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SECTION II
STUDY CONCEPT
Projected growth in long-term care needs will require a sizable
expansion of our capacity to provide long-term care services and that
expansion, in turn, will require substantially increased financing.
After reviewing evidence about current financing patterns and future
needs, the committee believes that simply increasing the dollar flow
into existing financing mechanisms may not be the optimal national
strategy for the future.
Study Focus
Three fundamental problems characterize current long-term care
arrangements:
· inadequate range of services and choice of setting
· poor quality of much of the care available
· fundamentally flawed financing arrangements that place about
one-half of the entire elderly population, including many not
previously below "poverty" classification thresholds, at risk of
financial impoverishment within a year of the onset of a severely
disabling chronic condition.
Most studies of long-term care have focused primarily on trying to
explicate or solve these problems. A number of valuable projects have
examined issues such as improving the quality of care in nursing homes
and developing programs to provide services to the functionally
impaired in community settings.14 On the financing side, efforts are
now under way to examine the financial feasibility of private long-term
care insurance and various strategies within existing programs,
particularly Medicaid, to encourage the substitution, where
appropriate, of less costly community services for institutional
care.
Components of an Optimal Long-Term Care System
The Institute's study proposes to build on these efforts but from a
different perspective. The focus of the proposed study will be the
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identification of public policy options and private initiatives that,
in combination, come closest to achieving an optimal balance of the
following desirable outcomes:
broader accessibility to needed care of acceptable quality
· wider personal choice of services and settings for care
· protection against personal financial catastrophe for individuals
and families
~ greater cost-effectiveness of services.
A major task in the proposed study will be to evaluate potential
policy interventions for achieving an acceptable balance between these
sometimes conflicting goals. The optimal long-term care system,
however, varies somewhat according to the perspectives of individuals
needing care, their families, and the larger society. The planning
committee identified the following goals as important from three
alternative perspectives:
· From the perspective of the functionally dependent individual,
the long-term care system should:
- maximize functional independence
maximize the opportunity for rehabilitation
maximize personal choice of services and settings
- ensure dependable and acceptable levels of quality
simplify procedures for obtaining services
~ provide protection against impoverishment due to illness.
· From the perspective of families, the long-term care system
should:
- protect the family against catastrophic financial resource
depletion; and
- protect the family against catastrophic personal resource
depletion that seriously compromises the independence and quality of
life of family members.
· From the perspective of the larger society, the long-term care
system should:
- be affordable to the country
- be equitable
- sustain appropriate informal care-giving by family members
and community volunteers
- be perceived as satisfactory to most Americans.
Achieving Desirable Outcomes
Risk-pooling strategies hold considerable promise for achieving an
optimal balance among these desirable features of a long-term care
system, especially when combined with effective gatekeeping mechanisms
to match appropriate services with individuals' needs.
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The Institute's proposed study will build on past work on
pooled-risk approaches to examine how such an approach could be
structured not only to provide a more rational source of financing but
also to create incentives to ensure improvement in the availability,
appropriateness, and quality of long-term care services. Thus,
although a major focus of the proposed study will be the development of
viable financing strategies using a pooled-risk approach, the ultimate
objective is to structure the financing to create a better system of
long-term care. Financial considerations have unduly influenced the
development of services for chronically impaired persons; we propose to
use the goals and objectives of an effective system of long-term care
to determine the design of the financing system.
Study Scope
The proposed study is broad in scope and should not be constrained
by current policies or programs. The policy options to be considered
will range from incremental changes in current programs to
comprehensive restructuring. The study will consider in detail how new
policies relate to the current system, and how a transition could be
effectively staged. Pooled-risk approaches might, for example, require
a transition period with partial benefits to current elderly and full
benefits phased in for future cohorts.
Study Population
The planning committee gave serious consideration to the design of a
study that would encompass the special service needs of the entire
long-term care population of all ages. Arguments in favor of such an
approach include the fact that the disabled of all ages currently
compete for the same resources--particularly Medicaid' public housing
assistance, and income supports such as SSI. Many of the service
programs effective in meeting the needs of the functionally impaired
elderly are applicable to younger populations as well. The committee
was concerned about the possibility that policies designed primarily to
serve the elderly might prejudice the options available to other
groups.
However, the concerns of a study of younger disabled populations
would be quite different than for the elderly. Basic education would
have to assume primary importance in the development of a system of
care for disabled children and young adults. Likewise, for disabled
adults under 65 years of age, vocational rehabilitation, employment,
and income supports would have to receive considerable attention. In
addition, some of the service delivery mechanisms that perform well for
subgroups of the nonelderly disabled, such as halfway houses for the
chronically mentally ill and intermediate care facilities for the
mentally retarded (ICF/MR), may not be directly relevant to improved
long-term care for the elderly.
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After careful consideration, the planning committee concluded that
encompassing the special service needs of the functionally impaired
under age 65 within the scope of this study would increase its size and
complexity to the extent that it would be difficult to manage
effectively, and it would not be feasible to complete the study within
a reasonable time period. Thus, the study will focus on the elderly
and their families but will do so recognizing the 1 Norm rare nomad
of under 65 age groups as well.
The committee strongly recommends that a separate follow-on study be
conducted on the special long-term care service needs of nonelderly
populations. The likelihood that at least 40 percent of the nation's
long-term care population in the year 2000 will be under age 65 makes
it imperative that public policies for those populations be formulated
and evaluated as soon as possible, and preferably in parallel with this
study of the elderly.
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~ ~ —~ ~ —O ~ ——~—,
Time Frame
The study will focus both on the near-term future from 1990 to the
year 2000, and on a longer-range period to the year 2020. The
committee believes that today's most critical issues, such as those
centering on cost-containment and alternative financing mechanisms,
will persist into the l990s, notwithstanding the possibility of public
or private sector actions to resolve them before then. Thus, although
the study will focus intently on the near future, it will not ignore
the need to develop a system of care appropriate for meeting the
nation's needs well into the next century.
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Representative terms from entire chapter:
functionally impaired
