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Models for Comprehensive Health Care Coverage for Older Adults

By

Roger I. Schreck

, MD

Last full review/revision Feb 2019| Content last modified Feb 2019
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NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version

In the United States, health care services for older adults are funded mainly by Medicare, Medicaid, the Veterans Health Administration, private insurance, and out-of-pocket payments. In addition, many states offer health-related benefits and programs, such as subsidies for transportation, housing, utilities, telephone, and food expenses, as well as help at home and nutrition services. Health care workers should help older patients learn about health benefits and programs to which they are entitled.

Individually, Medicare, Medicaid, Medigap, and private long-term care insurance have shortcomings in providing comprehensive geriatric care:

  • Medicare excludes long-term custodial care, some preventive services, and large amounts of prescription drug costs.

  • Medicaid belatedly intervenes after the patient is impoverished.

  • Medigap, like Medicare, excludes long-term care.

  • Private insurance is too expensive for most of older adults, leaves them vulnerable to financial catastrophe, and supports only fragments of long-term care.

Collectively, these programs rarely promote integration of acute and long-term care or coordination of health and social services. However, several integrated care models, using combinations of public funding and private insurance, have been developed to provide comprehensive geriatric care, including some long-term care.

Social health maintenance organizations (SHMOs)

SHMOs (see SHMOs at CMS.org) were demonstration programs financed by Medicare during the 1980s and 1990s. They used Medicare, Medicaid, and private patient payments to cover a wide range of care benefits managed by nurses, social workers, and physicians. However, they failed to show improved outcomes versus other programs of that time.

Program of All-Inclusive Care for the Elderly (PACE)

PACE is designed to keep patients living in the community as long as medically, socially, and financially possible. A PACE interdisciplinary team assesses patient needs and develops and implements a care plan.

PACE includes medical and dental care, adult day care (including transportation to and from the facility), health and personal care at home, prescription drugs, social services, rehabilitation, meals, nutritional counseling, and hospital and long-term care when needed. PACE programs provide social and medical services primarily in an adult day health center, supplemented by in-home and referral services. The PACE service package must include all Medicare and Medicaid covered services, and other services determined necessary by the interdisciplinary team for the care of the PACE participant. PACE may require a monthly fee.

The following is needed to qualify for PACE:

  • Age 55 or older

  • Live in the service area of a PACE organization (in a state with approved PACE providers)

  • Need nursing home-level of care (as certified by each state)

  • Be able to live safely in the community with help from PACE

Continuing care communities

A life-care community or continuing care retirement community provides housing, health care, and other services under packaged financing and management. These communities may have a clinic, an infirmary, or even a nursing home on the site, and housing is designed to accommodate disabled people. Many of these communities serve wealthy retirees willing to sign long-term contracts for their housing and care.

Some life-care communities fail because inflation and an aging population cause costs for services to exceed income. Some communities keep costs down by providing housing and minimal services with options to purchase additional services.

More Information

Click here for Patient Education
NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version

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