IMPLICATIONS. The findings of this project have important implications for changes in the

Transcription

1 IMPLICATIONS The findings of this project have important implications for changes in the policies and procedures utilized by insurance carriers, care management organizations, regulatory bodies, and consumer groups in order to best protect the rights and meet the needs of elderly consumers who purchase long-term care insurance. Implications for Insurers 1. Insurers should provide policyholders with better information at the time of their benefit eligibility determination regarding the specific details of their coverage, criteria for eligibility, the nature of care plans, the role of care management, and the appeals process. Policyholders also need to be more fully informed about the asset protection feature of their policies and the process of making the transition into Medi-Cal. 2. Insurers should review benefit eligibility assessment instruments to assure that they are consistent with CPLTC and HIPAA criteria. Slight differences between taxqualified policies (TQ) and non-tax-qualified policies (NTQ), for example, may necessitate different assessment instruments for post-1996 and pre-1997 policies. 3. Insurers should develop a better system for tracking claims, so that discrepancies with care plans can be more easily identified. 4. Insurers should consider providing care management organizations with incentives for identifying, documenting, and responding to their clients unmet needs. 5. Insurers may wish periodically to assess client satisfaction directly, rather than relying solely on care management organizations to do so.

2 204 Assuring Quality Care Under LTC Insurance Implications for Care Management Organizations 1. Eligibility assessments should be conducted by trained professionals to assure the accuracy and reliability of the assessment information. Assessments should take an all-inclusive look at a person s total needs and resources, including psychosocial well-being, culturally based attitudes and practices, rehabilitation potential, and need for assistance in managing care. Assessments, when possible, should include the direct observation of ADLs, the type of assistance needed to perform them, and any safety issues related to physical limitations or cognitive impairment. 2. In assessing cognitive impairment, a reliable and valid measure of behavioral disturbances that pose potential safety threats should be used, such as an aggregated version of the Behavioral Pathology in Alzheimer s Disease (BEHAVE-AD) scale (Appendix B). Also, translated versions of cognitive assessment tools, such as SPMSQ and MMSE (Appendix B), should be used with policyholders whose primary language is not English. 3. Care plans should reflect an all-inclusive look at a person s total needs and resources, including physical, cognitive, psychosocial, financial, familial, cultural, environmental, and other factors that might impact service needs or utilization. Care plans should include a comprehensive list of problems and corresponding goal statements, and should clearly delineate responsibility for arranging and coordinating care, including the care manager s role, if any. Goals should include improving functioning and promoting wellness, not just meeting basic ADL needs. 4. Care management organizations should adopt methodologies for assuring the accuracy and comprehensiveness of care plans.

3 Implications Care management organizations should educate policyholders about what to expect from care management, including the types of care management available and the charges for each. 6. Care management organizations should consider developing protocols for targeting more intensive care management to more complex cases, such as those involving unstable, comorbid physical and social conditions, cultural barriers, or unavailable family support. 7. Care management organizations should develop more reliable processes for identifying, documenting, and responding to unmet needs, including monitoring service use on a regularly scheduled basis. 8. Care management organizations should assess client satisfaction on a regular and ongoing basis, rather than relying on one-time, cross-sectional surveys. For example, client satisfaction questions should be incorporated into monitoring calls and be included in 6-month reassessment interviews. Assessment of client satisfaction 9. should include standardized instruments, such as the Home Care Satisfaction Measures, as well as specific questions about experiences with particular services or aspects of care. Implications for Regulatory Bodies 1. Oversight mechanisms should be established for assuring the accuracy of eligibility determinations and the adequacy of the assessment information upon which they are based. One possibility would be for an independent third party to review a sample of eligibility determinations on a quarterly or semiannual basis. Discrepancies or

4 206 Assuring Quality Care Under LTC Insurance instances of insufficient information could be noted and resolved through discussions with the relevant insurers. 2. Consideration should be given to allowing insurers to adjust eligibility determination scores on cognitive impairment screening instruments for policyholders with low levels of education and literacy. 3. Clarification is needed regarding whether certification that an individual is chronically ill, as required under HIPAA, requires actual assessment and face-toface contact with the policyholder, or whether a physician, professional nurse, or licensed social worker can certify an individual as chronically ill based on an assessment performed by an unlicensed assessor. 4. The roles of CMPAs, insurers, and TPAs need to be clarified, especially with regard to care plan approval and ongoing care monitoring. 5. Care management organizations should be required to review periodically a sample of care plans in terms of their accuracy and comprehensiveness. 6. Clarification is needed as to whether LTCI benefits are intended to meet all of a policyholder s care needs or are just intended to cover physical aspects of care as provided by nursing homes, assisted living facilities, and home care. 7. Regulations may need revision to assure objectivity and impartiality in cases in which care managers work for organizations that also provide other services included in an insured s plan of care. 8. Regulations should be revised to ensure that all policyholders receive some level of periodic monitoring to verify that the services being received are appropriate or that needed changes are identified, implemented, and documented in the care plan.

5 Implications Regulatory bodies may wish periodically to conduct an independent assessment of a client s experiences under LTCI. Implications for Consumer Groups 1. Consumers, including but not limited to policyholders currently receiving benefits, need better education about the coverage afforded by LTCI and its limitations. 2. Consumers who have purchased LTCI policies should be informed of the importance of contacting their insurance carrier or agent as soon as they become disabled, so that preventive services may be offered that might alleviate subsequent problems for policyholders and their caregivers. 3. Consumers, including but not limited to policyholders currently receiving benefits, need better education about what care management is and its potential role in identifying, obtaining, and monitoring needed services. 4. Research is needed regarding the impact of LTCI on policyholders out-of-pocket expenditures, policyholders physical and psychosocial well-being, and caregivers responsibilities and well-being.

6 208 Assuring Quality Care Under LTC Insurance