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Paul Willging Says...

April 1, 2006
by root
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A Professional Association Can Serve Society

A professional association can serve society The aging of America is pressuring state and federal governments to reevaluate the long-term healthcare system. By the year 2050, the number of Americans age 65 and over is expected to more than double, while those age 85 and older, who are most likely to use long-term care services, will account for 5% of the population, or triple the size of today's demographic. The oldest baby boomers are fast approaching retirement age, ushering in a generation of seniors larger than any previously served by the nation's healthcare system.

And yet within this environment, trade associations-particularly those representing nursing facilities-have had a tough row to hoe. Working at cross-purposes against prevailing sentiment, they represent an industry as much in need of public support as any I am aware of. And they receive far less. Whether the issue is reimbursement or regulation, lobbyists for nursing facilities seem more than most to be bucking adverse public perceptions. And this despite the uncontested need for their services.

You can imagine my excitement, therefore, when the Health Facilities Association of Maryland (HFAM) decided to take the "high road" in dealing with the nation's "demographic imperative." Last month I discussed the initiatives taken in my own county, as authorities there look to facilitate "aging in place." I spoke of the need for facility management to become conversant with (and accepting of) such initiatives. They are, after all, inevitable, and it's better to learn how to accommodate them than to oppose them. That's precisely what HFAM concluded as it responded to the state's request to restructure Maryland's long-term care program.

HFAM has been dealing with the Medicaid waiver issue for as long as I can remember. That issue in Maryland has shared the same roots as those in most other states: the need by state government to save public monies. State nursing home associations have reacted to waiver proposals in lockstep precision-arguing, essentially, against the proposals while requesting, simultaneously, more money and fewer regulations (as though that were enough to fix our long-term care "nonsystem."

HFAM decided on a different tack. To meet current and future challenges, the association proposed a brand new model of long-term care that puts consumers at the center. HFAM believed that long-term care, which for decades has been shaped by funding sources and provider preferences, should instead be driven by the needs, choices, and expectations of the elderly and disabled persons served, regardless of the setting in which they receive care.

Policy makers have just begun taking steps in this direction. Rising demand for choice, coupled with funding constraints, has led to President Bush's New Freedom Initiative, a nationwide effort to allocate resources more effectively while lifting barriers to community living for people of all ages who have disabilities or long-term illnesses. That initiative has encouraged many states to launch demonstrations and waiver programs that overhaul the delivery of services for Medicaid recipients. It was under this authority that Maryland submitted its own waiver request.

HFAM's counterproposal to the waiver request actually builds on and complements the emerging public policy shift, basically by introducing four essential components to the long-term care system:

  • Customer focus. The primary building block of this new model is the belief that consumers should be the drivers of long-term care. This includes the ability to choose long-term care options in the most appropriate setting and greater flexibility among healthcare providers in changing the way they offer services, all to create a truly customer-focused system.
  • Care coordination. The HFAM model is premised on linking the entire senior care system with a common assessment tool that provides a holistic picture of the individual's needs and preferences, regardless of the setting in which she receives care.
  • Data-driven management. To optimize quality and promote robust data collection and sharing among providers, HFAM calls for creating a database that crosses the long-term care continuum and follows individuals from one setting to another.
  • Adequate financing. The new model envisions a payment system that identifies, and adequately covers, the total cost of individuals' long-term care needs, maintains high quality, and remains stable despite budgetary pressures.

And just what is wrong with the current care system? Well, long-term care stakeholders-providers, consumers, and government entities alike-can all identify and agree upon the problems with what we have today, even as we debate the best solutions. HFAM providers believe that today's long-term care system is fundamentally hampered by a structure that has evolved, to a great extent, in response to the needs, demands, and availability of funding sources. Long-term care suffers from a structural failure to put consumers first.

Medicaid, for example, makes eligibility and level of care determinations for the vast majority (60 to 70%) of nursing home patients. Coverage and financing decisions have shaped the organization and availability of long-term care services along the continuum, stifling consumer choice and creating silos in which each provider type focuses on its own payer-driven rules and procedures, with no system-wide framework for coordinating vital clinical and quality management processes.