of provider.