State needs to proceed with caution in changes for long-term care

December 7, 2012 

Over the past 20 years, the state of Washington has planned and developed its long-term care system to help frail elders and people with disabilities to have the option of living in their own homes instead of nursing homes, and still receive needed services.

Over the years there have been many favorable national reviews of our state’s long-term care system. One recent analysis, commissioned by the AARP, found that our system ranks second in the nation with regard to the scope and choice provided to participants. Moreover, Washington ranks 30th nationally in per capita public expenditures on long-term care system. We are both effective and efficient in the care we provide. This success came about because of specific policies advanced by several governors and supported by bipartisan legislative budget and statutory decisions, consumers of long-term care services, their families, advocates and providers. We have created a system that enables people to have the option of living at home, as independently as possible, for as long as possible and still receive needed long-term care services at lower cost than if we followed the pattern of most other states that rely more heavily on institutional care.

Washington is now is about to become engaged in the next big system reform for long-term care – integrating these services with consumer health care, mental health care and other needs. This makes sense but it must be done right. As former heads of the Aging Program and the Medicaid Program in our state, we are concerned that more attention be focused on how to move toward needed integration of health and long-term care without turning the clock backward on the 20 years of progress made. The state of Washington and the federal government are discussing a plan to blend Medicaid and Medicare funds for people who are eligible for both programs. This is called the “dual eligible” waiver plan. The reasons for wanting to do this have merit. The goal is to better integrate the care for beneficiaries, especially to better manage the health care costs for people who use high cost hospital services.

Initial plans include two key strategies. The first strategy is to create Health Homes for the heaviest users in the system, those that are dually eligible who have multiple chronic care conditions and high health care cost. A care coordinator would help these individuals navigate the array of health care and social service providers. The second strategy is to contract with a provider in as many as three counties (King, Snohomish and Whatcom) to enroll dual-eligible people in a program of health and long-term care services. This means a provider will be paid a set amount per person per month to provide both health and long-term care services to enrollees.

Integration makes sense, but we are concerned that most health plans have very little experience in dealing with the long-term care needs of potential enrollees. Our current long-term care system relies on 13 Area Agencies on Aging, in partnership with the state, to provide needs assessment, case management and service arrangement to help keep people at home. While these beneficiaries of long-term care services have clear health needs, they also have needs related to basic activities of daily living and quality of life. Meeting all of these needs is the key to keeping people living as independently as possible.

We’ve not seen specific information that outlines how health plans will be able to meet these complex needs. We believe that it is very important to assure that the gains we have made over two decades in building our current long term care system not be put at risk by an understandable desire to reduce health care costs. Long-term care costs have been well managed in our state. We are skeptical about turning over management of the long-term care system to health plans that have been part of a less well-managed health care system.

Before moving ahead on the plan to move long-term care services for dual-eligible elders to a capitated system, managed by people rooted in the health care system, state policy makers need to be certain that access to our efficient and effective current long-term system will not be compromised for elders who need and rely upon these services for their dignity and independence.

Charles Reed is a former DSHS Assistant Secretary for Aging Services and Gerald Reilly is a former DSHS Assistant Secretary for Economic and Medical Services.

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