Exploring an uncertain future.

Though Washington is lagging, long-term care experts are a-buzz with talk of reform. This New York-based symposium crystalized their views

"Every long-term care facility should prepare itself to face the revolution underway in the health care system."

That was the keynote sounded by Nell Heyman, Executive Director and Senior Vice President of the Greater New York Hospital Association's long-term care division. The setting: a symposium co-sponsored by the GNYHA and the Hebrew Home for the Aged at Riverdale, a leading New York city-based long-term care facility. The purpose: to chart some sort of understanding of nursing homes' place in the health care system's tumultuous future.

"It was imperative that a forum be created to open up a dialogue on these is sues," said Jacob Reingold Executive Vice President of The Hebrew Home for the Aged at Riverside. "Despite all the controversy and debate surrounding health care reform, little previous attention has been paid to developing a coherent long-term care agenda. And given the demographic projections that our population of people over 85 will nearly triple to about 9 million over the next 40 years, these issues simply cannot wait."

Robyn Stone, PhD, Deputy Assistant Secretary of the Department of Health and Human Services and Chair of the Long-Term Care Work Group of the White House Task Force on Health Care Reform, attributed the lack of attention to "a grass roots lack of support for long-term care, because people do not understand the immediacy of the problem."

While the speakers all agreed that long-term care reform was long overdue, most concluded that the Clinton Health Security Act does not, in any way, address its most critical aspect -- the reliance on Medicaid to underwrite long-term care. Although applauding President Clinton's efforts to reform health care, Michael Dowling, Commissioner of the New York State Department of Social Services, asserted that the federal government "can't figure out how to finance long-term care.

"They're having a hard enough time trying to figure out how to finance basic coverage for the regular population, so the issue of long-term care is just an enormous added expense," he said. "And if they eliminate Medicaid completely and find some kind of financing mechanism at the federal level, I'm not sure they will know what to do. So when people think that national health insurance reform in Washington will solve the Medicaid cost problem, they are mistaken."

Carl S. Young, President of the New York Association of Homes and Services for the Aging, concurred: "Long-term care has generally been treated only in passing by most reform plans because of dollars and cents. Seeing it as a huge potential price tag in a time of federal deficit, I don't think the federal government has a handle on how they can really address long-term care. And if they don't devise a more cost-effective, yet consumer-responsive, way to provide these services, it's going to be a budget-breaker."

Dr. Stone acknowledged that "while some people recognize that long-term care is an expensive part of reform and the question of how to finance it is a real issue," she stressed that long-term care reform "is a very large part of the Health Security Act -- people don't understand how broad the provisions are." She admitted, however, that the long-term care provisions are "the most vulnerable part of the Health Security Act," adding, however, that "we need to have our toe in the door."

Though Dr. Stone asserted that "national reform is necessary to set some standards across the states," Commissioner Dowling maintained that long-term care reform required a much stronger federal response than the Health Security Act. In the absence of what he believes should be a comprehensive federal role, most long-term care reform is being enacted on the state level.

As an example that could have implications for other states, Governor Mario Cuomo's Long-Term Care Local Access Bill, currently before the New York State legislature, proposes to create a flexible, cost-effective long-term care system. Jane Gould, Director of the New York State Office for Aging, characterized the initiative as "one-stop shopping," i.e.: All eligible adults would undergo a uniform assessment, administered at the local level. Based on this evaluation, individuals would be matched up with the most appropriate and cost-effective providers.

Answering criticism that this process would stifle competition, Ms. Gould countered that "this system won't limit the marketplace because, in actuality, there will be more choices, as consumers can select the provider best suited to their specific needs." The system would reduce the Medicaid budget dramatically, Ms. Gould argued, "because individuals would have earlier intervention in their long-term careers, so their need to spend down to Medicaid would be delayed or negated."

Commissioner Dowling agreed that New York State needed to devise a better way to provide access to long-term care at the local level, and that referral systems directly linked to assessment systems must be developed. However, both Carl Young, of the State Association of Homes and Services for the Aging, and James E. Introne, President of Loretto, a non-profit comprehensive geriatric care facility in Syracuse, said they oppose the bill.

Explaining why he is planning to introduce counter-legislation, Mr. Young said he believes that the proposed bill would create an "authoritarian compulsory pass-through process." He said that information, not access, is the issue in establishing a long-term care system: "It's not as though people can't get into service; the problem is that people aren't sure which service is best for them." While he advocates the development of a uniform assessment process, Mr. Young urged local governments to develop comprehensive information services, which he believes would provide better direction and a full breadth of choice to consumers.

Mr. Introne characterized the Local Access Bill as "bureaucracy worrying about bureaucracy," calling instead for "much less regulated, much less centrally directed services than we have now." And Mr. Heyman agreed, arguing that local access objectives should "focus instead on educating citizens on how to enter the long-term care system appropriately, on streamlining bureaucracy, and on reimbursement reform."

All the experts agreed that the future for long-term care providers lies with the continued development and expansion of the continuum model of care. "Providers are trying to respond to a marketplace that is consumer-driven," said Mr. Young. "And it is clear that what consumers want is a genuine continuum, one that offers the most flexibility and has the most potential for cost-effectiveness."

"Nursing homes must reinvent themselves and diversify, because long-term care today encompasses much more than residential care," said Mr. Reingold. "A multi-tier institution like the Hebrew Home has to continually expand its array of services to stay competitive." Mr. Introne concurred: "Policy makers are just beginning to understand that long-term care is not just a question of nursing homes."

Because the Health Security Act expands home and community based services, Dr. Stone believes providers will "have to be there to meet that demand," noting that they are already headed in that direction. "Supply generally follows the dollars," she commented. She feels nursing homes will not be adversely affected by this shift: "We're not looking at a major substitution of home care for nursing home care -- in fact, we have not built that into our estimates at all."

Commissioner Dowling observed that "providers have already made enormous changes, and the long-term care field is going to continue to evolve at a rapid rate. Today's innovative nursing homes provide an entire continuum of care, and these are the ones that will survive in the long run."

Angela Sullivan writes for The Hebrew Home for the Aged at Riverdale.