Home care versus nursing home care: Who decides?

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Jeff A. Petty
Jeff A. Petty
The vast majority of those asked will say they want to stay in their homes as they age and have services delivered to them. We celebrate individuals making that choice and are striving to respond to that desire. So we continue to build an infrastructure to deliver services in a variety of settings.

But perhaps it is more complicated and nuanced than it first appears. It is certainly the American way to allow people to buy whatever they want with their money at a price negotiated between a willing buyer and seller. However, with so much of aging services paid directly from public dollars through Medicare and Medicaid and indirectly through Social Security, property tax abatements for seniors and so on, should there be boundaries on choices?

One way to think about this is to consider that the right of someone to wildly swing his fist around in any direction ends at the tip of his neighbor's nose. Put simply, of course, I can't unilaterally take actions that harm someone else. So what does that concept have to do with the ability to choose how and where we receive aging services-specifically the limitless right to receive these services in whatever setting we choose?

This debate becomes interesting and worthwhile when talking about society's obligation to provide certain supports and services. In the 1950s, before the advent of Medicare and Medicaid, 35% of the nation's seniors lived in poverty. Clearly, before Social Security, the facts would have been even grimmer than that. Society determined that a national retirement and healthcare system was imperative and that virtually every senior had certain minimum entitlements.

So the Social Security, Medicare and Medicaid programs were established. They have worked well—less than 10% of the nation's seniors live in poverty and virtually every senior has basic healthcare coverage. The result of these burgeoning programs, however, is that collectively they will, along with interest on the national debt, consume the entire budget of the federal government by 2030. So, we need to examine the appropriate level of support and services that should be provided moving forward so as not to place an undue burden on future generations.

Healthcare for sale?

For example, as aging services providers continue to expand various ways of delivering services, in the American culture it seems clear that anyone with enough money should be able to purchase whatever they are willing to pay for. But recognizing that Warren Buffett is on Medicare and Social Security, the proliferation of choice is more complicated.

Let's suppose there could be multiple ways to deliver needed services to the senior population under Medicare (and since Social Security provides the bulk of income for the majority of seniors, we could argue that the example holds true for any service) and further that each "costs" a different amount of money. Is the recipient allowed to choose any of the options, even acknowledging that all but one of these service delivery models costs everyone else more money? And, in raising that question, does it matter how much more?

I think it is even more complicated. Let's imagine a scenario where there are two different services packages or delivery systems that do in fact cost the same amount of money. But one is shown to be more effective than the other, producing clearly superior outcomes (assuming we were able to agree on and measure the desired outcomes). As above, with public dollars going into the entire fabric of aging services, should the recipient of the services be allowed to choose the less effective option?

It is fairly common to demand that the recipient of a service that is being subsidized or paid for by someone else must choose the least expensive alternative, or failing that, only gets the least expensive alternative covered. As an elected official said, "Suppose we told everyone to go to a store and pick out a television for themselves and we (i.e., someone else) would pay for it. How many people do you think would come out with a 12-inch black-and-white?"

We need to recognize that whatever services are paid for takes money away from everyone, and accordingly there is an obligation to take as little money as possible to "get the job done." As alternative service delivery methodologies proliferate, we need to remember that, unlike any other buyer-seller transaction, the consumer making the choice often isn't paying the bill. The typical consumer-driven model of demand ignores a crucial element that generally is only prevalent in healthcare—the payer.

So I think we need to establish rules. The first rule is that only the least expensive alternative is paid for. Anyone with sufficient funds can pay for whatever service they want, but the publicly funded programs do not pay for choice.

Similarly, the second rule is that only the most efficacious program is paid for—someone can't choose an alternative that doesn't work as well. That doesn't answer the scenario where a more expensive alternative produces better results—what are we willing to pay for then?

These rules leave many more issues unresolved that need to be resolved. But in the rush to endorse and create additional choices for consumers, such as home- and community-based service models, perhaps we should consider these as prudent benchmarks—before we begin.

Jeff A. Petty is president and chief executive officer of Wesley Enhanced Living, a multi-site CCRC organization based in suburban Philadelphia.


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