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Senior Citizen Opinions & Analysis
It’s Time To Coordinate Care for the Disabled and
Frail Elderly
An obscure provision of the Senate health bill
attempts to at least crack that barrier
 By Howard Gleckman, Senior Research Associate at
the Urban Institute
 Jan. 8, 2010 - Since the creation of Medicare and
Medicaid nearly 45 years ago, the government has operated on the bizarre
illusion that it can separate acute medical care from personal
assistance and long-term care. For real patients and their families,
this makes no sense. Someone who is sick often needs both medical
treatment and personal care. They should not have to worry about which
is which.
But because this artificial wall defines government
policy, it places many of the most vulnerable people in the nation at
risk and very likely wastes billions of dollars.
An obscure provision of the Senate health bill
attempts to at least crack that barrier. It would set up, for the first
time, a government office charged with coordinating care for more than
eight million “dual eligibles,” the poorest and sickest among us who
receive both Medicare and Medicaid benefits.
Organizing this care is
especially important for the frail elderly, who often suffer from
multiple chronic diseases, take a dozen or more medications, and may see
10 different doctors. And it matters to taxpayers who spend $200 billion
per year caring for these patients.
To understand the problem, think about a
75-year-old I’ll call Fred. At 2:00 one morning, Fred wakes up with
severe chest pains and breathing problems. He calls 911, and the EMTs
transport him to the local hospital. There, he undergoes aggressive
life-saving treatment, perhaps including major heart surgery, much of
which is paid for by Medicare.
But it turns out that Fred’s heart attack caused
serious damage to his heart muscle. As a result, it can no longer pump
blood through his system as efficiently as it should. This disease,
called congestive heart failure, is among the most common chronic
illnesses of the elderly. CHF can be managed for many years with a
combination of medications and other treatments, but it can be severely
debilitating. In time, as the damaged heart becomes steadily weaker,
getting out of bed, walking, eating, and making decisions become
harder.
Still, someone with CHF, as well as those with many
other chronic illnesses, can be cared for at home. But that requires a
trained aide or willing family member. If there is no one to provide
this help, patients such as Fred will almost surely wind up in a nursing
home or receiving a high level of care in an assisted living facility.
Now, let’s make the story a little more
complicated. Although Fred worked hard for most of his life, his heart
disease has drained all of his financial resources and he receives both
Medicare benefits and assistance through Medicaid, the joint state and
federal health program for the poor. Medicaid was originally designed to
provide health care for low-income mothers and their kids, but now
spends two-thirds of its dollars on the aged and disabled.
But, with the exception of a handful of limited
programs, Medicare and Medicaid do not coordinate their care. So
Medicare will pay for most of the cost of Fred’s hospitalizations and
for his medications, but - except for a limited period of time - not for
the health aide he needs to stay at home. That is Medicaid’s
responsibility.
The consequences of this are both potentially
deadly for Fred and costly for the rest of us. Fred needs someone to
help manage his meds, and help dress and feed him. He also needs someone
to get him on a scale every day or two.
That’s because weight gain is a
sure sign that his heart is not pumping well. With proper warning, his
doctors can get Fred back on track by simply adjusting his medications.
But if this signal goes unnoticed, he’ll almost surely end up back in
the emergency room.
And here is where this strange story takes its
final twist. The aide who could help Fred avoid a medical crisis simply
by weighing him is paid by Medicaid. But if she helps keep him out of
the hospital, the biggest beneficiary is likely to be Medicare. Not
surprisingly, cash-strapped states are not happy about having to pay for
aides who reduce costs for the feds.
There are a few models out there that hold great
promise for what could be. For instance, the Program for All-Inclusive
Care for the Elderly (PACE) provides both adult day care and high
quality medical treatment for these dual eligibles—and it is jointly
funded by both Medicare and Medicaid. The two programs ought to find new
ways to build on that model. And they could start by talking to one
another.
Howard Gleckman, a resident fellow at the
Urban Institute, is author of "Caring For Our Parents" and a frequent
writer and speaker on long-term care issues. -
View all previous Howard Gleckman columns at Kaiser Health News.
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This
information was reprinted from
kaiserhealthnews.org with permission from the Henry J.
Kaiser Family Foundation. You can view the entire Kaiser
Daily Health Policy Report, search the archives and sign up
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