Posted: October 27th, 2022
In your reponses, identify common themes among your post and your peers’ posts. Describe utilization by long-term nursing home residents under an ACO. Are there policy solutions to these themes? Is there a better way to reimburse long-term care organizations? What are gaps in the ACO model of reimbursement?
should be 100 to 150 words, with a minimum of one supporting reference included
The fact that I found most surprising regarding the cost of long-term care is that 1 in 10 older adults over the age of 50 that are in need of long-term care will be personally responsible for over $200,000 in costs. Although nearly half of adults 50 years of age and older will require a stay in a nursing home, only 10% of adults 62 years of age and older have private long-term care insurance (Braun et al., 2019). Another surprising factor is that Medicare does not cover the cost of long-term care service, placing financial responsibility on the patient and family (Willink et al., 2019). This is particularly surprising as Medicare is health insurance for older adults, and it is expected that they will need some type of long-term care service as they age. This adds to the financial challenges experienced by older adults as they are retired and may not have a steady stream of income. The older adult is responsible for the cost of housing, insurance, medication copays, health care deductibles, and the general cost of living just to name a few. In the event long-term care is needed, the services are paid for through private insurance, Medicaid if the individual is eligible due to low income, of out of packet by the patient or family. Payment patterns for long-term care in the nursing home include the majority of individuals entering the nursing home as a private payer and leaving as a private payer (Spillman & Kemper, 1995). Other payment patterns include individuals eligible for Medicaid, or individuals spending down assets to become eligible for Medicaid (Spillman & Kemper, 1995).
In the United States in 2017, the cost of nursing home care accounted for $166.3 billion dollars in health care cost, a number that is expected to grow to $270.7 billion dollars by 2027 (Chang et al., 2020). The Accountable Care Organization (ACO) is an alternative payment model that places the responsibility of the cost and quality of care directly on the providers, and the providers that are enrolled in the program are eligible to receive saving bonuses (Chang et al., 2020). The goal of this program is to provide highest quality of coordinated care with the goal of limiting the use of acute care such as unnecessary visits to the emergency room. This is made possible through communication between primary care providers, specialists, hospitals, and nursing homes.
Long-term care is reimbursed for services through Medicaid, private insurance, or through private pay. Low reimbursement rates can impact the quality of care delivered to aging adults in the long-term care setting as providers will have an increased case load, thus limiting their time spent with the patients. Pay-for performance payment models are a method of reimbursement through insurance companies that provide financial incentives to providers and health care facilities for meeting certain measures. This payment model has the potential to improve quality of care as it promotes quality of care versus quantity. In other words, a provider may be able to see 10 patients a day versus 20 patients a day due to the financial incentives with meeting certain measures; therefore, the time spent with the patient and the quality of care improves. Advantages of this model include more time spent with patients, improved quality of care, improved coordinated care, and reduced hospitalizations. As a leader of a long-term care organization, I believe it is cost effective to provide a more comfortable setting through cultural change. This is because if a patient feels comfortable and is living in a homelike setting, their emotional health can improve, thus improve their overall health and motivation.
From review of the learning material, it is surprising to learn the challenges older adults and individuals living with disability face in financing their healthcare. According to Willink et al. (2019), older Medicare beneficiaries with long-term services and support needs who do not qualify for Medicaid suffer additional financial burden and rely on their families for assistance. One-quarter of all Medicare beneficiaries spend 20% or more of their income on out-of-pocket health expenses and premiums (Willink et al., 2019). Ultimately, individuals who require long term services and support or those with chronic functional or cognitive impairment deplete their personal assets and become reliant on Medicaid eligibility. This is especially difficult for the spouse or family members of the loved one requiring services as they become financially depleted in an attempt to support the individual.
Accountable care organizations (ACOs) are voluntary formed organizations that are responsible for the costs and quality of care for a patient population. These organizations aim to improve the experience of care, the health of populations, and reducing healthcare costs (Barnes et al., 2014). ACOs offer hospitals and doctors incentive for paying for tests and procedures in order to keep costs down for patients (Gold, 2015). For long term care settings, this could alleviate the cost for privately paying clients. Payment models such as ACOs focus on process improvement to decrease patient concerns of how they will be charged for care.
A percentage of long-term care is reimbursed through financial aids such as Medicare and Medicaid. According to Castelluci (2019) Medicare pays at a much higher rate than Medicaid and accounts for a substantial percentage of nursing facility’s revenue. However, 75% of patients in nursing homes are covered by Medicaid whereas 11% of patients are covered by Medicare, and Medicare patients account for 30% of nursing home’s overall revenue (Castelluci, 2019). This is a major concern or older adults on Medicare as they are paying higher costs for care. This is concerning for Medicare beneficiaries with chronic conditions requiring more long-term support and services as it can become financially overwhelming. A pay-for-performance system would be beneficial to the Medicare beneficiary who has few to no medical needs as this keeps medical costs low.
Low reimbursement rates heavily impact the quality of care delivered to aging adults living in a long-term care setting. With low reimbursement rates, long term care settings have less of a budget to enhance the quality of the facility, such as updated equipment and providing engaging and stimulating activities. With low funding, long term care settings must prioritize patient safety and living essentials. Affording adequate staffing may also be impacted by low reimbursement rates as long-term care settings may not be able to afford to take on more employees.
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