Key Issues in Post Acute Care

(The dreaded nursing home discussion)

Robert E. Burke, PhD

Gordon A Friesen Professor of Healthcare Administration
The George Washington University
Milken Institute School of Public Health
October 16, 2017
 Disclaimer
Views Expressed Are Based on My Past Work
Experience
These Views Are Not to Be Considered as
Representative of the Wertlieb Institute, The
George Washington University Nor Any Public,
Private, Federal or State Agency.
 Definitions
Post acute care
Skilled Care
Rehabilitation Services
Home and Community Based Services
CCRC (Continuing Care Retirement
Communities)
Assisted Living
 Todays Goal
Provide you with some background and facts
and some stories so that you
Can interpret and add to the health policy
discussion with respect to health services for
the elderly, frail and disabled.
Thus, be better able to communicate to your
community about the key issues. (tell fiction
from fact and scares.)
 Objectives
To clarify some of the confusing issues and
topics in Long Term care
What is post acute/long term care
Who pays for what
Artificial complacency
The impending age wave real or imagined
Impact on all the labor force
 What is Long Term Care?
Confusing Question - All Post Acute Care?
Formal - paid
Skilled nursing home, intermediate care, custodial
care
Independent and Assisted Living
Home and Community Based Services
Aging in place, NORC
VNA, Home Health Care Aide, Homemaker
Informal unpaid family and friends
 Who pays for what
Private Pay
Medicaid
Medicare
Insurance long term care, disability and
workmens compensation
 When does long term care start
At the end of a hospital stay?
When there is a need for supportive services
Is it all medical and health care
What are the social needs?
Role of friends and family
 Indicators of Long term care need
Diagnosis
Functional Ability
Instrumental Activities of Daily Living (IADL)
Activities of daily living (ADL)
Late loss ADLs as trigger
bed mobility, transfers, eating and toilet use.
 Providers of Care
Volunteers
Friends and family (60%)
Paid
Clinical, home health aide, homemaker
What ties it together is case manager
New Demonstrations
VA
 Historical Information
Number of skilled nursing home facilities in
1977 was 16,000
Number of skilled nursing home residents in
1977 was 1.5 million
Do the math and see that the average size of
nursing homes was about 100 beds.
 Historical Information
Nursing homes as we know them really are a
post World War II phenomenon
County and religiously sponsored
State and locally operated until Medicare and
Medicaid certification in 1966.
Social security Amendments of 1972 increased
participation of proprietary nursing home
 Historical Information
In 2013 how many nursing homes are there?
How many nursing home beds are there?
 Historical Information
What happened?
Population age of admission depression
era?
Assisted living not regulated by federal
government..
Growth of home and community based
services.
 How Big is Long Term Care

It is very big
 Long Term Care Expenditures
Year Total Cost
In Billions

2000 $96.2

2005 $135.9

2010 $183.4
2017 $275
 Starting Points
Number of Certified SNF 16,500
Annual Turnover
Administrator 40 to 50%
DON - same
CNA up to and over 100%
Numbers seeking NHA Licensure decreased by one
third since 1990 (MCCA)
Number of ALF is over 40,000
Annual Turnover unknown as not reported
What does the nursing home business look
like?
It is most regulated health care business
Average 100 beds
Average 100 staff
80% census dropped from over 95%
At least 4 different payment systems,
Medicaid, Private, Insurance and Medicare
Annual Revenue of between $3 and $5 Million
 Nursing Home Facilities and Beds, by Type of Ownership 2010

Type of Number of Percent Number of Percent

Ownership Facilities Beds

For-Profit 10,759 65.4% 1,188,643 66.2%

Not-For- 4,676 28.4% 485,706 27.1%

Profit

Government 1,011 6.1% 120,923 6.7%

Total 16,446 100% 1,795,272 100%

 How Much is Long Term Care
Skilled Facility - $60 to $140,000 per year
Assisted Living about $40 to $85,000 per year.
It is an a la carte plan. (3 hots and a cot)
Assisted Living have an Admission fee which
ranges up to $1 million with a proportion
returnable to heirs
Home and Community After Medicare, what
the market will tolerate.
 Who Pays for Long Term Care
We all do
Medicare Premiums
Medicare Payroll tax deductions
General tax revenues that support Medicaid
Different insurances
LTC
Workmens Comp
Personal health
 Who Pays for Long Term Care
Private including insurances 40 to 50%
Medicare 10 to 20%
Medicaid - 40 to 50%

For some states, the largest item in the budget

is Medicaid.
 Skilled Long Term Care
Medicare Part A is for Acute Care but
SNF benefit is 100 days per spell of illness
First 20 days at full payment
Days 21 to 100 IF DETERMINED TO BE MEDICALLY
NEEDY have a copay of $164.50 per day to total
$13,160.
Average Medicare LOS
Ortho less than 20
CVA about 30
 Skilled Long Term Care
Medicare Part B is and Option for Physician
and Other Professional Services.
Medicaid Buy-In for Medicare Part B
Medicare Part C aka Medicare Advantage is an
HMO Option run by private insurance
companies
Medicare Part D is the Pharmacy Option
 Long Term Care Utilization
Data suggests that 20% of all over 65 will use a
nursing home for a 30 day stay.
BUT only 5% will use it for greater than 90
days.
Long Stay Nursing Home Admissions are
Female
84
Who need nursing supervision
 Who Regulates Long Term Care
Federal
Certification for Medicare and Medicaid
State
Licensure of facility, administrator and other key
personnel
Ombudsman
Local
Fire and Sanitation
 Remedies
Until OBRA 1987, there were no mid level
sanctions.
It was all or nothing
Result very few closings.very little real regulatory
punch
After OBRA 87 there is a plethora of sanctions.
False claims, fines for survey violations, No new
admissions
 Physicians in Long Term Care
Total number of MDs in US - approximately
750,000 estimate of AMA
Board Certified Geriatricians (?)
Physician Members of American Geriatric
Society 4,700
Physician Members of American Medical
Directors Association 5,300
 What Type of Long Term Care Do People
Want

What is perfect for me

Brief History of education for nursing home
administrators

1950s most common nursing home administrator

license was in situ.
Had the job, got the license.
1960s GWU starts an correspondence course in
nursing home administration.
1966 Medicare requirements more sophisticated
management required, GWU courses are
incorporated into the MHSA degree
Brief History of education for nursing home
administrators
1972 Social Security Amendments spell out the
general requirements for licensure for the States to
adopt.
1980s GWUs nursing home administrator program
receives national reputation
1998 The inception of the Wertlieb Institute
Today, GWU is only one of 5 nationally known
academic programs and we had no applicants this
year.
 News
Good
There will be a continued need for post acute care
Bad
Number of those seeking careers in geriatrics remains low
and more disturbing, applications for nursing home
administrator licenses has dropped
Indifferent
Boomers will not need nursing services until 2032.why
worry
 Boomers
Age 53 to 71 about 75 million Americans
How many are financially solvent for
retirement and health services?
Estimates vary but the majority are not.
How long will Boomers live?
Probably longer than their wealth
 Impact of WWFC
Recession of 2008-2009
Deflation of 401 (k) real cash value
Estimates to 40%
Deflation of real estate value
Wide regional variation in cash value of homes
Range for < 10% DC to > 50% Florida and Nevada
Why important
Change model for retirement
Change model for funding of CCRC/AL
 Impact of Health Reform
Evolving what impact will bundled payment
do?
Hospitals are becoming more interested
ACOs
LTC will not go away
Services and some provider or provider types
may change focus and locus
 New Ideas
Age Friendly Cities about 40 around the
world
WHO initiatives
Villages
Mutual support groups so seniors and disabled
may stay at home.
Paid family caretakers
Need for health insurance.
What types of Long Term Care is Available

Model is changing

Lack of funds
True or not
Lack of staff
 Who Will Take care of ME?
How do we encourage careers in post acute
care?
Attitude, it needs to be changed
Most dreaded words are Nursing Home
Values
A difficult one in our culture of immediate
replacement people are not cell phones or
i-pods
 Major Infrastructure Problems
Personnel Shortage
Regulatory Atmosphere
Reimbursement Strategies/ Liability Ins
Ownership
Inability to raise capital
Growth of other options
Assisted living
HCBS (home and community based services)
 Solutions
Market Forces
Just increase the awards and rewards
FEARthe usual American response
Increase regulations and requirements
A Plan
That focuses on recruitment and retention
Move out of our sacred silos to develop a program that the
post acute care industry wants and meets and expands
GWUMC capacity.
 Growing Paradox
Proprietary owned facilities and corporations
serve more Medicaid residents than the
nonprofits.
What does that say?
 Emerging Assisted Living Trends

Larger units
Increased amenities
Special Care
Wellness clinics
Residential character
 Dementing Illness/Alzheimers
Approximately 4 million Americans
5.5 million by 2010 & 14 million by 2050
4th leading cause of death in adults
100,000 deaths each year
Need for special programs
 Long Term Care Insurance
Should I purchase LTCI for
Self, Spouse, or Parents?
LTCI is asset protection, therefore, do I have
assets protect?
Financial Planners suggest the asset threshold
in cash is at least $600K
 Long Term Care Insurance
Should I buy LTCI?
ANSWERS.
DO THE MATH for your personal situation
Group policies tend to give more service
options per premium
Ask what the sales representatives
commission is.you might be surprised at
the answer.
 Whats Next?
Be on the look out for your parents.those
take-charge baby boomers.
The Tsunami is coming in the next decade.
Keep a sense of humor