World Future
Society
Cyber Society Forum
THE FUTURE OF YOUR OWN
HEALTH AND INDEPENDENCE
By Sam L. Ervin
Chairman and Chief Executive Officer
SCAN
SUMMARY:
The head of a groundbreaking Social HMO in Southern California shows why--and
how--Medicare can be revamped to meet the needs of the twenty-first century.
ake a moment to think
about a situation that you or a loved one may be facing now or in the near future. Imagine
that you are over 65, on Medicare, and you develop a chronic, debilitating disease. Your
doctor prescribes a drug to keep the disease under control, but the drug costs $300 a
month and does nothing for your symptoms of dizziness, weakness and severe joint pain. You
find it hard to bathe, dress yourself and prepare your own meals. You cannot drive your
car any longer. Now, imagine that you live alone and have no relatives nearby. How do you
manage?
Medicare will cover your visits to the doctor, but it
provides for none of the other things you desperately need such as help in paying for the
prescriptions, help taking a bath and getting dressed, help getting your meals, and
Medicare certainly won't help driving your car. What do you do? How do you maintain your
health and your ability to live independently?
Unfortunately, this is not a far-fetched scenario. This is
what countless seniors face today. Countless more will face this as the population ages.
Seventy-five million baby boomers will start turning 65 in 2010. And the Medicare that the
seniors of today and the baby boomers are counting on to help when they get sick is just
not designed to cover the full spectrum of their needs. Medicare was created in 1965 when
the world was a different place. Paying primarily for doctor visits and hospital stays was
sufficient in those days, because those were the high cost items. Life expectancy was
about 70 years and people were not living a long time with debilitating chronic
conditions. There were not as many expensive drugs on the market and there were often
family members nearby to help out when necessary.
It is a very different world today and Medicare needs to
undergo some radical changes to keep up. What changes must we make to assure the future of
our health and independence?
The Need: Change Medicare Now
You would be hard pressed to find any health care professional today that would not agree
that Medicare is a dinosaur. It was created nearly 40 years ago and has not kept pace with
the changes in our society. Medical science and technology have made impressive advances -
drugs and therapies to treat life-threatening diseases, transplants to replace damaged
organs, and other advances that allow people to live longer with chronic conditions. These
changes have made the acute care model of Medicare, where everything is based on a
"sickness episode", obsolete.
Additionally, Medicare was created in an age of
"normal" medical cost inflation. It was not necessary to have controls in place
to manage the cost and volume of the services being provided. Since that time our country
has experienced an unprecedented increase in the cost of medical care. In 1970, health
care spending was 7.1 percent of the GDP. Today, it is 13.4 percent of the GDP.
So it is clear that Medicare needs to be updated, but the
question is how. What type of program will meet the needs of the 21st century?
The Solution For Updating Medicare: The Social HMO
The answer is a program that meets the comprehensive needs of seniors, encourages
independence and does so in a cost-effective manner. Some believe that a model for the
program exists in what is called a Social HMO. The comprehensive nature of the model helps
to promote both the health and the independence of seniors.
This concept of care is timely and necessary to meet
current and future needs and should be available as an alternative for more Americans. The
track record of the Social HMO should inspire the design of the new Medicare.
The Social HMO takes into account medical care and social
services, and considers people who have long-term chronic conditions. That is important,
because right now, 52 percent of seniors have some chronic long-term condition.
Los Angeles Times Washington, D.C. columnist Bob Rosenblatt
offered a good description of SCAN and the complete benefits members enjoy in an article
titled "An Attempt at Improved Elder Care":
"Imagine an HMO for people on Medicare that throws in
some priceless extra services designed to help keep frail older Americans out of nursing
homes... Our imaginary HMO does a lot more outside the purely medical realm. This HMO
might send a health care worker to a woman's home several times a week to help her bathe.
Or it might dispatch a household aide to clean her home or prepare a few days' worth of
meals. Another time, this health plan might provide an otherwise homebound elderly man
with a day-care center for an afternoon, where he can socialize and get a break from the
usual routine."
This "daydream for the elderly and their
families," as the Los Angeles Times called it, is SCAN, a Social HMO, and the concept
can be the Medicare of the future.
The idea of updating Medicare to meet the needs of older
people originated in the early 1980s. A group of collaborative researchers from Brandeis
University and the Health Care Financing Administration designed a plan, later to be
called the Social HMO, that added certain non-Medicare covered social services to the
existing Medicare Health Maintenance Organization. Social services that were added
included care management and community-based services. Think of these services as assisted
living at home. The goal of the researchers' plan was to demonstrate that providing these
added services would help seniors avoid unnecessary nursing home placement and would do so
in a manner that remained budget neutral when compared with fee-for-service Medicare. The
model pools Medicare and Medicaid dollars and appropriate financial participation from the
individual, in the form of co-payments and, sometimes, monthly premiums.
In 1985, following up on the researchers' concept, the
Health Care Financing Administration designated four sites across the country as
demonstration projects to test how the Social HMO model would work.
The Senior Care Action Network (SCAN), in Long Beach,
California, had started some years earlier as a grass roots organization designed
primarily around social service to seniors.
It was selected as one of the four sites to bring to life
the Social HMO. As part of the demonstration project, SCAN members who meet nursing home
certification criteria based on the state's existing definition, are eligible for the
added services, which SCAN calls Independent Living PowerTM.
These benefits include care management, light housekeeping,
personal care, home delivered meals, both institutional and in-home caregiver relief,
adult day care, short-term nursing home benefits, transportation, and electronic
monitoring. They are provided to members based on an individualized care plan and do have
modest copayments. At SCAN, the copayment for most Independent Living PowerTM
services is $8.50 per home visit or adult day care visit and there is a ceiling on the
benefit as well as the monthly co-payment amount.
These extended care benefits are what really separate SCAN
and Social HMOs from Medicare and typical senior HMOs.
The Social HMO concept has been proven to work the way it
was intended. SCAN alone has kept more than 20,000 members who were nursing home certified
out of nursing homes since its inception.
At the onset of the demonstration SCAN serviced only the
Long Beach area of California. Today SCAN serves 50,000 members in four counties in
Southern California. Over 10,000 of the members meet state criteria for nursing homes, yet
only 470 are actually in nursing homes. Ten thousand may not sound like a lot of people,
given that Medicare serves 39 million, but that number makes SCAN the largest senior case
management company in America.
We have seen the success of SCAN as a Social HMO, but we
also see the opportunity for so many more seniors, nationwide, to benefit. That is why I
am urging that the Social HMO concept be woven into a new Medicare.
The Social HMO concept works because it combines medical
and community-based long-term care services designed to help seniors remain living
independently. Medicare today does not provide services that help seniors live
independently. We must change Medicare to include these necessary benefits.
As an example of how SCAN impacts the lives of seniors,
consider Cora Cocks, one of the founders of SCAN. She along with eleven other passionate
seniors founded SCAN and hired me as the executive director in 1978. She served on the
SCAN Board of Directors for many years and was famous for giving talks about "sex
over sixty." Cora has been a member of SCAN Health Plan since 1986. Today, she is 98
years old and after two strokes, she is as feisty as ever. She now walks with a walker,
but still insists on making her own bed, even though it takes her forty-five minutes. She
demands to live at home and our Independent Living PowerTM helps her do that.
What is it that older Americans want and need during their
senior years?
The answer is independence, but it is not defined the same
way for everyone. For some, independence means staying active and social. For others, it
may mean feeling that one is contributing to society in some way. Think about what
independence means to you and what it will mean as you age. Will Medicare help you to
maintain it?
Every one of our 10,000 members on Independent Living PowerTM
has a dramatic story, and the dramatic stories of some of our members have been featured
in various media.
A recent U.S. News & World Report article titled
"Growing Old In A Good Home" featured photographs on its cover, and throughout
the issue, of frail members of SCAN who live independently. The article talks about a
continuum of care that ends in a nursing home. It does not have to be this way. The
opening to the U.S. News article gives an idea of what SCAN members like best about their
health plan:
Ninety-two year-old Franklin Alexander lives in his dream
home by the ocean, caring for his wife, Myrtle. She's 95 and has dementia. But the couple
would not have that choice without the help of in-home care and medical supplies provided
by SCAN. "We're staying in our home looking out at the blue Pacific instead of going
into a nursing home," said Alexander. Obviously SCAN cannot guarantee an ocean view
for everyone, but we strive to deliver choice for seniors in how they live and where they
live.
SCAN supports caregivers by giving them a break. We provide
additional services they might not afford on their own. Most importantly, we help reduce
stress from the caregivers' lives. That is why a caregiver relief component must be part
of the new Medicare.
As a social worker, and the child of an aging parent
myself, I have seen how constant attention to the demands of a senior can cause stress,
and even anger and guilt. Caregivers may experience anger because they feel burdened with
the caregiving role. They may not be able to share responsibilities with unwilling or
distant siblings. They may feel guilty for even thinking about their own needs.
Social support services not only encourage the independence
of members, they relieve the burden on caregivers. There are two SCAN members who are good
examples of the benefits of caregiver relief, Eve and Robert Graham, both in their 70s.
Before SCAN, Eve had to leave Robert, who suffers from Alzheimer's, at home alone when she
went grocery shopping or to medical appointments. She felt uncomfortable leaving him alone
and she worried a lot when she was away from him. Now Robert is picked up at home five
days a week and goes to a day care center for Alzheimer's patients. Eve says she feels
more secure with him there. This peace of mind SCAN members enjoy is priceless. Why
shouldn't it be available to more older Americans? Help with caregiving can mean a normal
relationship with the senior, not a relationship with a constant sense of urgency. Getting
food in the house, getting prescriptions filled, helping with household chores, often
become emergencies. We can help avoid these situations with my vision of the new Medicare.
Along with providing complete care and promoting
independence for seniors, the Medicare of the future must control costs. Over the past
three decades health spending and hospital use increased more for the seniors than for
persons under age sixty-five.
One major cost is that of nursing home care. Seniors who go
to a nursing home often start out by paying out-of-pocket, sometimes as much as $50,000
per year. Many run out of money quickly. Studies show that 30 to 55 percent of seniors run
out of money within the first year of entering a nursing home. When that happens, seniors
are covered by Medicaid, which comes one hundred percent out of taxpayers' pockets. In
California, a one-year stay in a nursing home for an individual costs Medicaid around
$40,000. SCAN is able to keep that same individual in his own home while costing Medicaid
around $22,000 -- just a little more than half the cost of a nursing home. While these may
be simplistic comparisons, it is clear that having that individual on SCAN is more cost
effective.
In addition to saving the government money, SCAN saves
money for the individual. We conducted a study to determine how much it would cost a
senior, out-of-pocket, to purchase the services and supplies SCAN provides. It was found
that a frail older person would have to spend an average of $4,900 a year to purchase
equivalent services and supplies to keep himself independent at home -- and to someone on
a fixed income, that is a substantial amount of money. Nursing home costs for the
government and individual and out-of-pocket expenses are not the only costs the Social HMO
model can affect. Pharmacy costs and those associated with poor nutrition are also areas
for savings.
Congress is considering a prescription drug benefit for
Medicare. Let us remind them that while it costs money up front to support the benefit,
the health of Medicare beneficiaries and the long term savings through less acute care and
fewer hospitalizations will more than make up for these expenses.
Failure to take medications as prescribed is ultimately a
cost to taxpayers. One study estimated that unfilled prescriptions cost our country as
much as $25 billion in 1996, not including the indirect costs of decreased functioning and
reduced quality of life.
While national surveys indicate that 20 percent of
prescriptions are left unfilled each year, at SCAN, we make every effort to help our
members fill their prescriptions and take them. We do this through an unlimited drug
benefit with relatively low co-payments and by providing transportation to the pharmacy to
be sure they pick up their prescriptions.
Poor nutrition is another problem that leads to poor health outcomes and high medical
costs. Many seniors have difficulty getting to the grocery store. Some have difficulty
getting around their kitchens to prepare meals. Many choose convenience foods that do not
meet their nutritional needs and some simply forget to eat. Poor nutrition can lead to
increased risk for several chronic diseases including cardiovascular disease, diabetes,
arthritis, pulmonary and gastrointestinal disease and an increased number of physician
visits and increased hospital days. At SCAN, we have developed solutions to improve the
nutrition of seniors. We have a program of home-delivered meals specially prepared to meet
the nutritional needs of each individual. We also provide assistance with meal preparation
and grocery shopping. We believe that by spending a little more on this type of service,
we improve the quality of life of our members and save money down the road as medical
services are reduced.
Realities of 2001 and Beyond
The Social HMO model recognizes the realities of 2001. That is why we take care of our
members in so many ways. We know the projections for our aging population. We know that
many caregivers have jobs and that time away from their jobs costs money. We know that
costs of nursing homes are skyrocketing. Most of all, we know that seniors do not want to
be in nursing homes.
A program of comprehensive care and maintaining
independence for seniors works. This is what seniors want and need for their physical and
mental health.
We have proposed legislation to Congress to move the Social
HMO from demonstration project status to permanence and make the concept available to more
American seniors. Permanence with Integrity means that the legislation incorporates
a benefit design to assure a complete health plan. It also means that the payment
mechanism supports the benefits design -- the additional benefits -- and that payment
provides an incentive to keep people out of nursing homes.
Legislation for permanence will enable the Social HMO to
fill a necessary role in health care for all American seniors. With Congressional
approval, it will be possible for the Medicare of the future, following the model of the
Social HMO, to roll out across the United States.
The need for a Medicare of the future is clear. I have
emphasized the need to keep seniors independent and the need to control health care costs.
A viable solution for achieving these goals already exists within the Social HMO model.
Now it is up to concerned citizens to take action.
The decision on what the Medicare of the future looks like is going to be made in the US
Congress. Let your Congressional Representatives know how you feel. Urge them to make this
type of care available to more seniors and to yourselves when you get older.
About the Author
Sam L. Ervin is a trained social worker and chairman and
chief executive officer of SCAN, a nonprofit Social HMO based in Long Beach, California,
with 50,000 Southern California members.
SCAN pioneered a community-based system delivering
comprehensive health and personal care services to help its members remain living
independently. SCAN has helped keep more than 20,000 seniors who were nursing
home-certified out of nursing homes. The SCAN approach to preventive and long-term care
may very well serve as the model for solving many of the health care challenges facing the
country in the next 50 years. www.scanhealthplan.com
Read Comments
return to top
