s. him. 105-58 torn between two systems: improving torn between two systems: improving chronic care

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  • S. Him. 105-58

    TORN BETWEEN TWO SYSTEMS: IMPROVING CHRONIC CARE IN MEDICARE AND MEDICAID

    HEARING BEFORE THE

    SPECIAL COMMITTEE ON AGING UNITED STATES SENATE ONE HUNDRED FIFTH CONGRESS

    FIRST SESSION

    WASHINGTON, DC

    APRIL 29, 1997

    Serial No. 105-4 Printed for the use of the Special Committee on Aging

    U.S. GOVERNMENT PRINTING OFFICE

    40- 984 CC WASHINGTON: 1997

    For sale by the U.S. Government Printing Office Superintendent of Documents, Congressional Sales Office, Washington, DC 20402

    ISBN 0-16-055214-1

  • SPECIAL COMMITTEE ON AGING

    CHARLES E. GRASSLEY, Iowa, Chairman JAMES M. JEFFORDS, Vermont JOHN B. BREAUX, Louisiana LARRY CRAIG, Idaho JOHN GLENN, Ohio CONRAD BURNS, Montana HARRY REID, Nevada RICHARD SHELBY, Alabama HERB KOHL, Wisconsin RICK SANTORUM, Pennsylvania RUSSELL D. FEINGOLD, Wisconsin JOHN WARNER, Virginia CAROL MOSELEY-BRAUN, Illinois CHUCK HAGEL, Nebraska RON WYDEN, Oregon SUSAN COLLINS, Maine JACK REED, Rhode Island MIKE ENZI, Wyoming

    THEODORE L. ToTMAN, Stafl Director BRUCE D. LEsLEY, Minority Staff Director

    (11)

  • CONTENTS

    Page

    Opening statement of Senator Charles E. Grassley ............................................. 1 Statement of:

    Senator John Breaux ............................................................ 4 Senator Susan Collins ............................................................ 6 Senator Harry Reid ............. ....................................... 7 Senator Russell Feingold ............................................................ 10 Senator Ron Wyden ............................................................ 11 Senator John Warner ............................................................ 13

    Prepared statement of Senator Chuck Hagel ........................................................ 14

    PANEL I

    Karin von Behren, volunteer, Orange County Alzheimer's Association, Or- ange, CA ............................................................ 16

    Sue Paul, Augusta, ME ............................................................ 23 Richard Bennett, M.D., executive medical director for long term care, Johns

    Hopkins Geriatrics Center, Baltimore, MD ....................................................... 27 Lucy Nonnenkamp, project director, Medicare Plus II, Kaiser Permanente,

    Portland, OR ............................................................ 32 Jeanne Lally, vice president, Continuum Services and Chronic Care, Fairview

    Hospital and Healthcare Services, Minneapolis, MN .................. ..................... 59

    PANEL II

    William Scanlon, director, Health Financing and Systems Issue, Health, Edu- cation, and Human Services Division, U.S. General Accounting Office, Washington, DC .............. 93

    Bruce Bullen, commissioner, Massachusetts Division of Medical Assistance, Boston, MA ............................................................. 109

    Pamela Parker, director, Minnesota Seniors Health Options, St. Paul, MN ..... 126 Barbara Markham Smith, senior research staff, Center for Health Policy

    Research, Washington, DC .................... ........................................ 155

    (in)

  • TORN BETWEEN TWO SYSTEMS: IMPROVING CHRONIC CARE IN MEDICARE AND MEDICAID

    TUESDAY, APRIL 29, 1997

    U.S. SENATE, SPECIAL COMMITTEE ON AGING,

    Washington, DC. The committee met, pursuant to notice, at 9:36 a.m., in room

    SH-216, Hart Senate Office Building, Hon. Charles Grassley (chairman of the committee) presiding.

    Present: Senators Grassley, Warner, Hagel, Collins, Breaux, Reid, Feingold, and Wyden.

    OPENING STATEMENT OF SENATOR CHARLES GRASSLEY, CHAIRMAN

    The CHAIRMAN. Good morning, everybody. We appreciate all of you for participating, and obviously, this turnout for this meeting shows a very strong interest in the issues that I and my colleagues are going to discuss with you this morning. I am going to give an opportunity to each one of my colleagues to make an opening state- ment, because some of my colleagues have conflicts with other com- mittee meetings and will not be able to stay here for the entire meeting. I do appreciate my colleagues' attendance at these hear- ings, and so, I want to work with them, even if we have to go out of order to make it possible for them to make their statements, be- cause they deserve to be heard as well.

    The Senate Special Committee on Aging convenes to have this hearing on improving chronic care in Medicare and Medicaid. I ap- preciate all of you being here today to discuss the potential of im- proving this setup that does not work so well for Americans who are dually qualified. I am especially grateful to our distinguished panel of witnesses, many of whom have traveled a great distance to be here. Today's witnesses and most of the people in the hearing room are here because they are concerned about our Nation's health care system.

    I would like to add a special thanks to those here today who have come because they are caring for an individual with Alzheimer's disease. Today's hearing will explore the barriers in the health care system that stand in the way of most efficiently serving persons with chronic conditions. Individuals and family members coping with Alzheimer's disease can experience additional hardships due to the fragmentation in the system, particularly in Medicare and Medicaid programs. We hope to identify these particular barriers so that we can work on appropriate corrective measures.

    (1)

  • 2

    For many years Alzheimer's groups have educated members of Congress about important health care issues and about important advancements in medical research, and I appreciate the attendance and participation of those here today. For millions of elderly Ameri- cans, quality health care is one of the most important things in their lives. They depend on Medicare and Medicaid for health care coverage. For this reason, we must work to preserve and improve these programs.

    Today's hearings will examine Medicare and Medicaid. We will hear from experts who will discuss challenges in administering services to elderly people with chronic conditions who are eligible for both programs. A discussion about this group of elderly Ameri- cans has several layers. First, we know that elderly persons who are dually eligible for Medicare and Medicaid have poorer health than Medicare-only beneficiaries. They often have chronic condi- tions, such as Alzheimer's disease, diabetes, cancer, arthritis, men- tal illness, and chronic heart problems. These health conditions re- quire special attention. It takes the coordination of the individual families, doctors, nurses and other health experts to cope with these conditions. Fortunately, advances in medicine have provided many ways of managing these conditions. Yet, it is too often the case that elderly Americans with chronic conditions do not receive the appropriate medical and social services they desperately need.

    Without proper care, chronic conditions can quickly worsen. In such instances, the results can be very costly. What seems like a minor problem of health care can turn into a major one. This re- sults in ongoing trips to doctors or hospitals. Today, you will hear from one witness about how a minor fall precipitated a series of events well beyond that which was expected. Before being hospital- ized due to a fall, this individual was living independently at home with her husband of 51 years. Seven months later, after 16 moves and $126,000 of Medicare costs, the same individual is now living in a nursing home. Her dementia has advanced significantly, and she does not always recognize her family.

    Not only can fragmented care lead to a decline in an individual's well-being, but it can mean skyrocketing costs to an individual or family. Today, average nursing home care can cost $40,000 per year. Home health care can range from $50 to $200 per day. When paid by an individual, such health care expenses can quickly ex- haust a lifetime of family savings, and when paid by Medicare and Medicaid, program costs reach into the billions. The matter of costs is important to address, and we will talk today about costs to the individual and also to the Medicare and Medicaid programs.

    If YoU would look at these two charts over here, you will see that the first chart, the one on my left, that the dual eligible population accounts for approximately 30 percent of the spending in both Med- icare and Medicaid, even though the percentage of the population is a much, much smaller percentage. The second chart shows that, on average, dual eligibles have higher Medicare expenditures, espe- cially with respect to home health and skilled nursing facility serv- ices. So, we are here today to recognize the special care needed for the seniors with chronic conditions, and we are going to look at ways that the health care system can better serve individuals with

  • 3

    chronic conditions and become more efficient, so that we can save health care dollars.

    I now turn to my distinguished ranking member, Senator Breaux of Louisiana.

    [The prepared statement of Chairman Grassley follows:]

    PREPARED STATEMENT OF SENATOR CHARLES GRAssLEY

    Good morning ladies and gentlemen. The Senate Special Committee on Aging will come to order. 1 appreciate all of you being here today to discuss the potential for improving chronic care for elderly Americans. I am especially grateful to our distin- guished panel of witnesses-many of whom have traveled a great distance to be here this morning.

    Todays witnesses and most of the people in the heari

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