ACP Makes Recommendations for Improving Long-Term Services and Support Sector

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In position paper, ACP recommends multipronged public-private sector approach for reforming LTSS financing, addressing workforce shortages, adopting plans to ensure quality and safety

Sept. 9, 2022 (ACP) — An aging population and the pressures of the COVID-19 pandemic are straining the U.S. long-term care system. In a new position paper, the American College of Physicians spotlights the challenges facing the system and identifies crucial priorities for a wide-ranging overhaul.

“Similar to many other aspects of health care, the COVID-19 pandemic highlighted some of the challenges facing long-term services and support (LTSS) in our country,” said Dr. Ryan D. Mire, president of ACP. “We saw the devastating effect the virus had on residents in nursing homes, both because of their age and the higher risk associated with congregate living situations. We also saw the pandemic greatly exacerbate staffing shortages in these facilities. We need to ensure that the U.S. has a high-functioning LTSS system that is ready to meet increased demand and deal with potential future pandemics or other events that threaten the patients who depend on these services.”

ACP members regularly care for older adults who require LTSS either in facilities or at home, said Ryan Crowley, ACP senior associate for health policy. “It's appropriate for us to explore this aspect of American health care and provide guidance to policymakers,” he explained.

It is clear that the LTSS system is underfunded, understaffed, fragmented and too often neglected by policymakers, Crowley said. “Long-term care facilities like nursing homes have a long history of quality and safety problems,” he noted. “The LTSS and medical sectors don't always collaborate and coordinate well, which increases the risk of rehospitalization and other unwanted outcomes. Additionally, most people want to stay in their own homes as they age, but there are long wait lists for home- and community-based services in many states. Overall, the sector isn't delivering whole-person, patient-centered care.”

In the policy paper, published July 11 in Annals of Internal Medicine, ACP makes the following recommendations:

  • A multipronged public-private sector approach to reforming LTSS financing should be adopted, including a publicly funded, universal catastrophic LTSS insurance program as well as policies to make private long-term care insurance affordable, accessible and viable.
    “There's a misconception that Medicare will cover long-term services and supports, but it only covers short periods of LTSS following an acute care episode,” Crowley said. “Medicaid is an option for some, but middle-income people often have to deplete their financial resources to qualify. The private long-term care insurance market has collapsed in many areas and isn't a viable option.”
    Under one vision, Crowley said, a universal, public, catastrophic LTSS benefit could kick in after a waiting period. “The private LTSS insurance market would need to be reformed so that people have coverage until the catastrophic benefit starts,” he explained. “This will help ensure that people have the resources to cover the care they need and will inject some much-needed money into the system to support high-quality staff and improve safety and quality.”
  • Shortages in the workforce for the LTSS sector must be addressed through comprehensive training, pay increases, benefit packages and opportunities for career advancement and growth. Policies should be adopted that are designed to assist unpaid caregivers through respite care, training and reimbursement.
  • Evidence-based interventions should be adopted to ensure and improve the quality of LTSS across settings. These interventions should provide support for robust monitoring, enforcement of quality reporting and improvement requirements; federal minimum nurse staffing levels for nursing homes; expanded quality and safety information for consumers; research and implementation of emerging alternatives to institutional care; and models to better integrate medical care and LTSS.
  • Research should be conducted on the effect of ownership status on the LTSS sector, including quality of care, staff and patient safety, costs and staffing ratios. Nursing homes and other LTSS providers should be required to disclose comprehensive ownership and cost information, including private equity investment and related data.
    “Most nursing homes are owned by for-profit companies,” Crowley noted. “That's not necessarily a bad thing, but evidence shows that nonprofit nursing homes provide better-quality care. Private equity investors have also expanded into the LTSS sector. It's too early to understand the full impact, but there is some evidence that shows that private equity ownership increases short-term mortality among Medicare enrollees. Obviously, that's a huge concern and we need to know more about why it's happening. President Biden has indicated his support for more transparency in ownership, so hopefully change is coming.”
  • Funding, assistance and staff support should be provided for nursing homes and other LTSS organizations to develop and implement emergency preparedness plans and ensure the safety of patients and staff.

ACP believes these reforms are crucial as the population over age 65 is projected to increase by more than 15 million between 2020 and 2030, according to Mire.

“ACP is reviewing federal legislation that would set up a catastrophic LTSS benefit. The Centers for Medicare & Medicaid Services is pushing Medicaid programs to reimburse nursing homes based on quality outcomes and sufficient staffing,” Crowley said. “The Biden administration has signaled its support for several admirable goals, like achieving health equity in the LTSS sector and improving access to home- and community-based care.”

More Information

The position paper, “Long-Term Services and Supports for Older Adults: A Position Paper From the American College of Physicians,” is available on the Annals of Internal Medicine website.

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