Review: Disparities in Long-Term Care Building Equity Into Market-Based Reforms

Department of Health Studies, University of Chicago, 5841 S. Maryland Avenue, MC2007, Chicago, IL 60637, USA.
Medical Care Research and Review (Impact Factor: 2.62). 03/2009; 66(5):491-521. DOI: 10.1177/1077558709331813
Source: PubMed


A growing body of evidence documents pervasive racial, ethnic, and class disparities in long-term care in the United States. At the same time, major quality improvement initiatives are being implemented that rely on market-based incentives, many of which may have the unintended consequence of exacerbating disparities. We review existing evidence on disparities in the use and quality of long-term care services, analyze current market-based policy initiatives in terms of their potential to ameliorate or exacerbate these disparities, and suggest policies and policy modifications that may help decrease disparities. We find that racial disparities in the use of formal long-term care have decreased over time. Disparities in quality of care are more consistently documented and appear to be related to racial and socioeconomic segregation of long-term care facilities as opposed to within-provider discrimination. Market-based incentives policies should explicitly incorporate the goal of mitigating the potential unintended consequence of increased disparities.

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    • "To address these limitations, we expanded the Scorecard in several ways. First, we added a sixth dimension, disparities, to acknowledge the increasing heterogeneity of the LTSS population and the growing evidence of pervasive inequities in quality (Konetzka and Werner 2009). "
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    ABSTRACT: Health care in the United States is fragmented, inefficient, and rife with quality concerns. These shortcomings have particularly serious implications for adults with disabilities and functionally impaired older adults in need of long-term services and supports (LTSS). Three strategies have been commonly pursued by state governments to improve LTSS: expanding noninstitutional care, integrating payment and care delivery, and realigning incentives through market-based reforms. These strategies were analyzed using an evaluation framework consisting of the following dimensions: ease of access; choice of setting/provider; quality of care/life; support for family caregivers; effective transitions among multiple providers and across settings; reductions in racial/ethnic disparities; cost-effectiveness; political feasibility; and implementability. Although the analysis highlights potential benefits and drawbacks associated with each strategy, the limited breadth of the evidentiary base precludes an assessment of impact across all nine dimensions. More importantly, the analysis exposes the interdependent, complex system of care within which LTSS is situated, suggesting that policy makers will require a holistic and long-term perspective to achieve needed changes. Addressing the nation's LTSS needs will require a multipronged strategy incorporating a range of health and social services to meet the complex care needs of a diverse population in a variety of settings. Copyright © 2015 by Duke University Press.
    Journal of Health Politics Policy and Law 02/2015; 40(3). DOI:10.1215/03616878-2888460 · 1.37 Impact Factor
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    • "Rates of assisted living facility usage are lower for African-American older adults than other ethnic groups (Hernandez, 2012). This underutilization of assisted living facilities may be due to high service fees, access barriers, or cultural preferences by African-American older adults for informal and kinship care (Konetzka and Werner, 2009; Park et al., 2013). Also, African-American older adults in assisted living often reside in smaller facilities that are poorly lit, ineffectively cleaned, inadequately maintained, and insufficiently supplied with amenities (Hernandez and Newcomer, 2007; Howard et al., 2002). "
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    ABSTRACT: The purpose of this secondary data analysis study was to understand how older adults of an assisted living facility used photos to co-construct a shared narrative of home and plan for resident action. Focus group data from an earlier study of African-American older adults in assisted living facilities was explored using narrative analysis to highlight the dialogic process embedded in photovoice methodology. An analysis of content and narrative structure was used to identify the contributions of individual photo narratives to a shared group narrative.
    Qualitative Social Work 10/2014; 14(5). DOI:10.1177/1473325014561139
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    • "African Americans in both groups expected to rely largely on government programs and on friends and family, expressing belief that family members should take care of their own elderly relatives. This is consistent with some previous literature on the role of race in LTC decisions [19]. The high-education group had a broader range of exposure to different types of senior living arrangements, some private and some public. "
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    ABSTRACT: Objectives Time trade-off (TTO) methods are often used for utility assessments of different health states to measure quality of life (QOL). They have not generally been used to assess social preferences with respect to options for health care delivery, although the need for quantifying these preferences is arguably just as important. Policymakers are increasingly faced with decisions about how much to invest in, and how much to incentivize, particular modes of health care delivery, generally with little evidence about user preferences. Methods This study draws on long-term care (LTC) delivery modes as an example. Focus groups were conducted to approach this issue both qualitatively and quantitatively. In a qualitative pilot study, two focus groups discussed issues of the LTC decision-making process and preferences among different LTC options. The TTO was then used to assess QOL for each LTC option, conditional on a specific health state, and then quantified user’s LTC preferences by differential QOL between the two options. Results This study found that the TTO-elicited utilities and their differences are consistent with the LTC preferences revealed from focus group discussions. These preferences depend on levels of disability and education. Conclusions The modified TTO technique seems a feasible method to quantify preferences over LTC delivery options. These methods may be applicable to various health care alternatives in which better evidence is needed to guide funding policy.
    Value in Health 03/2014; 17(2):302–305. DOI:10.1016/j.jval.2013.11.010 · 3.28 Impact Factor
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