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December 2007 (Volume 85)
December 2007 | Bradford H. Gray
A peculiarity of the American health care system is that even though more than forty-seven million people lack health insurance, millions of others have coverage from more than one source. Of particular importance for policymakers are the more than seven million people who are covered by both the Medicare and Medicaid programs, the so-called dual eligibles. They are eligible for Medicare because they either have a disability or are sixty-five years of age or older, and they are eligible for Medicaid because they have a low income and few assets. Dual eligibility conveys significant advantages to this vulnerable population because Medicaid covers important services—including long-term care—that Medicare does not. But as David Grabowski notes in the first article in this issue, dual coverage also has some major disadvantages as these two programs currently operate.
In “Medicare and Medicaid: Conflicting Incentives for Long-Term Care,” Grabowski summarizes the research on the effects of coverage by both of these governmental programs, the former administered by the federal government and the latter run (and partly financed) by the states. He points out conflicting incentives that have adverse implications for cost containment, service delivery, and quality of care. In response to their resource constraints, the Medicare and Medicaid programs have adopted policies that shift some costs to the other program and reduce beneficiaries’ access to supposedly covered services.
Grabowski also analyzes evidence pertaining to three ways in which the problem might be addressed: the enrollment of dually eligible beneficiaries in capitated managed care plans funded jointly by the two programs, experiments with pay-for-performance to improve the quality of nursing home care, and the federal government’s assumption of Medicaid’s costs for treating dually eligible individuals. Reaching a political consensus on change in this area is difficult, but current demographic and budgetary trends will only increase the importance of these issues.
Home health care is one area in which dual Medicare and Medicaid coverage creates conflicting incentives, and it is the subject of the second article in this issue, “Care of the Chronically Ill at Home: An Unresolved Dilemma in Health Policy for the United States,” by Karen Buhler-Wilkerson. Family members—particularly women—have always been the primary home caregivers, but, as Buhler-Wilkerson shows, there is also a two-century history of home care services provided by formal caregivers. She focuses on the changing ways in which these formal services have been provided and financed.
She traces organized home care programs to the early nineteenth century and the work of wealthy religious women in Charleston, South Carolina, and other cities. Nonprofit visiting nurse services evolved from these efforts. In the early twentieth century, the Metropolitan Life Insurance Company established a program to cover the costs of home care for people for whom it provided life insurance, in the expectation that it would reduce mortality. Hopes that the coverage of home health services could be justified on cost-containment grounds are clearly not new.
Buhler-Wilkerson also shows that the moral hazard problems arising from providing coverage for home health services emerged very early. She shows that payers’ desires to make needed services available while not paying for less necessary services have generated “unavoidable tensions between fiscal reality and legitimate need.” The search for an acceptable balance among self-sacrifice, personal responsibility, and financial coverage in the home care of the chronically ill continues today.
Buhler-Wilkerson shows that policymakers and the public have historically viewed the long-term care of the chronically ill as a family responsibility, with public programs playing only a supportive role. But reliance on relatives and other informal caregivers has implications for other areas of policy concern as well, and policy tensions associated with home health care are the subject of the next article in this issue.
In “Labor Market Work and Home Care’s Unpaid Caregivers: A Systematic Review of Labor Force Participation Rates, Predictors of Labor Market Withdrawal, and Hours of Work,” Meredith Lilly, Audrey Laporte, and Peter Coyte survey the international literature on how informal caregivers’ provision of home care services affects their participation in the labor market. Care for chronically ill or disabled family members could have important effects on the labor force as well as on informal caregivers’ short- and long-term financial well-being. Society’s interest in a strong labor force thus may conflict with the provision of care for people needing assistance at home.
Lilly, Laporte, and Coyte’s review of the available research shows that people who provide informal care are no less likely than noncaregivers to be employed but that those with heavy informal caregiving responsibilities are more likely than noncaregivers to reduce their number of hours of paid employment or to withdraw from the labor market entirely. Whether and how ways can be found to support the continued labor force participation of informal caregivers, most of whom are women, is another challenge raised by the aging of many countries’ populations.
The next article, “The Emergence of Clinical Practice Guidelines,” by George Weisz, Alberto Cambrosio, Peter Keating, Loes Knaapen, Thomas Schlich, and Virginie Tournay, is a historical analysis of the development and spread of attempts to standardize various aspects of medical care. Weisz and his colleagues argue that the now ubiquitous practice guidelines that began to emerge in the 1960s and 1970s in the United States are properly understood as a continuation of standardization efforts that started much earlier. Procedural standards and protocols to be followed in specific situations depend on terminological, design, and performance standards that date back more than a century and provide the common classifications and measures needed to facilitate agreement on appropriate practices. Weisz and his colleagues interpret the emergence of clinical practice guidelines not as something that was imposed on physicians by policymakers or payers worried about cost increases or as an effort by physicians’ organizations to sustain professional autonomy, but as a continuation of long-term efforts to improve the quality of medical care.
The final article in this issue, “Knowledge Transfer and Exchange: Review and Synthesis of the Literature,” by Craig Mitton, Carol Adair, Emily McKenzie, Scott Patten, and Brenda Waye Perry, discusses research on the processes by which knowledge developed by researchers comes to be used by policymakers in health care. The articles identified in the authors’ search of the literature on this topic were disproportionately Canadian, which may be because the Canadian Health Services Research Foundation spent millions of dollars in a decade-long effort to promote what it termed knowledge transfer and exchange between researchers and policymakers and because the authors’ choice of search terms all contained the word knowledge. The research examining this Canadian experience is particularly useful in assessing knowledge transfer processes, even though the authors’ literature review also captured articles from Europe, the United Kingdom, and the United States.
Mitton and his colleagues selected the eighty-one most relevant studies from a total of 4,250 articles they identified in their original search. Of those eighty-one studies, they concentrated on those rating high on a quality scale and concluded that only limited evidence is now available regarding what strategies work in what contexts. Stated differently, notwithstanding the many ideas that have been published about how to enhance policymakers’ use of research, “evidence-based knowledge transfer” is not yet possible in health policy decision making.
Bradford H. Gray
Editor, The Milbank Quarterly
Author(s): Bradford H. Gray
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Volume 85, Issue 4 (pages 575–578)
Published in 2007
Medicare and Medicaid: Conflicting Incentives for Long-Term Care
Notes on Contributors