THE
COMMONWEALTH
FUND
Long-Term Care Policy:
Time for Attention
Karen Davis
President, The Commonwealth Fund
Long-Term Care Colloquium
June 5, 2004
kd@cmwf.org
www.cmwf.org
Long-Term Care a Serious and
Neglected Issue
2
• Need for long-term care policy
initiative
• Population at risk
• Current long-term care utilization
and financing
• Promising delivery models
• Policy options for change
THE
COMMONWEALTH
FUND
3
People Aged 65 and Older as a Share
of the U.S. Population,
Selected Years, 1900–2050
Percent
25
65 and Older
20
15
10
65 to 74
75 to 84
5
85 and Older
0
1900
1950
1980
1990
2000
2010
2020
2030
2040
Projected
Source: Congressional Budget Office, Financing Long-Term Care for the Elderly, April 2004.
2050
THE
COMMONWEALTH
FUND
Those Who Live Longer More Likely to Develop
Conditions that Require Ongoing Assistance, 2000
4
Percent of older people with functional limitations who need help of
another person
65 to 74
75 to 84
80 and older
25
19.8
20
15
9.3
10
5
10.9
4.0
8.2
1.8
3.9
1.7
3.5
0
IADLS only
1–2 ADLS
3–6 ADLs
Source: Center on an Aging Society analysis of National Center for Health Statistics, National Health
Interview Surveys, 2000, as reported in R.B. Friedland and L. Summer, Demography is Not Destiny,
Revisited, Forthcoming Publication – Do Not Cite or Distribute.
THE
COMMONWEALTH
FUND
Need for Long-Term Care in the Future
Will Increase
5
Projected number (in thousands) of people age 65 and older who
will need long-term care
14,000
12,000
10,000
9,200
12,300
12,100
2030
2040
10,400
8,000
6,000
4,000
2,000
0
2010
2020
Source: Congressional Budget Office, Projections of Expenditures for Long-Term Care Services for
the Elderly, 1999, as reported in R.B. Friedland and L. Summer, Demography is Not Destiny,
Revisited, Forthcoming Publication – Do Not Cite or Distribute.
THE
COMMONWEALTH
FUND
Number of People Using Supportive Services
Will Increase Substantially, 2000–2020
6
Projected number (in millions) of older Americans using supportive
services
4.5
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
Personal Care
Nursing Facility
Skilled Home
Care
Alternative
Residential Care
2000
2005
2010
2020
Source: Commission on Affordable Housing and Health Facility Needs for Seniors in the 21st Century,
A Quiet Crisis in America, A Report to Congress, 2002, as reported in R.B. Friedland and L. Summer,
Demography is Not Destiny, Revisited, Forthcoming Publication – Do Not Cite or Distribute.
THE
COMMONWEALTH
FUND
Impaired Elderly People by Level of
Impairment and Sources of Assistance, 1994
7
Number of impaired people (in thousands)
Informal Helpers Only
1,600
1,400
1,200
1,488
12%
10%
27%
9%
1,000
800
600
Both Paid and Informal Helpers
1,859
2,000
1,800
Paid Helpers Only
78%
1,389
47%
4%
64%
49%
400
200
0
IADL Only
1–2 ADLs
3–5 ADLs
Source: Congressional Budget Office, Financing Long-Term Care for the Elderly,
April 2004.
THE
COMMONWEALTH
FUND
8
Alternatives to Nursing Home Care Increasing
Proportion of National Long-Term Care Spending for Home and
Community-Based Services and Institutions, 1990–2002
Dollars (in billions)
HCBS Spending
$180
Institution Spending
$160
$140
$120
$100
$80
67
75
$60
$40
$20
$0
79%
21%
78%
22%
83
75%
25%
90
73%
27%
98
70%
30%
110
68%
32%
120
67%
33%
138
128 132 133
67%
67%
67%
33%
33%
33%
68%
32%
156
148
67%
33%
66%
34%
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Source: Center for Medicare and Medicaid Services, National Health Accounts – Historical National Health
Expenditures by Type of Service and Source of Funds: Calendar Years 1960–2002, as reported in R.B. Friedland and
L. Summer, Demography is Not Destiny, Revisited, Forthcoming Publication – Do Not Cite or Distribute.
THE
COMMONWEALTH
FUND
Elderly Nursing Home Residents* and Home
Health Care Patients^ by Age and Sex
Total Elderly Nursing Home Residents
= 1.5 Million
65 to 74 years
14%
[Male = 6%]
[Female = 8%]
85 years and older
50%
[Male = 9%]
[Female = 41%]
M
Total Elderly Home Health Care Patients
= 1.8 Million
85 years and older
23%
[Male = 5%]
[Female = 18%]
F
F
M
9
65 to 74 years
30%
[Male = 10%]
[Female = 20%]
M
M
F
F
M
F
75 to 84 years
36%
[Male = 11%]
[Female = 25%]
F
M
75 to 84 years
47%
[Male = 15%]
[Female = 32%]
*1997
^1996
Source: Congressional Budget Office, Financing Long-Term Care for the Elderly, April 2004.
THE
COMMONWEALTH
FUND
10
Long-Term Care Expenditures for the
Elderly by Sources of Payment, 2004
Total Institutional Care Expenditure
= $92.4 Billion
Total Home Care Expenditure
= $42.5 Billion
Other
2%
Out-of-Pocket
39%
Other
6%
Medicaid
40%
Out-of-Pocket
20%
Medicaid
25%
Private
Insurance
8%
Private
Insurance
3%
Medicare
17%
Medicare
42%
Note: Numbers may not add to 100 due to rounding.
Source: Congressional Budget Office, Financing Long-Term Care for the Elderly, April 2004.
THE
COMMONWEALTH
FUND
Medicaid’s Expenditures on Long-Term Care
for Elderly Beneficiaries,
Fiscal Years 1992–2004
11
Percent
40
Skilled Nursing Facilities
35
30
25
20
15
Home Health Care Services
10
5
0
1992
1994
1996
1998
2000
2002
* Expenditures for 2004 are projected
Source: Congressional Budget Office, Financing Long-Term Care for the Elderly, April 2004.
2004*
THE
COMMONWEALTH
FUND
12
Satisfaction with Nursing Home Care
In 2001, one-third of people with substantial nursing home experience expressed dissatisfaction
with the care that they, a family member, or a friend received in the last three years
Overall, how satisfied are you with the
services provided by the nursing home?
Very satisfied
32%
Somewhat
satisfied
32%
Would you recommend this facility to
someone else who needs nursing home
care?
Yes
62%
No
36%
Don’t know
3%
Very
dissatisfied
15%
Somewhat
dissatisfied
22%
Don’t know
2%
Note: Substantial nursing home experience defined as those who have been a resident in nursing home or
known someone in nursing home and visited at least once a month in past three years.
Source: Leatherman and McCarthy, Quality of Health Care in the United States: A Chartbook, 2002,
The Commonwealth Fund.
THE
COMMONWEALTH
FUND
13
Ratings of Nursing Home Staff and Staffing Levels
In 2001, a large minority of people with substantial nursing home experience in the last three
years reported inadequacies with staffing or mistreatment or abuse of residents by staff
Yes
A physician is available
whenever needed
0%
7
71
Staff provide adequate help at
mealtimes
Resident has been treated badly
or abused by staff
17
41
52
Staff are interested and
responsive to family concerns
Don't Know
33
51
Enough other staff on duty
whenever needed
No
73
5
21
6
6
69
25
10%
24
20%
30%
40%
50%
60%
70%
80%
90% 100%
Percent of people with substantial nursing home experience
Note: Substantial nursing home experience defined as those who have been a resident in nursing home or
known someone in nursing home and visited at least once a month in past three years.
Source: Leatherman and McCarthy, Quality of Health Care in the United States: A Chartbook, 2002,
The Commonwealth Fund.
THE
COMMONWEALTH
FUND
14
Nursing Home Quality of Life
In 2001, one-quarter or more of people with substantial nursing home experience in the last
three years reported dissatisfaction with quality of life in the nursing home or a quality problem
Yes
Nursing home is well set up for
physically disabled
10
9
32
59
5
72
23
10%
20%
30%
40%
1
25
74
Enough recreational activities to
meet residents' needs
8
16
76
Resident is bathed and groomed
in satisfactory manner
0%
Don't Know
26
64
Residents feel safe
Resident developed bed sores
or skin ulcers
No
50%
60%
70%
80%
90% 100%
Percent of people with substantial nursing home experience
Note: Substantial nursing home experience defined as those who have been a resident in nursing home or
known someone in nursing home and visited at least once a month in past three years.
Source: Leatherman and McCarthy, Quality of Health Care in the United States: A Chartbook, 2002,
The Commonwealth Fund.
THE
COMMONWEALTH
FUND
15
Age Distribution of the Registered
Nurse Population, 1980–2000
Source: National Sample Survey of Registered Nurses, Division of Nursing, Bureau of
Health Professions, Health Resources and Services Administration.
THE
COMMONWEALTH
FUND
The Culture-Change Movement
16
• There are several models of resident-centered care in nursing
homes
• The Pioneer Network is the umbrella organization for these
homes and models (www.pioneernetwork.net)
• In these homes, front-line staff decision-making enriches
activities and quality of resident life
• Staff turnover is reduced; high use of temporary nurses’ aides
is eliminated
• Culture change is occurring in not-for-profit and for-profit
homes
THE
COMMONWEALTH
FUND
17
Wellspring: A Tested Model for
Nursing Home Quality Improvement
• Organizes facilities into alliances
(collaboratives) of about 10 homes
• Uses module-based, team training on clinical
and non-clinical topics reinforced by follow-up
local activities
• Tracks and shares resident-level data to
identify and spread better practices among
member facilities
THE
COMMONWEALTH
FUND
Wellspring Nursing Homes Are Cited for Fewer
Deficiencies than Other Wisconsin Facilities
18
Percent of facilities with severe deficiencies cited by inspections
before, during, and after implementation of the Wellspring program
Wellspring homes
25
Non-Wellspring homes
22.2
20
15
10
12.5
7.2
9.5
5
0
7.3
0
Before
implementation
(2nd half 1995–
1st half 1996)
During
implementation
(2nd half 1996–
1st half 1998)
After
implementation
(2nd half 1998–
end of 2000)
Source: Robyn I. Stone, Susan C. Reinhard et al., Evaluation of the Wellspring Model
for Improving Nursing Home Quality, The Commonwealth Fund, August 2002.
THE
COMMONWEALTH
FUND
19
Total Cost
Mean cost per resident day
Wellspring
Non-Wellspring
$160
$140
$120
$100
$80
$60
$40
$20
$0
1993–94
1994–95
1995–96
1996–97
1997–98
Source: Robyn I. Stone, Susan C. Reinhard et al., Evaluation of the Wellspring Model
for Improving Nursing Home Quality, The Commonwealth Fund, August 2002.
THE
COMMONWEALTH
FUND
20
Public Perception of Government Enforcement and
Regulation of the Quality of Nursing Homes
Do you agree or disagree with the following statements…?
Strongly agree
Government is NOT
enforcing quality
standards for nursing
homes
T here is NOT enough
government regulation
of the quality of nursing
homes
Somewhat agree
39%
42%
Somewhat disagree
26%
24%
Strongly agree
18%
7%
14%
10%
Note: Don’t know not shown
Source: The NewsHour with Jim Lehrer/Kaiser Family Foundation/Harvard School of Public Health
National Survey on Nursing Homes, September 2001 (conducted April–June 2001).
THE
COMMONWEALTH
FUND
21
Who Do You Think Should Have the MAIN
Responsibility for Paying Nursing Home Bills?
When people are admitted to nursing
homes, who do you think should have the
MAIN responsibility for paying the bill?
Patients and
families
themselves
44%
Government
through tax
revenues
48%
(Asked of the 44% who say patients
and the families themselves should
be responsible) If a patient and their
family cannot pay the cost
themselves, who then should have
the MAIN responsibility for paying?
34%
Don’t know
8%
Government
if patient or
family cannot
pay the cost
themselves
8%
Charities
2%
Don’t know
Source: The NewsHour with Jim Lehrer/Kaiser Family Foundation/Harvard School of Public Health
National Survey on Nursing Homes, September 2001 (conducted April–June 2001).
THE
COMMONWEALTH
FUND
Interest in the Federal Government Doing
More to Help Pay the Cost of Nursing
Home Care
Would you favor or oppose the federal
government doing more to help pay the
cost of nursing home care, even if it would
require a substantial increase in taxes?
(Asked of the 70% who favor the
federal government doing more)
Would you prefer to have the federal
government…
Don’t know
4%
29%
Oppose
26%
Favor
70%
22
Expand
Medicare
21%
Give
people tax
credits
17%
Expand
Medicaid
3%
All of these
Source: The NewsHour with Jim Lehrer/Kaiser Family Foundation/Harvard School of Public Health
National Survey on Nursing Homes, September 2001 (conducted April–June 2001).
THE
COMMONWEALTH
FUND
Majority of Americans Favor Expanding
Medicare to Cover Most of the Cost of Nursing
Home Services for Those Who Need It
23
Would you favor or oppose the federal government expanding Medicare to cover most
of the cost of nursing home services for those who need it? Would you still favor this
if it could lead to a tax increase?
Favor even if
tax increase
65%
Oppose if tax
increase
15%
OPPOSE
27%
Oppose
initially
12%
Depends (vol.)
4%
Don’t know
4%
Source: The NewsHour with Jim Lehrer/Kaiser Family Foundation/Harvard School of Public Health
National Survey on Nursing Homes, September 2001 (conducted April–June 2001).
THE
COMMONWEALTH
FUND
In Order to Encourage More People to Purchase
a Private Long-Term Care Insurance Policy,
Would You…
24
…favor or oppose the federal government giving a substantial tax deduction or tax
credit to people who purchase such policies? Would you still favor this if it could lead
to a tax increase?
Favor even if
tax increase
59%
Oppose if tax
increase
22%
OPPOSE
30%
Oppose
initially
8%
Depends (vol.)
2%
Don’t know
9%
Source: The NewsHour with Jim Lehrer/Kaiser Family Foundation/Harvard School of Public Health
National Survey on Nursing Homes, September 2001 (conducted April–June 2001).
THE
COMMONWEALTH
FUND
25
Policy Options
• Tax credits/ health savings accounts for
long-term care insurance and long-term
care services
• Support of new delivery options
• Research on long-term care quality
improvement and effectiveness
• Medicaid expansion
• Medicare expansion
THE
COMMONWEALTH
FUND
Medicare Long-Term Care Benefit:
A Policy Framework
26
• Optional Medicare long-term care benefit
• Enroll as early as age 60 or as late as age 70
• Long-term care benefits with 10%
coinsurance and $3,000 ceiling
• 4% income as premium; general revenues to
finance the balance
• Quality standards
• Prospective payment for nursing homes and
home health
Source: Karen Davis and Diane Rowland, Medicare Policy: New Directions for Health and Long-Term
Care, Baltimore: Johns Hopkins University Press, 1986.
THE
COMMONWEALTH
FUND
27
Acknowledgements
Mary Jane Koren, Senior Program Officer, Frail
Elders Program, Commonwealth Fund.
Barbara Cooper, Senior Program Officer,
Commonwealth Fund; Karen Davis and Barbara
Cooper, American Health Care: Why So Costly,
Commonwealth Fund, June 2003 Senate Testimony.
Research assistance – Alice Ho, Research
Associate, Commonwealth Fund
Visit the Fund at: www.cmwf.org
THE
COMMONWEALTH
FUND