Home Care!
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It turns out that the crisis was not really due to a shortage of health services or that it cost too much. It was mostly over the amount of money that could be made and about who was going to get it. Nearly everyone agreed that doctors did not understand money and did not deserve to have it or even handle it. The public understood money even less and needed someone to manage it for them.
Politicians fought with the insurance industry for control and insurance companies battled with each other for market shares. It was like a bunch of dogs fighting over a bone. Some observers believed that a genuine health care crisis was actually created as the health care system was torn apart by the struggle. Everyone agreed that health care would never be the same
Insurance executives say they did a lot of good. Others aren't so sure lt is true that discipline was imposed on the system. Health care rationing was made palatable to the public by giving it different names. such as managed care health maintenance, capitation and free choice. Other names were changed. too. There were no more doctors or patients. They were relabeled providers and consumers. Doctors. nurses. social workers, technicians. and all other health care workers were lumped together as '-providers.'' This made them interchangeable and saved a lot of money that could go into profits for the insurance companies. As consumers, patients were empowered to make choices between health care packages without understanding the contents.
Health insurance companies profits skyrocketed' while doctors' incomes plummeted. Doctors burned out, patients burned up. and hospitals dosed down. If patients were displeased with empty packages they took out their anger on doctors for lack of more accessible targets Patient dissatisfaction gave the insurance companies an excuse to further reduce doctors' fees, which resulted in still more profits for the insurance companies.
Biological evolution did not end with Tyrannosaurus rex and health care evolution did not end with health insurance companies and HMOs. These organizations dominated the landscape for a while. but they made some fundamental blunders' which set the stage for their demise. Their biggest mistake was in. ignoring' or not knowing, Trump's Rules, which are as follows
1. Don't tell people what they need, give 'em what they want.
2, Make everyone feel like a winner.
The insurance companies and HMOs gave no one what they wanted and made everyone feel like losers.
Trump saw his chance and moved in. His thinking on the subject is described in his recent best-selling book. You bet Your Life. Trump reminds us that everything in life is a gamble' starting with which sperm will reach the egg. Taking chances is unavoidable, and we take them with every move we make. The best we can do is play the odds. Humans have adapted to this uncertainty in life in various ways and have even learned to enjoy it by making bets. People like excitement and thrills---even to flirt with danger but they also want security.
As Trump's argument goes: Although insurance is advertised as a way of buying security, it is in fact a form of gambling that may offer a sense of security. In insurance. as in casinos the player bets against the house, In life insurance, policy holders bet they ``ill expire before the policy does, while the company (the "house") bets they won't. In health insurance, policy holders bet they will need medical care costing more than the premium; the insurance company bets they won't need it, or at least that the company can avoid paying for it. The insurance industry is, in effect, a large gambling enterprise that represents itself as a quasi-public utility. The industry has been successful because of a combination of actuarial, financial, marketing, and political skills.
According to Trump, these capabilities, although impressive, are no match for those of the gaming industry. The gaming industry has a far better understanding of human motivations and behavior than the insurance industry (or the medical profession, for that matter). Both the insurance industry and the medical profession attempt to tell people what they need. Trump knows what people want. Trump knows people want excitement. They want to take chances, but to feel safe while doing so. He knows that people want to live recklessly while having the safety net of free health care. He will give them what they wan. No one should complain if he enriches himself and his partners while doing so.
Trump's health care financing plan took the industry by storm. Adding to his gambling establishment, he opened the Taj Mahal Health and Gaming Resort with headquarters in Atlantic City. He made health coverage automatic far anyone who plays, and for as long as they play. One can play roulette, blackjack, slot machines, craps, or any other game in the house It's all the same. Win or lose. the coverage is in proportion to amounts wagered. (A small percentage of sums wagered goes into the health care account.) As long as you play. you can never lose your health coverage And you still have a chance to win the jackpot.
Trump promotes his painless method of financing health care with slogans such as "Don't get sick, get lucky!"
After Trump added his health care package to the Taj Mahal operation, a revolution in health care financing took place almost overnight. Thousands of people from surrounding areas dropped their health insurance and headed for Atlantic City Gambling facilities strained under the onslaught, but were rapidly expanded.
As other gaming organizations followed Trump's example, new facilities were established in Atlantic City and Las Vegas. on riverboats ships at sea and in states throughout the nation. Whatever your favorite game of chance, you can now play it. and get free health coverage. Indian reservations, which already had legalized gambling have expanded their facilities and now offer free Native American health care for those who play. Home shopping networks have joined in by adding gambling channels. For those who are house-bound or prefer to stay at home for any reason. it is now easy to play on interactive television, 24 hours a day, 7 days a week, and gain health coverage while doing so.
Casinos overcame people's moral objections to gambling by donating some of the profits to charity or to other good causes. One week would be "Cancer Week," in which a fraction of each dollar wagered would go for cancer research: another week would he for AIDS research, or for the homeless. These charitable contributions are highly advertised and enable people to feel virtuous as they play.
Doctors rushed to Join the system. There was no red tape and no paperwork. In order to be providers, they merely had to play at the gambling tables. A remark by a well-known medical leader is often quoted: "Even if health care these days is just a crap shoot, now least there's a chance of winning something.'' Your best chance of finding a doctor now is at a casino. Medical school courses on managed health care have been replaced by courses on gambling and health care. They are the only classes in which students always stay awake.
As the gaming industry took over health care, the health insurance industry collapsed. Victims of their own misjudgment of human nature they
quickly lost their contracts and went into the red. Down but not out, health insurance companies and HMOs had huge cash reserves gained during the preceding years. With these resources they bought into the gaming industry and in the process drove the price of shares through the ceiling. wall Street went wild with joy.
Trump cites recent studies conducted by the Taj Mahal Institute for Medical Research showing clinics and hospitals to be half empty most doctors and patients would rather spend their time at the gaming tables. Ever since managed care set the standard by allowing a maximum of twenty minutes for any type of surgery, from ingrown toenails to kidney transplants, many people believe that their chances at the gambling table are better than they are on the operating table
Every advance in human society has its opponents. There are some voices from the medical field and elsewhere that denounce Trump's system as evil and corrupt. They say we are rapidly going to hell Trump reminds us that under managed care we were heading for hell anyway. Under his system, at least we can enjoy the trip.
Perhaps things could be done in better ways. Perhaps the time will come when human affairs are governed by benevolence and wisdom rather than by greed and folly.
Perhaps.
But don't bet on it.
GERALD D KLEE, M D.
Home care
Home care, also known as domiciliary care, is health care provided in the patient's home by healthcare professionals (often referred to as home health care or formal care; in the United States, it is known as skilled care) or by family and friends (also known as caregivers, primary caregiver, or voluntary caregivers who give informal care). Often, the term home care is used to distinguish non-medical care or custodial care, which is care that is provided by persons who are not nurses, doctors, or other licensed medical personnel, whereas the term home health care, refers to care that is provided by such licensed personnel.Home Care Concept
Home Care and Home Health Care are phrases that are used interchangeably in the United States, by both laypersons and professionals, to mean any type of care given to a person in their own home. Both phrases are used interchangeably regardless of whether the person requires Skilled Care by professionals or not.Home care aims to enable people to remain at home rather than use residential, long-term, or institutional-based nursing care. Care workers visit service users (patients) in the person's own home to help with daily tasks such as getting up, going to bed, dressing, toileting, personal hygiene, some household tasks, shopping, cooking and supervision of medication.
There may be differences in other countries about types of services delivered. In the United States, a Home Care Patient might receive care from Home Health Aide workers only; or a combination of Skilled Services by a Licensed Professional and Home Health Aide workers.
From the description of services for the United Kingdom, there are apparently large differences in the number of visits to a patient in the home (In the description below, care is given twice daily in the United Kingdom.) In the U.S., workers visit the home on a schedule determined in part by a Licensed Physician and in part by the type of insurance a patient has. Visits range from a few days a week, to every day. Visits are at minimum 2 hours' duration, but can range up to around-the-clock service in the U.S. (generally the longer hours are split between 2 or more workers).
Home Care In the United States
While there are differences in terms used in describing aspects of Home Care or Home Health Care in the United States and other areas of the world, for the most part the descriptions are very similar.Estimates for the U.S. indicate that most home care is of the informal variety with families and friends providing substantial amounts of care, including very high tech kinds of care as well as simpler assistance with bathing or dressing. For formal care, the health care professionals most often involved are nurses followed by physical therapists and home care aides. Other health care providers include respiratory and occupational therapists, medical social workers and mental health workers. Physicians may perform home visits also. To find such a physician, contact the American Academy of Home Care Physicians (AAHCP). In the U.S., home health care is generally paid for by private employer-sponsored health insurance or public payers (Medicare and Medicaid), or by private-pay (paid with the family's or patient's own resources).
Home Care ADLs and IADLs
Activities of daily living (ADL) refers to six activities (bathing, dressing, transferring, using the toilet room, eating, and walking) that reflect the patient's capacity for self-care. The patient's need for assistance with these activities for the Study mentioned was measured by the receipt of help from agency staff at the time of the survey (for current patients) or the last time service was provided prior to discharge (for discharges). Help that a patient may receive from persons that are not staff of the agency (for example, family members, friends, or individuals employed directly by the patient and not by the agency) was not included in the Study.Instrumental activities of daily living (IADL) refers to six daily tasks (light housework, preparing meals, taking medications, shopping for groceries or clothes, using the telephone, and managing money) that enables the patient to live independently in the community. The patient's need for assistance with these activities was measured in the Study by the receipt of help from agency staff at the time of the survey (for current patients) or the last time service was provided prior to discharge (for discharges). Help that a patient may have received from persons who are not staff of the agency (for example, family members, friends, or individuals employed directly by the patient and not by the agency) was not included in this Study.
Most agencies do not provide transportation, such as to doctor's offices. Workers can do errands for the patient though.
Home Care Licensure and providers in Florida
Florida is a Licensure State which requires different levels of licensing depending upon the services provided. Companion assistance is provided by a Home Maker Companion Agency whereas Nursing Services and assistance with ADL's can be provided by a Home Health Agency or Nurse Registry. The State licensing authority is the Agency for Health Care Administration (AHCA)AHCA.Home Care Aide worker qualifications
Entry-level qualifications in the USA require workers to have a High School Education or GED and some agencies require 1 year experience, and must pass a competency test. Competency implies the worker has knowledge of home and patient safety, ability to safely deliver personal care, proper use of assistive equipment (wheelchair, walker, cane, crutches, mechanical lifts, etc.), food preparation, care of the home, sanitary conditions, etc. Workers need to also display the ability to observe and report to the nurse any changes in the patient's overall condition. Many of the duties of home care workers involve good common sense also.Often workers have had experience in a Nursing Home (institutional care) prior to being hired in a home care agency. Workers can take an examination to become a State tested Certified Nursing Assistant (CNA) and be included in a State Registry. Other requirements in the U.S.A. include a background check (police check with finger-printing), drug testing, general references and applicant interview. There is no specialization of workers for particular types of patients, but employees receive individual instruction (usually by the Registered Nurse) as needed for specialized patient care.
Home Care Compensation
In the United States, registered nurses employed in the home care field receive on average around $22.00 to $30.00 per visit.Payment / reimbursement of other Skilled Services vary according to the specific discipline.
Home Health Aides are paid between $5.15 (current minimum wage) to approximately $12.00 per hour. Wages vary considerably by geographic region. These workers do not usually have any kind of benefits offered. They do not receive paid vacations, nor sick days. Currently there is high turn-over and frequent call-offs or no-shows by workers in the home health care / home care field.
Obviously, the agencies' fees are substantially higher, but traditionally reimbursement by State, Federal, or private insurance is lower than the charges billed. Agencies must pay for office and overhead, office staff, professional and non-professional salaries and must pay into the Worker's Compensation fund, etc.
Home Care Recent Supreme Court case
For years, home care work has been selectively classified as a companionship service and exempted from federal overtime and minimum wage rules under the Fair Labor Standards Act (FSLA). This April, the Supreme Court considered arguments on the companionship exemption, which stems from a case brought by a home care worker represented by counsel provided by SEIU. The original 2003 case, Evelyn Coke v. Long Island Care at Home, Ltd. and Maryann Osborne, argues that agency-employed home caregivers should be covered under overtime and minimum wage regulations.Evelyn Coke, a home care worker employed by a home care agency that was not paying her overtime, sued the agency in 2003, alleging that the regulation construing the companionship services exemption to apply to agency employees and exempt them from the federal minimum wage and overtime law is inconsistent with the law. The case has wound its way through the appeals process, and in January, the Supreme Court decided to hear the case this spring.
In the court decision, the court stated the Fair Labor Standards Amendments of 1974 exempted from the minimum wage and maximum hours rules of the FSLA persons "employed in domestic service employment to provide companionship services for individuals . . . unable to care for themselves." 29 U. S. C. ยง213(a)(15). The court found that the DOL's power to administer a congressionally created program necessarily requires the making of rules to fill any 'gap' left, implicitly or explicitly, by Congress, and when that agency fills that gap reasonably, it is binding. In this case, one of the gaps was whether to include workers paid by third parties in the exemption and the DOL has done that. Since the DOL has followed public notice procedure, and since there was gap left in the legislation, the DOL's regulation stands and home health care workers are not covered by either minimum wage or overtime pay requirements.
Home Care 2004 Study by NIHS
In February 2004, the National Center for Health Statistics (NIHS) conducted the "National Home and Hospice Study," which was updated in 2005.The data was collected on about approximately 1.3+ million (1,355,300) persons receiving home care in the USA. Of that total, almost 30% (29.5% or 400,100 persons) were under 65 years of age, while the majority, almost 70%, were over 65 years old (70.5% or 955,200 persons).
The 2005 chart data of estimates based on interviews with non-institutionalized citizens, however, shows a relatively stable number of about 6 to 7 percent of adults age 65 who needed help for personal care (ADLs) - this has remained about the same between 1997 and 2004. (Data has a 95% reliability.) Those aged 85 or older were at least 6 times more likely (20.6%) to need ADL assistance than those of age 65. Between age 65 and 85 years, more women than men needed help.
To review the 2005 Early Release data used, visit the NCHS-NHIS website to see the PDF files. NOTE: The 2005 data reflects data, still between 6 to 7%, is only based on interviews conducted between January to June 2005, so it remains to be seen whether the figure remained constant or changed through the end of 2005. Again, the 1998-2005 data is specific for over 65 or older and does not include any data for adults under 65 years old.
In the 2004 data, just over 30% (30.2 % or 385,500) of the total 1.3+million persons lived alone, but the study did not break this down by age groups. A large portion, 1,094,900 or 80.8% had a primary caregiver, and almost 76% (75.9% or 831,100 lived with the primary caregiver, typically the spouse, child or child-in-law, other relative or parent, in that order. (Paid help and the category of neighbor/friend/ or unknown caregiver would be, for the majority, were living with non-family (4.3%) or unknown living arrangement .) Most patients still need external help, even if the primary caregiver is a spouse.
A total of 600,900 persons received personal care.
Home Care Payment described in the 2004 study
Page 4 of the study describes the population break-down by type of payment used. Of the 1.3+ million:710,000 paid by Medicare - Medicare often is the primary billing source, if this is the primary carrier between two types of insurance (like between Medicare and Medicaid). Also, if a patient has Medicare and that patient has a "skilled need" requiring nursing visits, the patient's case is typically billed under Medicare.
277,000 paid by Medicaid - This number seems low for Community Based Services (CBS) or Home Care (HC), especially as a nationwide statistic.
235,000 paid by private insurance, or self/family - Private insurance includes VA (Veterans Administration), some Railroad or Steelworkers health plans or other private insurance. "Self/family" indicates "private pay" status, when the patient or family pays 100% of all home care charges. Home care fees can be quite high; few patients & families can absorb these costs for a long period of time.
133,200 all other payments - including patients unable to pay, or who had no charge for care, or those whose payment "source not yet determined or approved." Sometimes after "opening a case" (the formal paperwork process of admitting a patient to home care services, there can be a short period of time when the office has not yet received approval by one of two or more insurances held by the patient. This is not unusual. There can also be cases where the office must make phone calls to be sure a particular diagnosis is "covered" by the patient's primary insurance. This is not unusual. These delays explain, in part, a couple circumstances where payment source would be listed as "unknown."
Home Care CBLTC expenditures
Community-Based Long Term Care (CBLTC) is the newer name for Home Health Care Services paid by States' Medicaid programs. Most of these programs have a category called 'Medicaid Waiver' to define level of care being delivered.The Study "Medicaid Home and Community-Based Long Term Care Trends in the U.S. and Maryland" funded by the National Institute of Disability and Rehabilitation Research, Department of Education, Information Brokering for Long Term Care, The Robert Wood Johnson Foundation, focused on expenditures. In this study, the Medicaid Waiver Expenditures by Recipient Group in 2001 based on total expenditure of $14,218,236,802 was broken down in this manner of actual spending (presumably this is based on nationwide figures):
Home Care Mental Health
This data would be interpreted that the MR/DD population represents 39% of the study population of 832,915, and this population used 74% of the available resources of the total expenditure of $14,218,236,802. The aged/disabled population had a higher number of patients in need at 41%, but only had 17% of the total dollar expenditure. The Disabled/Physically Disabled Group (presumably minus the aged in the statistics given - but this group was not well defined in this study's report, as to age etc.), represented 5% of the population and used just 4% of allocated funding. Adding the Aged/Disabled with those of "Disabled/Physically Disabled," the total group would represent 45% in population which used just 22% of funding. Again, the 39% MR/DD used 74%, more than three times higher than the larger group of disabled citizens.Home Care In the United Kingdom
Home Care Home care providers
Homecare is purchased by the service user directly from independent home care agencies or as part of the statutory responsibility of social services departments of local authorities who either provide care by their own employees or commission services from independent agencies. Care is usually provided once or twice a day with the aim of keeping frail or disabled people healthy and independent though can extend to full-time help by a live-in nurse or carer.United Kingdom Home Care Association
Domiciliary care providers in the UK are able to join the United Kingdom Homecare Association (UKHCA), which is the professional association of domiciliary care providers in the independent, voluntary, not for profit and statutory sectors. The Association represents the views of over 1,540 home care providers, each of which agrees to abide by the UKHCA Code of Practice. UKHCA is often a point of contact for members of the public who wish to contact home care providers in their local area.Home Care Statutory Regulation
Home care agencies are regulated by statutory bodies in three of the four home nations. The regulator's function is to ensure that home care agencies work within the applicable legislation:Home Care in England
Regulator: The Commission for Social Care Inspection (CSCI)The Care Standards Act 2000
The Domiciliary Care Agency Regulations 2002
Home Care in Wales
Regulator: The Care Standards Inspectorate for Wales (CSIW)The Care Standards Act 2000
The Domiciliary Care Agencies (Wales) Regulations 2004
Home Care in Scotland
Regulator: The Care Commission The Regulation of Care (Scotland) Act 2001Home Care in Northern Ireland
There is no statutory regulation of domiciliary care at the time of writing (July 2005) although draft legislation is currently under consideration.Home Care Aids to daily living
An aids-to-daily-living (ADL) product is any product that helps persons with temporary or permanent disabilities perform everyday activities such as bathing, eating, and dressing. Some of the ADL product categories are:Dressing aids
Reachers, grabbers, and knobs
Medicine dropper and spoons
Reading accessories
Bathroom products (raised toilet seats, shower stools, hand-held showers, etc.)
Transfer benches
Eating utensils
Grab bars and safety rails
Pill crushers and cutters
Playing cards and accessories
Bedroom products (beds, overbed tables, pads, etc.)
Step stools
