Financing Health Care for Older Adults

1. Financing Health Care for Older Adults

2. Objectives • Summarize relevant facts and general guidelines of Medicare, Medicaid, and the Older Americans Act. • Differentiate among Medicare, Medicaid, and the Older Americans Act and discuss the essential elements of each and their relevance to care of older adults.

3. Objectives • Discuss the financing for primary care, hospital care, home care, hospice care, and nursing home care of older adults. • Explain how financing drives choice of health-care plan, setting, and extent of care. • Identify research priorities related to quality and cost of care for older adults.

4. Medicare • Enacted into law in 1965 (title XVIII of the Social Security Act) – The Health Insurance for the Aged and Disabled Act. • Foundation for retirees’ protection against heavy medical expenses. • Administered by the Centers for Medicare and Medicaid Services (CMS) formerly the HCFA

5. Medicare • Part A. Hospitalization Insurance (HI) • How financed? Social Security or Railroad Retirement funding • Inpatient hospitalization, limited care in skilled nursing facility, home health services, hospice care, therapy services

6. Medicare • Part B. Supplemental Medical Insurance (SMI) • How financed? Deducted from Social Security check • Physician services, hospital services, diagnostic services, outpatient rehab services, vaccination, dialysis supplies and support services, rural health clinic services, home health services

7. Medicaid • Title XIX of the Social Security Act enacted in 1965 • Federal / State entitlement program • Pays for medical assistance of certain individuals and families with low income and resources • Test for eligibility: low income

8. Medicaid: State responsibilities • Establishes its own eligibility standards • Determines type, amount, duration, and scope of services • Sets rate of payment for services • Administers its own program

9. Older Americans Act (OAA) • Created on July 14, 1965 • Takes responsibility for well-being of older adult citizens • Expanded opportunities to enrich their lives • Administered by State and Area Agencies on Aging

10. Older Americans Act (OAA) • Expanded opportunities to enrich their lives • Adequate income in retirement • Best possible physical and mental health • Suitable housing, independently selected, affordable • Full restorative services • Opportunity for employment

11. Older Americans Act (OAA) • Expanded opportunities to enrich their lives • Retirement in health, honor, dignity • Pursuit of meaningful activity • Efficient community services • Immediate benefit from proven research knowledge • Freedom, independence, and free exercise of individual initiative in planning and managing their own lives

12. OAA: Title III Grants for State and Community Programs on Aging • Access services: transportation, outreach, and case management • In-home services: homemaker, visiting and telephone reassurance, chore and supportive services • Legal assistance: financial, insurance, tax counseling, guardianship proceedings • Supportive services and Senior Centers

13. OAA: Title III Grants for State and Community Programs on Aging • Congregate and home delivered nutritional services • Disease prevention and health promotion services • National Family Caregiver Support Program • Training, Research, and Discretionary Projects

14. OAA: Title III Grants for State and Community Programs on Aging • Community Service employment for Older Americans • Grants for Native Americans • Vulnerable Elder Rights Protection Activities: • Ombudsman Program • Prevention of Elder Abuse, Neglect, and Exploitation • Legal Assistance Development Program

16. Primary Care Services • Medicare is primary payer for primary care services: Physicians and Nurse Practitioners / Clinical Nurse Specialists • Fee-for-service (FFS) option • Covers office visits, ambulance services, ER care, visits in the home, hospital, nursing home • Preventive services: immunizations, mammography, prostate cancer screening, colorectal cancer screening, glaucoma screening

17. Hospital Payment • Medicare is primary payer for in-hospital and physician / nurse practitioner services • Medicare deductible: does not fully cover MD and other services • Most older adults carry supplemental insurance (MediGap insurance)

18. Home Care • Medicare is primary payer for short-term skilled nursing care in the home (typically 3 months or less) • Rehabilitation services, wound care, catheter care, teaching patient and family to give injections • Covers RN, PT, OT, Home health aides, durable medical equipment,

19. Home Care • Medicaid pays for long-term home health care • Type and amount of care available varies from state to state • Medicaid-covered services • Home Health Attendants • Physician, Nurse Practitioner • Professional Nursing Home visits

20. Nursing Home • Medicare pays for short-term (100 days or less) skilled nursing home care – medically unstable. • Skilled care: rehab services, wound and catheter care, teaching patient and family to give injections • Older adult must be able to participate in rehab to qualify for Medicare coverage

21. Nursing Home • Medicaid pays for long-term nursing home health care • Care varies from state to state • Approximately 40% of care is paid out-of-pocket by older adult and family

22. Hospice Care • Medicare is primary payer • Eligibility is based on anticipated death within 6 months • Hospice can be delivered at home, in a hospital, nursing home, or hospice facility • Aggressive pain and symptom management • Cancer, heart disease, chronic obstructive pulmonary disease, dementia

23. Social Services • Families are primary source of social services for older adults • Older Americans Act (OAA) is primary source of publicly-funded social services. • OAA is administered by the Area Agencies on Aging (AAA) • Services: congregate meals, meals-on-wheels, transportation, and ombudsman services

24. Limitations in Primary Care Services • Low Medicare reimbursement for geriatric practitioners and geriatricians • No reimbursement for geriatric interdisciplinary team activities • Medicaid is “means-tested” – older adults must meet state income limits to qualify

25. Limitations in Hospital Payment • Some older adults still require acute care services at the time of discharge. • Whether and where older adults receive these acute care services influences short- and long-term recovery

26. Limitations in Home Care Services • Medicare reimburses only for skilled care. • Low reimbursement for geriatric nurse practitioners and geriatricians. • Older adults must meet state income limits in order to qualify for Medicaid reimbursed home care services.

27. Limitations in Nursing Home Payment • Older adults must meet income limits in order to qualify for Medicaid-reimbursed long-term care nursing home placement. • Frequent and often unnecessary transfer of nursing home residents from the nursing home to the hospital.

28. Limitations in Hospice Payments • Tends to focus on cancer rather than other diagnoses. • Reluctance to access hospice in a timely manner due to Hospice criteria • On average, older adults receive Medicare hospice for only a few days prior to death.

29. Limitations in Social Services Payment • Funding is very limited for social services under the Older Americans Act. • Older adults may qualify for services, but these services may not be available.

30. Research Priorities • Cost savings realized through health promotion activities • Home care quality and cost versus nursing home care quality and cost • Planning for long-term care – attitudes of aging baby boomers about providing financially for long term care.

31. Summary • Summarized facts / guidelines of Medicare, Medicaid, and the Older Americans Act • Financing for primary care, hospital care, home care, nursing home care, hospice, and social services • Limitations of financing health care • Research priorities

32. Questions?