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Financing Health Financing Health Care for Older Care for Older AdultsAdults

ObjectivesObjectives

Summarize relevant facts and general Summarize relevant facts and general guidelines of Medicare, Medicaid, and guidelines of Medicare, Medicaid, and the Older Americans Act.the Older Americans Act.

Differentiate among Medicare, Medicaid, Differentiate among Medicare, Medicaid, and the Older Americans Act and discuss and the Older Americans Act and discuss the essential elements of each and their the essential elements of each and their relevance to care of older adults.relevance to care of older adults.

ObjectivesObjectives

Discuss the financing for primary care, Discuss the financing for primary care, hospital care, home care, hospice care, hospital care, home care, hospice care, and nursing home care of older adults.and nursing home care of older adults.

Explain how financing drives choice of Explain how financing drives choice of health-care plan, setting, and extent of health-care plan, setting, and extent of care.care.

Identify research priorities related to Identify research priorities related to quality and cost of care for older adults.quality and cost of care for older adults.

MedicareMedicare

Enacted into law in 1965 (title XVIII of the Enacted into law in 1965 (title XVIII of the Social Security Act) – The Health Social Security Act) – The Health Insurance for the Aged and Disabled Act.Insurance for the Aged and Disabled Act.

Foundation for retirees’ protection Foundation for retirees’ protection against heavy medical expenses.against heavy medical expenses.

Administered by the Centers for Administered by the Centers for Medicare and Medicaid Services (CMS) Medicare and Medicaid Services (CMS) formerly the HCFAformerly the HCFA

MedicareMedicare

Part A. Hospitalization Insurance (HI)Part A. Hospitalization Insurance (HI)

How financed? Social Security or Railroad How financed? Social Security or Railroad Retirement fundingRetirement funding

Inpatient hospitalization, limited care in Inpatient hospitalization, limited care in skilled nursing facility, home health services, skilled nursing facility, home health services, hospice care, therapy serviceshospice care, therapy services

MedicareMedicare

Part B. Supplemental Medical Insurance Part B. Supplemental Medical Insurance (SMI)(SMI)

How financed? Deducted from Social How financed? Deducted from Social Security checkSecurity check

Physician services, hospital services, Physician services, hospital services, diagnostic services, outpatient rehab diagnostic services, outpatient rehab services, vaccination, dialysis supplies and services, vaccination, dialysis supplies and support services, rural health clinic support services, rural health clinic services, home health servicesservices, home health services

MedicaidMedicaid

Title XIX of the Social Security Act Title XIX of the Social Security Act enacted in 1965enacted in 1965

Federal / State entitlement programFederal / State entitlement program

Pays for medical assistance of certain Pays for medical assistance of certain individuals and families with low income individuals and families with low income and resourcesand resources

Test for eligibility: low incomeTest for eligibility: low income

Medicaid: Medicaid: State responsibilitiesState responsibilities

Establishes its own eligibility standardsEstablishes its own eligibility standards

Determines type, amount, duration, and Determines type, amount, duration, and scope of servicesscope of services

Sets rate of payment for servicesSets rate of payment for services

Administers its own programAdministers its own program

Older Americans Act Older Americans Act (OAA)(OAA)

Created on July 14, 1965Created on July 14, 1965

Takes responsibility for well-being of Takes responsibility for well-being of older adult citizensolder adult citizens

Expanded opportunities to enrich their Expanded opportunities to enrich their liveslives

Administered by State and Area Administered by State and Area Agencies on AgingAgencies on Aging

Older Americans Act Older Americans Act (OAA)(OAA) Expanded opportunities to enrich their Expanded opportunities to enrich their

liveslives Adequate income in retirementAdequate income in retirement Best possible physical and mental healthBest possible physical and mental health Suitable housing, independently selected, Suitable housing, independently selected,

affordableaffordable Full restorative servicesFull restorative services Opportunity for employmentOpportunity for employment

Older Americans Act Older Americans Act (OAA)(OAA) Expanded opportunities to enrich their livesExpanded opportunities to enrich their lives

Retirement in health, honor, dignityRetirement in health, honor, dignity

Pursuit of meaningful activityPursuit of meaningful activity

Efficient community servicesEfficient community services

Immediate benefit from proven research Immediate benefit from proven research knowledgeknowledge

Freedom, independence, and free exercise of Freedom, independence, and free exercise of individual initiative in planning and managing individual initiative in planning and managing their own livestheir own lives

OAA: Title III OAA: Title III

Grants for State and Community Programs on Grants for State and Community Programs on AgingAging

Access services: transportation, outreach, and Access services: transportation, outreach, and case managementcase management

In-home services: homemaker, visiting and In-home services: homemaker, visiting and telephone reassurance, chore and supportive telephone reassurance, chore and supportive servicesservices

Legal assistance: financial, insurance, tax Legal assistance: financial, insurance, tax counseling, guardianship proceedingscounseling, guardianship proceedings

Supportive services and Senior CentersSupportive services and Senior Centers

OAA: Title III OAA: Title III

Grants for State and Community Programs Grants for State and Community Programs on Agingon Aging Congregate and home delivered nutritional Congregate and home delivered nutritional

servicesservices

Disease prevention and health promotion Disease prevention and health promotion servicesservices

National Family Caregiver Support ProgramNational Family Caregiver Support Program

Training, Research, and Discretionary ProjectsTraining, Research, and Discretionary Projects

OAA: Title III OAA: Title III

Grants for State and Community Programs Grants for State and Community Programs on Agingon Aging Community Service employment for Older Community Service employment for Older

AmericansAmericans

Grants for Native AmericansGrants for Native Americans

Vulnerable Elder Rights Protection Activities:Vulnerable Elder Rights Protection Activities: Ombudsman ProgramOmbudsman Program Prevention of Elder Abuse, Neglect, and ExploitationPrevention of Elder Abuse, Neglect, and Exploitation Legal Assistance Development ProgramLegal Assistance Development Program

Elements MEDICARE MEDICAID AGENCIES ON AGING

Source of financing

Federal through separate payroll contributions paid by employees, employers, and self-employed persons

States Federal

Age Eligibility

65 and older (covers some people less than 65 who are disabled)

All ages Entitlement

$ Eligibility Entitlement, that is almost everyone 65+ irrespective of income

Low income and resources

65 and older

Administration

Administrator of the Centers for Medicare and Medicaid Services (CMS); Voluntary insurance organizations

States, under broad federal guidelines

Area Agencies on Aging

Primary Care ServicesPrimary Care Services

Medicare is primary payerMedicare is primary payer for primary care for primary care services: Physicians and Nurse Practitioners / services: Physicians and Nurse Practitioners / Clinical Nurse SpecialistsClinical Nurse Specialists Fee-for-service (FFS) optionFee-for-service (FFS) option Covers office visits, ambulance services, ER care, visits Covers office visits, ambulance services, ER care, visits

in the home, hospital, nursing homein the home, hospital, nursing home

Preventive services: immunizations, Preventive services: immunizations, mammography, prostate cancer screening, mammography, prostate cancer screening, colorectal cancer screening, glaucoma screeningcolorectal cancer screening, glaucoma screening

Hospital PaymentHospital Payment

Medicare is primary payerMedicare is primary payer for in-hospital for in-hospital and physician / nurse practitioner and physician / nurse practitioner servicesservices

Medicare deductible: does not fully cover Medicare deductible: does not fully cover MD and other servicesMD and other services

Most older adults carry supplemental Most older adults carry supplemental insurance (MediGap insurance)insurance (MediGap insurance)

Home CareHome Care

Medicare is primary payerMedicare is primary payer for short-term for short-term skilled nursing care in the home (typically skilled nursing care in the home (typically 3 months or less)3 months or less) Rehabilitation services, wound care, Rehabilitation services, wound care,

catheter care, teaching patient and family to catheter care, teaching patient and family to give injectionsgive injections

Covers RN, PT, OT, Home health aides, Covers RN, PT, OT, Home health aides, durable medical equipment, durable medical equipment,

Home CareHome Care

MedicaidMedicaid pays for long-term home health pays for long-term home health carecare

Type and amount of care available varies Type and amount of care available varies from state to statefrom state to state

Medicaid-covered servicesMedicaid-covered services Home Health AttendantsHome Health Attendants Physician, Nurse PractitionerPhysician, Nurse Practitioner Professional Nursing Home visitsProfessional Nursing Home visits

Nursing HomeNursing Home

MedicareMedicare pays for short-term (100 days pays for short-term (100 days or less) skilled nursing home care – or less) skilled nursing home care – medically unstable.medically unstable. Skilled care: rehab services, wound and Skilled care: rehab services, wound and

catheter care, teaching patient and family to catheter care, teaching patient and family to give injectionsgive injections

Older adult must be able to participate in Older adult must be able to participate in rehab to qualify for Medicare coveragerehab to qualify for Medicare coverage

Nursing HomeNursing Home

Medicaid Medicaid pays for long-term nursing pays for long-term nursing home health carehome health care

Care varies from state to stateCare varies from state to state

Approximately 40% of care is paid out-Approximately 40% of care is paid out-of-pocket by older adult and familyof-pocket by older adult and family

Hospice CareHospice Care

Medicare Medicare is primary payeris primary payer

Eligibility is based on anticipated death within Eligibility is based on anticipated death within 6 months6 months

Hospice can be delivered at home, in a Hospice can be delivered at home, in a hospital, nursing home, or hospice facilityhospital, nursing home, or hospice facility

Aggressive pain and symptom managementAggressive pain and symptom management

Cancer, heart disease, chronic obstructive Cancer, heart disease, chronic obstructive pulmonary disease, dementiapulmonary disease, dementia

Social ServicesSocial Services

Families are primary source of social services Families are primary source of social services for older adultsfor older adults

Older Americans Act (OAA) is primary source Older Americans Act (OAA) is primary source of publicly-funded social servicesof publicly-funded social services. .

OAA is administered by the Area Agencies on OAA is administered by the Area Agencies on Aging (AAA)Aging (AAA)

Services: congregate meals, meals-on-Services: congregate meals, meals-on-wheels, transportation, and ombudsman wheels, transportation, and ombudsman servicesservices

Limitations in Primary Limitations in Primary Care ServicesCare Services

LowLow Medicare reimbursement for Medicare reimbursement for geriatric practitioners and geriatriciansgeriatric practitioners and geriatricians

No reimbursement for geriatric No reimbursement for geriatric interdisciplinary team activitiesinterdisciplinary team activities

Medicaid is Medicaid is “means-tested”“means-tested” – older – older adults must meet state income limits to adults must meet state income limits to qualifyqualify

Limitations in Hospital Limitations in Hospital PaymentPayment

Some older adults still require acute Some older adults still require acute care services at the time of discharge. care services at the time of discharge.

Whether and where older adults Whether and where older adults receive these acute care services receive these acute care services influences short- and long-term influences short- and long-term recovery recovery

Limitations in Home Care Limitations in Home Care ServicesServices Medicare reimburses only for skilled Medicare reimburses only for skilled

care.care.

Low reimbursement for geriatric nurse Low reimbursement for geriatric nurse practitioners and geriatricians.practitioners and geriatricians.

Older adults must meet state income Older adults must meet state income limits in order to qualify for Medicaid limits in order to qualify for Medicaid reimbursed home care services.reimbursed home care services.

Limitations in Nursing Limitations in Nursing Home PaymentHome Payment

Older adults must meet income limits Older adults must meet income limits in order to qualify for Medicaid-in order to qualify for Medicaid-reimbursed long-term care nursing reimbursed long-term care nursing home placement.home placement.

Frequent and often unnecessary Frequent and often unnecessary transfer of nursing home residents transfer of nursing home residents from the nursing home to the hospital.from the nursing home to the hospital.

Limitations in Hospice Limitations in Hospice PaymentsPayments

Tends to focus on cancer rather than Tends to focus on cancer rather than other diagnoses.other diagnoses.

Reluctance to access hospice in a Reluctance to access hospice in a timely manner due to Hospice criteriatimely manner due to Hospice criteria

On average, older adults receive On average, older adults receive Medicare hospice for only a few days Medicare hospice for only a few days prior to death.prior to death.

Limitations in Social Limitations in Social Services PaymentServices Payment

Funding is very limited for social Funding is very limited for social services under the Older Americans services under the Older Americans Act.Act.

Older adults may qualify for services, Older adults may qualify for services, but these services may not be but these services may not be available.available.

Research PrioritiesResearch Priorities

Cost savings realized through health Cost savings realized through health promotion activitiespromotion activities

Home care quality and cost versus Home care quality and cost versus nursing home care quality and costnursing home care quality and cost

Planning for long-term care – attitudes of Planning for long-term care – attitudes of aging baby boomers about providing aging baby boomers about providing financially for long term care.financially for long term care.

SummarySummary

Summarized facts / guidelines of Summarized facts / guidelines of Medicare, Medicaid, and the Older Medicare, Medicaid, and the Older Americans ActAmericans Act

Financing for primary care, hospital care, Financing for primary care, hospital care, home care, nursing home care, hospice, home care, nursing home care, hospice, and social servicesand social services

Limitations of financing health careLimitations of financing health care

Research prioritiesResearch priorities

Questions?