An Attempt at Improved Elder Care
Imagine an HMO for people on Medicare that throws in some priceless extra services designed to help keep frail older Americans out of nursing homes.
An ordinary health maintenance organization gives the regular Medicare benefits, helping pay hospital and doctor bills. In California, HMOs have tried to compete to sign up the senior population by providing prescription drug benefits, which aren’t included in the traditional Medicare program.
But our imaginary HMO does a lot more outside the purely medical realm. This HMO might send a health care worker to a woman’s home several times a week to help her bathe. Or it might dispatch a household aide to clean her home or prepare a few days’ worth of meals. Another time, this health plan might send a van to take an otherwise homebound elderly man to a day-care center for an afternoon, where he could socialize and get a break from the usual routine.
This daydream for the elderly and their families has been a reality since 1985 in three locations--Long Beach; Portland, Ore.; and Brooklyn, N.Y. Congress has placed an enrollment ceiling of 36,000 on each of the plans. A fourth plan, based in Las Vegas, has been operating since 1996. Former U.S. Sen. Bill Bradley, seeking the Democratic presidential nomination, wants a big boost in federal spending for these programs to emphasize home and community care for the elderly as a much preferred alternative to nursing homes.
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Sam Ervin, who runs SCAN, the Long Beach HMO, was an eager and attentive listener at L.A. Valley College in Van Nuys recently when Bradley unveiled his health blueprint. Ervin has 33,500 people enrolled in SCAN (Senior Care Action Network), which serves Los Angeles, Orange, Riverside and San Bernardino counties. If the limits are lifted, Ervin envisions boosting enrollment to 100,000 or more within three years.
SCAN is doing TV advertising for the first time this year to spread the word about its extra services. “The most frequent reaction our salespeople get is that ‘this seems too good to be true,’ ” Ervin said.
SCAN’s special mission is to go the extra mile to keep people out of nursing homes, and many of the customers it has drawn are typically older, sicker and frailer than the general population on Medicare.
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People go into nursing homes because they cannot manage on their own some of the basic activities of daily living: getting out of bed and walking, using the toilet, dressing, bathing and eating. These are not strictly medical problems, and Medicare doesn’t pay for custodial care in nursing homes.
If someone who has joined SCAN has the problems that would normally require nursing home admission, the HMO will assign a case worker and make available all the extra benefits: personal health aides, homemaker and chore helpers, and transportation to doctors and clinic offices. Another extra is a necklace with a button to push to summon paramedics in case of emergency.
Respite care also is available. Suppose a family member is caring for the person in the HMO. To give the caregiver time off from this difficult responsibility, SCAN might provide the HMO member with a week at no charge in a nursing facility. Or SCAN might keep the member at home but send in extra home aide to provide more hours of care.
About 16% of SCAN members get the extra services.
SCAN and its counterparts are called “social HMOs” because they go beyond the medical model, and form a collaboration with family members to keep the individual in the community rather than being forced to enter a nursing home. “The family caregivers no longer have to shoulder the burden alone,” Ervin said.
In return for the extra services, the social HMOs get extra payments from the federal government under the Medicare programs, receiving more than the conventional Medicare HMOs get. The value of the additional services at a social HMO like SCAN can be as much as $12,000 a year, according to the Health Care Financing Administration, which runs Medicare.
The social HMOs, despite years of successful operation, are still classified as demonstration projects by the federal government. Congress is waiting for a report from Health and Human Services Secretary Donna Shalala on whether to lift the limits beyond 36,000 to make social HMOs available to more of the nation’s 40 million Medicare beneficiaries.
The potential stumbling block is, as always, money. Congress is waiting for the Health Care Financing Administration to discuss the best way to calculate payments if it expands the social HMOs. This is a tricky issue, because the HMO industry already is engaged in a bitter argument with the government, asserting that payments are being squeezed unfairly for the regular Medicare HMOs. The HMO industry talks of a “fairness gap,” and says its ability to deliver such popular benefits as prescription drugs will be imperiled by the government’s stingy payment policy. Federal officials respond by saying that payments are sufficient--even generous.
The government invited health plans to create a second generation of social HMOs in Florida, Northern California, Colorado, Massachusetts and South Carolina, but none of them got off the drawing board because of uncertainty over profitability under the current cost structure.
The social HMO is “still a pretty revolutionary idea,” said Susan Pisano, a spokeswoman for the American Assn. of Health Plans, the HMO industry organization.
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Q: Must immigrants become citizens to be eligible for Medicare A and B?
A: Medicare is automatically available at age 65 to anyone who has been enrolled in the Social Security system as a worker. Legal immigrants who have been in the U.S. for five years can buy into the system by paying for both Part A, which covers hospital bills, and Part B, which covers doctors’ charges.
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Rosenblatt is a speaker Sunday at noon at The Times’ Festival of Health at USC.
* Have questions? Write to Bob Rosenblatt, Health Dollars & Sense, L.A. Times, Times Mirror Square, Los Angeles, CA 90053. Or e-mail [email protected].
