Long Term Care
Nursing Home Care
We included the cost of long-term care attributable to visual impairment and blindness for persons aged 65 and older. Long-term care includes residential care services including nursing homes and skilled nursing facilities. Skilled nursing facilities are generally short-term duration facilities and are covered by Medicare in the age 65 and older population. Nursing home care is typically longer term, with costs paid out-of-pocket, through private insurance, or Medicaid. We identified the number of Americans in nursing homes and the proportion of Americans in nursing homes by age based on the 2004 National Nursing Home Survey. The prevalence of visual impairment and blindness among nursing home residents by age group was observed in the Baltimore Eye Study. We calculated the marginal rate of institutionalization in nursing home care due to visual impairment or blindness based on the relative difference in prevalence in nursing home populations versus the prevalence in the age-matched general population. We then multiplied this marginal rate of institutionalization by the prevalent visually impaired or blind population to estimate the number of persons nursing home care at any point during the year due to visual impairment or blindness. We then multiplied this by the average duration of nursing home stays per year and by the annual cost of nursing home care from the 2011 Genworth Financial Cost of Care Survey. The total nursing home care cost estimate was $16.8 billion, as shown in Table 13.1.
Table 13.1. Nursing Home Cost Estimates
Nursing home costs are paid by patients, government and private insurers. Some individuals have private insurance or retirement insurance plans that cover all or part of nursing home costs. Medicare offers short-term coverage for nursing home care, but most government spending on nursing home care is through the Medicaid program. Often, individuals will pay for nursing home care out-of-pocket until their funds are exhausted and then quality for Medicaid assistance. In a Georgetown University policy brief, Ellen O’Brien details the breakdown of nursing home care spending by payer, reporting that Medicaid and Medicare cover 46% and 12.4%, respectively, while private insurance pays 7.7%. 27.9% is paid out of pocket while another 6.1% is paid through other private sources. We allocate nursing home costs to government, insurance, and patient payers based on these allocations, such that payment by government is $13.2 billion, payment by insurance companies is $1.3 billion, and out-of-pocket costs are $5.7 billion.
Skilled Nursing Facility Care
The nursing home estimate does not include skilled nursing facilities, which offer short-term acute care and are mostly paid for by Medicare. Javitt, et al. (2007) estimated excess Medicare costs for skilled nursing facility placement attributable to visual impairment and blindness. We updated these excess costs per person to 2013 US$, and multiplied by our estimates of the 2011 prevalent population for each corresponding visual acuity level. This yields a total estimate of $3.4 billion in Medicare costs for skilled nursing facility placement due to vision loss.(Table 13.2)