Commentary

Capitation in Long-Term Care: Playing with People's Lives

Thus, pharmacists working in long-term care are particularly troubled by the capitated payment arrangements now taking the health care world by storm. The reasons for their consternation are many:

• Institutionalized residents of nursing homes and other long-term care facilities are typically frail elderly people with multiple medical problems.
• The capitated limits of some programs, notably Tennessee's program, are ridiculously low and grossly inadequate for the acuity levels of most long-term care residents.
• Low reimbursement is forcing nursing homes to use less skilled staff for key tasks such as drug administration.
• Even as consultant pharmacists see the need for doing more to assure proper pharmacotherapy for their patients, they face declining remuneration-that is, if they are able to keep their contracts at all.

Quite simply, society has a decision to make. Extension of short-sighted capitation schemes to cover the frail, institutionalized, elderly population will create an insoluble problem for health care professionals in balancing fiscal realities with ethical considerations. Further, it is quite possible that costs to the entire health system will increase as sick residents of nursing homes are transferred to subacute- and acute-care institutions.

The problem does not lie in the inadequacy of actuarial tables to predict morbidity over a large population. Rather, the failure is with capitated systems' inadequate responses to outliers in the system-and the financial burden this places on providers' care for residents with serious health conditions.

ASCP's Board of Directors is considering a policy opposing capitation as a payment mechanism for pharmaceutical products and services for the institutionalized frail elderly unless three conditions are met:

• Adequate risk-adjustment capitation models are developed.
• Evidence is gathered to show that capitation will not drive up total health care spending.
• Guidelines that set a minimum standard of care for the use of pharmaceutical products and services in these residents are established and maintained.

Without these three common-sense steps, consultant pharmacists will find themselves in an increasingly untenable position. Failure to develop evidence of the real impact of capitated care could easily end up costing payers and society more than the current system-as well threaten the health and safety of our nation's elderly.

L. Michael Posey
Academics Editor