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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

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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.

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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.