care of the chronically ill at home: an unresolved dilemma in health policy for the united states
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Care of the Chronically Ill at Home: An Unresolved Dilemma in Health Policy for the United States. Courtney Roberts. Buhler-Wilkerson, K. (2007). Care of the chronically ill at home: An unresolved dilemma in health policy for the united states. The Milbank Quarterly , 85 (4), 611-639. - PowerPoint PPT PresentationTRANSCRIPT
Care of the Chronically Ill at
Home: An Unresolved
Dilemma in Health Policy for the United
StatesCourtney Roberts
Buhler-Wilkerson, K. (2007). Care of the chronically ill at home: An unresolved dilemma in health policy for the united states. The Milbank Quarterly, 85(4), 611-639.
Introduction Chronically ill patients have always needed
assistance at home- not a new problem No agreement has been reached concerning the
proper balance between governmental resources and private resources
Private and public insurers have created financial incentives to contain costs
Continuous and repetitious efforts to solve problems of the chronically ill reflect the unavoidable tensions between fiscal reality and legitimate need
The history of organized home care for the chronically ill makes clear the contemporary policy dilemma
Origins of Organized Home Care
Care of the sick was a part of domestic life in the early nineteenth century
Charleston’s Ladies Benevolent Society (LBS) Earliest known organized
effort to care for the sick at home
Wealthy women of Charleston, SC
Entered homes of the poor and dependent to offer care and comfort
Urbanization, industrialization, immigration, and danger of infectious diseases had transformed cities to unhealthy places to live
Insurance Coverage for Visiting Nurses
Metropolitan Life Insurance Company (1909) Dramatically improved nurse organizations with an
insurance payment scheme Increasing life span of policyholders lowered number of
death claims as well as cost of premiums, which attracted more policyholders
Nurses could extend services to more patients due to additional funds
Nurses not happy about having to conduct work in a scientific and businesslike fashion, but liked the financial support
Industrial insurance purchased by poor and working-class populations was known as insurance for the masses
The Unseen Plague of Chronic Illness
Visiting nurses were caring for more and more patients with heart disease, cancer, strokes, diabetes, and arteriosclerosis
Louis Dublin (physician) was one of the first to observe the shift to chronic disease Tracked the mortality of policyholders
In a desperate search for ways to pay for chronic care, Sophie Nelson was commissioned to test the ability of nurses to cure the progress of chronic illness Results showed that limited & unlimited care of chronically ill produced
same outcomes Key question was whether a payment system could be established that
was stringent enough to avoid paying for long-term person care, elastic enough to care for patients with the potential to recover & humane enough to cover the care of patients requiring skilled care to minimize sufferings
Old Age Assistance dramatically rebalanced the locus of care for chronically ill
Social Security Act encouraged incremental expansion of private nursing homes for chronically ill older people
Changing Times, New Challenges
The nursing services of the MLI and Hancock continued to grow until the Depression Policies lapsed, and the cost
per nurse’s visit rose; this combination made visiting nurses seem like a less economically viable method of preventing death or attracting customers
The closing of MLI’s nursing service seemed inevitable
Hancock also experienced a change in social and health care circumstances Funding medical research
was a better investment
The Postwar Search for a New Paradigm
Ernest Boas (physician) argues that justice & decency demanded community support for those unable to help themselves Believed that communities should establish policies to care for chronically
ill Haphazard development needed to be replaced by a consistent
policy with central responsibility and the authority to offer comprehensive care
Only a reconceptualization of health services for chronically ill and identification of new sources of payments would bring about an alternative system of care
Commission on Chronic Illness: joint effort from American Medical Association, American Hospital Association, American Public Health Association, American Public Welfare Association, and American Public Welfare Association
Solving the problems of chronically ill required money, housing, and adequate medical and nursing care The creation of a single coordinated structure for all would solve
these complex health care problems
Back-to-the-Home Care Movement
The government and the American Medical Association studied home care and pronounced its coming of age
Home care= dynamic approach to far-reaching problems of chronic illness Proclaimed a crucial & respected
component in continuum of care Montefiore Hospital Home Care
Program Seen as a hospital truly moving into
the future First permanent, organized example of
home care Coordinated home care programs were
descendants of Montefiore Program Caring for the sick in their homes was
more natural and humane and reduced costs of hospital care
Patients happier at home Conclusion was that only in cases of
serious illness was home care a reasonable benefit to include in an insurance premium
Devising a Federal Policy for Home Care
Home care appeared, disappeared & reappeared during the decade of debate and resulted in Medicare & Medicaid
The ability to save money always assumed the availability of unpaid family caregivers who would supplement professional care
Care at home=home health care Government-sponsored home care programs came to be
financed mainly through the federal Medicare program, Medicaid, and Title III of the Older Americans Act Implementation of Medicare program marked a new era for
home care Less than perfect solution to health care needs of aging &
chronically ill
Home Care as an Alternative to Nursing Home Care
Thought to be a cost-effective substitute, but did not actually reduce costs
Families sought relief Medicaid actually offered more
extensive coverage for chronically ill and also paid for long-term care Paid for both institutional and home-based
long-term care for chronically ill poor
Home Care Utilization Expands Variety of legislative, judicial & regulatory changes
lead to expansion of home care benefits Omnibus Reconciliation Act of 1980: removed limits on
number of home care visits, prior hospitalization requirements & deductibles
Fox vs. Bowen and Duggen vs. Bowen changed composition of agencies that provided home service By end of 1980s, 1/3 of all Medicare-certified home care
agencies were for profit Proprietary agencies provided more visits compared
with those by nonprofit or governmental agencies Introduction of hospital prospective payment system:
hospitals & physicians became interested in bring hospital home homecare became more expensive as more patients
were discharged
Home Care Utilization Expands Integration of acute & home care services became popular in
1990s Attempt to integrate & coordinate care across settings by
experimenting w/ service delivery & financial models Hope to address problems of fragmented services, cost
containment, misgivings about social welfare services, restrictive reimbursement, burden of family caregiving
Important lessons about integration & financial problems were learned, but no universal paradigm was accepted
Medicare’s coverage for home care considered out of control Ambiguity over liberalized interpretations of criteria for eligibility
& coverage created opportunity for providers of home care to recast Medicare benefit Number of visits doubled to meet needs of short-term acute illness
began to provide long-term care to chronically ill Federal government found home care difficult to manage/control Expansion of home care deemed unsustainable and demands for
reform were proclaimed
Home Care Utilization Expands Growth of home care raised questions of how much
and what kind of home care would be paid for, who should receive it & who would provide it and for how long
Inability of policymakers to visualize elements, outcomes, or value of home care Difficult to decide whether caring for sick at home was a
civic duty or family responsibility Caused unease
Balanced Budget Act of 1997 Radically transformed Medicare home care benefit Outcomes were swift & dramatic Home care characterized by family caregiving, not
services
Family Caregiving Cost of unpaid care provided
by family members to chronically ill/disabled was absent Investment far exceeds
government spending Physical, mental, and economic
costs undeniable Complex, costly, exhausting,
and may continue for years without assistance or training Rarely acknowledged by
policymakers, but is an essential aspect of health care
Multifaceted and enormous policy issue Families seek private
assistance Hard to afford services
Home Care’s Future Federal bureaucrats & policymakers repaired
some of the legislation’s damage to home care system Changes in financing= reinvention of care
Payment system implemented in October 2000 Most dramatic change affecting home care since
Medicare Movement of home care from cost-based
payment to predetermined payment intended to provide financial incentives for more efficient care delivery Means new set of opportunities and risks
Home Care’s Future Metropolitan Life Insurance Company
Goal: intensive & targeted approach to home care aimed at constraining growth through better management & monitoring
Increases in skilled care, decreases in visits by home health aides, fewer users, & brief episodes of care indicate that these new incentives have successfully transformed Medicare back to focusing on short-term care
No significant negative impact on patients’ function, health status, hospital readmission, or emergency room use
Appropriate payment rates are latest topic in debate between those providing care & the government
Conclusion Crushing burden of indefinite home care expenses for family
members of chronically ill patients By 20th century, the needs of a growing elderly population
prompted decades of research, policy development, experimental models & proposals for new paradigms of care delivery & financing
Waiting for a complete breakdown of long-term care before definitive action is taken
History of home care explains much about current challenges and their possible resolution, but only if we are willing to confront an enduring set of questions w/ measured & balanced answers
Home care will be the answer when long-term care policy debate moves beyond economic analysis of the role of home care in continuum of care
Public financing of long-term care at home needs to be viewed as a matter of quality of life & safety, as well as an investment in greater function & independence
Ability to save money using home care will depend on the availability of family members
Conclusion It is difficult to envision an approach to care at home that
would create an universally acceptable balance of self-sacrifice, personal responsibility, & expanded financial resources (public & private)
Difficult to resolve whether home care is a publicly funded civic duty or private family responsibility Policymakers & public believe that long-term care is a
family responsibility Seems unlikely that home care will become the
cornerstone of delivery of care for chronically ill Private, unseen & uncontrollable nature of caring for sick at
home, combined w/ open-ended nature of chronic illness make institutionalization of home care essentially untenable in context of political, social & economic realities, cultures and incentives
Individual responsibility is likely to remain the “American way” at least for the foreseeable future