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Unit 5: Week 5 - Chapter 11 Outline

CHAPTER ELEVEN: LONG-TERM CARE REIMBURSEMENT

LEARNING OBJECTIVES

After completing this chapter, the reader will be able to

 1.  Understand how long-term care services are reimbursed.

2.  Identify and define key public sources of reimbursement, including Medicare and Medicaid.

3.  Identify and define private reimbursement sources, including private pay and private long-term care insurance.

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

5.   Understand the trends affecting long-term care reimbursement.

 

CHAPTER HIGHLIGHTS

Introduction

·         The long-term care system in the United States is reimbursement driven, meaning that the way care is provided is highly dependent on the way it is financed.

·         Services are not universally and uniformly available.

·         Each of the provider segments along the continuum of care has its own unique mix of payment sources

Origins and Development

·         Began as charity-based care for all except the very wealthy.

·         State and federal governments began to get involved in protecting the welfare of the poor and needy.

·         Social Security Act of 1935

·         Medicare and Medicaid in 1965

Current Reimbursement Options

·         Can be broken into three categories for easier study: public sources, private sources, and public-private partnerships.

Public Reimbursement Sources

·         Medicare and Medicaid are by far the most prominent sources of public funding of long-term care and other types of health care.

·         Medicare

·         Title XVIII of the Social Security Act.

·         Its primary purpose was to provide health care coverage for the elderly.

·         Four parts:

·         Part A - provides hospital insurance, including some sections of long-term care (skilled care, home health care, hospice),

·         Part B - provides supplementary medical insurance that covers physician care,

·         Part C - deals with managed care organizations,

·         Part D - covers medications.

·         Medicare: What’s Covered?  

·         Skilled nursing services - in nursing facilities or units in hospitals.

·         Subacute care - covered under the category “post-acute care,” it is generally provided in Medicare-certified SNFs or units and is reimbursed through the SNF mechanism.

·         Home health care - is the primary provider of reimbursement for home health care services.

·         Hospice - for people who are certified to be terminally ill, with 6 months or less to live. The care must be palliative rather than curative, and as with other types of Medicare coverage, must be delivered by a provider organization that is certified by that program.

·         Other - coverage may be included in settings such as assisted living or adult day care under some Medicaid waiver programs.

·         Medicaid

·         Title XIX of the Social Security Act

·         Covers only those who are “medically indigent” and who cannot pay for their own health care or have insurance

·         Has no age limitations

·         Is jointly funded by the federal and state governments and is run by the states under federal guidelines

·         Medicaid: What’s Covered?  

·         Nursing care facilities – covers just about all services.

·         Assisted living - called “residential care facilities” in some states, coverage is far from universal, varying from state to state, but it is growing. Much of the Medicaid coverage of assisted living has resulted from waiver programs.

·         Home health care - Medicaid is the largest source of funding for home health care agencies and is often used to supplement Medicare coverage for low-income seniors.

Other - Other forms of long-term care, such as subacute care, hospice, and adult day care, are generally not covered by Medicaid, but may be covered as a supplement to Medicare or under some of the waiver innovations.

·         State Efforts to Reduce Medicaid Expenses  

·         Medicaid is one of the top two or three most expensive items in many state’s budgets.

·         Increased efforts to reduce Medicaid costs.

·         By reducing the amount of care received by Medicaid recipients in nursing facilities.

·         By raising the eligibility requirements for institutional care

·         Through increased use of managed care.

·         Medicaid “Spend Down” Requirements - Consumers must use up all other resources before they can become eligible for Medicaid.

·         Payment Bundling

·         Other Public Funding Sources

·         Includes the Supplemental Security Income (SSI) program, the Veterans Administration, and the Older Americans Act.

·         Serve limited populations.

Private Reimbursement Sources – account for about one-third of all long-term care coverage.

·         Out-of-Pocket Payments

·         Less than one quarter of the total costs.

·         Private Long-Term Care Insurance

·         A small, but growing portion of long-term care financing.

·         Little is covered under employer-sponsored policies.

·         Public-Private Partnerships

·         Programs that seek ways to provide incentives for individuals to purchase long-term care insurance.

·         The primary incentive is asset protection in return for meeting some of the cost of long-term care.

·         In 2006 Congress approved legislation clearing the way for expanded, nationwide public–private long-term care (LTC) insurance partnerships.

·         Managed Care - a system of health care delivery that tries to manage the cost of health care, the quality of that health care, and access to that care.

·         Managed Care: How it Works – organizations that delivered health care to a specified group of members on a fixed-rate basis, regardless of how much service they required.

·         Managed Care and Long-Term Care

·         For long-term care, it has taken hold much more in some parts of the country than in others.

·         It has grown in public payments, particularly Medicaid.

·         Types of Managed Care: Provider Arrangements - (1) per diem, (2) discount from charges, (3) case rates and (4) capitation.

·         Medicaid and Medicare Managed Care.

·         Medicaid - In the past 15 years, states have increasingly relied on managed care for Medicaid benefits.

·         Medicare managed care is found in the form of Medicare Advantage plans.

·         Managed Care: Making the Transition – Long-term care providers must look carefully before partnering with a managed care organization, but it usually makes sense.

·         Managed Care: A Tarnished Image – has suffered from a perception that MCOs put cost control ahead of quality of care or the interests of consumers.

Significant Trends and Their Impact

·         Private Managed Care – is becoming increasingly attractive.

·         Public Managed Care – is growing as a way to save costs.

·         Prospective Payment – has replaced retrospective reimbursement for most of long-term care.

·         Emphasis on Community-Based Care – is the result of both cost-cutting and increased demand for consumer choice.

·         Incentives for Purchase of Private Long-Term Care Insurance – few incentives today, but more needed if it is to be an important reimbursement source.

·         Liability Costs and Tort Reform – expensive lawsuits have drive up insurance costs, but there has been little in the way of reforming the tort system.

·         Financing Reform – There has also been much talk about reforming the overall U.S. healthcare system, which really means reforming the healthcare financing system. The debate, which culminated in the Affordable Care Act of 2010 (ACA), centers on providing coverage for people needing acute and preventive care.

 

LECTURE OUTLINE

A.  Identify learning objectives for the session

B.  Introduce the lecture topic

      1.   Discuss what it means that the long-term care system is reimbursement-driven.

      2.   Review the background of the current reimbursement system and how it came about.

C.  Current Reimbursement Options: Explain the difference between public (government) and private (nongovernment) reimbursement sources.

D.  Medicare. Explain:

      1.   What Medicare is

      2.   How it came about

      3.   What it covers in long-term care:

            a.   Skilled nursing services

            b.   Subacute care

            c.   Home health care

            d.   Hospice

            e.   Other

E.   Medicaid. Explain:

      1.   What Medicaid is

      2.   How it differs from Medicare

      3.   What it covers in long-term care:

            a.   Nursing care facilities

            b.   Assisted living

            c.   Home health care

            d.   Other

      4.   State efforts to reduce Medicaid expenses, including “Spend-down” requirements.

F.   Other Public Reimbursement Sources: Explain that there are several other reimbursement sources, such as SSI, VA, and OAA, but they are smaller.

G.  Private Reimbursement Sources. Discuss the types of private reimbursement, including:

      1.   Out-of-Pocket Payments

      2.   Private Long-Term Care Insurance

      3.   Public/Private Partnerships

H.  Managed Care: Discuss managed care and its impact on long-term care, including:

      1.   How it works

      2.   Types of managed care/provider arrangements

      3.   Making the transition to managed care

·         Taking the big step

·         Capabilities needed

·         State of readiness

      4.   Managed care’s tarnished image

I.    Trends: Discuss the following trends in long-term care reimbursement and their implications for long-term care:

      1.   Private managed care

      2.   Public managed care

      3.   Prospective payment

      4.   Emphasis on community-based care

      5.   Incentives for purchase of private LTC insurance

      6.   Liability costs/efforts at tort reform

J.    Financing Reform. Discuss what is happening (or not happening) re reform of long-term care financing.

K.  Summarize the discussion, recapping the key points of the lecture.

 

VOCABULARY TERMS

Affordable Care Act (ACA) – Passed in 2010 to greatly expand coverage of millions, as well as adding many new mandates and regulations. Also known as “ObamaCare”.

Beneficiary - the recipient of funds, property, or other benefits, as from an insurance policy or will.

Case management - the process of coordinating services received by a patient or resident; with a focus on cost-effectiveness.

Consumer Bill of Rights and Responsibilities (managed care) - addresses a number of consumer rights, focusing directly on the complaints heard about managed care.

Entitlement program - a program to which an individual is entitled merely by belonging to a certain group (Medicare is an entitlement program for the elderly. Medicaid is an entitlement program for the medically indigent).

Health Maintenance Organization (HMO) - an organization that, for a prepaid fee, provides a comprehensive range of health maintenance and treatment services - a form of managed care.

Managed care - term covering a variety of health care systems or organizations (e.g., HMOs, PPOs) that combine the provision of care with payment for that care.

Managed care bill of rights - a document describing certain rights that consumers have in dealing with managed care organizations.

Medicaid - Title XIX of the Social Security Act. Passed in 1965, it provides health insurance for those who cannot afford it, the "medically indigent."

Medically Indigent - - a Medicaid term describing people who cannot afford health insurance coverage, thus qualifying for Medicaid.

Medicare - Title XVIII of the Social Security Act. It provides health insurance for the elderly, and some disabled people.

Medicare trust fund - the fund that provides monies for Medicare reimbursement of providers.

Part A – the section of Medicare that provides hospital insurance, including some sections of long-term care (skilled care, home health care, hospice).

Part B – the Medicare section that provides supplementary medical insurance that covers physician care.

Payment Bundling - the ACA created a system of payment bundling where a single entity would receive a sum of money to cover the costs of an episode of care spanning two or more providers

Private long-term care insurance - - private insurance designed specifically to cover long-term care.

Private payment - term used to describe consumers payments for services out of their own funds.

Prospective payment system (PPS) - method by which skilled nursing facilities and some other long-term care providers are paid by Medicare.

Public–private partnerships - a group of pilot projects funded by the Robert Wood Johnson Foundation to demonstrate ways to better utilize public and private resources to pay for long-term care.

Reimbursement driven - term meaning that the amount and type of care received by a long-term care consumer is dependent on that individual’s reimbursement coverage.

Robert Wood Johnson Foundation - private philanthropic foundation known for funding of health related research and demonstration projects, such as the “Public/Private Partnerships.”

Spend down - requirement that individuals reduce their assets to certain levels before qualifying for Medicaid.

Waiver programs - OBRA provision that allows states to apply for a waiver from Medicaid rules to implement innovations in how their state programs are run.