Long Term Care (should it be covered or not)

[Gij]

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Long term care is one of those issues that seems to me to be a growing problem. Of course the ideal approach is that in our ideal system where access to healthcare is universal, all the costs for the long term care should be covered. However, that seems to be far from practical. This, I think is one of those areas that rationing needs to be done on the dollar amount that can be spent. Otherwise it is simply unaffordable. Imagine an 18 years old who becomes quadriplegic in a car accident. Caring for this patient might have an annual cost of $70,000. When considering the huge burden that this will have on the healthcare system over the many years, is it reasonable to expect insurance (private or public) to cover this? If not, who is responsible for the cost when the patient can't afford it? The example might not be a frequent occurrence, but with an aging population, long term care is becoming a bigger problem. Any thoughts? discussion on other countries' approach might be useful.

 

[Labslave]

Long term care is one of those issues that seems to me to be a growing problem. Of course the ideal approach is that in our ideal system where access to healthcare is universal, all the costs for the long term care should be covered. However, that seems to be far from practical. This, I think is one of those areas that rationing needs to be done on the dollar amount that can be spent. Otherwise it is simply unaffordable. Imagine an 18 years old who becomes quadriplegic in a car accident. Caring for this patient might have an annual cost of $70,000. When considering the huge burden that this will have on the healthcare system over the many years, is it reasonable to expect insurance (private or public) to cover this? If not, who is responsible for the cost when the patient can't afford it? The example might not be a frequent occurrence, but with an aging population, long term care is becoming a bigger problem. Any thoughts? discussion on other countries' approach might be useful.

It would not be reasonable for a private insurance company to pick up the bill for something like this, and that's precisely why coverage should NOT be delivered from a cost effective/profit-based perspective. A private insurance company would be eating a lot of dough on an individual like this...which is why cherry picking takes place in the current system we employ in the USA. It is also why many individuals in predicaments such as this 'go without' for a long period of time (patients with kidney problems, etc.). Yet, our outdated system continues to wreak its havoc on our nation...

I'm of the opinion that we shouldn't worry about whether or not long-term care for an individual like this is practical from a monetary standpoint. This is one of the major reasons why I support a tax-funded healthcare system that is based on the patient first and NOT on profit. You would eliminate the need of making a 'choice' in a situation like this and we wouldn't be having this discussion right now.

But does a choice really exist in this situation in the first place? I mean, shouldn't we be obligated to take care of the patient irrespective of the cost, especially when the alternative is death??? At what point does healthcare become "unaffordable" when a person's life is at stake???

I'd also be interested in an explanation of this "rationing on the dollar amount that can be spent" business. I guess I don't get it.

 

[Gij]

It would not be reasonable for a private insurance company to pick up the bill for something like this, and that's precisely why coverage should NOT be delivered from a cost effective/profit-based perspective. A private insurance company would be eating a lot of dough on an individual like this...which is why cherry picking takes place in the current system we employ in the USA. It is also why many individuals in predicaments such as this 'go without' for a long period of time (patients with kidney problems, etc.). Yet, our outdated system continues to wreak its havoc on our nation...

I'm of the opinion that we shouldn't worry about whether or not long-term care for an individual like this is practical from a monetary standpoint. This is one of the major reasons why I support a tax-funded healthcare system that is based on the patient first and NOT on profit. You would eliminate the need of making a 'choice' in a situation like this and we wouldn't be having this discussion right now.

But does a choice really exist in this situation in the first place? I mean, shouldn't we be obligated to take care of the patient irrespective of the cost, especially when the alternative is death??? At what point does healthcare become "unaffordable" when a person's life is at stake???

I'd also be interested in an explanation of this "rationing on the dollar amount that can be spent" business. I guess I don't get it.

I am for the universal single payer health coverage. There is no doubt that from the standpoint of a care provider cost should be covered regardless. My question is that if this is practical (even assuming we have the most efficient single payer universal coverage). This can be truely unaffordable, when considering the aging population which increasingly become in need of long term care. The problem is not a simple one to resolve. The cost of long term care is huge. I am not arguing for rationing. I am saying that I have not seen this issue addressed based on the cost and our buying power. I am interested in seeing the possibilities being discussed based on numbers and estimated costs. Rationing is the last thing that one would like think of in healthcare, but if the resources are limited (like organs available for transplant for example) then priorities need to be considered in utilization of the resources.

 

[chef_NU]

But does a choice really exist in this situation in the first place? I mean, shouldn't we be obligated to take care of the patient irrespective of the cost, especially when the alternative is death??? At what point does healthcare become "unaffordable" when a person's life is at stake???

I'd also be interested in an explanation of this "rationing on the dollar amount that can be spent" business. I guess I don't get it.

This is why ours and many other health care systems are screwed up. The public's perception of how health care should be managed is fundamentally flawed. The vast majority of people think that care should never be withheld in the face of substantial medical need. This is just plain wrong. We absolutely have a choice. As a country, we need to have politicians who have the balls to come out and say it: we can't afford to give everyone the health care they need. When we try to do that, the system collapses because (A) we spend half of our GDP providing quality care for everyone, or (B) we create huge government debt by providing care without the taxes to fund it (as we are doing now). Of course, the answer is to make cost-effective care the number one priority. It is my opinion that the best way to do this is to force people to either pay out of pocket or contract with private insurance companies. If you are uninsurable, too bad. I know its not nice, and it doesn't sound good. But this is the only sustainable way to run a quality health care system in the modern world.

 

[Gij]

This is why ours and many other health care systems are screwed up. The public's perception of how health care should be managed is fundamentally flawed. The vast majority of people think that care should never be withheld in the face of substantial medical need. This is just plain wrong. We absolutely have a choice. As a country, we need to have politicians who have the balls to come out and say it: we can't afford to give everyone the health care they need. When we try to do that, the system collapses because (A) we spend half of our GDP providing quality care for everyone, or (B) we create huge government debt by providing care without the taxes to fund it (as we are doing now). Of course, the answer is to make cost-effective care the number one priority. It is my opinion that the best way to do this is to force people to either pay out of pocket or contract with private insurance companies. If you are uninsurable, too bad. I know its not nice, and it doesn't sound good. But this is the only sustainable way to run a quality health care system in the modern world.

I don't think you are saying that healthcare is to be blamed for our deficit, but just to state my position, I don't think healthcare is to be blamed for our debt. If US spends more on healthcare than other countries, the expenditure on military is much much much more than that of other countries (I wish I could give you some $ amount). I don't know how much "liberation" of Iraq has cost us? These are issues that can be discussed extensively.
I also think that trying to cover long term care regardless of the cost might not be practical. Anybody with some numbers/stats that could help this discussion become less about philosophies and more about practicality?
(all opinions are still welcome)

 

[QuantumMechanic]

If you are uninsurable, too bad. I know its not nice, and it doesn't sound good. But this is the only sustainable way to run a quality health care system in the modern world.

Say you're highly at risk for heart disease (family hx, aging male, etc.) and a insurance company in your idealized free market refuses to take on your risk. And say, your doctor tells you that you need a bypass surgery that costs several hundred thousand dollars. What then? Is it too bad, that you just don't happen to have 500k in the bank (or even if you had a retirement fund, you have to spend your entire lifesavings to have a surgery to make you live longer!!! ) to pay for the surgery? The problem with free market insurance is that these companies (rightly, economically) will refuse to cover the people that need the insurance the most. If this was the case, there would be an uproar in this country because of a lack of medical insurance for the people most in need of insurance. In the end, either the government has to be the payer or the government has to force the insurance companies to take on more risk than they should economically have to take in this free market situation.

 

[DrBowtie]

It would not be reasonable for a private insurance company to pick up the bill for something like this, and that's precisely why coverage should NOT be delivered from a cost effective/profit-based perspective. A private insurance company would be eating a lot of dough on an individual like this...which is why cherry picking takes place in the current system we employ in the USA. It is also why many individuals in predicaments such as this 'go without' for a long period of time (patients with kidney problems, etc.). Yet, our outdated system continues to wreak its havoc on our nation...

I'm of the opinion that we shouldn't worry about whether or not long-term care for an individual like this is practical from a monetary standpoint. This is one of the major reasons why I support a tax-funded healthcare system that is based on the patient first and NOT on profit. You would eliminate the need of making a 'choice' in a situation like this and we wouldn't be having this discussion right now.

But does a choice really exist in this situation in the first place? I mean, shouldn't we be obligated to take care of the patient irrespective of the cost, especially when the alternative is death??? At what point does healthcare become "unaffordable" when a person's life is at stake???

I'd also be interested in an explanation of this "rationing on the dollar amount that can be spent" business. I guess I don't get it.

Without being practical, the government would turn into companies like Ford and GM who are now in the retirement/pension business rather than the car business. I'm sure you have seen these companies tanking lately.

 

[DrBowtie]

Say you're highly at risk for heart disease (family hx, aging male, etc.) and a insurance company in your idealized free market refuses to take on your risk. And say, your doctor tells you that you need a bypass surgery that costs several hundred thousand dollars. What then? Is it too bad, that you just don't happen to have 500k in the bank (or even if you had a retirement fund, you have to spend your entire lifesavings to have a surgery to make you live longer!!! ) to pay for the surgery? The problem with free market insurance is that these companies (rightly, economically) will refuse to cover the people that need the insurance the most. If this was the case, there would be an uproar in this country because of a lack of medical insurance for the people most in need of insurance. In the end, either the government has to be the payer or the government has to force the insurance companies to take on more risk than they should economically have to take in this free market situation.

The whole concept of insurance is to pool risk. It would be illogical for companies to add a high risk person without first adding many low risk people too.

I am a large supporter of free market everything, but I acknowledge that this is a sticky situation where government intervention is probably needed for the lower class.

 

[bananaface]

Anybody with some numbers/stats that could help this discussion become less about philosophies and more about practicality?
(all opinions are still welcome)

Currently, about 1/4 of healthcare spending for those 65 or older is on long term care. You can count on a spike in utilization if services become covered, and a spike in those age 65 and older in the coming years. That's a hefty chunk of change. IMO, we are better off focusing spending on all cost effective areas, because they allow us to do the most good with our available funds, and then prioritizing spending in non cost effective areas or using those cost savings to cover people who could not otherwise afford healthcare.

 

[bananaface]

The whole concept of insurance is to pool risk. It would be illogical for companies to add a high risk person without first adding many low risk people too.

I am a large supporter of free market everything, but I acknowledge that this is a sticky situation where government intervention is probably needed for the lower class.

What would ideally happen is the massive numbers of uninsured healthy folks would decide to buy in, decreasing the average burden overall. The question is, what can we do to get them to opt in? Most would prefer to be insured, but feel that they are unlikely to encounter major medical problems.

 

[DrBowtie]

What would ideally happen is the massive numbers of uninsured healthy folks would decide to buy in, decreasing the average burden overall. The question is, what can we do to get them to opt in?

One way would be to make it like car insurance and require it, but I am STRONGLY against that.

 

[Gij]

The whole concept of insurance is to pool risk. It would be illogical for companies to add a high risk person without first adding many low risk people too.

I am a large supporter of free market everything, but I acknowledge that this is a sticky situation where government intervention is probably needed for the lower class.

I think free market is good in general, but when it comes to healthcare I don't think free market is the best way to go. Maybe the reason is that the nature of what is purchased is different from say a car. That's a whole discussion to itself, but if I may add one other thing before getting too side tracked, I think one of the reasons for the high cost of care is the free market in which high-cost technologies with very limited effectiveness can thrive (or at least stay viable). Interventions based on these technologies truely send the price of long term care through the roof.

 

[DrBowtie]

I think free market is good in general, but when it comes to healthcare I don't think free market is the best way to go. Maybe the reason is that the nature of what is purchased is different from say a car. That's a whole discussion to itself, but if I may add one other thing before getting too side tracked, I think one of the reasons for the high cost of care is the free market in which high-cost technologies with very limited effectiveness can thrive (or at least stay viable). Interventions based on these technologies truely send the price of long term care through the roof.

Yes, the new technology is a large factor in the cost, but are you suggesting a disintegration of research/technology? That would be a huge mistake. It is this new technology that is largely showing up in academic centers who often treat the majority of the underserved. Where do you think the new Rads/Rad Onc/Surgery technology is being introduced?

 

[Lindyhopper]

. . . we can't afford to give everyone the health care they need. When we try to do that, the system collapses because (A) we spend half of our GDP providing quality care for everyone, or (B) we create huge government debt by providing care without the taxes to fund it (as we are doing now).

HALF of GDP on quality care? I assume you are just totally pulling numbers out of your a$$. The US spends approx 15% of GDP on health care. Other developed countries spend spend about 8-10%. These single payer nations have government imposed "rationing", while the US allocates care based on both market forces & governmental policy.

 

[Gij]

Yes, the new technology is a large factor in the cost, but are you suggesting a disintegration of research/technology? That would be a huge mistake. It is this new technology that is largely showing up in academic centers who often treat the majority of the underserved. Where do you think the new Rads/Rad Onc/Surgery technology is being introduced?

As someone who has worked on developing cheap medical technology (in academia and in collaboration with industry), I know that effective medicine does not need to be expensive. However, people don't want to think outside the box. In academia there is some freedom as the money comes from government. In industry thinking outside the box is a taboo. Sticking to convention = taking less risk, and risk = what investors and CEOs hate (I have seen their reactions in person). You make the drug, then when your patent runs out (and when there is no room for extension through legal avenues) you make the extended release version to keep the price high with minimal or no improvement in the overall effectiveness of the intervention. The most important part: this strategy actually WORKS! (Example : Prilosce patent ran out in 2001 and NEXIUM, "the purple pill", was born) I acknowledge that incremental improvement that come with high price tags have made the medical technology in this country somewhat better than that of other countries but at a price that even despite the poor/limited distribution of the resources is still outrageously high (I am referring to the 15% of GDP spent in this country on healthcare 44% of which by the way is supplied by the government).
The idea that more money gets us better technology is a) intuitive and b) has been repeated so many times that goes unchallenged. However, whether looking at it from personal experience or comparing it with how other countries' less expensive healthcare measures against us, higher expenditure does not bring better results.
We do need to reward innovation, but when it is truly innovation. This needs leadership; the invisible hands of free market can't do that for us.

 

[Gij]

To get us back on track: does anybody know how other developed countries handle long term care? Average age is higher in some European countries so that might be a good indicator of how this problem will be in the US in the near future (assuming that we are hopefully moving towards universal coverage as they have now).

 

[Lindyhopper]

One reason that most advanced "single payer" nations have cheaper drug prices is their superior buying power. These huge government buyers can effectively negotiate cheaper prices. In the US each individual has little negotiating power. This results in higher prices. The US market thus pretty much pays the cost of drug developement. The rests of the world sort of rides along.
It's not obvious what if anything the US should do about this.

 

[DrBowtie]

One reason that most advanced "single payer" nations have cheaper drug prices is their superior buying power. These huge government buyers can effectively negotiate cheaper prices. In the US each individual has little negotiating power. This results in higher prices. The US market thus pretty much pays the cost of drug developement. The rests of the world sort of rides along.
It's not obvious what if anything the US should do about this.

True. As the superpower, we are expected to take on the majority of the cost for anything.

 

[bananaface]

One reason that most advanced "single payer" nations have cheaper drug prices is their superior buying power. These huge government buyers can effectively negotiate cheaper prices. In the US each individual has little negotiating power. This results in higher prices. The US market thus pretty much pays the cost of drug developement. The rests of the world sort of rides along.
It's not obvious what if anything the US should do about this.

Drug costs account for only 10% of US healthcare spending, contrary to the popular perception that they are the root of the problem. There is much more going on than rising drug costs, although they are a minor contributing factor.

 

[Lindyhopper]

Drug costs account for only 10% of US healthcare spending, contrary . . .

Interesting statistic. ( scources would be nice but Hey, it's not a research seminar) But 10% really is a significant part of health care costs. & health care is a huge part of our economy. In many instances drugs are also cost effective.
Two things annoy me about pharma. 1) It doesn't seem fair that the cost of developement is so disproportionately paid by the American consumer. But I'm not sure there is anything we can do about it without choking off important innovation.
2) It seems like marketing is very well funded.

 

[bananaface]

Interesting statistic. ( scources would be nice but Hey, it's not a research seminar) But 10% really is a significant part of health care costs. & health care is a huge part of our economy. In many instances drugs are also cost effective.
Two things annoy me about pharma. 1) It doesn't seem fair that the cost of developement is so disproportionately paid by the American consumer. But I'm not sure there is anything we can do about it without choking off important innovation.
2) It seems like marketing is very well funded.

It was a statistic presented in class. The slide reference listed it as "California HealthCare Foundation 2004a". But, I don't find an accompanying list of references at the end of the presentation. I can ask for it. That group put out several reports in 2004, which are searchable from here: http://www.chcf.org/search/index.cfm

*edit*
Here it is:
http://www.californiahealthline.org/index.cfm?Action=dspItem&itemID=96335

 

[Lindyhopper]

That's a great link. Thanks alot. Are you an MPH student?

 

[Doctor Bagel]

The whole concept of insurance is to pool risk. It would be illogical for companies to add a high risk person without first adding many low risk people too.

I am a large supporter of free market everything, but I acknowledge that this is a sticky situation where government intervention is probably needed for the lower class.

You're right, it works by pooling right. I actually think that's a good argument for nationalized health care -- the more people you have in the pool, the more distribution of cost/risk.

Also, what happens when everybody is relatively high risk? With an aging population and an obesity epidemic, low risk people are rapidly disappearing.

 

[chef_NU]

Say you're highly at risk for heart disease (family hx, aging male, etc.) and a insurance company in your idealized free market refuses to take on your risk. And say, your doctor tells you that you need a bypass surgery that costs several hundred thousand dollars. What then? Is it too bad, that you just don't happen to have 500k in the bank (or even if you had a retirement fund, you have to spend your entire lifesavings to have a surgery to make you live longer!!! ) to pay for the surgery? The problem with free market insurance is that these companies (rightly, economically) will refuse to cover the people that need the insurance the most.

Then you're f*cked.

 

[chef_NU]

Also, what happens when everybody is relatively high risk? With an aging population and an obesity epidemic, low risk people are rapidly disappearing.

How do we give people incentive not to get fat, smoke, do drugs, etc? It's not to place government regulations on the food industry, or give huge settlements to plaintiffs against big tobacco. It's to make the *******es who do these things ante up when its comes to paying for their poor health decisions. The only way to change people's personal behavior is to give them financial incentive.

 

[Gij]

Somebody questioned the accuracy of the cost of medication being 10% of the total cost. I wanted to say that although I do not remember the source, I also believe that figure is accurate.
10% is relatively small, but it is interesting to know that 1) compare to other healthcare costs, cost control on drugs has been very minimal and therefore the percentage has been rising 2) the drug companies have by far the largest margin of profit of all industries(after all the $ they spend on development, trial etc.). I believe the margin is 25% but someone please double check this.
I think the discussion has been very good since we have incorporated some numbers and stats, but to get back on track, can somebody please give a definition of what constitude long term care. I think the cost of medicines and services is a general issue that affect all aspects of healthcare including long term care, but there are issues unique and in many respect harder to resolve that are specific to long term care. I am still interested in seeing how this is handled in older/social countries.

 

[bananaface]

That's a great link. Thanks alot. Are you an MPH student?

No problem. 🙂

I am a pharmacy student, third year.

 

[bananaface]

Somebody questioned the accuracy of the cost of medication being 10% of the total cost. I wanted to say that although I do not remember the source, I also believe that figure is accurate.
10% is relatively small, but it is interesting to know that 1) compare to other healthcare costs, cost control on drugs has been very minimal and therefore the percentage has been rising 2) the drug companies have by far the largest margin of profit of all industries(after all the $ they spend on development, trial etc.). I believe the margin is 25% but someone please double check this.
I think the discussion has been very good since we have incorporated some numbers and stats, but to get back on track, can somebody please give a definition of what constitude long term care. I think the cost of medicines and services is a general issue that affect all aspects of healthcare including long term care, but there are issues unique and in many respect harder to resolve that are specific to long term care. I am still interested in seeing how this is handled in older/social countries.

I provided a link to my source on the previous page. It was 10% in 2002.

Here is a link to an overview of LTC. Many services included are non-medical in nature.

LONG TERM CARE--FUNDING AND PROVIDERS

What Is Long Term Care?
When a person requires someone else to help him with his physical or emotional needs over an extended period of time, this is long-term care. This help may be required for many of the activities or needs that healthy people take for granted and may include such things as:

Walking
Bathing
Using the bathroom
Incontinence
Pain management
Preventing unsafe behavior
Preventing wandering
Providing comfort and assurance
Physical or occupational therapy
Attending to medical needs
Counseling
Feeding
Answering the phone
Meeting doctors' appointments
Providing meals
Maintaining the household
Shopping and running errands
Providing transportation
Administering medications
Managing money
Paying bills
Doing the laundry
Attending to personal hygiene
Personal grooming
Writing letters or notes
Making repairs to the home
Maintaining a yard
Removing snow
The need for long-term care help might be due to a terminal condition, disability, illness, injury or the infirmity of old age. Estimates by experts are that at least 60% of all individuals will need extended help in one or more of the areas above during their lifetime. The need for long-term care may only last for a few weeks or months or it may go on for years. It all depends on the underlying reasons for needing care.

Temporary long term care (need for care for only weeks or months)

Rehabilitation from a hospital stay
Recovery from illness
Recovery from injury
Recovery from surgery
Terminal medical condition
Ongoing long term care (need for care for many months or years)

Chronic medical conditions
Chronic severe pain
Permanent disabilities
Dementia
Ongoing need for help with activities of daily living
Need for supervision
Long-term care services may be provided in any of the following settings:

In the home of the recipient
In the home of a family member or friend of the recipient
At an adult day services location
In an assisted living facility or board-and-care home
In a hospice facility
In a nursing home

 

[Labslave]

Then you're f*cked.

Although this may seem like a childish response on my part, I doubt you would have the same attitude if you found yourself or one of your close loved ones in this situation.

 

[astrife]

.

 

[Gij]

People suffer and die everyday. Their lives are no more important than mine or yours; they are just victims of circumstantes (sometimes circumstances they create). The question then becomes is putting together a universal health-care system that will decrease effeciency and quality at the higher-end and raise it for those at the lower end worth that suffering and dieing. It all comes down to your personal opinion about whether people are responsible for their own personal problems (heart disease, diabetes, etc...) and their failure to insure themselves before they were plagued with a long-term ailment or the government is responsible for their problems. Personally, if I ever make it to the world of MD's I don't want my paycheck being capped because I'm not allowed to focus on profits I have to focus on the ******* who snacked too much and didn't insure himself before he got diabetes.

You are entitled your opinion, but here is the way I look at it: you probably agree that what happens to a group of people, regardless of the source, affects the whole society. I am trying to say taking care of the needy is simply not a matter of compassion. Therefore, labeling inability to attain healthcare "personal problem" might not be very true as the consequences affect (even financially) you and me and even all those who do everything just perfect. I believe in personal responsibility as well as the responsibility of society towards individuals. I think there needs to be a balance so that healthy behaviors are promoted (by education as well as by disincentives for unhealthy behavior), but to the extent we can afford we all need to give to make healthcare accessable. Needing long term care is often not a metter of choice. There are accidents, genetic disorders, aging etc.
So I think, the focus of the argument for long term care coverage is not whether it ideally should or should not be available, but to what extent we can afford it?

 

[Isis33]

the question that needs to be asked is do all citizens have a right to healthcare? Of course, the answer is a resounding yes.
Then do all people have the right to the exact same options in healthcare amidst all the expensive new technology thats available? This would be yes in an ideal world but the cold truth is that its simply not possible to subsidize this. Somebody once compared it to going into a car dealership with 20,000 dollars and demanding the 40,000 car. You just can't have it, because the resources aren't there.
This wouldn't be America, land of opportunity, if the wealthy people were forced to settle and give up healthcare that they could afford.
The only solution seems to be a two tiered system where we must focus on the lower tier immensely making sure that the uninsured and homeless are receiving a good standard of basic quality care, and that they dont feel they have to wait till something catastrophic happens to go the emergency room (driving up costs for everyone). In the second tier, those who are willing to pay for more, new technology that hasn't been proven yet, can have those options but they would still be guaranteed the first tier through a nationally based system