Imagine an 85-year-old woman still living at home who suffers from heart failure and arthritis. Her doctors treat her medical conditions and her kids and a home health aide provide personal care such as cooking, dressing and bathing. She gets care that falls in a gray area in between, including help giving her pills and checking her weight to be sure her heart condition is well-controlled. She needs a suite of services to help maintain the best possible quality of life. But this care is rarely coordinated and often separated by impenetrable walls that waste billions of dollars and put older adults at risk.
Due to the way the U.S. pays for health care and long-term care, these services are delivered by people who almost never talk to one another. For example, Medicare will pay for her heart failure drugs, but not for the aide who helps her get dressed. Her long-term care insurance or Medicaid may pay for her aide, but not for her health care. And, her cardiologist may not even know she has a rheumatologist, much less communicate with him or her. And neither doctor may ever talk to her home health aide.
We need to break down these barriers between medical treatment and the personal and social care that most of us need as we age. Nearly all older adults live with chronic illness that often can be best managed with social, non-medical supports. Thus, we need to refocus our health system to better organize personal care with medical treatment and develop a sustainable way to finance those supports and services.
But How Would We Do This?
There are a few models out there. PACE (the federal Program for All-Inclusive Care for the Elderly) combines Medicare’s health services and Medicaid’s personal services into a single package. In some states, managed care insurance companies operate demonstration programs for those who are eligible for Medicare and Medicaid (known as dual eligible) that also combine medical treatment with personal care.
These programs work differently than traditional fee-for-service Medicare. They are built on a model where the government pays the operators a fixed monthly rate for each patient. In exchange, some provide the full range of medical and personal care. They are at financial risk if their costs exceed the government payment, but can reap additional profits if they can keep costs down and still provide outstanding care.
Consumer groups, providers, insurance companies and government should always work together to create a model that fully and successfully, integrates care in a way that can save money and meet quality standards.