Last year marked the 50th anniversary of Medicare and Medicaid. These two programs (including state funding) represent 37 cents of every dollar spent on health care in the United States. There are more than 54 million Medicare beneficiaries and 64 million Americans on Medicaid.
As one of the defining moments of President Lyndon Johnson’s Great Society, much has changed with the nation and with Medicare since President Harry Truman was given card No. 1. Of all the tweaks and changes over the past half-century, three stand out.
The first occurred in 1972 with the expansion of Medicare to provide coverage to disabled Americans (until then the program was exclusively for those age 65 or older). The second transpired with the passage of the Balanced Budget Act of 1997, which allowed Medicare beneficiaries the option of receiving benefits through capitated health insurance Part C plans that would later be known as Medicare Advantage plans (many seniors had been doing so via a series of demonstration projects that dated back to the early 1980s). The third occurred in 2003 with the signing of the landmark Medicare Prescription Drug Improvement and Modernization Act, which provides a prescription drug benefit for seniors and people living with disabilities.
Five Ways to Better Care for Seniors
All three of these revisions were designed to respond to public need. Now, with Medicare entering its second half-century and 10,000 baby boomers turning 65 every day, it is time to ask what is needed when it comes to caring for our nation’s seniors. Here are five places to start:
First, we need to acknowledge that for too long, society has conveniently grouped “older Americans” into one standardized bucket. Under closer inspection, we find that the bucket has leaks. As healthy baby boomers start collecting Medicare — while at the same time the number of centenarians is growing to numbers once thought unimaginable — it is time to accept that all seniors are not alike. Nobody would argue that the lifestyle habits and health care needs of a 25-year-old are far different from those of a 50-year-old. Yet, for some unexplainable reason, our society has failed to adequately recognize the same 25-year difference between a 65-year-old and a 90-year-old. It’s time we did and, in doing so, better develop programs that speak to what seniors at various stages in the life cycle want and need when it comes to their health care.
Second, we need a better way to care for low-income, chronically ill Medicare beneficiaries who, in overwhelming numbers, want to remain in the comfort of their own homes. This means the creation, support and funding of a special-needs plan that targets home- and community-based services for low-income Medicare beneficiaries who need assistance with basic activities of daily living.
Enabling these seniors to remain in the community by providing them the support they need — and working through Medicare Advantage plans, which already have a demonstrated competency — will significantly improve the quality of life for these seniors and their families while simultaneously delivering savings to both the state and federal governments.
Third, we need to confront a caregiver crisis in America: A large percentage of today’s home caregivers are seniors themselves. Spending days and nights caring for a loved one — perhaps a spouse of 50 years — can take a heavy physical and mental toll on those delivering the care. In many cases that toll is so great that the caregiver’s own health is compromised. The result is a household of two ailing adults not only challenged by their physical illnesses, but suddenly in need of assistance with normal daily activities such as transportation, grocery shopping, cooking and bathing.
This caregiver crisis requires an incentivized system that supports people who take on this very important role. Among the ideas being suggested are broadening tax deductions or tax credits for caregivers’ expenses and expanding family- and medical-leave benefits for full-time workers. These suggestions have merit as do many others. Most importantly, they send a message that our society recognizes and values the important role caregivers play in making our communities whole.
Fourth, we need to focus senior care on the right care in the right setting at the right time…and that includes avoiding costly and uncomfortable hospitalizations or emergency department visits whenever possible. A study by the UCLA School of Nursing found that while the hospital emergency department is a frequent source of care for vulnerable, older adults, seniors often enter the emergency department simply because of incomplete or misunderstood information. That failure of communication often continues during the ED visit and frequently results in what nurses call the “million dollar workup” — numerous costly and unnecessary invasive examinations, which yield vague findings that had little to do with the original problem.
For those seniors who need hospitalization, we need to take a new look at transition planning: What happens to seniors upon discharge? What are we doing to really understand not only our patients’ physical condition but also every detail about their prior level of functioning and living arrangements awaiting them at home? How do we ensure that seniors will take (and can afford) the prescribed medication? How will they get to their doctor’s office for follow-up care?
Fifth, let’s all agree with unquestioned certainty that coordinated care works. The stark truth is that fee-for-service medicine is often fragmented, redundant and wasteful while incentivizing doctors and hospitals to maximize services. It has failed. It is time to shift to a model that rewards organizations and providers who embrace coordinated care and high-quality performance. Such a model not only reduces human and economic costs for patients, taxpayers and the government, but is the most balanced, ethical and humane way to care for patients.
Path to Coordinated Care
With many older adults living longer, it is relatively common for senior patients to have six or more chronic conditions and to routinely take more than a dozen medications. The complex interactions between these chronic conditions and medications requires geriatric health specialists to emphasize health management, disease management and medication management programs. That’s where care coordination is most effective. Repeated studies have shown that seniors enrolled in managed care experience fewer hospital admissions and readmissions, fewer ED visits, and lower overall medical costs.
The key is emphasizing primary prevention, early intervention and effective care coordination throughout the spectrum of care. At-risk seniors can be part of geriatric health-management or disease-management programs and can benefit from a medication-management program that focuses on the correct match between diagnosis and drugs. Medicare Advantage helps to ensure the appropriate use of services, improve the coordination of care with different providers, and improve clinical outcomes every step of the way.
Today about 11 percent of our country is 65 or older and, in just two decades, one in every five Americans will be elderly. Many of the facts that we have known to be true need to be reexamined through fresh lenses. Only then can we appropriately treat and maintain the health of this growing population in ways that make us as a nation proud.
Chris Wing is CEO of SCAN Health Plan in Long Beach, Calif.