APHA's "hot ideas" for 1997.

The annual meeting of the American Public Health Association (APHA) plays the role of "stock exchange" in the marketplace of ideas on health care. Unlike other medical societies, most APHA members are involved in researching, lobbying and implementing health policy changes. It has generally been a safe bet to assume, therefore, that the issues and debates raised during the Association's annual meeting will prove to be the hot topics in health policy for the coming year.

APHA's 1991 meeting, for example, foreshadowed the imminent health care reform debates by offering no fewer than three separate research panels on long-term care financing: a panel devoted to nursing home reimbursement, a panel on the subject of the cost-effectiveness of home health care for the elderly, and a presentation on managed care for Medicare. Fully one-fourth of all of the papers offered by members of the APHA section on gerontological health focused on reimbursement issues. Two years later, though, few sessions were devoted to long-term care financing - presumably no longer a hot topic due to its absence from the Clinton Administration's omnibus health care bill. Presentations focused instead on the quality of care concerns raised by the deadline for implementing OBRA, the "bull market" topic of 1994 and 1995.

APHA's most recent meeting concluded just last November. If it held true in its role of intellectual stock market, then policy debates on nursing home issues in 1997 will not be devoted to either general discussion of long-term care financing or to specific issues raised by OBRA - two perennial issues that, this time, failed to attract much attention. Rather, many offerings at last year's APHA gerontology sessions centered on two relatively new questions: how to operate nursing homes and home health care as part of a long-term continuum of care, and what should be done with the discovery that a small minority of the elderly consume an overwhelming percentage of publicly-financed health care.

At first glance, these seem to be very distinct issues, but the presentations at APHA showed that failure to maintain a continuum of care is closely related to health care "overuse".

One such presentation used data from the Medicare Current Beneficiary Survey to document that those relatively few Medicare-eligibles who had four or more hospitalizations during the past three years are responsible for most Medicare costs. According to Leonard W. Gruenberg of the Long-Term Care Data Institute in Cambridge, Massachusetts, the records show that this group of patients - roughly one-sixth of Medicare recipients - are responsible for 75% of all Medicare expenditures.

Gruenberg also reported that Medicaid recipients generally consumed more Medicare dollars than other Medicare beneficiaries (although, contrary to popular belief, the survey also found that patients requiring care for mental health or mental impairment averaged relatively low costs, as compared with patients with coronary problems, who presented higher-than-average bills to the public sector system).

The tie-in to the health care continuum was presented in other sessions that examined nursing homes and home care as substitutes for hospital care. Obviously, if the single most important determinant of Medicare cost is hospitalization, then the rational answer to the public sector health care cost crisis is to reduce hospital stays. Dr. Janet Hunt-McCool and her Georgetown University colleagues used the Medicare Current Beneficiary Survey to answer the question, "What would Medicare have spent if less home health care had been available?" The researchers found multiple ways that professional home health care reduced the demand for hospital-based services. Hunt-McCool and HCFA officials claimed that this helped keep the Medicare budget in check.

A panel discussion made a similar case for expanding the role of nursing facilities in subacute and acute care. Dr. James Zimmer of the University of Rochester Medical Center, as well as representatives of HCFA, claimed that skilled nursing facilities can assume a large amount of the respiratory and coronary care provided by hospitals with only a relatively small investment in acute care nursing skills, intravenous and ventilator therapy, and more intensive monitoring. The panel members acknowledged that there is little rigorously designed research to support this view, but implied that funding for studies to make a stronger case for an acute care role for skilled nursing facilities makes more sense than slash-and-burn cuts in the Medicare and Medicaid budgets.

Indeed, these and other APHA presentations struck a note that puts the recent national election debates on Medicare and Medicaid into sharp relief. The campaigners discussed the issues in very general and usually emotional ways, but typically offered solutions appealing more to accountants than to health care patients and providers. Most Republicans and Democrats seemed to agree that, if spending on Medicare is capped, health care providers will somehow find a way to live within an ever-tighter budget. The APHA presenters in 1996 sent a very different message: "real world" senior citizen health care is not that simple, and solutions to out-of-control costs can be found in how care is delivered, rather than how it is paid for.