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A key feature of private long-term care insurance is that medical underwriters screen out would-be buyers who have health conditions that portend near-term physical or cognitive disability. We applied common underwriting criteria based on data from two long-term care insurers to a nationally representative sample of individuals in the target age range (50-71 years) for long-term care insurance. The screening criteria put upper bounds on the current proportion of Americans who could gain coverage in the individual market without changes to medical underwriting practice. Specifically, our simulations show that in the target age range, approximately 30 percent of those whose wealth meets minimum industry standards for suitability for long-term care insurance would have their application for such insurance rejected at the underwriting stage. Among the general population-without considering financial suitability-we estimated that 40 percent would have their applications rejected. The predicted rejection rates are substantially higher than the rejection rates of about 20-25 percent of applicants in the actual market. In evaluating reforms for long-term care financing and their potential to increase private insurance rates, as well as to reduce financial pressure on public safety-net programs, policy makers need to consider the role of underwriting in the market for long-term care insurance., (Project HOPE—The People-to-People Health Foundation, Inc.)

Under health care reform, new financing and delivery models are being piloted to integrate health and long-term care services for older adults. Programs using these models generally have not included residential care facilities. Instead, most of them have focused on long-term care recipients in the community or the nursing home. Our analyses indicate that individuals living in residential care facilities have similarly high rates of chronic illness and Medicare utilization when compared with matched individuals in the community and nursing home, and rates of functional dependency that fall between those of their counterparts in the other two settings. These results suggest that the residential care facility population could benefit greatly from models that coordinated health and long-term care services. However, few providers have invested in the infrastructure needed to support integrated delivery models. Challenges to greater care integration include the private-pay basis for residential care facility services, which precludes shared savings from reduced Medicare costs, and residents' preference for living in a home-like, noninstitutional environment., (Project HOPE—The People-to-People Health Foundation, Inc.)

High-quality end-of-life care is an important component of high-quality long-term care, yet many elderly individuals receiving long-term care services do not obtain good care as they approach death. This study provides a systematic review of articles that describe care received at the nexus of long-term care and end-of-life care. The articles identified three primary types of barriers to high-quality end-of-life care in long-term care settings: delivery system barriers intrinsic to long-term care settings, barriers related to features of coverage and reimbursement, and barriers resulting from the current regulatory approach for long-term care providers. The authors recommend areas for future research that would help to support progress on public policy that governs the provision of care at this important intersection.

A significant rebalancing of the long-term care system away from nursing homes toward home- and community-based services (HCBS) has occurred over the past two decades. This article reports the results of the Commonwealth Fund Long-Term Care Opinion Leader Survey (N = 1,147) on issues related to supporting HCBS. Respondents expressed strong enthusiasm for rebalancing of the long-term care system toward HCBS. In particular, respondents supported system-based approaches for this expansion, with the majority indicating that greater care coordination was the single most preferred approach for rebalancing the system, helping consumers make informed long-term care choices, and supporting caregivers. Building on the long-term care specialists' enthusiasm for system-based reforms, we encourage state policy makers to pursue HCBS models that are linked to Medicare, engage primary care physicians, and are based on rigorous evaluations.

Purpose: The purpose of this article is to explore how the introduction of Medicare Part D is changing the operations of long-term-care pharmacies (LTCPs) and nursing homes, as well as implications of those changes for nursing home residents., Design and Methods: We reviewed existing sources of information and interviewed stakeholders across various perspectives. We conducted 31 semistructured telephone interviews with key stakeholders between November 2006 and January 2007., Results: Part D represents a substantial departure from how prescription drugs were previously financed and administered in nursing homes, and nursing home providers and LTCPs have struggled in adapting to some of these changes. Part D increased the variation around formularies and drug management processes for residents at the facility level, creating additional burden on clinical and pharmacy staff and introducing a tension between facilities' need to dispense medications quickly and assuring of coverage for those drugs. Nursing home and LTCP stakeholders perceive wide variation across Part D plans in their ability to meet the needs of nursing home residents., Implications: Although LTCPs, nursing homes and their clinicians, and Part D plans will gain experience with the benefit in the nursing home setting over time, stakeholders we interviewed identified a range of longer term issues and questions that merit attention as the benefit proceeds.

Many states have responded to growing Medicaid long-term care expenditures by limiting the number of long-term care providers through certificate-of-need (CON) programs and moratoriums on new construction or certification for participation in the Medicaid program. This article focuses on the use of these policies in 13 states. Most of the 13 states control the supply of nursing home beds and hospital conversions with CONs or moratoriums, but they are struggling to adapt the role of supply policy to the growth of home health and residential care. As an increasing proportion of Medicaid long-term care spending goes to these nursing home alternatives, supply policy needs to keep pace with the changing provider market and the changing demographics of the consumer market if it hopes to ensure access to long-term care and control Medicaid expenditures.

In the thirteen Assessing the New Federalism states, strategies to control the rate of increase in long-term care spending are extremely varied, especially in comparison with acute care's single-minded focus on managed care. States use three broad strategies: offsetting state spending with increased private and federal contributions, making the delivery system more efficient, and using traditional cost-control mechanisms, including controlling the nursing home bed supply and cutting Medicaid reimbursement rates.