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Dr. Robert Burke, Gordon A. Friesen Professor of Health Care Administration; Chair of the Department of Health Services Management and Leadership George Washington University
Dr. Robert Burke, Gordon A. Friesen Professor of Health Care Administration; Chair of the Department of Health Services Management and Leadership George Washington University
Dr. Robert Burke, Gordon A. Friesen Professor of Health Care Administration; Chair of the Department of Health Services Management and Leadership George Washington University
Gordon A Friesen Professor of Healthcare Administration The George Washington University Milken Institute School of Public Health May 19, 2014 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.
Definitions Post acute care Skilled Care Rehabilitation Services Home and Community Based Services CCRC (Continuing Care Retirement Communities) Assisted Living Todays 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. Thus, be better able to communicate to your community about the key issues. (tell fiction from fact and scares.) 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 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, NORC VNA, Home Health Care Aide, Homemaker
Who pays for what Private Pay Medicaid Medicare Insurance long term care, disability and workmens 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 Volunteers Friends and family (60%) Paid Clinical, home health aide, homemaker What ties it together is case manager New Demonstrations ACA VA 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 era? Assisted living not regulated by federal government.. Growth of home and community based services. 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 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
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-For- Profit 4,676 28.4% 485,706 27.1% Government 1,011 6.1% 120,923 6.7% Total 16,446 100% 1,795,272 100% 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. (3 hots and a cot) 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 tolerate. Who Pays for Long Term Care We all do Medicare Premiums Medicare Payroll tax deductions General tax revenues that support Medicaid Different insurances LTC Workmens 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 $152 per day to total $12,160. 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 GWUs nursing home administrator program receives national reputation 1998 The inception of the Wertlieb Institute Today, GWU is only one of 5 nationally known Masters 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 FEARthe 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/Alzheimers Approximately 4 million Americans 5.5 million by 2010 & 14 million by 2050 4 th 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. Whats 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
Pauline Vaillancourt Rosenau With The Assistance of Paul Newhouse Management, Policy, and Community Health School of Public Health University of Texas Health Science Center Houston, Texas, USA
Medication A.R.E.A.S. Bundle: A Prescription for Value-Based Healthcare to Optimize Patient Health Outcomes, Reduce Total Costs, and Improve Quality and Organization Performance