‘Silver Tsunami’ of Older Residents Shapes Debate on Long-Term Care Policy

Andrew Kitchenman | September 15, 2014 | Health Care
Experts at NJ Spotlight conference look at what form services will take – and how they will be funded

U.S. Rep. Frank Pallone (D-6th) speaks during NJ Spotlight forum on long-term care.
The “silver tsunami” of older New Jersey residents who need long-term support and services is spurring the growth of home- and community-based services, but it’s also increasing the need for skilled nursing facilities, as well as reshaping the type of care residents receive and how the state will pay for it.

These were among several topics discussed during a recent NJ Spotlight conference that brought together long-term care policy experts to discuss the future of such services in the state.

U.S. Rep. Frank Pallone (D-6th) said a top priority is reshaping how the country pays for long-term services, moving from a Medicaid-based system that requires residents to “spend down” their assets before government funding kicks in.. He would instead like to see an insurance-style system accessible to all seniors, similar to the primary medical care and hospital care provided through Medicare.

“There’s nothing that I find more abhorrent than asking people to spend down their assets in order to be eligible for Medicaid in order to pay for their care,” Pallone said.

Pallone noted that the issue has been debated for decades, saying he discussed it with U.S. Rep. Claude Pepper of Florida before Pepper died in 1988.

Two contradictory factors currently are swirling around the issue, Pallone said. On the one hand, the growing number of baby boomers entering retirement is leading to a potential crisis in the ability to pay for their services, while a Congress frozen by partisan and ideological divisions over healthcare policy is unlikely to take action.

“Until we get to the point where the Affordable Care Act is accepted on a consensus basis by Democrats and Republicans – which, we’re certainly not there — any effort to expand Medicare or come up with, you know, a federal initiative on long-term care isn’t even in the cards,” said Pallone, adding that action on the issue could be “several years away.”

New Jersey’s system is evolving rapidly as part of the state’s five-year Medicaid comprehensive waiver. On July 1, the state launched managed care for long-term services and supports, which will allow the state to place a greater emphasis on care provided at home and in community-based assisted living facilities.

Technology will help the state to assess and improve how these services are provided, according to Theresa Edelstein, New Jersey Hospital Association vice president of post-acute care policy and special initiatives.

“I think the focus needs to remain on what does the person need; what is the best setting for them to receive what they need; and ultimately when they do need the nursing home, that we make sure as a society that we have provided for the highest quality nursing home care possible,” said Edelstein, a former nursing home administrator.

“There is this time period now during this transition to long-term services and supports when nursing homes in particular have to be creative and find the survival strategy that precedes the increased need for long-term care beds,” she said, adding that medical technology and pharmaceutical advances may reduce the nursing-home need.

Assemblyman Gary S. Schaer (D-Bergen and Passaic), the Assembly budget committee chairman, calculated that the future need for nursing homes could be as high as two and a half times the current capacity.

One area that could both lower costs and help the state improve the quality of life of older patients with serious illnesses is palliative care, the medical specialty focused on treating symptoms rather than curing diseases.

Donald L. Pendley, president of the New Jersey Hospice and Palliative Care Organization, said palliative care should be incorporated earlier than it currently is in patients’ care, including for nursing home residents.

“It’s my opinion that all care provided in nursing homes and in assisted livings should be informed by palliative care,” said Pendley, who said nursing home residents frequently experience a great deal of physical suffering.

Those involved in implementing the managed long-term services said it’s showing positive signs in the early stages, with residents expressing gratitude for being able to get care in their homes.

“We have a tremendous opportunity here to integrate care for people in a real way that Medicaid hasn’t been able to scale in the past,” said Jennifer Langer Jacobs, vice president of long-term services and support operations for managed-care insurer Amerigroup New Jersey.

Jacobs said the state has done a good job of bringing stakeholders together to work on managed care, and she is hopefully that progress will continue through the remaining time on the waiver, which ends in June 2017.

“I would like to think the conversations we are having two and a half years from now are about what we can do to further innovate this system,” Jacobs said. She added that many people and caregivers were confused by the previous system and that she is hopeful that the waiver will bring clarity to the long-term services.

Evelyn Liebman, of AARP, said it’s essential that the state establish a system of strong oversight of the managed care, including strong contract monitoring; establish a strong state quality assurance team; ensure there are adequate provider networks; provide robust education and enforcement of consumer rights; and set rates that ensure payers are solvent and good providers are attracted.

Several panelists raised concerns about whether home health aides are adequately compensated.

Horizon NJ Health CEO Erhardt H.L. Preitauer, whose organization is the state’s largest Medicaid plan, said the data collected as part of the managed care program could address compensation.

“Because we’re integrating everything, we’re going to have data after six months or a year that maybe we didn’t have before,” which may demonstrate that providers are saving more than previously understood, he said.

Audience member Ira Marks, a Lawrence-based certified public accountant and financial planner, said the private insurance market for long-term care isn’t functioning well, with insurers seeking annual double-digit increases.

Pallone said this reflects failure to resolve the issue in ACA, which included the Community Living Assistance Services and Supports Act, a program for voluntary community-based long-term care insurance that was later repealed.

He said it is beneficial to discuss long-term care and end-of-life issues, a topic that many people prefer not to think about.

“You’re making people talk about something that they don’t want to talk about, but they must talk about in terms of their future and where we go as a country,” he said.

AARP, Horizon NJ Health, Amerigroup and the New Jersey Hospital Association sponsored the conference, which was held at the Robert Wood Johnson Fitness and Wellness Center in Hamilton Township, Mercer County.

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