FOCUS - October 29, 2004

October 29, 2004

Neurology:
Alzheimer's Plaques Reversed in Mice by Blocking Cholesterol Pathway

Metabolism:
Cellular Stress Appears to Link Obesity, Diabetes

Structural Biology:
Interdisciplinary Team Yields High-res Clathrin Model

Pathology:
Blood Flow Mechanics Affect Genetics in Vascular Cells

School History:
Book and Forum Recognize Achievement of African Americans at HMS

Medical Education:
Education Reform Aims for Longitudinal Clinical Experience

Muscle Loss Pathways Proliferate

Fine-particle Pollution Linked to Blood Pressure Boost

Human Cell Therapy Center Created at CBR Institute

Lieberman to Head Faculty Affairs

Five Faculty Members Become AAAS Fellows

Ground Broken for New Fenway Housing

Grant Funds HSPH Initiative for Preparedness Against Terrorism

Long-term Care: Averting a National Crisis

Front Page

FORUM

Long-term Care: Averting a National Crisis

Erica Seiguer
Photo by Graham Ramsay

Innovations in medicine are enabling individuals to triumph over disease and live longer lives. At the same time, major advances during the last several decades have intensified the challenge of providing and supporting long-term care. It is estimated that by 2020, 12 million Americans will need this care. As the population ages and lives longer with chronic health conditions, the need for such services will only grow. Families will increasingly face difficult choices about how to care for loved ones and how to pay for this care.

Long-term care encompasses medical and social services for individuals with chronic conditions and physical and mental disabilities, and can take place in the home, community, or live-in facilities such as nursing homes and assisted-living residences. Long-term care is expensive and not covered by Medicare, which pays for medically necessary skilled nursing facilities or home health care for restricted periods of time. The great majority of people needing long-term care will be cared for solely by friends and family. These caregivers are often torn between the desire or obligation to keep their aging relatives in the home and the strain that this intensive care puts on their families and finances.

Paying for Care

Of the almost $140 billion spent on long-term care in the United States in 2002, about two thirds was spent on nursing home care and one third on community and home health care. The average cost per year for care in a nursing home is about $70,000, with tremendous variation across states. The average cost per day ranges from $99 in Louisiana to $561 in Alaska, where the annual cost of care exceeds $200,000. The high cost of long-term care can impoverish individuals and families.

Poor elderly who qualify for Medicaid can avail themselves of the nursing home and home health benefits of that program: one third of Medicaid's budget is spent on long-term care. Some individuals spend down or shift assets in an effort to qualify for Medicaid, a practice discouraged by federal law.

The costs to patients and families who do not enter a nursing home are high. In addition to the financial burden associated with constant care for an ill relative, recent studies have shown that family members caring for those with chronic illnesses are more likely to suffer from depression and other illnesses themselves.

The Commonwealth Feels the Crunch

Here in Massachusetts, where 70 percent of nursing home residents are insured by Medicaid, officials in the commonwealth's Division of Health Care Finance and Policy are well aware of the financial burden of paying for long-term care. Douglas Lapp, acting pricing policy manager, agrees that while not by design, Medicaid has become the de facto long-term care insurance policy for many. In Massachusetts, this amounts to $2 billion per year spent on nursing home care. According to Lapp, some states, including Massachusetts, have employed creative financing strategies, including user fees, to direct more resources to long-term care. "It is always difficult to balance the needs of the three major stakeholders: the nursing home providers, nursing home residents, and the commonwealth as a health care payer (ultimately the taxpayers), given limited state resources," he said.

In addition to the financial burden associated with constant care for an ill relative, recent studies have shown that family members caring for those with chronic illnesses are more likely to suffer from depression and other illnesses themselves.

Encouraging individuals to think ahead and invest in long-term care insurance (LTCI) has met with limited success, according to Amy Lischko, assistant commissioner in the Division of Health Care Finance and Policy. "The state has had numerous task forces on LTCI, and we've looked at ways to increase participation. Unfortunately, even when employers offer group rates to their employees, the take-up rate has been very low." Lischko notes that while the commonwealth wants to encourage people in their 50s to think ahead to health needs in their 80s, this has proved difficult, since individuals in their 50s are often concerned with other pressing expenses, such as college tuition for their children. One potential solution, suggests Lischko, is the health savings account. "If people start contributing to these accounts when they are 25 years old, they may have accumulated enough for LTC by the time they need it," she said.

There is also debate about the best model for long-term care. Some argue that care is delivered more efficiently in the community or home and suggest that individuals be treated in those settings. "There is an interest in people being treated in the least-restricted environment, in the community," said Lischko, but proponents of this care model have come up against the nursing home industry. "We would need more money to be able to move some of the care into the community," she said, "and that's been a struggle. Some believe it's not cheaper to keep people in the community."

--Erica Seiguer, a sixth-year MD-PhD student studying economics in Harvard's Doctoral Program in Health Policy

Websites of Interest

Massachusetts Division of Insurance Guide to Long-term Care Insurance

Medicare's Long-term Care Website (CMS)

U.S. Administration on Aging: Health and Long-term Care Costs and the Elderly

The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.