Will efforts to modernize home health programs survive insurance reform’s end game? Providing insurance coverage to as many low-income uninsureds as possible has been an organizing principle in 2009’s health reform discussions, and reconciliation of the House and Senate versions will require satisfying some members that sufficient subsidies will be available to permit the promise of extended coverage to reach the neediest. The ripple effects of those discussions may reach other reform issues, as leadership attempts to meet budgetary targets. It would be a shame if this process led to a retreat from the current bills’ innovative long-term care provisions.
 As I’ve described previously, the reform effort has contemplated an interesting mix of Medicare and Medicaid improvements to expand access to community based care for people with disabilities and chronic illness. And the CLASS Act’s inclusion in the mix gives some hope to those with needs for assistance with Activities of Daily Living (ADLs), as well as their family caregivers. Those involved in caregiving for a chronically ill family member can testify that they’re not looking to dodge responsibility; to the contrary, they’re hoping to gain assistance to continue providing assistance in the community, to avoid the need for isolating and expensive institutional care for their loved ones.
Health Affairs’ January 2010, Volume 29, Number 1 — “Advancing Long-Term Services & Supports” - (subscription required for some content) is a welcome source of information and analysis in this area. H. Stephen Kaye and coauthors provide timely data filling out our understanding of who is served, and where. It is clear that people in need of nursing and personal care assistance prefer to live at home rather than in a nursing home. About 8.4 million people of all ages with ADL difficulties receive services in their communities, while about 1.6 million receive services in nursing homes. The median monthly cost in the home care setting, in 2009 dollars, is $928, compared to $5,243 in nursing homes. About 75% of those in the community live with relatives. 90% have mobility impairments, 55% have cognitive impairments, and 31% have sensory impairments. Other articles shed some light on programmatic and financial barriers to improving access to home services.
- Terrence Ng and coauthors describe the gaps, overlaps, and regional variation in long term care coverage provided by Medicaid and Medicare. In particular, they report wide variation in states’ adoption of Medicaid waivers and other mechanisms for extending community-based home care. For example, Iowa’s participation rate in Medicaid home and community-based care is 16.8 per 1,000, while Virginia’s rate is only 3.21 per 1,000. The authors also highlight the effects of the failure to coordinate Medicare and Medicaid for long-term care, and the cost-increasing effect of hospital readmissions, traceable in part to Medicare’s poor coverage of long-term care. The current Senate bill, at Sections 2401- 2406, would encourage expansion of Medicaid rebalancing efforts.
- The Public Policy Institute’s Susan Reinhardt discusses programs supporting the community preference of people with nursing and home care needs. She describes diversion and transition programs. Transition (”downstream”) programs are dedicated to moving to appropriate community settings those who would like to leave nursing homes. Diversion (”downstream”) programs fund home and community based services, to forestall or prevent institutionalization in the first place. She points to the reform bills’ support for the Community Living and Money Follows the Person Demonstrations.
- Two pieces do an excellent job of introducing us to those who provide home care. Carol Levine and others describe the plight of family caregivers, traditionally thought of as “informal” caregivers, but clearly the foundation of home health care. Howard Gleckman provides case studies of non-family member home care workers, highlighting the physical and financial difficulties under which they labor. As needs for chronic care in general and home care in particular increase in coming years, the long-neglected needs of these family and non-family caregivers will have to be addressed. Congress is famously solicitous of the financial concerns of physicians, our most highly compensated caregivers. It is time to focus on the needs of those millions of direct caregivers who every day provide compassionate personal services to our most vulnerable friends and family members.
The January issue of Health Affairs helps to highlight the growing importance of the financing of long-term care. As we age, and as our needs shift from acute to chronic care, we must wean ourselves from a financing perspective that emphasizes dazzling high-tech interventions and instead embrace the human-scale care offered by home health aides, visiting nurses, and physical therapists. The pending bills don’t make this shift, but they nudge the battleship a bit. They leave long-term care financing fragmented among various public and private programs, but they do support some promising programs.
The CLASS Act (Senate bill Section 8002) is a voluntary, opt out social insurance program that would provide some support for home care services. For the reasons described last year by Howard Gleckman, the CLASS Act is incomplete; among other things, its voluntary nature could create selection problems. It is a start, however, and would put a useful if imperfect patch on a torn system. I’ll cite to one final article from the Health Affairs issue to point to a better way. John Creighton Campbell and coauthors‘ discussion of public long-term care insurance in Germany and Japan contains the germ of a solution to the woes our system suffers. Both the German and Japanese systems have universal coverage, support family caregivers, and accord beneficiaries a large degree of control over services received. And they do so at a cost roughly comparable to that experienced by American public payers (Germany a  bit less, Japan a bit more). Organizing long-term care financing through one social insurance program yields efficiency dividends, eliminates stigma concerns, and encourages care at the level and location preferred by recipients. Maybe it’s too early to be pushing for the next step in long-term care reform, but why can’t we do what the Germans and Japanese have done? At the very least, let’s not cut back on the progress made in the current bills as we strain for the finish line.
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- Attributing Sources of Variation in Patients’ Experiences of Ambulatory Care
This study, which seeks to explain the variation in how patients rate their experiences with primary care providers, concludes that individual physicians themselves account for the largest share of this variation, particularly in terms of the quality of their communication with patients and their support for health promotion. - How Do They Compare? New and Updated Resources on the Senate and House Health Reform Bills
- Scott & White Healthcare: Opening Up and Embracing Change to Improve Performance
Founded in 1897 in Temple, Texas, Scott & White is the largest multispecialty health care system in the state, and delivers a comprehensive continuum of care to its health plan members and constituents. This case study explores Scott & White's quality improvement measures and how they are linked to greater system efficiency. - The Health Insurance Provisions of the 2009 Congressional Health Reform Bills: Implications for Coverage, Affordability, and Costs
This Commonwealth Fund report analyzes the provisions of the health reform bills passed by the U.S. House of Representatives and Senate that seek to expand and improve health insurance coverage. - Person-Centered Care for Nursing Home Residents: The Culture-Change Movement
In a Health Affairs "Web First" article published Jan. 7, The Commonwealth Fund's Mary Jane Koren, M.D., takes a look at "culture change" in long-term care—how the growing movement to transform America's nursing homes got started, and where it might be headed.
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- Analysts Question Savings, Revenue in Health Care Bill
As Democratic leaders continue talks this week over how to pay for health care legislation, they are coming under renewed pressure from independent analysts who question whether long-term savings called for in the bill are realistic. - New Breast Screening Limits Face Reversal
Annual mammograms, seemingly on their way out under new federal guidelines last year, may be coming back. - President Signals Flexibility on Health Plan Tax
President Obama told union leaders at a private White House meeting on Monday that he remained committed to taxing high-cost insurance policies as a way to drive down health costs. - Democrats Will Continue Aggressive Agenda
When the American people went to the voting booth more than a year ago, they sent a message to Washington: The status quo is unacceptable. - Obama Attempts to Assuage Union Leaders
President Obama sought on Monday evening to assuage organized labor's misgivings about the health-care overhaul, even as several key union leaders warned that the bill's final outlines could severely dampen their enthusiasm for the Democratic ticket in this year's elections.
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- Researchers ask why optimism is associated with health, pessismism with disease
- Pharmacists dispense pills, counsel patients, screen for illness, give vaccines
When Charley John tells people he's a pharmacist, he knows what many of them think: that he spends his workdays sequestered behind a counter doling out pills, dropping them into little plastic vials and handing them to customers. - Four readers vow to get fit via parkour, triathlon and other exercise regimes
We asked you to send us your fitness-related resolutions, and judging by the response, 2010 is going to be quite a year. You're going to race 10Ks, marathons and triathlons. You're biking across Iowa and even the whole country. Brides (and a groom) vow to look better for the big day, parents want to... - House Democrats confer on health-care reform
Worried House Democrats held a caucus-wide conference call Thursday to strategize about health-care reform before lawmakers return to Washington next week. - Healthful-living experts weigh in with their New Year's resolutions
By the time you turn 49, as I recently did, the tradition of making New Year's resolutions has lost some of its luster. What remains to be resolved that hasn't been resolved before?
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- Today's Globe
Partners' costs, Dr. Jacob Rice, medical marijuana, health care overhaul, placebo effect - Swine flu's impact shifts during second wave, study finds
By Stephen Smith, Globe Staff When swine flu arrived in Boston last spring, children and teenagers disproportionately bore the brunt of the novel viral infection. But when a second wave of illness swept the city in the fall, it was... - Stanford move on CME puzzles critics of industry influence
Stanford University has been in the vanguard of medical schools combating influence from the drug and medical device makers on education. It was the first in the nation to refuse funding from industry for specific topics in postgraduate educational programs.So... - In case you missed it
In the Sunday Globe:Marcelo Alves hopes Mass. General doctors can help him get a heart transplant, but his status as an illegal immigrant could be a fatal complication.Health care has remained one of the few bright spots in an otherwise... - Today's health and science
G Health:� cardiac rehab, video in end-of-life decisions, antibacterial soaps, light-exacerbated migraines in blind people, vitamin D and heart death disparitiesStudies show that cardiac rehab helps heart attack survivors avoid future trouble. So why do so few take advantage...
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- This is your brain on nouns
Even as a young man, my father always had lots of words that stood in for nouns he couldn't call to mind when he needed them. "Hand me that whatchamacallit," he'd say, pointing to the hammer just beyond his reach.... - 2010 means ... (drumroll) ... new dietary guidelines!
It's 2010 -- and we all know what that means. Yes! Time for a brand-new iteration of the Dietary Guidelines for Americans. Those simple-sounding pieces of government eating advice are spawn of a surprisingly arduous process. A team of 13... - There’s no good time for a stroke, but there may be a better time
You might think that the weekend is a particularly bad time to suffer a stroke. Hospitals have smaller staffs, and academic medical centers are more likely to rely on interns, residents and fellows. A Canadian study from a few years...
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- The Mammography Guidelines And Evidence-Based Medicine
As someone who has spent the last several years promoting the development of a comparativeness effectiveness center that would encourage the production of more objective information about what works medically, for whom, and under what circumstances, it is hard not to feel discouraged by the reaction to the breast cancer screening guidelines recently announce […] - Health Affairs Blog: Top 10 in 2009
We offer readers the annual “top 10″ list of most-read posts from Health Affairs Blog. Health reform topped the list in 2009. If you missed any of these posts, here’s your chance to catch up on your reading. Propaganda And Prejudice Distort The Health Reform Debate by Merton Bernstein Nurse Shortage Eases Under Recession by Jane Hiebert-Wh […] - New Wonk Review Focuses On Health Reform
On The Health Care Blog, Brian Klepper presents some of the best in recent health policy blogging in the first Health Wonk Review of the year. Brian provides readers with a collection of interesting observations on health reform, including Alain Enthoven’s recent response to Atul Gawande on the Health Affairs Blog. Copyright � 2010 Health Affairs […] - Health Care Reform: State Winners And Losers
Back in October, as health care financing options were being hotly debated and proposals changing on an almost daily basis, one of us noticed an editorial on health care reform in West Virginia’s Martinsburg Journal. We were struck by the extent of opposition to financing the reform package through a tax on high earners. West [...] - Recession Slowed Health Spending Growth, CMS Analysts Say In Health Affairs
Amid one of the worst economic recessions in recent history, U.S. health spending grew 4.4 percent in 2008, its slowest rate in nearly 50 years. However, overall health spending, which reached $2.3 trillion in 2008 — $7,681 per person — still increased faster than the overall economy, federal analysts reported yesterday in the January issue [ […]
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Will efforts to modernize home health programs survive insurance reform’s end game? Providing insurance coverage to as many low-income uninsureds as possible has been an organizing principle in 2009’s health reform discussions, and reconciliation of the House and Senate versions will require satisfying some members that sufficient subsidies will be available to permit the promise of extended coverage to reach the neediest. The ripple effects of those discussions may reach other reform issues, as leadership attempts to meet budgetary targets. It would be a shame if this process led to a retreat from the current bills’ innovative long-term care provisions.
Health Affairs’ January 2010, Volume 29, Number 1 — “Advancing Long-Term Services & Supports” - (subscription required for some content) is a welcome source of information and analysis in this area. H. Stephen Kaye and coauthors provide timely data filling out our understanding of who is served, and where. It is clear that people in need of nursing and personal care assistance prefer to live at home rather than in a nursing home. About 8.4 million people of all ages with ADL difficulties receive services in their communities, while about 1.6 million receive services in nursing homes. The median monthly cost in the home care setting, in 2009 dollars, is $928, compared to $5,243 in nursing homes. About 75% of those in the community live with relatives. 90% have mobility impairments, 55% have cognitive impairments, and 31% have sensory impairments. Other articles shed some light on programmatic and financial barriers to improving access to home services.
The January issue of Health Affairs helps to highlight the growing importance of the financing of long-term care. As we age, and as our needs shift from acute to chronic care, we must wean ourselves from a financing perspective that emphasizes dazzling high-tech interventions and instead embrace the human-scale care offered by home health aides, visiting nurses, and physical therapists. The pending bills don’t make this shift, but they nudge the battleship a bit. They leave long-term care financing fragmented among various public and private programs, but they do support some promising programs.
The CLASS Act (Senate bill Section 8002) is a voluntary, opt out social insurance program that would provide some support for home care services. For the reasons described last year by Howard Gleckman, the CLASS Act is incomplete; among other things, its voluntary nature could create selection problems. It is a start, however, and would put a useful if imperfect patch on a torn system. I’ll cite to one final article from the Health Affairs issue to point to a better way. John Creighton Campbell and coauthors‘ discussion of public long-term care insurance in Germany and Japan contains the germ of a solution to the woes our system suffers. Both the German and Japanese systems have universal coverage, support family caregivers, and accord beneficiaries a large degree of control over services received. And they do so at a cost roughly comparable to that experienced by American public payers (Germany a
bit less, Japan a bit more). Organizing long-term care financing through one social insurance program yields efficiency dividends, eliminates stigma concerns, and encourages care at the level and location preferred by recipients. Maybe it’s too early to be pushing for the next step in long-term care reform, but why can’t we do what the Germans and Japanese have done? At the very least, let’s not cut back on the progress made in the current bills as we strain for the finish line.