Medicare Reform: A Push Towards Home Based Care
Medicare Reform: A Push Towards Home Based Care Miami University Charles Benandi, Justin Drew, Bernadette Miller, Bethlehem Terrefe
Medicare Reform: A Push Towards Home Based Care Introduction
Currently, people age 65 and older account for 13% of the U.S. population (Shi & Singh, 2010). It is projected that by the year 2030, more than 70 million Americans will be age 65 or older representing twenty percent of the U.S. population (National Association of Area Agencies on Aging, 2011). The major component of this demographic shift, the baby boomers, represents a unique challenge to the healthcare system as they are a more diverse group then prior generations (Frey, 2010). The baby boomer population is generally better educated, is anticipated to have longer involvement in the workforce, and will expect to age in place (Frey, 2010). The last component, aging in place, indicates a strong desire to remain independent. However, this isn’t a new concept. Current members of this age group desire to maintain their independence yet encounter barriers with autonomy/control, housing, economic security, familial/social networks, and health and social care (Seidel, 2010). In order to meet current and increasing desire for aging in place policies and programs will need to be created to support the demand. To alleviate some of the pressure, focus can be placed on the Medicare beneficiary subgroup of the 65 and older demographic. In 2011, there were nearly 47.7 million Medicare beneficiaries (StateHealthFacts.org, 2011). Therefore, it can be demonstrated that keeping care within the home versus institutionalization can positively affect client satisfaction, be cost effective, and reduce ethical dilemmas involving care. To facilitate aging in place, two Medicare programs are suggested that have proven benefit to clients; implementation of the primary care medical home model of care and increased respite care coverage.
Medicare Reform: A Push Towards Home Based Care Cost Comparison
Many aging adults, with health problems, chose to live at home, take advantage of respite programs, or go into long term care facilities. There are negative and positive aspects to these options, however; costs can play a major role when making a decision of this nature. With the increase in aging adults, home health and respite care has become very popular and caregivers are being hired through agencies, privately, or registries. For example, many states have care providers that are registered through the state and are provided to families who may need some form of home health care for themselves or their loved ones. At times providers allow informal caregivers a break from the burden of taking care of their loved one. They also allow one to stay in their own home and receive care instead of being institutionalized. Many of the providers registered may be licensed or non-licensed home health aides, nurses, physical and/or occupational therapists. Some families pay out of pocket for these home health services whether it be cooking, cleaning, help with activities of daily living (ADL’s), etc. Many are also eligible for respite care, depending on their income, which allows up to two weeks of care per year. Most states offer programs that use a Medicaid waiver to allow direct federal payments to family caregivers for their services. But this means, in most cases, that only care recipients whose income is low enough for Medicaid status qualify (Ramnarace Cynthia, 2011). Others are eligible to receive Medicare, with a doctor’s order, which pays for services depending on the situation. Currently Medicare will not cover homemaker services or personal care like bathing, dressing, or grooming (2012 Medicare costs, 2012). Medicare Part A: Monthly premium is $451 for those who pay a premium. You pay $0 for home health care services, 20% of Medicare approved amount for durable medical
Medicare Reform: A Push Towards Home Based Care equipment, $0 for hospice care, up to $5 per prescription, and 5% of Medicare approved respite care. With hospital inpatient stays you pay $1,156 deductible per benefit period; $0 for the first 60 days of each benefit period with $578 per lifetime of service day after day 90 of each benefit period. Skilled nursing facility stays are $0 for the first twenty days of each benefit period
then $144.50 per day for days 21-100 each benefit period. Medicare Part B: monthly premium is $99.90 or higher depending on income. With respect to home health services you pay $0 for Medicare approved services. You pay 20% of Medicare approved amount for durable medical equipment. You pay 20% of the Medicare-approved amount for most doctor services. Part C and D costs will vary (2012 Medicare costs, 2012). Home health care hourly rates and long term care facility rates can vary from state to state. The average home health care rate is $19-$21 dollars an hour. Assisted living communities cost on average $3,293 monthly. The average Nursing home or long term care facilities rate averages $205-229 a day or $3,293 a month. The average room rate for an Alzheimer’s unit is $206-228 a day and $75,190-83,220 annually (Metlife Market Institute, 2010). Improved Client Satisfaction and Outcomes Nursing homes serve as permanent residences for people who are too frail or sick to live at home or as a temporary facility during a recovering period. However, many people need a nursing home level of care but would prefer to remain in their own home with the help of their family and friends, community services, and professional care agencies. There is a lot of controversy as to having an alternative to nursing homes. Instead of the elderly going to a nursing home care facility and spending outrageous amounts of money, family-nursing care is one alternative.
Medicare Reform: A Push Towards Home Based Care
Family healthcare nursing is the process of providing for the health care needs of families that are within the scope of nursing practice. Family nursing can be aimed at the family as context, the family as a whole, the family as a system, or the family as a component of society (Hanson & Boyd & May, 2008). There are individuals who need special care, and require a only a little bit of skilled care, but there are others that require more skilled care but only for brief periods of time. Most people would like to stay in their homes for as long as possible. Continuing care retirement communities (CCRCs) may offer an efficient way to provide a broad continuum of Long Term Care (LTC) if a universal Long Term Care entitlement is established. Among the more fundamental approaches to conserve nursing home use are (1) to provide supportive services in the community and (2) to pay Long Term Care providers a capitated fee, thereby assigning them the responsibility for making decisions concerning the allocation of LTC services among patients enrolled in their plans (Conover & Shayne & Sloan, 1995). Studies have shown that nursing home residents do not appreciated many things that they have to live with in their nursing home facility. These include but are not limited to laundry, environment, and food. Patient satisfaction is a clear indicator of quality of care and a component of quality care (Wolosin, 2008). Patients continuously judge and evaluate what is happening to them when taken care of and meeting their needs. When allowed to be in their own home, these needs are met; patients receive better results because of their interaction with the facilitator. This one on one interaction perceives as a better outcome than what is displayed at nursing homes. Home health care organizations across the nation made steady improvement in patient satisfaction in 2006 after sporadic improvements over the past four years. In 2007, performance remained relatively consistent from the end-of-year performance (Wolosin, 2008).
Medicare Reform: A Push Towards Home Based Care There are many different home health care agencies around the world. According to Metro Home Health Care, patients gave their company above a 96% rating for each survey questions. Questions included, “Was the care appropriate for your needs,” “Do you know more about your illness and its treatments,” “The staff treated my family, my home, and my
belongings with respect,” etc. This provides an example that home health care can perform great in-homes care for their patients. Ethical Considerations When determining the end of care life for an individual, there are many ethical considerations that should be taken into account. It is important to look at the health care given to someone from all viewpoints: the person who needs the health care, the family of the person, the health care professional/s providing the care, and the person or group that is funding the health care. For people who can take care of themselves and need minimal help, home care might be an obvious choice. However, when people need extensive care that family and friends may not be able to provide, that person could become a burden. No matter what the condition of the person in need of health care, as a human they are ethically entitled to the best and most personal care that can be provided to them. Those who enter a nursing home typically have a life expectancy that typically ranges from nine to twelve months. If the person is co-morbid and has other diseases or issues, such as dementia, the final phase of life tends to be even shorter (Seymour et al., 2010). Ethically, most people would say that a person should be allowed to live as long as they possibly can. As the statistics show however, people who move into a nursing home tend to have a life expectancy that is very short. It is morally sound to allow someone to die comfortably, rather than them feeling like they were tortured prior to death. By giving people who would be admitted to a
Medicare Reform: A Push Towards Home Based Care
nursing home the option to live in their own home, Medicare would be granting those people the option to live comfortably and have a possibility of living a longer life. On the other hand however, there is the rationale that care in a nursing home allows the person to be more highly monitored, have access to better health care equipment, and have more interactions with other people. Tonnessen et al. (2011) state that in Norway where home based care is an option to every person, there are not enough supplies and funds to give everyone the best care that they should get. If home based care were offered to everyone in the United States then there could conceivably be a shortage of nurses, health care supplies, and other conveniences that nursing homes offer. If that were the case then people would say that it is unethical to allow people the option of home care if there were not the possibility of everyone getting equal care and the correct care they need. However, if Medicare were to change its policy to allow home based care, then proper considerations and precautions would have to be taken to make sure that everyone was receiving the best care that they could get. A study completed by Oresland et al. (2011) showed how nurses who embark on home based care are often caught in the middle of an “endless journey.” In the context of the article it states that nurses are always fighting a changing regimen and need to be prepared on a daily basis for any type of problem that may arise. Though this may have a negative connotation in the eyes of the nurse, in reality it is a good thing for the patient. Not only would home care provide people with the undivided attention of trained health care professional, but it would give them someone to socially interact and form a close relationship with. In a nursing home a patient would only have the opportunity to interact with people on the nursing home’s watch. They also would always have different nurses to interact with and would not have the ability to form a deep relationship, especially if they are going to be there for less than a year. Because of this they
Medicare Reform: A Push Towards Home Based Care would not be getting the undivided attention and care that they might need or the opportunity to form a close bond with another person. Another important ethical consideration is the manner and standards to which the nurse practitioners hold their selves. Each and every day brings new challenges and oddities that may
not have been previously experienced. There is a certain dynamic between each patient and nurse and a level of mutual trust that must be upheld for the relationship to be beneficial to both parties, (Salas and Cameron, 2010). The nurse practitioner is in the home of the patient and therefore must maintain a level of respect for that person and their things. Because of this the legal issues that go along with having someone placed into the home for care must be followed very closely and the nurse must abide by all rules both morally and lawfully. With the correct guidelines and rules put into place though, each nurse practitioner can be held accountable for their actions. Therefore, it would be possible for Medicare to put a system into place whereby nurses could be in a patient’s home and uphold the morals and standards that are expected of them. Whether it is in the nursing home or in a patient’s private home, the main goal of doctors and nurse practitioners should be the prolongation of a patient’s life the to the best degree possible (Dreyer et al., 2011). There may be those that disagree that people should be granted the opportunity to stay in their own home, but Medicare’s top priority should be helping to keep people alive for as long and as healthily as possible. By giving individual privatized care, keeping the mental state high of the patient by having one on one interaction with a nurse, and by allowing the patient to remain as comfortable as possible in their own home, Medicare would be morally and ethically abiding by that notion.
Medicare Reform: A Push Towards Home Based Care Suggested Changes to Medicare In its current form, Medicare has limited benefits regarding home health care. Medicare describes home health as a service that helps one get better, to regain their independence, and become as self-sufficient as possible (Centers for Medicare and Medicaid Services, 2010). However, in order to receive these benefits the Medicare member must meet certain criteria; a physician’s order, physician certified need for intermittent skilled nursing care, physical/occupational therapy, and/or speech-language pathology services, a Medicare certified
home health care provider, and physician certified home-bound status (Centers for Medicare and Medicaid Services, 2010). The home health coverage supplied by Medicare, then, only covers a single, short term remediable situation (Edes, 2010). Therefore non-skilled assistance with activities of daily living, termed custodial care, is not covered by Medicare (Medicare.gov, 2009). Two recommendations for changes with Medicare can be made that put more emphasis on care in the home instead of institutionalization. However, it is important to first recognize why changes in Medicare creates resistance from opponents. The Medicare program has been subjected to fraud and abuse including inaccurate billing for services, excessive administrative staff, “kickbacks” for referrals, billing non-covered medical supplies, and inappropriate use of home health services (Stanhope & Lancaster, 2010). In response to such activities and to attempt to control costs the Balanced Budget Act of 1997 was implemented which introduced new reimbursement methods for the Medicare home health benefit (Davitt, 2009). This intensified the aforementioned restrictions to home health care which caused drastic cuts in services to patients due to agencies needing to balance low and high maintenance patients (Davitt, 2009) because more impaired patients are more likely to exhaust the per-beneficiary cap (Davit & Marcus, 2008). However, several
Medicare Reform: A Push Towards Home Based Care
consequences occurred from this piece of legislation. Non-skilled services, such as home health aide and medical social work, were greatly reduced causing several agencies to switch dually eligible patients from Medicare to Medicaid so more services could be obtained (Davitt & Sunha, 2008). There was a noticeable increase in referrals to other aging services and an increase in informal caregivers to supplement services (Davitt & Sunha, 2008). Therefore during this shifting of care from one system to another it is suggested that overall cost reduction is not occurring because the only change happening is which component of the health care system is paying for care; from federal to state and state to local (Davitt & Sunha, 2008). Today an estimated 40 million people are aged 65 and older with projections to double by the year 2050; largely a result of the baby boomer population (Jacobsen, Kent, Lee &Mather, 2011). This massive demographic shift, with current coverage criteria, will create an ever expanding barrier to care for those wishing to maintain independence at home and avoid institutionalization. One suggestion is to increase implementation and maintenance of the primary care medical home model of care. This model strengthens primary care through the reorganization of existing practices to provide patient-centered, comprehensive, coordinated, and accessible care in the home (Rich et al., 2012). A study done on a current Veterans Affairs (VA) home-based primary care program of 11,334 recipients showed 62 percent reduction in hospital bed days of care, 88 percent reduction in nursing home bed days of care, and in increase in all home care visits by 264 percent with total costs dropping from $38,000 per patient to $29,000, a net 24 percent reeducation in overall costs for the VA (Edes, 2010). ProvenHealth Navigator, another home-based primary care program, was able to demonstrate an 18 percent reeducation in inpatient admissions and an overall 36 percent reduction in readmissions (Gilfillan et al., 2010). In response to the success of these programs, the Independence at Home program became part of
Medicare Reform: A Push Towards Home Based Care the Patient Protection and Affordable Care Act of 2010 which will aim to create a government funded home-based primary care program (Row, 2011). The program is slated to start a three year demonstration this year to determine its success in reducing projected Medicare expenditures (Centers for Medicare and Medicaid Services, 2011; Row, 2011). Even with increased accessibility to care in the home, the role of the informal caregiver
will continue to be significant in filling the gaps in care provision. Caregiver burden becomes a major issue with many reporting financial burden and increased stress, depression, substance abuse, loss of sleep, health and mental problems, employment loses, and increased personal isolation (Cabin, 2008; Lilly et al., 2012). Caregiver burnout has been noted to cause an increase in institutionalization of the patient without significant reduction of caregiver burden after placement (Cabin, 2008). Therefore it is not surprising that one study out of Canada found respite care as the most requested form of support for informal caregivers (Lilly et al., 2012). Respite care is defined as any service that provides the informal caregiver temporary relief of responsibility of care while meeting the disabled persons’ needs for assistance (Shi & Singh, 2009). Studies have shown that with the availability and use of respite care, caregiver burden is decreased (Wilkie & Barr, 2008; Jardim & Pakenham, 2010). Currently, Medicare only covers respite care for hospice patients requiring short-term admission to a Medicare-approved Facility; some home-care may be available under particular circumstances (Centers for Medicare and Medicaid Services, 2011). By expanding eligibility criteria and coverage to support respite care, the issue of caregiver burden can be addressed and ultimately avoid burnout and unnecessary institutionalization.
Medicare Reform: A Push Towards Home Based Care Conclusion As the population continues to age it is important to discover new options of long term health care for everyone. One way that people will be able to receive health care is in their home. It is important that Medicare looks to change its policies to help match the needs of its patients. However, there are many people that believe that home health care is not feasible for
the majority of people due to the costs and distribution of resources. Both sides of the argument have validity, but it is important to look at the policies from the viewpoint of the people involved in care of the patient, including the patient themselves. Many times the family of the person requiring health care has more of a burden than they can handle. The costs of providing the care themselves and the physical and mental toll that it puts on them often become too great to bear. Then the patient must be considered. There are ethical considerations such as allowing the person to die comfortably and the higher level of care that can be provided to them in their own homes. Obviously if there are overarching circumstances, such as recent dismissal from a hospital, then the nursing home may be the correct option. Also, if the person requires a level of care that cannot be provided in the home, then it should be provided in a facility that can handle it. However, for the population that is capable of staying in the home, Medicare should provide funds and change their policy to allow for long term nursing care in the home.
Medicare Reform: A Push Towards Home Based Care References Cabin, W. D. (2008). Moving Toward Medicare Home Health Coverage for Persons with Alzheimer's Disease. Journal of Gerontological Social Work, 51(1/2), 77-86. Centers for Medicare and Medicaid Services. (2010).Medicare and Home Health Care. Retrieved from http://www.medicare.gov/Publications/Pubs/pdf/10969.pdf Centers for Medicare and Medicaid Services. (2011).Independence at home demonstration. Retrieved from https://www.cms.gov/DemoProjectsEvalRpts/downloads/IAH_FactSheet.pdf
Centers for Medicare and Medicaid Services. (2011).Medicare hospice benefits. Retrieved from http://www.medicare.gov/Publications/Pubs/pdf/02154.pdf Davitt, J. K. (2009). Policy Changes in Medicare Home Health Care: Challenges to Providing Family-Centered, Community-Based Care for Older Adults. Journal Of Family Social Work, 12(4), 291-308. Davitt, J. K., & Marcus, S. C. (2008). The Differential Impact of Medicare Home Health Care Policy on Impaired Beneficiaries. Journal Of Policy Practice, 7(1), 3-22. Davitt, J. K., & Sunha, C. (2008). Tracing the History of Medicare Home Health Care: The Impact of Policy on Benefit Use. Journal Of Sociology & Social Welfare, 35(1), 247-276. Dreyer, A., Førde, R., & Nortvedt, P. (2011). Ethical decision-making in nursing homes: Influence of organizational factors. Nursing Ethics, 18(4), 514-525. Edes, T. (2010). Innovations in Homecare: VA Home-Based Primary Care. Generations, 34(2), 29-34. Frey, W. H. (2010). Baby Boomers and the New Demographics of America's Seniors. Generations, 34(3), 28-37. Gilfillan, R. J., Tomcavage, J., Rosenthal, M. B., Davis, D. E., Graham, J., Roy, J. A., & ... Steele, J. D. (2010). Value and the Medical Home: Effects of Transformed Primary Care. American Journal Of Managed Care, 16(8), 607-a615. Hanson, S., Boyd, S., May, A. (2001). Family health care nursing: Theory, practice, and research. (Second ed.). Philadelphia, PA: F.A. Davis Company. Jacobsen, L. A., Kent, M., Lee, M., & Mather, M. (2011). America’s Aging Population. Population Bulletin, 66(1), 1-18. Jardim, C., & Pakenham, K. (2010). Carers of adults with mental illness: Comparison of respite care users and non-users. Australian Psychologist, 45(1), 50-58.
Medicare Reform: A Push Towards Home Based Care
Lilly, M. B., Robinson, C. A., Holtzman, S., & Bottorff, J. L. (2012). Can we move beyond burden and burnout to support the health and wellness of family caregivers to persons with dementia? Evidence from British Columbia, Canada. Health & Social Care In The Community, 20(1), 103-112. Medicare.gov. (2009). Long-term care. Retrieved from http://www.medicare.gov/longtermcare/static/home.asp Metlife Market Institute. (2010, October). The 2010 MetLife survey of nursing home, assisted living, adult daycare services, and home health care costs. Retrieved from http://www.metlife.com/assets/cao/mmi/publications/studies/2010/mmi-2010-marketsurvey-long-term-care-costs.pdf National Association of Area Agencies on Aging. (2011). Policy 2011 priorities: Promote the health, security, well-being, of older adults. Washington D.C.: Markwood, S., Gotwals, A., & Hertz, K.J. Öresland, S., Määttä, S., Norberg, A., & Lützén, K. (2011). Home-based nursing: An endless journey. Nursing Ethics, 18(3), 408-417. Ramnarace Cynthia. (2011, December 15). [Web log message]. Retrieved from http://www.aarp.org/relationships/caregiving-resource-center/info-102010/lfm_get_paid_as_a_family_caregiver.html Rich, E. C., Lipson, D., Libersky, J., Peikes, D. N., & Parchman, M. L. (2012). Organizing Care for Complex Patients in the Patient-Centered Medical Home.Annals Of Family Medicine, 10(1), 60-62. Santos Salas, A., & Cameron, B. L. (2010). Ethical openings in palliative home care practice. Nursing Ethics, 17(5), 655-665. Seidel, D. (2010). Design for an ageing population: promoting independence and quality of life. Australasian Medical Journal, 2(11), 142-145. Seymour, J., Kumar, A., & Froggatt, K. (2011). Do nursing homes for older people have the support they need to provide end-of-life care? A mixed methods enquiry in England. Palliative Medicine, 25(2), 125-138. Shi, L. & Singh, D.A. (2010). Essentials of the U.S. health care system (2nd Ed.) Boston: Jones & Bartlett Publishers. Shi, L., & Singh, D. (2009). Essentials of the united states health care system. (second ed.). Boston: Jones & Bartlett Learning.
Medicare Reform: A Push Towards Home Based Care
Sloan, F., Shayne, M., & Conover, C. (1995). Continuing care retirement communities: prospects for reducing institutional long-term care. Journal Of Health Politics, Policy And Law, 20(1), 75-98. Stanhope, M., & Lancaster, J. (2010). Foundations of nursing in the community, communityoriented practice. St. Louis, MO: Mosby. StateHealthFacts.org. (2011). Total number of Medicare beneficiaries, 2011. Retrieved from http://www.statehealthfacts.org/comparemaptable.jsp?ind=290&cat=6 The Official U.S. Government Site for Medicare, (2012). 2012 Medicare costs. Retrieved from website: www.medicare.gove/cost/ Tønnessen, S., Nortvedt, P., & Førde, R. (2011). Rationing home-based nursing care: professional ethical implications. Nursing Ethics, 18(3), 386-396. Wilkie, B., & Barr, O. (2008). The experiences of parents of children with an intellectual disability who use respite care services. Learning Disability Practice, 11(5), 30-36. Wolosin, R. (2008). Advancing excellence in health care: Home health care survey. Retrieved from http://www.qualitymeasures.ahrq.gov/content.aspx?id=28153