WASHINGTON—The Bush administration believes it can improve services for Medicaid beneficiaries and help the program's shaky bottom line by caring for more elderly and disabled patients in their homes or through community-based programs.
Experts say doing so is much cheaper than institutional care and allows some of Medicaid's most fragile patients to remain more self-sufficient.
"Anything that keeps a person out of a nursing home preserves their ability to maintain their dignity and their independence," said Dr. David Bean, a geriatric psychiatrist in Sioux Falls, S.D.
President Bush's 2006 budget proposal seeks $500 million over five years to move some of the disabled out of institutions and into these community programs. For patients who make the switch, the federal government would pay the entire cost of care in the first year and then split the cost with states—anywhere from 50 to 70 percent—in subsequent years.
While no similar money is earmarked for the elderly, the administration hopes to help states expand community services for a growing number of aging Americans.
The administration also wants Congress to allow states to offer those services to elderly and disabled Medicaid patients without federal approval.
Health and Human Services Secretary Michael Leavitt said expanding community care services gives patients more care options and saves money for Medicaid, the health plan for the poor and disabled that's paid for by the states and federal government.
Nationally, Medicaid has roughly 2 million patients in institutional care and about 1 million in community care programs. States that offer the services on a large scale, such as Ohio, Oregon and Vermont, have seen annual savings of up to $25,000 per patient over the cost of nursing home care.
"Providing the care that lets people live at home if they want is less expensive than providing nursing home care," Leavitt said. "Medicaid should not force these people to live in institutions."
But some feel the quality of the community-based services could suffer if federal oversight is reduced and states, already burdened by rising Medicaid costs, use their new autonomy to cut program costs.
"This isn't being done to make Medicaid a better program. It's being done to cut the federal budget deficit, and we're concerned that they may be going too fast without talking about assuring that (patients) get appropriate services and whether they're going to be safe," said Janet Wells, the public policy director for the National Citizens' Coalition for Nursing Home Reform, an advocacy group for long-term care residents.
Kenneth Thorpe, chairman of the health policy management department at Emory University in Atlanta, agreed. "If you allow states a tremendous amount of experimentation with these home- and community-based programs, you have to have some examination that the services being delivered are of high quality and clinically effective."
More than 70 percent of the state community-based programs reviewed by the federal Centers for Medicare and Medicaid Services had one or more patient care problems, according to a 2003 report by the Government Accountability Office, the investigative arm of Congress. The most common were failure to provide necessary patient services, poor case management and inadequate patient care plans developed by caregivers.
The report also found that the Centers for Medicare and Medicaid Services doesn't hold the states accountable for submitting annual community program reports on time.
In the past year, the agency has worked with its regional offices to improve program evaluations and improve the way patient satisfaction is measured, said administrator Mark McClellan.
Medicaid seniors such as Alice Terrell of Columbus, Ohio, are pleased about the idea of expanding home-based care because most seniors don't want to live in nursing homes.
"I just preferred to be at home with people that you know who care about you," Terrell said recently in her home. "It was just the idea of being around your friends and family."
Elderly and disabled advocates agree that, with proper patient support services such as meal delivery and transportation to medical appointments, community-based care is a better option than nursing homes.
Just the prospect of entering a nursing home can send seniors into a depressive spiral, Bean said. "It's a major issue. They can't drive the car anymore. They could lose the home they've lived in for many years, their social network. These are all major losses."
States have offered community-care programs for nursing home-eligible Medicaid patients since the early 1980s. Funding problems have limited enrollment, however, and waiting lists are common and likely to increase as the nation's elderly population grows.
Vermont saves about $25,000 a year per person by serving roughly 2,000 Medicaid patients in community programs instead of nursing homes. Since 1996, the state has used those savings—about $50 million a year—to expand the programs.
Ohio pays an average of $12,600 a year for each of its 24,000 Medicaid patients in community care, compared with more than $55,000 for those in institutional care.
Officials in New Hampshire, hoping to reap similar savings, say their community care proposal will save the state $142 million over five years. In Oregon, about 20,000 nursing home-eligible patients are in community care; only 5,600 are in nursing homes.
Home-care patients typically receive regular visits from a visiting home health aide who helps with some medical needs and other tasks such as bathing, meal preparation, household chores and errands. Patients with less severe needs often live at home and get medical and personal care at adult day-care centers.
Other community-care services include assisted-living facilities and "board-and-care homes," which are smaller facilities, sometimes single-family homes, where three to 16 patients live. Still others are in adult foster homes, where private families are paid to provide their care.
A wheelchair-bound survivor of two strokes, Terrell chose community-based care instead of a nursing home.
For four hours each day, Frances McDaniel works as Terrell's home care aide, helping her with meals, hygiene and housekeeping. Terrell entered the program three years ago after surgery to implant a pacemaker. She has no regrets.
A retired nurse in her 70s, McDaniel is close in age to Terrell, and the two are friends who call each other "Miss Alice" and "Miss Frances." "We've grown on each other," Terrell said.
"I don't know what I'd do without her," McDaniel replied. "She's almost like family."
When run properly with strong support services, patients do better in community-based care, said Rick Harris, director of the Alabama Bureau of Health Provider Standards, which regulates the state's nursing homes. But he said the quality of care could suffer if the programs expand and the state and federal oversight doesn't keep pace.
"The question is are we willing to put the time, money and resources into the regulation of these programs?" Harris said. "It's just something that needs an awful lot of study."
(c) 2005, Knight Ridder/Tribune Information Services.
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