Are Long-Term Care Coordinators Friend Or Foe?

By Peter M. Goldstein

The most misunderstood and maligned benefit ever to find its way into a long-term care insurance policy is that of the care coordinator.

This poor, unsuspecting Registered Nurse (or Master Level Social Worker) has been characterized by agents selling a non-care coordinator product as a storm trooper hired by the insurance company whose only job is to challenge the assessment of the policyholder's long trusted physician and prevent cli~ents from receiving the care they need. They claim the coordinator acts as a gatekeeper whose mission is to save the insurance company money at the expense of the policyholder.

Nothing could be further from the truth!

To see how the care coordinator came about, let's review the evolution of LTC policies.

In the beginning, no distinction was made between acute care (medical) and long-term care (chronic). Early LTCs only covered nursing home confinement based on medical necessity, after a prior hospital stay. These~ triggers were the true gatekeepers which limited access to benefits.

With the advent of DRGs (Diagnostic Related Groups), the settings for convalescent care expanded from hospitals and nursing homes to include the home~, assisted living facilities~, and adult day care centers. In response, the home care industry became the fastest growing segment of the health care field. Now, caregivers are not only RNs and therapists (skilled), but also home health aides and personal care assistants.

The insurance industry ~responded accordingly, by redefining covered services in their policies, so that nursing home contracts now include home health care and certain homemaker services.

The industry also focused on when care is needed. A shift away from acute care measures was made toward a benefit trigger that relates to functionality, namely Activities of Daily Living. ADLs are not only less subjective and easier to assess, but also more accurately correlated to need for long-term care.

Today, the LTC goal is to allow people to remain independent in their home for as long as possible.

But, in view of the lack of knowledge seniors and their families have about the chronic care delivery system, combined with the dizzying array of providers and services now available, it is obvious that people need a care coordinator to help.

After all, ~when senior~s are discharged from the hospital, partially paralyzed from a stroke, how will they know what types of care are available? Where do they find this care? How do they arrange and manage it? Is the family any better prepared than they are to deal with these issues?

This is the domain of the care coordinator. The coordinator assists the insured and family in getting the proper care from a reputable provider as well as monitors the care and sees to it that the changing needs of the patient are met.~

When our first policy with a care coordinator benefit was released, the reaction from agents was mixed. Those selling it highlighted the positive aspects of a care advoc~ate. But agents selling a competing product tried to create fear that the care coordinator would override the client's doctor and disallow or limit the benefits payable.

With most LTC policies, the insurance company, not the doctor, has the ultimate decision whether to pay a claim. In making that determina~tion, the insurer will gather information f~rom different sources, possibly including attending physician statements and assessments and plans of care from the care provider. When a care coordinator benefit is available, it may also request a face-to-face assessment from the coordinator as an additional tool.

In no way, however, does the care coordinator determine eligibility for benefits. Therefore, the conversation about who makes the decision, the care coordinator or the doctor, is false and mislead~ing.

In the future, I believe the care coordinator will likely be part of every LTC policy.

The service is a tremendous benefit to clients, helping them and their families get the care they need. It also benefits the insurance industry, by helping reduce fraud, keep providers honest, and guarantee quality care. The result will be better experience, lower rates, and more companies in the market.

Mr. Goldstein is senior vice president and chief marketing officer in the Boulder, Colo. office of U.S. Care, where he specializes in LTC programs~.

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