Will Medicare Pay for Long-Term Care?

“Long-term care” means the health and support services that we may need as we age or have a disability. Long-term care may include care provided in a person’s home, such as home health care, in-home companion care and assistance with household tasks. Long-term care may also be provided in a residential facility, such as a nursing home, assisted living or adult family home.

Many people believe that Medicare will cover the cost of nursing home care or home care. But it is important to know that Medicare and most private health insurance cover only limited, medically necessary care. Medicare does not cover personal care—assistance with bathing, dressing, supervision for patients with Alzheimer’s disease and so forth.

The National Clearinghouse for Long-Term Care Information now offers information to help consumers plan ahead for future needs, select the right level of care, and locate resources. Information includes:

Planning ahead for long-term care includes understanding the financial resources that can help.


Unnecessary Hospitalizations: Bad for Seniors, Bad for the Economy

The January 22 cover story of the Journal of the American Medical Association focused on the growing problem of unnecessary hospitalization. As our nation’s lawmakers wrangle over the topic of health care reform, this is one thing everyone can agree on: these unnecessary hospital trips cost money, and aren’t good for the health of seniors. Policymakers are looking at ways to protect the well-being of our vulnerable seniors and, in the process, saving money for Medicare and consumers.

For Seniors, Is This (Hospital) Trip Necessary?

Hospital care is expensive. Yet according to a recent report from the Medicare Payment Advisory Commission (MedPAC), 60 percent of all Medicare emergency room visits and 25 percent of hospital admissions are “potentially preventable.” And this is not just a matter of money. Hospitals, it turns out, are not always the best care setting for seniors. Researchers are looking at ways to keep older adults out of the hospital. This includes:

  • Encouraging patients to be treated by their primary physician rather than at the emergency room
  • Better preventive care and management of diabetes, heart failure and other common health problems
  • Helping seniors manage their medications
  • Identifying and treating depression, which increases emergency room use
  • Improved healthcare education and information for consumers.

Avoiding the Hospital Revolving Door

Re-hospitalization is also an expensive and dangerous problem. According to the National Association of Area Agencies on Aging (n4a), nearly 20 percent of Medicare patients discharged from the hospital are readmitted within 30 days, costing over $26 billion every year. Why are seniors readmitted at such a high rate? Sometimes they have nowhere else to go—they can’t get an appointment with their primary care physician or don’t understand their care instructions. Studies show that in other cases, patients are released too soon: almost half of all surgical complications happen after discharge. And often, the reason for readmission is unrelated to the condition for which the patient was hospitalized. (See “Is Post-Hospital Syndrome Real?” below for more about this.)

For hospitals, there is a new emphasis on preventing unneeded readmissions. Medicare penalties are one reason for the concern: beginning in October, Medicare began reducing payments to certain hospitals which have high rates of preventable readmission.

Of course, not all readmissions can be prevented. But healthcare agencies are taking steps to help seniors, professionals and consumers address the problem. The Agency for Healthcare Research and Quality (AHRQ) calls for improvements in care transitions between the hospital and care facility or home:

  • Education for patients about their diagnosis and treatment while they are in the hospital and upon discharge
  • Making appointments for needed follow-up care
  • Improved instructions on how to take medications
  • Following up with patients within a few days of discharge

Improved communication is also important. Said Dr. Elizabeth Rasch of the National Institutes of Health, “When a person has an emergency department visit, their primary care providers often don’t know or don’t get the results of that visit, and vice versa. The emergency department often doesn’t know about the complex medical history people bring with them. That’s where things tend to break down.”

The AHRQ also recognizes that patients may be unable to remember discharge instructions. Family caregivers play a valuable role. Hospital discharge planners, geriatric care managers or other professionals may also be of help at this time.

Is “Post-Hospital Syndrome” Real?

Care received in a hospital saves the lives of millions of seniors each year, and helps many enjoy a higher level of independence and quality of life. Yet studies over the past few years have confirmed that a hospital stay can have a negative impact on seniors. In a January 2013 study appearing in the New England Journal of Medicine, Yale University’s Dr. Harlan Krumholz showed that many hospital readmissions are for a medical condition that is different from the initial cause of hospitalization—”post-hospital syndrome,” a 30-day period where patients are at risk.

A stay in the hospital can leave seniors vulnerable to medication problems, urinary tract and other infections, sleeplessness, bedsores, and even falls, which can lead to a more serious problem than that for which the senior was admitted. Of special concern is hospitalization delirium—a sudden state of confusion that sometimes occurs after surgery or a serious illness. This temporary event is sometimes mistaken for dementia—and delirium has been found to raise the risk of or hasten the course of cognitive decline in some patients.

Hospitals are making changes to support better outcome for elders. Some have opened geriatric emergency departments to meet the special needs of frail older patients, with such features as specially trained personnel, a quieter setting and thicker mattresses for comfort and bedsore prevention. Experts are calling for more geriatric training in medical and nursing schools, as well as policies that make geriatrics a more attractive specialty for med students.

Consumer Resources

Download the Agency for Healthcare Research and Quality booklet: “Taking Care of Myself: a Guide for When I Leave the Hospital.”

The Joint Commission healthcare accreditation organization offers the “Speak Up” series of patient education brochures and videos.

The Eldercare Locator offers the online booklet “Hospital to Home: Plan for a Smooth Transition.”

Read more about the post-hospitalization syndrome study in the New England Journal of Medicine.

Copyright © AgeWise, 2013


Seniors, Families Can Help Prevent a Return Trip to the Hospital

The Agency for Healthcare Research and Quality (AHRQ) offers information to help patients safely transition after hospital care.

According to the U.S. government, one-fifth of patients covered by Medicare return to the hospital within 30 days. The AHRQ tells us that these readmissions cost about $17 billion each year. Readmissions can also slow down a patient’s recovery.

As of October, Medicare’s reimbursement rate will reflect the ability of hospitals to prevent unnecessary rehospitalizations. Hospitals with high readmission rates for heart attack, pneumonia and heart failure are now paid less than those with fewer readmissions.

Older patients are at higher risk of returning to the hospital because they are more likely to be frail and have chronic conditions. Other reasons are more avoidable: Older patients may need help with transportation to follow-up appointments. And they may need extra support when leaving the hospital for home, or when transitioning to a skilled nursing facility.

AHRQ has developed a new guide for patients: Taking Care of Myself: A Guide for When I Leave the Hospital, an easy-to-understand plan for what to do when you or a loved one leaves the hospital. The guide can be used by both hospital staff and patients during the discharge process, and provides a way for patients to track their medication schedules, upcoming medical appointments, and important phone numbers. You can download a free copy of the guide on the AHRQ website or order a copy to be sent to your home.

The AHRQ’s Dr. Carolyn Clancy says, “Helping patients improve their health once they leave the hospital is not easy or automatic. The new effort by hospitals to prevent readmissions is a big step in the right direction. You can help by learning what you should do when you or your loved ones are in the hospital.”

© IlluminAge AgeWise 2012

Most Americans Will Need Long-Term Care, But Few Plan for It

The Associated Press-NORC Center for Public Affairs Research recently announced the publication and availability of a major survey that provides a new baseline of understanding about what Americans 40 years or older believe about their need for long-term care services, what such care would cost, and how such issues fit into their concerns about growing older. The survey reveals that while there is widespread concern among this population about the need for long-term care, little is being done to plan for it.

“It is estimated that 70 percent of Americans who reach the age of 65 will need some form of long-term care for an average of three years each,” said Trevor Tompson, director of the AP-NORC Center. “The rapidly aging population brings with it important social and public policy questions about preparing for and providing quality long-term care. This survey establishes what Americans 40 and over understand about the need for long-term care and reveals troubling facts about what is being done to prepare for it.”

Statistics about the aging of America are compelling. Population projections for 2030 show that older Americans—the classic Baby Boom generation—will make up 19 percent of the population, up from 12 percent today and totaling 72 million people. To deepen understanding and to provide accurate information about long-term care issues, the AP-NORC Center carried out its survey by conducting 1,019 interviews with a nationally representative sample of adults who are at least 40 years old.

Critical issues revealed by the survey include:

  • There are widespread misperceptions of the cost of long-term care, with most underestimating the cost of nursing home care and overestimating what Medicare will cover.
  • Nearly one-third of older Americans would rather not think about getting older at all, and when prompted, a majority worry about losing their independence. Significant majorities prioritize factors that promote independence as they age such as homes with no stairs; and living close to family members, health care services, and stores.
  • While few are setting aside funds to deal with long-term care issues, there is broad concern about key issues of aging such as loss of mental ability, being a burden to family, leaving unpaid debts, and being alone without family or friends.
  • Though Americans 40 years or older are concerned about issues of aging, only 41 percent have taken the step of talking about long term care preferences with their families, and only 35 percent have set aside money to pay for long term care needs.
  • There is faith in family, with 68 percent of Americans age 40 or older feeling they can rely on their family a great deal or quite a bit in time of need, with another 15 percent saying they can rely on their family for at least a moderate level of support.
  • There is majority support for public policy options for financing long-term care, with more than 75 percent in favor of tax incentives to encourage saving for long-term care expenses and 51 percent in favor of a government administered plan.

The Associated Press-NORC Center for Public Affairs Research survey of perceptions, experiences, and attitudes of Americans about long-term care was conducted from February 21 through March 27, 2013 with 1,019 adults age 40 or older. AP and NORC staff collaborated on all aspects of the study, with input from NORC’s Health Care Department and AP’s subject matter experts. Additional information, including the Associated Press stories and the survey’s complete topline findings, can be found on the AP-NORC Center’s website (www.apnorc.org). Funding for the survey was provided by The SCAN Foundation (www.thescanfoundation.org).

Source: Associated Press-NORC Center (www.apnorc.org)

Tips for Buying Long-Term Care Insurance

Information from Kaiser Health News on the complicated topic of long-term care insurance.

The question of whether to get long-term care (LTC) insurance bedevils consumers and their advisers. Unlike medical insurance, it is intended primarily to cover people who need assistance with so-called activities of daily living—for example, the care of a dementia patient or someone recovering from a broken hip. It can be expensive: Premiums range from $1,000 to $5,000 a year, depending on the age, sex and health of the purchaser as well as the extent of the coverage. And policy details can be confusing.

Kaiser Health News experts offer four things to consider as you make the decision:

  1. Determine if you qualify financially. Don’t buy if the out-of-pocket cost for the coverage would be more than you can afford. Consumer Reports advises people that if their net worth, excluding their home, is below $300,000, long-term care insurance is not a good buy for them. The National Association of Insurance Commissioners also recommends that consumers spend no more than 5% of their income on a long-term care policy. If you need long-term care but have few financial resources, Medicaid should quickly kick in to pay, although that will probably limit your choices for care. On the other hand, if you have a lot of resources (some financial advisers put that threshold at $2 million), you may be able to self-insure and pay the costs as they arise, thereby eliminating the need to buy a policy.
  2. Shop around. Unlike car insurance where you can switch carriers easily, it can be expensive to change long-term care policies because the premiums increase as you age and you lose the investments already made. Comparison shopping is critical. Some companies and associations (such as alumni groups and AARP) offer group policies with relatively liberal eligibility, making it easier to obtain coverage if the policyholder has any health issues. However, these policies may have more limited benefits than individually purchased plans.

If you are young or in excellent health, a group plan may also be more expensive; you may end up paying more to subsidize your less healthy peers. And if you are certain you want LTC insurance, the younger you are, the better. Your annual premiums will be smaller, and you have less chance of being denied for health reasons.

  1. Know what’s covered. Policies differ greatly, so know what you are buying. What services are covered? How long is the disability period before benefits kick in and what happens if you move from one facility to another? How much does the policy pay per day for nursing home care, home-health care and assisted living? How long will benefits last? Is there an inflation adjustment that anticipates rising medical costs as you age? How long are benefits extended (one, three or five years, or indefinitely)? Who determines benefit eligibility—your doctor, or the insurance company’s doctor—and on what basis? Are pre-existing conditions excluded? Does the policy cover mental or nervous disorders, alcoholism, drug abuse or self-inflicted injuries?

The National Association of Insurance Commissioners advises consumers to look for policies that include at least one year of nursing home or home health care coverage, including intermediate and custodial care; coverage for Alzheimer’s disease; inflation protection; a guarantee that the policy cannot be terminated because you get older or your health deteriorates; no requirement that the beneficiary has to first be hospitalized to receive benefits; and a 30-day cancellation period after purchase.

  1. Check out the insurance company. Review a carrier’s record with your state insurance commissioner’s office. Find out how long it has been in business, its complaint record, and history of raising rates. Stick with a company that has an A financial rating.

Also, the National Association of Insurance Commissioners (http://www.naic.org/index_ltc_section.htm) and the American Association for Long-Term Care Insurance (http://www.aaltci.org/long-term-care-insurance) have consumer guides on their websites. The Department of Health and Human Services provides extensive information on its National Clearinghouse for Long Term Care website (www.longtermcare.gov).

This article was reprinted from Kaiser Health News (www.kaiserhealthnews.org) with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente. Read Calculating a Long-Term Care Policy (www.kaiserhealthnews.org/Stories/2012/January/24/calculating-a-long-term-care-policy.aspx) to learn more about whether long-term care insurance is a good idea for you.