Journal of Gerontological Nursing

EDITORIAL 

Long Term: Insurance Considerations

Joan Ouinn, MSN, RN, FAAN

Abstract

Long-term care, whether provided in a nursing home or at home, can become a catastrophic event for older adults and their families. Average monthly nursing home costs can exceed $4000 per month while 24-hour care at home can be more expensive. It is clear from studies reviewed, experts consulted, and industry surveys that remaining at home for as long as possible is the preferred consumer choice among long-term care options. It is also clear that those needing long-term care services, their families, and their physicians do not necessarily know what services exist, how to access these services, and how to negotiate service delivery in an effective manner. The result is that higher levels of care are obtained for longer periods of time than may be necessary to meet specific individual need.

The most marketable long-term care product, to address the diverse needs mentioned above, will be one that offers home-care services as part of the benefit and includes not only health-related, skilled services, but social support services such as adult day care, homedelivered meals, and chore and companion services as well. However, unless utilization is controlled, the pricing of such a product will be prohibitive and available to only a few older adults and their families who can afford the cost. In addition, as long-term care insurance will be developed and marketed by for-profit commercial health insurers, the profitability of the products will be of much concern to them.

There are several ways to control inappropriate service utilization. One can require very large consumer copayment or qualifying periods. This method will not be very attractive to many consumers as a plan that pays benefits before the consumer has paid a great deal of expense out of pocket. Another way that many insurers are considering is a managed care approach which provides for the controls necessary to allow for provision of a full range of long-term care service options, thus accommodating consumer choice.

Central to this managed care approach is care/case management. Care/case management was conceived and developed by nurses in early 1970 demonstration projects such as Triage in Connecticut, Access in New York, and South Carolina's Long Term Care Demonstration Project. These pilot projects defined and then implemented approaches to planning, organizing, and coordinating short- and long-term care for older people and their families. Cost containment was clearly one objective of these programs.

However, the care/case management approach is also concerned with the organization and sequencing of services, as well as the resources needed to respond to an individual's total care problems. In most programs, care/case management service is provided by specially trained healthcare professionals (nurses, social workers, rehabilitation counselors). They act as diagnosticians, problem solvers, brokers, gatekeepers and consumer advocates in the long-term care system.

There is a critical connection between long-term care insurance products and care/case management services. Healthcare professionals have a unique opportunity to use their skills in delivering coordinated, comprehensive services to older people who are in need of them. Through expert evaluation of individual consumer need, coupled with judicious use of a multitude of available services, control of healthcare service utilization and thus dollars will result in many older adults and their families being able to afford long-term care insurance. At the same time, they will receive just the services necessary for them to maintain their independence. Thus, the catastrophic consequences of long-term care, both financial and emotional, may be lessened for many individuals.…

Long-term care, whether provided in a nursing home or at home, can become a catastrophic event for older adults and their families. Average monthly nursing home costs can exceed $4000 per month while 24-hour care at home can be more expensive. It is clear from studies reviewed, experts consulted, and industry surveys that remaining at home for as long as possible is the preferred consumer choice among long-term care options. It is also clear that those needing long-term care services, their families, and their physicians do not necessarily know what services exist, how to access these services, and how to negotiate service delivery in an effective manner. The result is that higher levels of care are obtained for longer periods of time than may be necessary to meet specific individual need.

The most marketable long-term care product, to address the diverse needs mentioned above, will be one that offers home-care services as part of the benefit and includes not only health-related, skilled services, but social support services such as adult day care, homedelivered meals, and chore and companion services as well. However, unless utilization is controlled, the pricing of such a product will be prohibitive and available to only a few older adults and their families who can afford the cost. In addition, as long-term care insurance will be developed and marketed by for-profit commercial health insurers, the profitability of the products will be of much concern to them.

There are several ways to control inappropriate service utilization. One can require very large consumer copayment or qualifying periods. This method will not be very attractive to many consumers as a plan that pays benefits before the consumer has paid a great deal of expense out of pocket. Another way that many insurers are considering is a managed care approach which provides for the controls necessary to allow for provision of a full range of long-term care service options, thus accommodating consumer choice.

Central to this managed care approach is care/case management. Care/case management was conceived and developed by nurses in early 1970 demonstration projects such as Triage in Connecticut, Access in New York, and South Carolina's Long Term Care Demonstration Project. These pilot projects defined and then implemented approaches to planning, organizing, and coordinating short- and long-term care for older people and their families. Cost containment was clearly one objective of these programs.

However, the care/case management approach is also concerned with the organization and sequencing of services, as well as the resources needed to respond to an individual's total care problems. In most programs, care/case management service is provided by specially trained healthcare professionals (nurses, social workers, rehabilitation counselors). They act as diagnosticians, problem solvers, brokers, gatekeepers and consumer advocates in the long-term care system.

There is a critical connection between long-term care insurance products and care/case management services. Healthcare professionals have a unique opportunity to use their skills in delivering coordinated, comprehensive services to older people who are in need of them. Through expert evaluation of individual consumer need, coupled with judicious use of a multitude of available services, control of healthcare service utilization and thus dollars will result in many older adults and their families being able to afford long-term care insurance. At the same time, they will receive just the services necessary for them to maintain their independence. Thus, the catastrophic consequences of long-term care, both financial and emotional, may be lessened for many individuals.

10.3928/0098-9134-19870501-03

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