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Transcript of Dually Eligible People With Medicare and Medicaid “The Elderly and Disabled Poor” Sheldon Hersh,...
Dually Eligible People With Medicare and Medicaid
“The Elderly and Disabled Poor”
Sheldon Hersh, MDNew Orleans, Louisiana
© 2003 National Coalition for Dually Eligible People
2
Table of Contents
1. Dually Eligible People2. Second-Class Medicare3. The Nursing Home Burden4. Possible Solutions5. Geriatrics — An Ailing Specialty6. The Past, Present, and Future
3
Section 1.
Dually Eligible People
4
Dually Eligible People Have Both Medicare and Medicaid They have Medicare because they
worked, paid taxes, and earned their Medicare when they become elderly or disabled.
They have Medicaid because they are still so poor that they qualify for their state’s Medicaid program for the needy.
5
Dually Eligible People with Medicare and Medicaid Are: “The elderly and disabled poor” – Senator
Breaux
Six million of the oldest, poorest, sickest, and most disabled people in the nation
Disproportionately elderly, women, minorities, and mentally or physically disabled people
The fastest-growing and most expensive Medicare population
6
Dually Eligible People Are Vulnerable and Poor An older, female population with a large
percentage of minorities 80% < $10,000/yr, 20% < $5,000/yr 28% under 65 y.o. – the “non-elderly disabled” Live alone, have fewer educational skills,
poorer vision and hearing Generally in poor health, have difficulty
performing their Activities of Daily Living (ADLs)
25% live in nursing homes
7
Dually Eligible People Have More Chronic Illness
Alzheimer’s disease Amputation Arthritis Asthma Chronic renal failure Colitis Congestive heart failure COPD Dementia Depression Diabetes Esophageal disease
GI Bleeding Hip fracture Ischemic heart disease Liver disease Mental retardation Myocardial infarction Osteoporosis Parkinson’s disease Psychosis Schizophrenia Seizures Stroke, and More. . .
Source: Perrone. Profile of Dually Eligible Seniors in Mass. 1999.
8
Dually Eligible People Are Frail and Require More Medical Services
Hospital Nursing home Skilled nursing
facility Home health Emergency room Physician services Prescription meds
Physical therapy Rehab services Laboratory services Hospice care Inpatient psychiatry X-rays And More . . .
9
Dually Eligible People Have More Difficulty
Obtaining Medical Care They are less likely to have a primary care
physician.
They are twice as likely to report difficulty obtaining health care.
They are four times as likely to use the emergency room or hospital for their healthcare needs.
They are more likely to delay health care due to cost.
10
Dually Eligible People Are Twice as Expensive as
Non-Dually Eligible PeopleDually eligible people comprise Only 17% of the Medicare and
Medicaid population.
Yet these same people use Almost 35% of of all
Medicare and Medicaid money.
The cost of caring for these people Totaled $106 Billion in 1995.
Source: Breaux, John. Torn Between Two Systems.
Medicare Population:
ELDERLY or DISABLED
MedicaidMedicaidPopulation:Population:
POORPOOR17%
Medicare
$MedicaidMedicaid
$$35%
11
Section 2.
Second-Class Medicare
12
Insurance Reimbursement Affects
Access to Health Care
Accessto
Health Care
Uninsured Medicaid Medicare BoutiquePhysician
Insurance ReimbursementLess $ More $
100%
0%
13
How Crossovers WorkJanuary 2000 – With Crossovers
80-Year-Old Woman withDiabetes, Hypertension, Arthritis, Alzheimer’s DiseaseNew Patient – 45-minute Office Visit – Level 4
Medicare AllowedAmount
$126
Medicaid Payment
$126
MedicarePayment
“Crossed Over”
Total Payment
14
How Crossovers WorkFebruary 2000 – Without
Crossovers45-minute Office Visit for the Same New Patient
$126 Allowed
$34Paid
34/126 = 27% Paid
73% LOSS
$126 Allowed
101/126 = 80% Paid
20% LOSS
Medicare Deductible NOT Met Medicare Deductible Met
$101 Paid
15
The Elimination of Crossover Payments for
Dually Eligible People is a “Geriatric Penalty”
My Response to This Geriatric Penalty:
House Calls to NewDually Eligible Patients
Geriatric Clinic Hours
STOPPED
DECREASEDBY 10%
16
My New Orleans Dually Eligible Population, 2000
89% African American
79% Women
34% Mentally or Physically Disabled
100% Poor
HOME VISITS100% to Disabled African Americans
17
African-American Population and
The “Southern Black Belt”African Americans, as a Percent of Total Population, by County
Source: U.S. Census Bureau. Census 2000.
70.0 to 86.5
50.0 to 69.9
25.0 to 49.9
12.3 to 24.9
5.0 to 12.2
1.0 to 4.9
0.0 to 0.9
African Americans Are 12.3%
Of the U.S. Population
18
The “Southern Disability Belt”Percentage of People with Any Disability,
In the 16- to 64-year-old Population, by State in 1990.
Source: U.S. Census Bureau. Census Disability Data. 1998.
15% to 20%
20% to 25%
25% and over
19
100% 100% 100%
80%
50%
"First-Class Medicare" "Second-Class Medicare"
Second-Class Medicare Medicare in Louisiana & 2/3 of All States is a
Two-Tiered Discriminatory Benefit System
Violates the
Civil Rights Act &
The Americans with
Disabilities Act
Healthy &
Wealthy Seniors
•Elderly•Poor•African Americans & Other Minorities
•Women•Physically Disabled
Mentally Disabled
Taxes Paid Benefits Taxes Paid Benefits
Four Million Dually Eligible With Medicare & Medicaid
Decreased Access To
Health Care
20
Section 3.
The Nursing Home Burden
21
Most Nursing Home Residents AreDually Eligible People
Percent of Medicare Beneficiaries Living in
Nursing Homes
Nursing Home Population
2%
24%
0%
5%
10%
15%
20%
25%
Non-DuallyEligible
Dually Eligible
Dually Eligibl
e~70%
Non-Dually Eligible
~
Source: HCFA
22
Medicaid Payments forDually Eligible People, 1995
4% 3%6%
85%to Nursing
Homes
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Physicians Inpatient Hospital Prescriptions Nursing Homes
Source: HCFA
23
30% of Medicaid Budgets Is Spent to HouseDually Eligible People in Nursing Homes
Dually eligible people consume 35% of all Medicaid money — Senator John Breaux
85% of all money spent by Medicaid on dually eligible people is spent on their nursing home care — HCFA
MedicaidNursing HomePayments forDually EligiblePeopleAll OtherMedicaidServices
30% $ for 1.5 Million People (4%)
70% $ for 40 Million People (96%)
Therefore, 85% x 35% = 30% of state and federal Medicaid budgets is spent to house dually eligible people in nursing homes.
Only 70% of Medicaid budgets is available to pay for all other services, patients, and healthcare providers.
24
Second-Class Medicare
Louisiana Decreases Home Visit $ by 81%
And Saves $108
Pays $26,000/Year When Patient Is Admitted to Louisiana Nursing Home
Decreased Medical Access and Increased Nursing Home Costs
$26,000/Year
$500 Million Louisiana Nursing
Home Bill For 26,000
Dually Eligible People
95-Year-OldDually
EligibleWoman withAlzheimer’s
Disease
BUT
3% of Total
Louisiana Expenditures
The State View
25
Second-Class Medicare
Decreased Medical Access and Increased Nursing Home Costs
$500 Million LA Nursing
Home Bill for 25,000 Dually Eligible People
1.8% of TotalFederal
Expenditures
$34 Billion National
Nursing Home Bill for
1.5 Million Dually Eligible
People
$500 Million LA Bill
$500 Million Louisiana
Nursing Home Bill for Dually
Eligible People
The National View
26
Medicare-Medicaid Payment SeesawMedicare Pays for
Acute CareMedicaid Pays for
Chronic Care
Physician Office, Hospital, Home Health Nursing Home
80% Federal Medicare $
80% Louisiana Medicaid $
27
Medicare-Medicaid Payment SeesawWith Physicians and Crossovers, 1999The Seesaw Tips to the Left
More FederalMedicare $
Less LouisianaMedicaid $
Physician Office, Hospital, Home HealthNursing HomePhysician Gatekeeper and Patient Advocate
Louisiana Scorecard
Patients and Families: PleasedPhysicians: PleasedLA Treasury: Pleased
28
Medicare-Medicaid Payment Seesaw
Without Physicians & Crossovers, 2001The Seesaw Tips to the Right
Less FederalMedicare $
More LouisianaMedicaid $
Louisiana Scorecard
Patients and Families: DispleasedPhysicians: DispleasedLA Treasury: Displeased
Physician Office, Hospital, Home Health
Nursing Home
29
For Louisiana and All State Treasuries
Community Care is a Bargain
Nursing Home Care
is a BurdenBecause Dually Eligible People Are Medicare-
Medicaid
Medicare80%
Federal $
Because Dually Eligible People Become
Medicaid-Medicare
Medicaid 80% State $Medicaid
20% State $
Medicare 20%
Federal $
30
Effects of a $27 Million LouisianaNursing Home Raise, 2002
Community Care Would Bring $101 Million Additional Federal Funds Into Louisiana
$27 Million Louisiana Medicaid
$7 MillionFederal Medicar
e
Could Have Purchased $135 Million of Community
Services
Will Purchase Only $34 Million of Nursing
Home Services
$108 Million Federal
Medicare
$27 Million
Louisiana
Medicaid
31
78% of Nursing Home Costs Are forCustodial Services — Room and Board,
ADLs$500 Million LA Nursing Home Bill $34 Billion National Nursing Home Bill
2.4% of All Louisiana Expenditures
1.4% of All Federal Expenditures
$390Million
CustodialServices
$110MillionMedicalServices
$27Billion
CustodialServices
$7 Billion
MedicalServices
Custodial Care for Dually Eligible People Costs:
32
Section 4.
Possible Solutions
33
Escalating Costs for Dually Eligible People
$106Billion
$120Billion
90
100
110
120
130
140
150
160
1995 1997 2003
$ Billions
?
34
National Coalition for Dually Eligible PeopleA Louisiana Not-for-Profit Corporation
Dedicated to Improving Access and Health Care forElderly and Disabled Dually Eligible People with
Medicare and Medicaid — “The elderly and disabled poor”
www.nacdep.org
35
Elephant Cartoon
“The TV keeps talking about a Healthcare Elephant, but I don’t see any elephant!”
36
Bottom Line for Louisiana and the Nation
Keep Dually Eligible People IN the Community and OUT of Nursing Homes.
Dually Eligible People Need “First-Class” Access to Community Medical Services.
The Medicare-Medicaid Payment Seesaw: For dually eligible people, decreasing community services or payments for physicians, home health, medications, transportation, etc., will increase state Medicaid nursing home costs.
37
Short-Term Solution
State Level Restore Crossover Payments in 2/3 of the States
Federal Level Change the Balanced Budget Act of 1997
– OR –
Pay Crossovers with 100% Federal Funds
38
A “Federal Crossover Program”
An estimated $1.5 billion “Federal Crossover Program” may decrease the $34 billion national Medicaid nursing home bill for dually eligible people by improving their access to community healthcare.
The federal government is already legally obligated to pay more than one-half of this estimated $1.5 billion Medicaid bill.
If the federal government invests an additional $750 million — averaging $15 million per state — in a “Federal Crossover Program” and saves only 2.2% of our national Medicaid nursing home bill, the program would be a social, a financial, and a political success.
39
Medicare Money Saved by Regulating Direct-to-Patient Advertising of
“FREE” Geriatric Medical Equipment Could Help Fund A
Federal Crossover Program.
“FREE” - Scooters and electric wheelchairs “FREE” - Comfort knee supports “FREE” - Heating pads “FREE” - Seat-lift chairs
One “FREE” $7,744 electric wheelchair could pay the 20% Medicare coinsurance and improve access for 787 dually eligible people in Louisiana in 2002.
40
Long-Term Solution
Dually Eligible People Need an Integrated Healthcare System
Which Combines:
Medicare’s Acute and Community Care Programs
Medicaid’s Long-Term Care and Medication Programs
Case Management Tools and Coordination of Services
41
Section 5.
Geriatrics — An Ailing
Specialty
42
This “Geriatric Penalty” Erodes The Specialty of
Geriatrics “The major reason for the shortage of
geriatricians is poor . . . reimbursement.” — Dr. John Burton, congressional testimony, 2001
No matter how high Medicare raises its rates, geriatricians treating dually eligible people will always be losing a minimum of 20%.
Geriatricians will be financially wise to shun states such as Louisiana that have a “geriatric penalty” in favor of states that do pay crossovers.
43
Making Rounds with Two Louisiana Geriatricians, January
2002
Total Payment for Dually Eligible Patients = $ 351 Total Payment for Non-Dually Eligible Patients = $1,019 $351/$1,019=34%, a Loss of 66% or $668
0
20
40
60
80
100
120
140
160
Insur. Payment
$
Non-DuallyEligible
DuallyEligible
Physician Services
44
Section 6.
The Past, Present, and
Future
45
The View From 1978 — Not Much Has Changed
In 1978, dually eligible people were older, 71% were female, and “the proportion of . . . minority races was four times as great. . . [and] the death rate was 50% higher. . . .”
“Perhaps the excess morbidity and mortality of the poor as they enter their senior years, reflect a lifetime of poor nutrition, housing, and other non-medical factors that are believed to influence health status.”
Source: McMillan. Health Care Financing Review 4 (1983): 19-46
46
What Causes Healthcare Costs to Increase ?
Population growth — 77 million baby-boomers
Expensive new technology and treatments
“The elderly and disabled poor” Dually eligible people with Medicare and Medicaid This medical-social problem requires more research The “final social safety-net” — long-term care
47
$0
$50,000
$100,000
$150,000
$200,000
$250,000
65 70 75 80 85 90 95 100 101
MedicareServices
Nursing HomeCare
Home Care
PrescriptionDrugs
Age at Death
Exp
endi
ture
s P
er P
erso
n
Spillman. NEJM 342 (2000): 1409-15
Cumulative Healthcare ExpendituresAt Age of Death
48
“Racial and ethnic minorities tend to receive a lower quality of
healthcare . . . .” — Institute of Medicine, Unequal
Treatment: Confronting Racial and Ethnic Disparities in Healthcare, 2003
“Racial and ethnic disparities in healthcare . . . are associated with worse outcomes . . . are unacceptable. . . . [and occur along with] discrimination in many sectors of American life.”
“This higher burden of disease and mortality among minorities . . . results in a less healthy nation and higher costs for health and rehabilitative care.”
49
Dually Eligible People — at the Center of the Next
Debate Because of their frailty, their social and
racial demographics, their great expense, and their expanding growth rate, dually eligible people — “the elderly and disabled poor” — will occupy a central position in the upcoming debates over national healthcare financing and disparities in health care in the 21st century.