Individually, Medicare, Medicaid, Medigap, and private long-term care insurance have shortcomings in providing comprehensive geriatric care, which includes the medical, nursing, and supportive needs of the elderly patient. Medicare excludes long-term custodial care and many preventive services; Medicaid belatedly intervenes after the patient is impoverished; Medigap, like Medicare, excludes long-term care and outpatient prescribed drugs; and private insurance is unaffordable by most elders, leaves them vulnerable to financial catastrophe, and supports only fragments of long-term care. Collectively, these programs rarely promote integrated acute and long-term care or coordination of
ealth and social services. However, several model projects have demonstrated that with organized delivery of services using combinations of public funding and private insurance, comprehensive geriatric care can be adequately financed.
Social and health maintenance organizations (SHMOs) are demonstration programs conducted by Medicare. They use Medicare, Medicaid, and private patient payments to cover a complete range of care benefits managed by nurses, social workers, and physicians. Patients not eligible for Medicaid benefits use private payments to cover a limited amount of long-term care, principally in the home. Like an HMO, an SHMO is at financial risk for the cost of services and has a stake in frugality.
The Program of All-inclusive Care of the Elderly (PACE) is a federally supported, multisite program of comprehensive care. Its primary objective is to keep patients in the community as long as medically, socially, and financially possible. A professional multidisciplinary team assesses patient needs, develops a care plan, integrates primary care and other services, and arranges for the implementation of services. The project is sponsored by one or more facilities and community groups; the project sponsor receives a preset amount of Medicare, Medicaid, and private funds and guarantees the provision of benefits at a capitated rate. If the costs of benefits exceed the pooled funds, the project covers the loss.
In San Francisco’s Chinatown, On Lok, the forerunner of PACE, provides prepaid comprehensive care for elderly persons who have a level of impairment that usually requires admission to a nursing home. On Lok provides adult day care and coordinated, comprehensive services, including custodial or personal care, drug treatment, dentistry, and housekeeping services in a community housing project. Fewer than 6% of On Lok participants (who enroll for life) have needed nursing home placement, and hospital admissions and lengths of stay are half those for comparable elders.
The life-care community or continuing care retirement community is a model for combining housing, health care, and other services under packaged financing and management. These communities may have a clinic, an infirmary, or even a nursing home on the site, and housing is designed to accommodate disabled persons. The most extensive of these communities serve wealthy retirees willing to sign long-term contracts for their housing and care. Some life-care communities have failed when inflation and an aging population caused costs for services to exceed income. Some communities keep costs down by providing housing and minimal services with options to purchase additional services (see also Life-Care Communities in Ch. 24).
In 1990, the US Bipartisan Commission on Comprehensive Health Care (the Pepper Commission) developed a model approach to long-term care financing that resembles Social Security. Throughout their working lives, Americans would contribute a portion of earnings to a long-term care fund, with services administered by state government and community organizations. This fund would provide custodial care <!– /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-parent:”"; margin:0cm; margin-bottom:.0001pt; mso-pagination:none; mso-layout-grid-align:none; text-autospace:none; font-size:10.0pt; font-family:”Times New Roman”; mso-fareast-font-family:”Times New Roman”;} @page Section1 {size:841.7pt 595.45pt; mso-page-orientation:landscape; margin:43.9pt 73.5pt 18.0pt 72.0pt; mso-header-margin:35.4pt; mso-footer-margin:35.4pt; mso-columns:2 not-even 315.35pt 66.0pt 314.85pt; mso-paper-source:0;} div.Section1 {page:Section1;} –>
for as long as a person needed it at home and for 3 mo in a nursing home I he panel also proposed a liberalized Medicaid program for persons who need longer nursing home stays. In consideration of national health reform in the early 1990s, some proposals omitted long-term care on the grounds that the nation could not afford it.
According to one study, long-term care costs will rise substantially if no major changes are made; the $54.7 billion spent on nursing home care and the $20.7 billion spent on home care in 1993 will increase to * 126.2 billion and $40 billion, respectively, in 2018. The study also concluded that private insurance was unlikely to have a major effect on individual and Medicaid spending for long-term care and that social insurance was central to the financing and delivery of long-term care (home and community-based care plus 3 mo in a nursing home) with supplementation by private insurance and liberalized Medicaid
