Long-Term Care Options in an Era of Health

Long-Term Care: Options in an Era of Health Reform Joshua M. Wiener, Ph. D. RTI International www. rti. org RTI International is a trade name of Research Triangle Ins

Why Long-Term Care? • Large projected growth in the number of people with disabilities • Federal and state governments spend over $200 billion on long-term care • People with long-term care needs have high physician, hospital, prescription drug and other acute care costs • Current long-term care system is broken 2 www. rti. org 3/18/2018

Long-Range Options for Reform: Financing • Political divide over role of government programs vs. private sector initiatives • Key issue is fiscal sustainability for the future • Private insurance and reverse mortgages • Social Insurance, Medicare and Medicaid expansion, and increases in Older Americans Act and other appropriated programs • Major changes (including private insurance) will require large increases in direct government spending or expensive tax incentives www. rti. org

Long-Range Options for Reform: Service Delivery • Broad, bipartisan, liberal/conservative consensus to promote a more balanced long-term care system and more consumer control • Participant-directed home care, money follows the person, expansion of assisted living • States may lack the will or the wallet, but already have the legal authority • More direct government service funds (e. g. , Medicare, Medicaid or Older Americans Act, or other appropriated programs) or infrastructure grants www. rti. org

Long-Range Options: Workforce • Long-term care is provided primarily by people not machines • Long-term care workforce shortages, problems of recruitment and retention, understaffed facilities, inadequate training and career ladders, low salaries and fringe benefits • Overlap with quality issues • Increasing staffing in nursing homes, wages, and fringe benefits potentially expensive • Grant programs for workforce initiatives, such as worker registries, training, and culture change www. rti. org

Long-Range Options: Quality • Quality an ongoing issue in long-term care • Reform options include: – Increase mandatory requirements, such staffing levels in nursing homes, minimum training for direct care workers – Voluntary approaches that are external to providers, such as Nursing Home Compare, increase funding for Ao. A Ombudsman program, reform payment system – Voluntary strategies that are internal to providers, such as practice guidelines and change organizational culture • Some options, such as increasing staffing levels, will increase costs to Medicare and Medicaid • Create new grant programs to states, providers and others to improve workforce www. rti. org

Starting the Conversation • Bipartisan consensus “low-cost” recommendations • Focus more on service delivery system, workforce, and quality rather than financing reform • Assume availability of couple of billion dollars maximum • What can be done at the federal level? • Way too timid or way too bold? www. rti. org

Starting the Conversation: Options (cont. ) • Educating the American people • National Commission on Long-Term Care • Relatively minor changes to Medicaid program, such as medically needy, personal needs allowance, and spousal impoverishment • Increase funding for direct service programs, such as Older Americans Act and other appropriated programs • Establish grants to states and others for infrastructure development (e. g. , Aging and Disability Resource Centers and participant-directed services) www. rti. org

Starting the Conversation: Options (cont. ) • Establish workforce grant program to promote culture change, worker registries, and training programs • Increase financial support for relatively low-cost quality initiatives, such as Ao. A Ombudsman program, Medicaid pay-for-performance demonstrations, and strengthen federal requirements that states monitor quality of home and community-based services • Increase funding for research and development, including demonstrations that address chronic illness, disability, and long-term care www. rti. org

Conclusions • Long-term care is not the centerpiece of health reform, but it can and should play a role • Our day will come • Comprehensive reform will cost money, but low-cost options can make contribution • The “window” for health reform www. rti. org