Integrating Acute and Long-Term Care

Prologue: One of many legacies left by the late Rep. Claude Pepper (D-FL) was the concept of integrating acute and long-term care. His Medicare Long-Term Care Catastrophic Protection Act of 1987—the original proposal for federally sponsored long-term care insurance—introduced the notion that both acute and long-term care can be strengthened if their provision is closely linked together. In this paper Walter Leutz, Mitch Greenlick, and John Capitman draw on the experience of the social health maintenance organization (social HMO) program to illustrate the success of such an integrated approach. Unfortunately, the health care reform legislation that has emerged from the debate of summer 1994 keeps the two separate. The Clinton plan and the plan advocated by Rep. Jim McDermott (D-WA) and Sen. Paul Wellstone (D-MN) were the only two plans that expanded long-term care benefits. Even if they had survived the debate, neither plan would have linked the acute and long-term care systems very strongly. As these authors point out, such a linkage can have a positive impact on the entire medical care system. Leutz is an associate research professor at the Institute for Health Policy, The Heller School, Brandeis University, in Waltham, Massachusetts. He is one of the pioneers in work on the social HMO. Leutz holds a doctorate from The Heller School. Greenlick, who received his doctorate in medical care organization from the University of Michigan, founded the Kaiser Permanente Center for Health Research located in Portland, Oregon, and has served as its director for thirty years. Capitman, who holds a doctorate in social psychology from Duke University, is a research professor and director of long-term care at the Institute for Health Policy at Brandeis. Abstract: Advocates of health system reform are striving to assure that a valuable new benefit for home- and community-based long-term care is included. Yet in many legislative proposals, a long-term care benefit is kept separate from the rest of the benefit package. Experience from the social health maintenance organization (social HMO) demonstration shows that for the elderly at least, community long-term care can be integrated with acute care, at a manageable cost. Acute and chronic disease and disability are experienced concurrently. Moreover, disability is not confined to a small group of permanently disabled persons but affects many other persons for short periods. Integration of long-term and acute care in a managed care model serving a broad population may promote more effective acute care and more efficient and affordable long-term care.