Federal Incentives to Reform Long-Term Care Under the Affordable Care Act: State Adoption of the Balancing Incentive Program, 2011-2014.

OBJECTIVES: The Balancing Incentive Program (BIP) was an optional program for states within the Patient Protection and Affordable Care Act to promote Medicaid-funded home and community-based services (HCBS) for older adults and persons with disabilities. Twenty-one states opted to participate in BIP, including several states steadfastly opposed to the health insurance provisions of the Affordable Care Act. This study focused on identifying what factors were associated with states' participation in this program. METHODS: Event history analysis was used to model state adoption of BIP from 2011 to 2014. A range of potential factors was considered representing states' economic, political, and programmatic conditions. RESULTS: The results indicate that states with a higher percentage of Democrats in the state legislature, fewer state employees per capita, and more nursing facility beds were more likely to adopt BIP. In addition, states with fewer home health agencies per capita, that devoted smaller proportions of Medicaid long-term care spending to HCBS, and that had more Money Follows the Person transitions were also more likely to pursue BIP. DISCUSSION: The findings highlight the role of partisanship, administrative capacity, and program history in state BIP adoption decisions. The inclusion of BIP in the Affordable Care Act may have deterred some states from participating in the program due to partisan opposition to the legislation. To encourage the adoption of optional HCBS programs, federal policymakers should consider the role of financial incentives, especially for states with limited bureaucratic capacity and that have made less progress rebalancing Medicaid long-term services and supports.

[Difficulties and Policy Recommendations Related to the Deployment of Long-Term Care Resources in Taiwan`s Indigenous Areas].

Changes in the demographic structure in Taiwan have increased the need for long-term care (LTC). Person-centered and community-based care is being advocated. The need to address the specific LTC needs of Taiwan`s indigenous peoples has been a part of national LTC policy since National Long-term Care Plan 2.0 was adopted in 2015. The provision of LTC services and the deployment of related resources in indigenous areas generally lag behind Taiwan`s other areas. Potential reasons for this disparity include lack of in-charge, dedicated units; exclusive use of normative service models in indigenous areas; and conflict between talent cultivation and rooted development. Future policy should focus more on providing cultural care in indigenous areas and on offering more flexible and diversified development possibilities. The implementation of these policies may promote the development of LTC and the successful deployment of LTC resources in Taiwan`s indigenous regions.

Stepping into the Breach of Federal Inaction: Reforming the Financing of Long-Term Services and Supports in the Post-CLASS Era.

The growing need for long-term services and supports (LTSS) poses significant challenges to both individuals and government. This article documents the continuing failure to tackle this problem at the national level-a failure that was most recently seen in the fallout from the Affordable Care Act (ACA), which included the single piece of national legislation ever enacted to comprehensively address LTSS costs: the Community Living Assistance Services and Supports (CLASS) Act. The CLASS Act was passed as part of the ACA (Title 8) but was repealed in 2013. Following its demise, policy experts and some Democrats have made additional proposals for addressing the LTSS financing crisis. Moreover, significant government action is taking place at the state level, both to relieve financial and emotional burdens on LTSS recipients and their families and to ease pressure on state Medicaid budgets. Lessons from these initiatives could serve as opportunities for learning how to overcome roadblocks to successful policy development, adoption, and implementation across states and for traversing the policy and political tradeoffs should a policy window once again open for addressing the problem of LTSS financing nationally.

COVID-19 in the Long-Term Care Setting: The CMS Perspective.

Safeguarding the health and promoting the well-being and quality of life of the most vulnerable and fragile citizens is a top priority for the Centers for Medicare & Medicaid Services (CMS). In response to the Coronavirus Disease 2019 (COVID-19) pandemic, numerous regulatory policies and 1,135 waivers of federal requirements have been implemented by CMS to give long-term care providers and professionals flexibility to meet the demands of resident and patient care needs during this public health emergency. Goals for these policies and waivers are increasing capacity, enhancing workforce and capability, improving oversight and transparency, preventing COVID-19 transmission, and reducing provider burden. J Am Geriatr Soc 68:1366-1369, 2020.

[Impact of the Dependency Act on regional spending on social services]. / Impacto de la Ley de Dependencia sobre el gasto autonómico en servicios sociales.

OBJECTIVE: In this paper we address whether the System for Personal Autonomy and Care of Dependent Persons contributes to increasing the volume of resources of the public social services system (displacement effect) or, on the contrary, whether this development has taken place at the expense of other social services (substitution effect). METHOD: Panel data analysis is used to explain how per capita expenditure on social services evolves in the Spanish Regions under the common regime in the period 2002-2016. RESULTS: The implementation of the Dependency Act is associated with a 14% increase in the level of per capita expenditure on social services. This effect raises 25% when the variable explained is expenditure on current transfers of a social nature. On the other hand, law changes introduced in 2012 and 2013 were associated with a reduction in per capita expenditure on current transfers of around 10%. CONCLUSIONS: This evidence would refute the hypothesis that the System for Personal Autonomy and Care of Dependent Persons had merely a "substitution" effect on autonomous spending on social services.

Psychotherapy in Psychiatry: Fighting Alternative Facts.

In the Canadian province of Ontario, the Ministry of Health and Long-Term Care is proposing to impose arbitrary limits on access to psychotherapy provided by physicians. This column presents and debunks 3 myths associated with this ill-conceived proposal: (1) that long-term psychotherapy costs the health care system too much money, making it necessary for the government to curb this spending; (2) that long-term psychotherapy is a non-evidence-based treatment being needlessly spent on the worried well; and (3) that we need to focus on quick treatments, not long ones.

LTC 2.0: The 2017 reform of home- and community-based long-term care in Taiwan.

Taiwan planned to establish a social insurance-based long-term care system in 2016. However, due to the change in political parties that year, it was decided that Taiwan's long-term care policy would remain a tax-based financing scheme. The new policy focuses on providing home- and community-based service (HCBS); a three-layer HCBS service network within towns and districts was set to provide the 17 types of services in the HCBS spectrum, including preventive care. The reform was criticized as being too restrictive and lacking flexibility. However, the HCBS service spectrum has been widened, the target group has been enlarged, and thus HCBS utilization has increased. A rolling amendment has continued into 2018: the HCBS system requirement has been eased, and a new capitalized fee-for-service payment system has been launched. This paper discusses the analysis of the policy reform.

From fragmentation toward integration: a preliminary study of a new long-term care policy in a fast-aging country.

BACKGROUND: Taiwan, one of the fastest-aging countries in the world, started implementing version 1.0 of its long-term care (LTC) plan in 2008. In 2017, LTC Plan 2.0 began a new era with its goal to integrate Taiwan's fragmented LTC service system. LTC Plan 2.0 also aims to establish an integrated community-based LTC system incorporating both health care and disability prevention. This three-tier model consists of the following: two LTC services with a day-care center as their base and case management (Tier A), a day-care center and a single LTC service (Tier B), and LTC stations that provide primary prevention services and respite services for frail community-dwelling older adults to prevent further disabilities (Tier C). A defined cluster of agencies in a local area works together as a Tier ABC team. LTC Plan 2.0 is a new policy for Taiwan, and hence it is important to understand the agencies' initial difficulties with implementation and identify future challenges to help further policy development. METHODS: This preliminary study explored the challenges to implementing LTC 2.0 through in-depth interviews based on Evashwick's integration mechanisms with representatives from three service teams. We interviewed three chief executive officers and three case managers. RESULTS: We found that the LTC Plan 2.0 mechanisms for service integration have been insufficiently implemented. Recommendations include (1) Build up the trust between agencies and government, avoid duplication of LTC services within Tier ABC team, and encourage agencies within a team to create a shared administrative system with the same mission and vision. (2) Clarify the roles and responsibilities of government care managers and agency case managers. (3) Provide an integrated information system and create an official platform for sharing client records across different agencies and caregivers. (4) Establish a tool and platform to track the budget and payment across different levels of service as soon as possible. CONCLUSION: There is an increased demand for LTC services in Taiwan because of its rapidly aging population. Our findings shed some light on the challenges to developing integrated LTC services and thus may help both policymakers and service providers find ways to overcome these challenges.

Catastrophic risk associated with out-of-pocket payments for long term care in Spain.

OBJECTIVES: This study analyses the financial burden associated with the introduction of copayment for long-term care (LTC) in Spain in 2012 for dependent individuals. MATERIAL AND METHODS: We analyse and identify households for which the dependency-related out-of-pocket payment exceeds the defined catastrophic threshold (incidence), and the gap between the copayment and the threshold for the catastrophic copayment (intensity), for the full population sample and for subsamples based on the level of long-term care dependency and on regional characteristics (regional income and political ideology of party ruling the region). RESULTS: The results obtained show there is a higher risk of impoverishment due to copayment among relatively well-off dependents, although the financial burden falls more heavily on less well-off households. Our findings also reveal interesting regional patterns of inequity in financing and access to long-term care services, which appear to be explained by an uneven development of LTC services (monetary transfers versus formal services) and varying levels of copayment across regions. CONCLUSIONS: The new copayment for long-term care dependency in Spain is an important factor of catastrophic risk, and more attention should be addressed to policies aimed at improving the progressivity of out-of-pocket payments for LTC services within and between regions. In addition, formal services should be prioritised in all regions in order to guarantee equal access for equal need.

A value-critical policy analysis of the nursing home reform act: a focus on care of African American and Latino residents.

Improving nursing home care has been a central legislative focus since the 1980s; The major response effort to address these reports of poor-quality care was first met with a federal rule in 1987, the Nursing Home Reform Act (NHRA). Since enactment of the NHRA in 1987, and despite an increasing utilization of nursing home care by aging minorities, the standardization of care practice, or quality indicators (e.g., structural, process, and outcome measures), within long-term nursing home care have remained relatively unchanged. This paper reports a value-critical policy analysis of the most recent final action rule, effective on November 28 of 2016 by the Centers for Medicare and Medicaid Services (CMS) with a particular focus on its impact on African-American and Latino older adults. This paper presents results of two policy analyses. Taken together, this merged analysis focuses on an overview of the problem, the groups most affected by the problem, current program goals and objectives, forms of benefits and services, and a current state of the social problem. Following the analysis, we present changes and improvements to be made, as well as proposals for reform and recommendations for policy changes.

Ontario's Retirement Homes and Long-Term Care Homes: A Comparison of Care Services and Funding Regimes.

ABSTRACTGrowing demand for beds in government-subsidized long-term care (LTC) homes in Ontario is causing long waitlists, which must be absorbed by other residential alternatives, including unsubsidized retirement homes. This study compares Ontario's LTC homes and retirement homes for care services provided, funding regimes, and implications of differential funding for seniors. Descriptive data for both types of homes were collected from public and proprietary sources regarding service offerings, availability, costs, and funding. Overlaps exist in the services of both LTC and retirement homes, particularly at higher levels of care. Although both sectors charge residents for accommodation, most care costs in LTC homes are publicly funded, whereas residents in retirement homes generally cover these expenses personally. Given waitlists in Ontario's LTC homes, many seniors must find residential care elsewhere, including in retirement homes. Several policy alternatives exist that may serve to improve equity of access to seniors' residential care.

The impact of Dependency Act benefits on employment.

OBJECTIVE: To assess the amount of employment generated from the effective development of the Dependency Act in 2012, by evaluating the number of jobs depending on whether in-kind services or cash benefits were applied. METHODS: The level and total costs of dependency were obtained by using the Survey on Disability, Personal Autonomy and Dependency Situations of 2008. The consumption of dependent households was collected from the Household Budget Survey of 2012 carried out by the Spanish Statistics Institute. The impact on employment was estimated using an extended Input-Output model based on Symmetric Input-Output Tables and labour data from the Spanish National Accounts Base. RESULTS: The total estimated costs of dependency in 2012 were 4,545 million Euros for in-kind services and 2,662 for cash benefits. One hundred and ninety-five thousand, six hundred and sixty-eight jobs were generated in 2012 from dependency costs, and132,997 were linked to in-kind services and 62,671 to cash benefits. Every million Euros allocated for dependency by the Government returned 53.33 jobs linked to in-kind services and 46.21 to cash benefits. Furthermore, 341,505 jobs would have been created if dependency benefits had been exclusively offered via in-kind services. CONCLUSIONS: Dependency benefits were equally distributed between in-kind services and cash benefits in 2012. Given that two out of three job positions generated from dependency benefits are linked to in-kind services, while the remaining third is generated by cash benefits, we conclude that around 146 thousand more jobs would have been generated if benefits had been offered as in-kind services instead of overusing cash benefits.

Homeowner Behavior, Health Status, and Medicaid Payment Eligibility: Evidence from the Deficit Reduction Act of 2005.

This paper analyzes the effect of a change in the status of housing equity as a protected asset for Medicaid long-term care payment eligibility. A difference-in-difference-in-differences strategy is employed to estimate the effect of the policy on the housing equity holdings of potentially treated individuals. Using a panel of unmarried homeowners, the policy induced treated individuals who were likely to require long-term care to hold less housing equity by values of $82,000 to $193,000 relative to control individuals. This equates to relative reductions of 12 to 29 percent for treated individuals after the policy change. Similar effects are not observed when considering health measures less predictive of long-term care services and for a sample of married households who were unlikely affected by the policy. These estimates confirm the importance of the housing asset as a shelter for Medicaid eligibility.

Experiences of the Kansas Extended Care Permit Providers: A descriptive study.

Purpose: A total of 40 states to date have expanded the role of dental hygienists with the goal of improving access to basic oral health services for underserved populations. In Kansas, legislative changes have resulted in the Extended Care Permit (ECP) designation. The purpose of this study is to describe the experiences of registered dental hygienists in Kansas holding ECP certificates (ECP RDH) as of July of 2014.Methods: Secondary data analysis was performed utilizing data collected from a survey conducted in 2014 by Oral Health Kansas. All registered ECP RDH's were sent the 32-item survey via Survey Monkey®. Descriptive statistical analyses consisted of frequency distributions, and measures of central tendency. Inferential analyses using t-tests and ANOVA were conducted to compare groups.Results: A total of 73 responses were received from the (n= 176) surveys that were e-mailed for a 41% response rate. Of the clinicians who responded, 80%, worked at least part-time and in school settings. The most consistent barriers to providing care were the inability to directly bill insurance (52%), financial sustainability (42%) and physical requirements (42%). Follow-up tests found significant differencs between clinician groups when examining barriers.Conclusion: Although the ECP legislation appears to be expanding access to care for citizens in Kansas, significant barriers still exist in making this a viable model for oral healthcare delivery.

Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2018 Rates; Quality Reporting Requirements for Specific Providers; Medicare and Medicaid Electronic Health Record (EHR) Incentive Program Requirements for Eligible Hospitals, Critical Access Hospitals, and Eligible Professionals; Provider-Based Status of Indian Health Service and Tribal Facilities and Organizations; Costs Reporting and Provider Requirements; Agreement Termination Notices. Final rule.

We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems for FY 2018. Some of these changes implement certain statutory provisions contained in the Pathway for Sustainable Growth Rate (SGR) Reform Act of 2013, the Improving Medicare Post-Acute Care Transformation Act of 2014, the Medicare Access and CHIP Reauthorization Act of 2015, the 21st Century Cures Act, and other legislation. We also are making changes relating to the provider-based status of Indian Health Service (IHS) and Tribal facilities and organizations and to the low-volume hospital payment adjustment for hospitals operated by the IHS or a Tribe. In addition, we are providing the market basket update that will apply to the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits for FY 2018. We are updating the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) for FY 2018. In addition, we are establishing new requirements or revising existing requirements for quality reporting by specific Medicare providers (acute care hospitals, PPS-exempt cancer hospitals, LTCHs, and inpatient psychiatric facilities). We also are establishing new requirements or revising existing requirements for eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) participating in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. We are updating policies relating to the Hospital Value-Based Purchasing (VBP) Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition (HAC) Reduction Program. We also are making changes relating to transparency of accrediting organization survey reports and plans of correction of providers and suppliers; electronic signature and electronic submission of the Certification and Settlement Summary page of the Medicare cost reports; and clarification of provider disposal of assets.

[10-year anniversary of the Long-term Care Charter : Time to take stock]. / 10 Jahre Pflege-Charta : Zeit, Bilanz zu ziehen.

Ten years ago, the Charter for People in Need of Long-term Care was published in Germany. The Charter contains a series of basic rights for people in need of long-term care. At the initiative of the Federal Ministry for Family Affairs, Senior Citizens, Women and Youth (BMFSFJ), this was developed in a complex consensus process together with the Federal Ministry of Health (BMG) and representatives from all areas of care. Since then, the Charter has gained practical relevance in various areas of care and has entered into legislation. The article looks at the dissemination and impact of the Charter following a review of the social and legal environment. Further implementation requirements and the revision of the charter are discussed.