Expert opinion on 2017 care reform

Interview with Dr. Carpenter, expert in the care sector

Due to the fact that we published our article series on the care reform, we received many questions and positive feedback from our readers – many thanks for that! Since Mr. Dr. carpenter was among them and gave us a valuable hint, we took the opportunity and asked him for his expert opinion.

Who is our interview partner?

Our interview partner Dr. med. Jorg A. Zimmermann was born in Freiburg and came professionally via several stations such as Munich, New York, Cologne and Leipzig finally to Berlin, where he has now been living and working for seven years. After his medical studies, he worked as a doctor in trauma and reconstructive surgery and then became a supervisory board member in a publicly traded medical device company for a few years. From this company took Mr. Dr. Zimmermann many experiences and ideas with that can be applied very well in the care sector as a service.

Quote: "For this reason, I was already intensively occupied with the benefit law of the statutory long-term care insurance at that time. It quickly became clear to me that those in need of care and their families are often completely uninformed about the benefits to which they are entitled, and there is little concrete support
In the enforcement of these claims, there are. I wanted to change that.".

Now leading and founding Dr. Zimmermann already for over 15 years companies in the health and care market, including the "PflegeBox" and "Familiara". We are very happy that he agreed to the interview and found time for us.

We hope you enjoy reading! Those who like are also welcome to share it with their contacts.

Expert opinion on ambulatory care

ACIO: We imagine the situation as follows: The person in need of care has "a good day" on the assessment day for classification by the MDK and thus receives a lower care level than he would actually need.

Question:
How should people in need of care or. caregivers the best way to proceed when applying for the new levels of care?

Dr. Carpenter:
The problem of phased or time-of-day fluctuations, which then lead to falsely low ratings, is one we know from other situations besides dementia. Many underlying diseases, z. B. Parkinson's disease, as well as certain permanent medications, have a highly variable effect on physical and mental performance. In this respect, you should observe very carefully in advance of an appraisal whether and to what extent these fluctuations occur. It is certainly also helpful to document possible differences over a certain period of time in a care diary. In any case, be sure to bring up these variations during the MDK review process.

Question:
If the person in need of care has been classified too low, what should be the next steps?

Dr. Carpenter:
First of all, you should have an expert check whether the assessment in the MDK report is correct. Unfortunately, when reviewing these expert opinions, we repeatedly find that care-relevant circumstances were not sufficiently appreciated and the actual need for assistance of the person concerned was incorrectly assessed. This will be no different under the new system, which will assess the limitations of a person's independence.

If it is clear that errors were made in the assessment, the first step should be to file an informal appeal within the statutory time limit of one month from receipt of the decision. We always recommend that you do this in writing by registered mail.

It is very important to prepare a detailed statement of the grounds for opposition. If no professional justification for the objection is provided, the insurance company can decide on the basis of the file – without reassessing the person. This should be avoided in any case, because an objection without technical justification will be rejected in the majority of cases.

If possible, the statement of objection should always be made by a specialist. Here it is essentially a matter of attacking and questioning the expert opinion point by point. This is the only way to convince the MDK to schedule another assessment to critically review the initial assessment again.

If you want to be absolutely sure to do everything right the "second time around", you should hire a professional for the entire appeal process. This then also includes the personal accompaniment in the renewed assessment appointment. Such a benefit comes with some financial investment, but pays off when you get money retroactively from the fund after a successful appeal.

ACIO: Because the application for care levels can occur for the first time for the person in need of care or the caregiver, the question of possible supporters arises. Do specialists have a way generally, v.a. but in the case of a misclassification, to support?

Question:
What options do specialists have to assist the person in need of care or family caregivers? Are there any noticeable changes in this respect with the introduction of PSG II??

Dr. Carpenter:
Unfortunately, my physician colleagues are often underinformed about the options available under the state's long-term care insurance program. In my estimation, this situation hasn't changed much after the introduction of PSG II. They are therefore rarely good advisors when it comes to applying for benefits or appealing a suspected misclassification.

I see a more important role for physicians in the interaction of the different players in hospital and practice with external support services. Doctors can – often as the first point of contact for those affected – take on a certain steering function in the "jungle of care insurance". The aim is not only to help those in need of care, but also to keep an eye on the family caregivers in order to identify possible health consequences of their often great physical and emotional strain at an early stage.
ACIO: Topic: Funds of outpatient care at home. How long does it take until benefits are paid from long-term care insurance for the first time?

Question:
What is the best way to receive benefits as quickly as possible? Is there a specific course of action that is advisable to take?

Dr. Carpenter:
The law stipulates that a maximum of 25 business days – five weeks – may elapse between the initial application for long-term care insurance benefits and the corresponding decision. Unfortunately, the legislator has suspended this deadline in view of the additional burden placed on health insurance funds and MDK by the introduction of the nursing grades. We therefore expect that in 2017 you will have to wait a little longer for your benefit promise.

Within the parameters that apply to everyone, however, you can try to speed things up a bit and avoid delays with the help of professional care consultants. This is especially true for appeals, which often drag on for many months.

Question:
Which services do you think you can take care of yourself, and which would be better left to a care service?

Dr. Carpenter:
This question must always be answered according to the individual care situation. What does the person want? Are there relatives to provide care? Can relatives ensure professionally correct care or is a care service needed? If, for the foreseeable future, the only option may be inpatient care in a home?

The deciding factor – in addition to the personal preferences of those affected and possible pre-existing conditions related to care – is always what cash and in-kind services are available. Ultimately, the decision as to which care services should be provided or "bought in" must be made depending on the available budget. And because this budget depends quite significantly on the level of care, you should try to achieve the highest possible rating at every stage of needing care.

Question:
Or does it make more sense to claim caregiver benefits in full after all?

Dr. Carpenter:
In addition to care provided solely by relatives (care allowance) and care provided solely by an outpatient care service (care benefit in kind), there is also the option of a combination benefit in accordance with Section 38 of the German Social Code (SGB XI). Here, laypeople and professionals "share" the care. If the available amounts for the care service are not exhausted, one receives a pro rata care allowance paid out.

Questions about inpatient care

ACIO: Assumed situation: After a hospital stay a need for care is given. There is a so-called "quick classification" based on the medical findings (of course still by the MDK) in care level 3. Person in need of care enters nursing home, but where it is determined that a maximum of care level 2 is needed.

Question:
Is it possible that the person needing care will have to move out to receive outpatient care, as the nursing home will obviously earn more from care level 3 than 2? Can there be examinations?

Dr. Carpenter:
It is often necessary to make a quick decision on a provisional need for care by way of an emergency application on the basis of records. This is z. B. if after a stroke and after completion of the immediate therapeutic measures the care in a so-called stationary short-time care must be ensured.

Since long-term care insurance benefits are generally only granted if the need for care is expected to persist for at least six months, the insurance fund must schedule a review whenever it can be expected that the current level of need for care will not persist permanently.

If a reexamination of an inpatient reveals a downgrade or even a complete disallowance of the need for long-term care, you should first have the chances of an appeal reviewed. When those odds are low, all parties need to talk about a possible solution. While I don't know of any case where a nursing home resident was "shown the door" in the short term, a downgrade becomes a financial problem in the medium term for both the affected person and the inpatient facility, and it needs to be resolved.

Question:
What challenges will there be for nursing grades 2 and 3 in terms of inpatient care?

Dr. Carpenter:
Until the end of 2016, the higher the care level for inpatient care, the higher the statutory co-payment for those affected. This often resulted in avoiding necessary upgrades in view of the additional financial burden. This regulation no longer exists since 2017; the statutory co-payment is now the same for all care levels 1 to 5.

From a nursing home's perspective, the billable in-kind benefit at level of care 3 just about covers costs; at level of care 2, it's actually a minus business that has to be "cross-subsidized" through the higher levels of care 4 and 5. According to many professionals I spoke with, this was one reason for the legislature's intention to "steer" lower levels of care more toward outpatient care and higher levels of care more toward inpatient care. Whether there will be corresponding shifts between the two areas in subsequent years remains to be seen.

In any case, those with a level of care 2 or 3 should have regular assessments to see if an upgrade might be a possibility. And operators of inpatient facilities are sure to significantly step up what used to be called "care level management" – the regular checking of nursing home residents for opportunities to be upgraded.

ACIO: Due to the 2017 care reform, "outpatient before inpatient" now applies even more strongly.

Question:
In your estimation, what is the impact of nursing reform on the staffing and care situation in inpatient facilities?

Dr. Carpenter:
I don't think it will be possible to tell for at least a year what impact the various new regulations under PSG II have had. I would not like to make a prediction at this point.

Question:
What does the future hold for retirement homes/residential homes/nursing homes?? What alternatives are there in the future?

Dr. Carpenter:
There is an increasing demand for alternative care and nursing concepts, whereby the flexibility of the offer is in the foreground. Many customers want the greatest possible independence and privacy, combined with proximity to care services should they be needed in the future.

Some providers have responded to this in recent years. I know of structural concepts in which a couple can initially move into a shared apartment and use outpatient support if needed. If this "assisted living" is no longer possible due to a partner's deteriorating health, the person concerned can be cared for more intensively within the building or neighborhood while the partner remains living nearby. I think these concepts are the future.

Question:
Are "traditional retirement homes" becoming less common or is it time to establish a different business model that is more like retirement communities or multi-generational homes?

Dr. Zimmermann:
"Classic" retirement homes will still exist in the future. I think, however, that in the future it will be increasingly a matter of differentiating features. This can be a professional specialization, but also a thematic offer to the residents. For myself, at least, I would first prefer a facility that gives me the opportunity to intensively "live" my personal hobbies and interests.

Care shared houses have long been established, not least from the economic point of view of the outpatient care services; multi-generation houses are still rather rare. In any case, operators of inpatient facilities will have to open up more and more to outpatient services as well. It is my firm belief that solutions in which the de facto boundaries between these two sectors no longer exist have the greatest potential for the future.

How do you assess the overall situation with the new care reform??

ACIO: What impact will the motto "outpatient before inpatient" have on caregivers, those in need of care, and their funds in general?

Question:
How do you see the comparison between the situation in 2016 and the current reform?

Dr. Carpenter:
In short, PSG II is perhaps the first reform in more than 20 years of long-term care insurance that really deserves the name. With the new concept of need for care, there has been a real paradigm shift – away from "minute care" to a more holistic view of how much help a person needs in his or her entirety. However, with the 64 items that have to be assessed to determine the degree of care, the assessment system has also become significantly more complicated.

Question:
Who will really be helped by the Nursing Care Strengthening Act II?

Dr. Carpenter:
In theory, all those for whom mental deficits are paramount: Patients with dementia or with psychiatric illnesses. They often have no physical limitations and were disadvantaged in the old "minute care" system. However, some experts fear that many who would have met the requirements for care level I in their initial application under the old system and would now be in care level 2 will be "pushed" into the unattractive care level 1 under the new assessment guidelines. Only time will tell whether this proves to be the case.

Question:
What is the mood among the experts on the subject??

Dr. Carpenter:
At the moment I feel a certain nervousness on all sides. Many appraisers from MDK or Medicproof do not yet feel confident in the "new appraisal assessment" – or are not even adequately trained. Even our consultants and experts have little practical experience with it so far. However, we have been preparing intensively for a year and are confident that the general uncertainty will soon subside.

Question:
Benefits for outpatient care have improved. But are they also sufficiently for a complete, satisfactory care?

Dr. Zimmermann:
Surely there is some positive correlation between the amount of benefits and how happy people are with your situation. In other words, a ranking that is too low in the subjective estimation, combined with correspondingly lower cash and in-kind benefits, is often perceived as a slight. Ultimately, however, there are many other factors that determine whether the individual perceives the care situation as satisfactory.

At least the first steps have been taken in the right direction; many benefits important to those in need of outpatient care have increased. You should be able to continue to stay higher in the future if the general price trend makes it necessary.

I dare to doubt whether the available budgets, even after increasing the statutory contributions to the long-term care insurance, will be sufficient to cushion the actual needs. At some point, I think we'll have to get comfortable with the idea of setting aside up to five percent of our monthly income to achieve a long-term care retirement system that is adequately funded for everyone.

ACIO: Thank you again for the interview, Dr. Carpenter.

Our conclusion:
We agree that people who are or become in need of long-term care cannot be adequately cared for by the resources available from long-term care insurance. The state absorbs only part of the burden and the additional support of services such as those of the company "Familiara" or a private supplementary care insurance should therefore be used.