Transcript Key Issues in Post Acute Care Robert E. Burke, PhD Gordon A Friesen Professor of Healthcare Administration School of Public Health and health.

Key Issues in Post Acute Care
Robert E. Burke, PhD
Gordon A Friesen Professor of Healthcare Administration
School of Public Health and health Services
The George Washington University
April 10, 2013
Disclaimer
• Views Expressed Are Based on My Past Work
Experience
• These Views Are Not to Be Considered as
Representative of the Wertlieb Institute, The
George Washington University Nor Any Public,
Private, Federal or State Agency.
Today’s Goal
• Provide you with some background and facts
and some stories so that you
• Can interpret and add to the health policy
discussion with respect to health services for
the elderly, frail and disabled.
Objectives
• To clarify some of the confusing issues and
topics in Long Term care
• What is post acute/long term care
• Who pays for what
• Artificial complacency
• The impending age wave – real or imagined
• Impact on all the labor force
0o
A
1950
US
n
3
2
1
b
cty
94
Population Pyramid
• Past (Ideal)
Population Pyramid
• Currentish
Population Pyramid
• Future
Definitions
•
•
•
•
•
Post acute care
Skilled Care
Rehabilitation Services
Home and Community Based Services
CCRC (Continuing Care Retirement
Communities)
• Assisted Living
Who pays for what
•
•
•
•
Private Pay
Medicaid
Medicare
Insurance – long term care, disability and
workmen’s compensation
When does long term care start
•
•
•
•
•
At the end of a hospital stay?
When there is a need for supportive services
Is it all medical and health care
What are the social needs?
Role of friends and family
Indicators of Long term care need
•
•
•
•
Diagnosis
Functional Ability
Instrumental Activities of Daily Living (IADL)
Activities of daily living (ADL)
– Late loss ADLs as trigger
Providers of Care
•
•
•
•
Friends and family (60%)
Paid
Clinical, home health aide, homemaker
What ties it together is ‘case manager’
Historical Information
• Number of skilled nursing home facilities in
1977 was 16,000
• Number of skilled nursing home residents in
1977 was 1.5 million
• Do the math and see that the average size of
nursing homes was about 100 beds.
Historical Information
• Nursing homes as we know them really are a
post World War II phenomenon
• County and religiously sponsored
• State and locally operated until Medicare and
Medicaid certification in 1966.
• Social security Amendments of 1972 increased
participation of proprietary nursing home
Historical Information
• In 2013 how many nursing homes are there?
• How many nursing home beds are there?
Historical Information
• What happened?
• Population – age of admission – depression?
• Assisted living – not regulated by federal
government…..
• Growth of home and community based
services.
What is Long Term Care?
• Confusing Question - All Post Acute Care?
• Skilled nursing home, intermediate care,
custodial care
• Independent and Assisted Living
• Home and Community Based Services
– Aging in place
– VNA, Home Health Care Aide, Homemaker
Starting Points
• Number of Certified SNF – 16,500
• Annual Turnover
– Administrator – 40 to 50%
– DON - same
– CNA – up to and over 100%
• Numbers seeking NHA Licensure decreased by one
third since 1990 (MCCA)
• Number of ALF is over 40,000
• Annual Turnover – unknown as not reported
How Big is Long Term Care
• It is very big…………
Long Term Care Expenditures
Year
Total Cost
In Billions
2000
$96.2
2005
$135.9
2010
$183.4
What does the nursing home business look
like?
•
•
•
•
•
It is most regulated health care business
Average 100 beds
Average 100 staff
80% census – dropped from over 95%
At least 4 different payment systems,
– Medicaid, Private, Insurance and Medicare
• Annual Revenue of between $3 and $5 Million
Nursing Home Facilities and Beds, by Type of Ownership
Type of
Ownership
Number of
Facilities
Percent
Number of
Beds
Percent
For-Profit
10,759
65.4%
1,188,643
66.2%
Not-ForProfit
4,676
28.4%
485,706
27.1%
Government
1,011
6.1%
120,923
6.7%
16,446
100%
1,795,272
100%
Total
How Much is Long Term Care
• Skilled Facility - $60 to $120,000 per year
• Assisted Living about $40 to $60,000 per year.
It is an “a la carte plan.”
• Assisted Living have an Admission fee which
ranges up to $1 million with a proportion
returnable to heirs
• Home and Community – After Medicare, what
the market will bear.
Who Pays for Long Term Care
• We all do
– Medicare Premiums
– Medicare Payroll tax deductions
– General tax revenues that support Medicaid
– Different insurances
• LTC
• Workmen’s Comp
• Personal health
Who Pays for Long Term Care
• Private – including insurances 40 to 50%
• Medicare –
10 to 20%
• Medicaid 40 to 50%
• For some states, the largest item in the budget
is Medicaid.
Skilled Long Term Care
• Medicare Part A is for Acute Care but
– SNF benefit is 100 days per spell of illness
– First 20 days at full payment
– Days 21 to 100 IF DETERMINED TO BE MEDICALLY
NEEDY have a copay of $141 per day to total
$11,280.
– Average Medicare LOS
• Ortho – less than 20
• CVA – about 30
Skilled Long Term Care
• Medicare Part B is and Option for Physician
and Other Professional Services.
• Medicaid “Buy-In” for Medicare Part B
• Medicare Part C aka Medicare Advantage is an
HMO Option run by private insurance
companies
• Medicare Part D is the Pharmacy Option
Long Term Care Utilization
• Data suggests that 20% of all over 65 will use a
nursing home.
• BUT only 5% will use it for greater than 90
days.
• Long Stay Nursing Home Admissions are
– Female
– 84
– Who need nursing supervision
Who Regulates Long Term Care
• Federal
– Certification for Medicare and Medicaid
• State
– Licensure of facility, administrator and other key
personnel
– Ombudsman
• Local
– Fire and Sanitation
Remedies
• Until OBRA 1987, there were not mid level
sanctions.
• It was all or nothing……
– Result very few closings….very little real regulatory
punch
• After OBRA 87 there is a plethora of sanctions.
Physicians in Long Term Care
• Total number of MDs in US - approximately
750,000 estimate of AMA
• Board Certified Geriatricians (?)
• Physician Members of American Geriatric
Society – 4,700
• Physician Members of American Medical
Directors Association – 5,300
What Type of Long Term Care Do People
Want
• What is perfect for me
Brief History of education for nursing home
administrators
• 1950s – most common nursing home administrator
license was “in situ.”
– Had the job, got the license.
• 1960s – GWU starts an correspondence course in
nursing home administration.
• 1966 – Medicare requirements more sophisticated
management required, GWU courses are
incorporated into the MHSA degree
Brief History of education for nursing home
administrators
• 1972 Social Security Amendments spell out the
general requirements for licensure for the States to
adopt.
• 1980s GWU’s nursing home administrator program
receives national reputation
• 1998 The inception of the Wertlieb Institute
• Today, GWU is only one of 5 nationally known
Master’s Programs in the US
– Duke, Hopkins, USC, and North Texas
News
• Good
– There will be a continued need for post acute care
• Bad
– Number of those seeking careers in geriatrics remains low
and more disturbing, applications for nursing home
administrator licenses has dropped
• Indifferent
– Boomers will not need nursing services until 2032….why
worry
Impact of Health Reform
•
•
•
•
NOT CLEAR
ACOs
LTC will not go away
Services and some provider or provider types
may change focus and locus
What types of Long Term Care is Available
• Model is changing
• Lack of funds
– True or not
• Lack of staff
Who Will Take care of ME?
• How do we encourage careers in post acute
care?
• Attitude, it needs to be changed
– Most dreaded words are Nursing Home
• Values
– A difficult one in our culture of immediate
replacement – people are not cell phones or
i-pods
Major Infrastructure Problems
•
•
•
•
Personnel Shortage
Regulatory Atmosphere
Reimbursement Strategies/ Liability Ins
Ownership
– Inability to raise capital
• Growth of other options
– Assisted living
– HCBS (home and community based services)
Solutions
• Market Forces
– Just increase the awards and rewards
• FEAR……the usual American response
– Increase regulations and requirements
• A Plan
– That focuses on recruitment and retention
– Move out of our sacred silos to develop a program that the
post acute care industry wants and meets and expands
GWUMC capacity.
Growing Paradox
• Proprietary owned facilities and corporations
serve more Medicaid residents than the
nonprofits.
• What does that say?
Emerging Assisted Living Trends
•
•
•
•
•
Larger units
Increased amenities
Special Care
Wellness clinics
Residential character
Dementing Illness/Alzheimer’s
• Approximately 4 million Americans
• 5.5 million by 2010 & 14 million by 2050
• 4th leading cause of death in adults
• 100,000 deaths each year
• Need for special programs
Long Term Care Insurance
• Should I purchase LTCI for
– Self, Spouse, or Parents?
• LTCI is asset protection, therefore, do I have
assets protect?
• Financial Planners suggest the asset threshold
in 2005 dollars $600K
Long Term Care Insurance
•
•
•
•
Should I buy LTCI?
ANSWERS…….
DO THE MATH for your personal situation
Group policies tend to give more service
options per premium
• Ask what the sales representatives
commission is…….you might be surprised at
the answer.
What’s Next?
• Be on the look out for your parents….those
take-charge baby boomers.
• The Tsunami is coming in the next decade.
• Keep a sense of humor