It’s Time To Coordinate Care For The Disabled And Frail Elderly

Jan 04, 2010

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Since the creation of Medicare and Medicaid nearly 45 years ago, the government has operated on the bizarre illusion that it can separate acute medical care from personal assistance and long-term care. For real patients and their families, this makes no sense. Someone who is sick often needs both medical treatment and personal care. They should not have to worry about which is which.

But because this artificial wall defines government policy, it places many of the most vulnerable people in the nation at risk and very likely wastes billions of dollars.

An obscure provision of the Senate health bill attempts to at least crack that barrier. It would set up, for the first time, a government office charged with coordinating care for more than eight million “dual eligibles,” the poorest and sickest among us who receive both Medicare and Medicaid benefits. Organizing this care is especially important for the frail elderly, who often suffer from multiple chronic diseases, take a dozen or more medications, and may see 10 different doctors. And it matters to taxpayers who spend $200 billion per year caring for these patients.

To understand the problem, think about a 75-year-old I’ll call Fred. At 2:00 one morning, Fred wakes up with severe chest pains and breathing problems. He calls 911, and the EMTs transport him to the local hospital. There, he undergoes aggressive life-saving treatment, perhaps including major heart surgery, much of which is paid for by Medicare.

But it turns out that Fred’s heart attack caused serious damage to his heart muscle. As a result, it can no longer pump blood through his system as efficiently as it should. This disease, called congestive heart failure, is among the most common chronic illnesses of the elderly. CHF can be managed for many years with a combination of medications and other treatments, but it can be severely debilitating. In time, as the damaged heart becomes steadily weaker, getting out of bed, walking, eating, and making decisions become harder. 

Still, someone with CHF, as well as those with many other chronic illnesses, can be cared for at home. But that requires a trained aide or willing family member. If there is no one to provide this help, patients such as Fred will almost surely wind up in a nursing home or receiving a high level of care in an assisted living facility.

Now, let’s make the story a little more complicated. Although Fred worked hard for most of his life, his heart disease has drained all of his financial resources and he receives both Medicare benefits and assistance through Medicaid, the joint state and federal health program for the poor. Medicaid was originally designed to provide health care for low-income mothers and their kids, but now spends two-thirds of its dollars on the aged and disabled.

But, with the exception of a handful of limited programs, Medicare and Medicaid do not coordinate their care. So Medicare will pay for most of the cost of Fred’s hospitalizations and for his medications, but - except for a limited period of time - not for the health aide he needs to stay at home. That is Medicaid’s responsibility.

The consequences of this are both potentially deadly for Fred and costly for the rest of us. Fred needs someone to help manage his meds, and help dress and feed him. He also needs someone to get him on a scale every day or two. That’s because weight gain is a sure sign that his heart is not pumping well. With proper warning, his doctors can get Fred back on track by simply adjusting his medications. But if this signal goes unnoticed, he’ll almost surely end up back in the emergency room.

And here is where this strange story takes its final twist. The aide who could help Fred avoid a medical crisis simply by weighing him is paid by Medicaid. But if she helps keep him out of the hospital, the biggest beneficiary is likely to be Medicare. Not surprisingly, cash-strapped states are not happy about having to pay for aides who reduce costs for the feds. 

There are a few models out there that hold great promise for what could be. For instance, the Program for All-Inclusive Care for the Elderly (PACE) provides both adult day care and high quality medical treatment for these dual eligibles—and it is jointly funded by both Medicare and Medicaid. The two programs ought to find new ways to build on that model. And they could start by talking to one another. 

Howard Gleckman, a resident fellow at the Urban Institute, is author of "Caring For Our Parents" and a frequent writer and speaker on long-term care issues.