Book Review

Growing Old Gracefully

Beyond Medicare: Achieving Long-Term Care Security

N Engl J Med 1994; 331:487August 18, 1994

Article

Beyond Medicare: Achieving Long-Term Care Security
By Malvin Schechter with Irma Schechter. 159 pp. San Francisco, Jossey-Bass, 1993. $34.95. ISBN: 1-55542-583-6

Beyond Medicare proves that we need a new policy for long-term care. Malvin Schechter describes how this care should be prescribed, delivered, managed, and financed. By the year 2011, the current middle-aged population will have reached the age of 65 or over, and many more people will live into their 80s than currently. We will care for a higher percentage of frail and disabled patients; community-based services will surge.

The Schechters contend that long-term care is not a privilege but a right. They believe that society must fund such care and that each patient deserves an assessment that takes into account his or her culture, lifestyle, social supports, and individual resiliencies. To finance and deliver this care, the authors advocate a single-payer system with a case-management approach financed by social insurance, such as payroll deductions contributed over a lifetime by employers and employees.

This book has several weak points. First, it emphasizes nursing home care as an important solution. Most state government officials, knowing that state budgets pay for the bulk of nursing home costs, want to reduce the rate of increase in nursing home care. The federal government will not pay for such care.

Second, health care professionals and government officials know that all public and private nursing homes have a powerful incentive to accept the healthier patients who will fit into their reimbursement framework, and they have a financial disincentive to discharge patients.

Third, case management for the elderly is difficult. Criteria for the discharge of disabled patients are difficult to establish. The elderly are distrustful of case management, which they view as a form of rationing. Case management can be influenced by patients, articulate family members, or aggressive physicians. Case managers are undertrained and overworked. Their decisions are variable, especially in this group of patients with ambiguous conditions.

Fourth, the heavy emphasis on payroll taxes is logical but not politically workable.

Fifth, the book does not sufficiently examine the issue of rationing. Most authorities know that the projections in this book will far exceed the available funds. Advanced medicine can prolong the life of almost all patients who are old, confused, disabled, and dependent. We will soon have to face the issue of withholding care from some patients, which is the central issue in controlling the costs of care for this group of patients.

Finally, the book does not sufficiently emphasize home care, which has the economic advantage of using the overhead of the home rather than of the nursing home. The family provides free care to the patient in lieu of the very expensive care provided by nurses, licensed practical nurses, and aides. Family care provides more and better care in the home than that provided by staff in the nursing home, as evidenced by the increasing number of nursing homes with empty beds, the drop in private care censuses, and the increasing number of nursing home bankruptcies, even during a time of apparently increasing need for care. And the book does not mention the self-interest of children who care for their elderly parents to preserve their inheritance.

Manuel J. Lipson, M.D.
Spaulding Rehabilitation Hospital, Boston, MA 02114