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. Framing the Issues of I , Home and Community . . .. .. . Care-: Response . ~ . . . . . Earl M. CoDier, Ir. The current Medicare, Medicaid, and, to a large extent, Commercial payment systems reinforce and perpetuate Me organization of the health care system as it was in 1965given what society wanted then from its institutions and what the technology of the time aBowed. Today, however, technology has changed greatly. As population demography and our own lives have changed, we realize that we want something different in the way of services that are delivered, and we want different kinds of institutions to deliver them. Perhaps because ~ am a lawyer, I am most interested in process. I have no answers to substantive issues such as the right way to increase . access to the system, the right amount of quality, or the right way to measure quality. Those things are elusive to me, and I prefer the kind of processes that win permit relatively good, substantive judgments to be made, given the circumstances at the time, and that will permit those judgments to be reexamined and changed as time passes. In the simplest teens, the process that I am most interested in is one that I think has some hope of assisting the health care system in its transition from its place in 1965 to where we want it to go. ~ also think Mat money win be provided to let it happen. For want of a better word, I call this process "case management," a currently used tem1 that means many different things to different people. 28

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ISSUES OF HOME AND COMMUN17Y CARE: RESPONSE 29 CASE MANAGEMENT I see case management as having Me parts. Identif cation of the case, as early as possible. The case has its own context: it could be a career of care, as Dr. Kane men- tionedi; it could be a limited, perhaps catastrophic, episode of illness; or it could be the balance of life of a frail or an unfrai} elderly person. Assessment of the case, first by the person who wants to pur- chase or obtain the services necessary to the case, and then by the person who win provide the services necessary to the case. There must be as complete an assessment as possible in the circumstances by both the person wanting the services and the person wanting to provide them. Provision of the services in a coor~natedfashion. Present tech- niques for coordination do not work very wed because they are tied to outdated types of institutions and old definitions of Be system. In the "old days," a patient's primary care physician would see a medical episode of illness and would coordinate with specialist consultants (usually in an inpatient setting in which the facility provided, under one roof, a fairly weB-coordi- nated enterprise with charts easily available and continuity in He nursing care). CHANGES IN MEDICAL CARE We now see significant changes in two areas. First, the episode, instead of being a medical illness, is becoming increasingly non-medical in nature. It win be much more difficult for me old institutions defined around medical needs to caner out their coordinative functions. Second, the doctor's role is undermined because the doctor is trained in and primanly focused on medical management. An enormous amount of technology exists today Cat allows on- line information to be available for remote site management, for continu- ity development, and for keeping up with a complex plan of therapy; a great deal of technology is available to assist in case identification, both volume. tSee Robelt Kane, "Home and Community Care of the Elderly: Framing the Issues," in this

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30 EARL M. COLLIER medical and social, for case assessment, and even for case coordination af er assessments have been completed. People have not thought in these terms, however, and they have been slow to use these technologies. As a tactician, I regard Medicare as a poor innovator. It is good at taking the system as it finds it, dealing with it, and reinforcing it. That is what Medicare did in 1965 it assigned a legislative and regulatory def~rution to hospitals as the institutions were then understood, and pro- ceeded. When Medicare can find institutions defined in ways that are trustworthy and that it can understand and feel comfortable with, Medi- care has lithe resistance to accepting them. A hospice is a good example of an institution that was not wed defined in the early 1980s, but when they became accepted and they were given a nonnative definition, then Congress allowed Medicare to pay for hospices. The difficulty, therefore, is not changing Medicare when something weB-defined comes along; it is Refiring something new in acceptable terms for Medicare. OPPORTUNITIES FOR PROGRESS I see a few short-term, rich opportunities for progress coming. One area that is drawing a lot of attention is catastrophic illness. AR the payers have spent a lot of money on consultants who have told them that ad Weir insured groups, of whatever size or location, have far less than 10 percent of the insured people incurring 50 percent or more of the cost. The money will move in that direction, and He case management process win follow it because those cases are so big that case management is an affordable overhead for the payers, even though it is a rudimentary tech- nology at the present time. As catastrophic case management in a medical setting begins to take hold and the technologies for case management become a lithe clearer, case management win move away from a medical focus toward the "careers of care" that Dr. Kane describedepisodes that embrace both medical and social activities and services. The second rich opportunity for progress that will be well sup- ported is Me development of long-term-care insurance policies. Most of the good long-term-care policies reflect the elements of case identifica- tion and case assessment. These policies win allow flexible benefits of a social and medical nature as long as the cases have been assessed first, as long as Me care is coordinated, and as long as the insurance company is

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ISSUES OF HOME AND COMMUNTIY CARE: RESPONSE 31 thoughtful about it. I would particularly recommend looking at recent filing on- long-term care insurance that the Rochester Blue Cross placed with the insurance commissioner of New York State. The third opportunity for private funds, and which we would like Medicare to pick up eventually, is housing. Housing is the biggest problem of long-term care because it incurs the biggest expense. The simplest way to solve some of the problems in home care is to redefine what is the home, which should be very easy to do over the next 20 or 30 years for this cohort of people. Last, the provider industry, particularly at me local market, is con- solidadng. Bringing providers together in more integrated systems Trough ownership of contractual relationships is good for the health care industry and should be encouraged, so that by 1997, the system will be reorgan- ized, a new set of institutions will be in place that is more wed adapted to our~complex service delivery needs, and it win be adapted to our new technologies. Then Medicare can put Me money behind it and reinforce it.