Long-Term Care

PROLOGUE: As if the challenge of inventing a new medical modelfor chronic illness weren’t enough, the institutionaland community infrastructure through which nursing and supportiveservices are provided to the frail, infirm, and disabled facesmany difficulties as well. Nursing homes, home health agencies,and other subacute care providers are struggling to adapt tonew Medicare payment systems that not only reduce their reimbursementbut also introduce complicated new evaluation and data requirements.

The theory that an adequate flow of patient data might supplanttoday’s cumbersome and unsatisfactory quality regulationhas a long way to go to become operational. Sensitivity to qualityproblems in nursing homes was evident in the Bush administration’sdisavowal of plans to reduce oversight in September 2001.

More fundamentally, younger persons with disabilities have spearheadeda movement for more consumer direction of long-term care services,and more than half of the states have launched experiments inconsumer-directed care. Advocates see potential for gains inquality and cost-effectiveness as well as autonomy.

In the following papers Ted Benjamin examines issues raisedby this emerging trend, and Robyn Stone explores the ramificationsof the "disability model" for financing long-term care. Perspectivesby Mark Pauly and Judith Feder follow Stone’s discussion.Then Kieran Walshe tackles the difficult problem of improvingnursing home regulation by looking at alternative models ofregulation in other countries and other parts of the healthcare system. Finally, Robert Kane and Rosalie Kane discuss theimplications of differences in attitudes and preferences betweenolder and younger long-term care patients.

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