USE OF HEALTH CARE SERVICES
Older persons are more likely to use health care services than younger persons. While the elderly made up only 12% of the US population in 1990, they accounted for 34% of all hospital stays and 45% of all hospital days. For persons over age 65, the average length of stay was 8.7 days; for persons under age 65, it was 5.3 days. In 1990, older persons averaged nine contacts with physicians, while those under age 65 averaged only five contacts. Per capita spending on health care for those age 65 and older was $5360, compared with $1286 for those under age 65. Persons over age 65 use 34% of all prescription medications, with older Americans taking an average of 4.5 medications at any one time.
Older persons also use institutional services, such as nursing homes, more than younger persons. Evolving social and demographic dynamics have reduced the number of family members available to care for impaired elders. Older persons, particularly women, are likely to be widowed, and when they become very old, their children may be elderly themselves. The increasingly transient and mobile nature of American society and the increased divorce rate have contributed to geographic separation of families and weaker family ties.
The number of single-parent households, most headed by women, continues to grow. This phenomenon as well as new economic and social realities that foster a dependence on two-income households have produced a steady growth of women in the work force—women who in the past would have functioned as caregivers. Today, the demands of a job may diminish a woman’s ability to provide the informal support needed by elderly relatives. These factors together with the increased prevalence of disease suggest that the demand for both noninstitutional support systems and institutional services by an expanding population of dependent elderly will continue to grow.

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