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

5/18/ 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

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, Medicaid liberalization, 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

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 infrastructure grants

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

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 AoA 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

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?

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

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

Conclusions Long-term care is not the centerpiece of health reform, but it can and should play a role Experience of Europe guarantees that long-range demographics will put long-term care high on the nation’s policy agenda in the future Comprehensive reform will cost money, but low-cost options can make contribution The “window” for health reform