Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 52
Special Perspectives on
.
Home and Community Care
.. . . . . ... . . . .
Lynn M. Etheredge
Government and private insurance should be expanded for home and
community care. But third-party payers need guidance so Hey can
insure and administer these benefits. For example, how should insurers
define the services that are most important to cover? To appreciate the
insurers' needs to answer such questions, we must understand the extent
to which home- and commun~ty-based care differs from medical care.
For example, who is the provider of services? For many years, the answer
has been simple for health insurance companies and government. Hospi-
tals and physicians provide medical care.
INSURERS' PERSPECTIVES
Who is a qualified provider of home- and commuruty-based care?
An insurance company cannot rely on accrediting or licensing organiza-
tions. The loins Commission accredits only about 1,000 of-the 12,000 to
15,000 home care providers. Many more people could provide services.
But costs win go up and quality win go down if insurers are not selective
about providers.
What are the standards of care? Insurance companies have written
contractual language for years around the term "medically necessary."
That certainly is an elastic term, but the ability to define the benefit for
home- and community-based care is a much greater problem. Much
hospital care, nursing home care, and social work agency care could be
shifted into liabilities of a third-party insurer.
The development of useable standards is complicated by how
varied the availability of home- and community-based care is in the
52
OCR for page 53
SPECIAL PERSPECTIVES ON HOME AND COMMUNE CARE
53
United States. Among the states, nursing home beds per capita vary by 4
to 1; Medicare's home heady benefits vain by more than 30 to 1. Only
some areas, such as New York, have well-defined home- and commun~ty-
based care programs.
The Medicare program and Blue Cross/Blue Shield, its major
administrators, are now swing to learn some answers to these questions.
Medicare has expanded its home health services and added a hospice
benefit. The Congress recently added a respite care benefit of up to 80
hours a year. These are not very generous benefits. The moves are
important, nevertheless, because Medicare Will become more experienced
with home and community care providers and how to pay for their
services. Moreover, the Blue Cross/Blue Shield system will be able to
apply this experience to their pnv ate insurance business.
The insurers' difficulty of managing home and community care
has led many people to the same conclusion as Mr. Collier stated earlier):
the importance of having a case manager for getting third-party payers
into this system. Home and community care is such a potentially open-
ended benefit that I suspect insurers will ask that case managers be
accountable to them and operate within fairly well-def~ned budget l~mita-
tions and other rules.
Building A System
In the traditional medical model, two people interact~he clot
clan and the patient and insurers mostly just pay bills. In home- and
community-based care, however, many more people are involved in im-
portarlt ways; if we want quality care, appropriate care, and affordable
care, expanding insurance coverage is not enough. These actors have to
be involved.
· The ability of the family to provide care, support, and over
services is critical to Me success of the system.
· Physicians must undertake new roles that involve coordinating
with all the other persons In the system.
· Hospitals must be responsible about not dumping padents be-
cause the diagnosis-related group (DRG) payment has run out.
~ See Ead M. Collier, Jr., "Franiing the Issues of Home and Community Care: Response '
in this volume.
OCR for page 54
54
LYNN M. ETHEREDGE
· State governments have to be involved in improving Medicaid
benefits and in licensure to ensure quality of the people provid-
.
.
1ng services.
The federal government must improve Medicare and, Hugh
the Food and Drug Administration, has a role in Be regulation
of medical devices.
· Professional associations, such as the loins Commission, should
establish standards of home care.
· Manufacturers have a role in training people and making prod-
uct instructions clear enough so that equipment can be used at
home.
· Providers of services face many more obligations than simply
sending an aide to a house; they often need to cooperate with
over providers and have back-up services for training family
members.
Third-party payers must figure out how to interact with the
other components and how their payment rules are going to
relate to all the other actors.
In all this complexity, we are challenged to ensure that the system
and the decision makers help the elderly patient. We must devise systems
of care in which all interested parties can work well together, and we must
never lose sight of the welfare of the individual elderly patient.
Representative terms from entire chapter:
home care
