Transcript Module 18. Financing Health Care for Older Adults

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Financing Health
Care for Older
Adults
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.
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.
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
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
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
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
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
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
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
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
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
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
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
Elements
MEDICARE
MEDICAID
AGENCIES ON
AGING
Source of
financing
Federal through separate States
payroll contributions paid
by employees, employers,
and self-employed
persons
Federal
Age Eligibility
65 and older (covers
All ages
some people less than 65
who are disabled)
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 Area Agencies
broad
on Aging
federal
guidelines
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
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)
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,
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
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
Nursing Home
 Medicaid pays for long-term nursing
home health care
 Care varies from state to state
 Approximately 40% of care is paid outof-pocket by older adult and family
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
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-onwheels, transportation, and ombudsman
services
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
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
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.
Limitations in Nursing Home
Payment

Older adults must meet income limits
in order to qualify for Medicaidreimbursed long-term care nursing
home placement.

Frequent and often unnecessary
transfer of nursing home residents
from the nursing home to the hospital.
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.
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.
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.
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
Questions?