July 2008 Data Brief Commission on a High Performance Health System Health Care Opinion Leaders’ Views on the Future of Long-Term Care M ichelle D oty, M ary J ane K oren , and K aren D avis For more information about this ABSTRACT: The 15th Commonwealth Fund/Modern Healthcare Health Care Opinion study, please contact: Leaders Survey asked a diverse group of experts for their perspectives on the future of Michelle McEvoy Doty, Ph.D. long-term care in the United States. Four of five of the experts surveyed believe that it is Associate Director, Research important or very important to secure adequate financing of long-term care, improve qual- The Commonwealth Fund E-mail mmd@cmwf.org ity of long-term care facilities, and develop a health care workforce that is sufficient in size and skill to provide long-term care. Adding a long-term care benefit to Medicare, financed by a premium, is favored by nearly four of five respondents. Over two-thirds (69%) say it is important or very important for presidential candidates’ health reform plans to address quality and financing of long-term care.      Overview Over the next quarter-century, the number of adults age 65 or older is estimated to double—from 35 million to 71 million—creating accelerating demands on the 1 U.S. health care system. With the aging of the baby boom generation, the increasing life expectancy of Americans, and spending on long-term care for the 2 elderly projected to more than double over the next 30 years, there is ample rea- son to be concerned about how the nation will provide its aging population with high-quality care and a good quality of life—and, equally important, how it will finance that care. The latest Commonwealth Fund/Modern Healthcare Health Care This and other Commonwealth Opinion Leader Survey asked about the most urgent challenges facing long-term Fund publications are online at www.commonwealthfund.org. To care and potential strategies for addressing them. Experts in sectors as diverse as learn more about new publications academia, health care delivery, health industry, business, labor, consumer advo- when they become available, visit cacy, and government agreed that the three most urgent challenges facing long- the Fund’s Web site and register to receive e-mail alerts. term care are securing adequate financing, improving the quality of care in long- Commonwealth Fund pub. 1157 term care facilities, and developing a health care workforce that is sufficient in Vol. 10 size and skill to provide long-term care. The majority of opinion leaders also 2T he  C ommonwealth F und agreed that payment for long-term care should primar- expenditures are financed by public programs, primar- 3 ily be a shared responsibility between individuals and ily Medicaid and Medicare. As the population ages, the government; in fact, nearly four of five (79%) sup- the share of health spending accounted for by the long- port adding a long-term care benefit to Medicare, term care sector will grow, placing increasing demands financed by a premium. Moreover, experts agreed that on government budgets. payment incentives would be the most effective strat- Not surprisingly, four of five respondents to egy for improving the quality of home health services the survey said it is urgent or very urgent to secure and the care delivered in nursing homes and assisted- adequate financing (80%), develop a health care work- living facilities. force that is sufficient in size and skills to provide long-term care (82%), and improve the quality of The Health Care Opinion Leaders Survey long-term care facilities (80%) (Figure 1). Three- The Commonwealth Fund and Modern Healthcare fourths think that forming a sufficient supply of home- commissioned Harris Interactive to solicit the perspec- and community-based services is urgent or very urgent tives of a diverse panel of health care experts on issues (76%). Two-thirds think establishing information on related to the delivery, financing, and quality of long- long-term care facilities and providers for consumers term care. The survey—the 15th in a continuing series and families is urgent or very urgent. About half agree of health care opinion leader surveys—was conducted that establishing sufficient regulations and enforcing online within the United States between June 2 and them (51%) and adopting information technology sys- June 30, 2008, among 1,078 leaders in health policy tems (48%) are urgent challenges. and innovators in health care delivery and finance. (See box on page 10 for complete study methodology.) Who Should Pay for the Long-Term Care Needs of Americans? Leading Challenges Facing Long-Term Care Much has been made of projections that show Long-term care is an important but often neglected Medicare and Medicaid consuming an ever-greater part of the health care system. It accounts for more share of the federal budget and the nation’s gross than 10 percent of all national health expenditures, or domestic product. But simply shifting costs onto older upwards of $200 billion. Two-thirds of long-term care Americans will not make the financial problem disap- Figure 2. More Than Half of Opinion Leaders Say Long-Term Care Figure 1. Policymakers Cite an Adequate Workforce, Improving Costs Should Be Shared by Individuals and the Government Quality, and Securing Adequate Financing as the Most Urgent Challenges Facing Long-Term Care “Whom do you think should pay for long-term care? Costs for long-term care should be… “In your opinion, how urgent are the following challenges facing long-term care Mostly paid by for policymakers and health care leaders to address?” employers Not sure 0% 1% Very urgent Urgent Mostly paid by government Developing a healthcare workforce that 48 34 82 programs is sufficient in size and skill to provide long-term care 8% Improving the quality of care in 46 34 80 Shared by long-term care facilities Mostly paid by individuals and Securing adequate financing of 54 26 80 individuals and/or long-term care the government their children Forming a sufficient supply of home- and 39 37 76 55% community-based services 11% Establishing adequate information on long-term care facilities and providers for 24 43 67 consumers/families Shared by individuals, 13 38 51 Establishing sufficient regulations and their enforcement employers, and the 15 33 government Adopting information technology systems 48 26% Source: Commonwealth Fund Health Care Opinion Leaders Survey, June 2008. Source: Commonwealth Fund Health Care Opinion Leaders Survey, June 2008. H ealth C are O pinion L eaders ’ Views on the F uture of L ong -Term C are 3 pear. Few individuals have sufficient savings to pay opinion leaders—nine of 10—feel that the long-term for long-term care if they were to become unable to care insurance industry needs strong regulation care for themselves, and insurance for long-term care (91%) (Table 1). is still quite limited. Among the other options, transferring respon- Opinion leaders overwhelmingly agree that sibility for Medicaid long-term care from states to the individuals and their families should not shoulder all federal government was supported by three of five the responsibility for paying for long-term care (Figure respondents (63%). Although respondents from the 2). Instead, the most-endorsed approach among leaders business sector, health insurance, and other health care from all sectors is that government and individuals industries were least supportive of this option, over should share the responsibility for paying for long- half (55%) were nevertheless in favor of making such term care (55%). A minority (26%) of panelists indi- a change. Leaders in academia, research, government, cated that employers, together with individuals and the labor, and consumer advocacy were among those most government, should share the responsibility for paying opposed to a policy that would provide tax incentives for long-term care. for individuals to purchase private long-term care While many nations have turned their attention insurance; three of 10 leaders in health care delivery to their aging populations and have established sys- also opposed this approach (Table 2). tems for financing long-term care, the United States A majority of long-term care providers are for- has taken little action to address the issue. We asked profit entities. Recent congressional hearings have opinion leaders to weigh in on alternative approaches raised questions about practices within the for-profit for paying for the country’s long-term care needs, as sector that undermine quality and value of care pro- 4 well as on policy strategies for controlling the growing vided. When we asked opinion leaders what they cost of long-term care (Figure 3). thought of a policy that would limit Medicare and Overall, respondents favor adding a long-term Medicaid long-term care participation to only non- care insurance benefit to Medicare, financed by a pre- profit facilities and agencies, only one of three had a mium (79%). Fewer respondents, though still a strong favorable opinion, while over half opposed or strongly majority, favor providing tax incentives for individuals opposed such a shift in policy (Figure 4). Still, 14 per- to purchase private long-term care insurance (64%). cent of respondents were not sure whether to support At the same time, an overwhelming majority of or oppose this strategy, suggesting that there is uncer- Figure 3. To Pay for Long-Term Care, Majorities of Opinion Leaders Figure 4. One of Three Opinion Leaders Would Favor a Policy to Favor Adding a Long-Term Care Benefit To Medicare, Limit Medicare/ Medicaid Long-Term Care Participation to Only Financed by a Premium Nonprofit Facilities and Agencies; Over Half Would Oppose It “Would you favor or oppose a policy that would limit Medicare and Medicaid “Below are three broad policy mechanisms that have been proposed to address sms proposed long-term care participation to only nonprofit facilities and agencies? paying for long-term care. Please indicate your level of support for eac one.” cate each suppor t for eac Please indicate your level of support for this.” Strongly favor Favor Strongly favor Not sure 10% 14% Add a long-term care benefit to 39 40 79 Medicare, financed by a premium Provide tax incentives for Strongly Favor individuals to purchase private 27 37 64 oppose long-term care insurance 20% 16% Transfer the responsibility for Oppose Medicaid long-term care from 27 36 63 40% states to the federal government Source: Commonwealth Fund Health Care Opinion Leaders Survey, June 2008. Source: Commonwealth Fund Health Care Opinion Leaders Survey, June 2008. 4T he  C ommonwealth F und tainty about the possible ramifications of such a mea- Most experts, however, expressed doubt about sure on access to needed long-term care services. the potential effectiveness of voluntary quality assur- ance and improvement efforts in which nursing homes The Quality of Long-Term Care select problem areas and set their own improvement Since the federal nursing home reform law went into targets. Still, there are significant voluntary efforts effect in 1987, the quality of care in nursing homes now under way that have shown promise. One notable across the country has improved significantly. In par- example is the Advancing Excellence in America’s ticular, the use of physical restraints by nursing home Nursing Homes campaign, a high-level public–private 5 staff has dropped considerably. Still, serious concerns partnership that is helping nursing homes meet specific about the quality of long-term care remain. performance targets. So far, 44 percent of nursing Opinion leaders were asked to share their homes—nearly 7,000 homes—have joined the cam- thoughts on the effectiveness of a number of paign. Compared to non-participating facilities, first- approaches that might ensure the delivery of higher- year data show greater improvements in the clinical 6 quality care by home health providers, nursing homes, goal areas selected by participating nursing homes. and assisted-living facilities. From a list of policy strategies, nearly three-fourths of leaders (74%) agreed Help for Consumers and Families that using payment incentives to improve quality— The need for long-term care sometimes comes with lit- such as earmarked rate enhancements to improve staff- tle warning. It can be precipitated by a stroke or other ing levels, decrease turnover rates, or restrict use of health calamity, as well as by the sudden loss of a fam- temporary agency staff—would be the most effective ily caregiver. But even when families have time to pre- approach (Figure 5). Six of 10 respondents (61%) also pare, they often have little information to help them said that expanding the public availability of informa- weigh the suitability of alternatives. Having a guide to tion on the quality and price of nursing home and point the way is viewed as an effective strategy for home health care would prove effective. Over half of helping people make informed long-term care choices. respondents (56%) said that having a full-time physician or The survey asked respondents to evaluate the nurse practitioner on site at nursing homes would be effectiveness of various strategies that would help peo- an effective strategy for improving long-term care. ple make informed choices when navigating the long- Figure 5. Using Payment Incentives to Promote Quality Figure 6. Consumers and Families Need Assistance in Perceived to Be Most Effective Potential Strategy for Making Informed Choices About Long-Term Care Improving Long-Term Care “How effective do you think each of the following strategies would be in helping “How effective do you think each of the following strategies would be in people make informed choices when navigating the long-term care system?” assuring and improving high quality of care in home health, nursing homes, and assisted-living arrangements?” Very effective Effective Very effective Effective Formal care coordination services that Using payment incentives to explicitly link people to available long-term 31 43 74 promote quality* 24 50 74 care options Counseling services that help people Increased public availability of quality and 26 48 74 navigate available service options when price information on nursing home and home 22 39 61 long-term care is needed health care Having a medical home* to link families Having a full-time physician or nurse 68 39 56 and services and offer shared 38 30 practitioner on site at nursing homes 17 decision-making with the family Investment in long-term care information Having a medical home* to link technology and linking patient records with 14 39 53 families and services and offer shared 24 43 67 regional hospitals decision-making with the family Voluntary efforts to improve quality and Public information campaigns aimed at 6 19 25 stimulating people to plan for future 7 22 29 set goal areas long-term care needs *Such as earmarked rate enhancements to improve staffing levels, decrease turnover *”Medical home” is defined as a patient-centered primary care practice that is designed rates, or limit use of agency staff. to offer accessible, continuous, and coordinated care. Source: Commonwealth Fund Health Care Opinion Leaders Survey, June 2008. Source: Commonwealth Fund Health Care Opinion Leaders Survey, June 2008. H ealth C are O pinion L eaders ’ Views on the F uture of L ong -Term C are 5 Figure 7. Majorities of Opinion Leaders Are at Least Figure 8. Nearly One of Three Opinion Leaders Familiar with Somewhat Familiar with Culture Change and the Culture Change Believe It Has Been Effective in Improving the Resident-Centered Care Movement Quality of Care in Nursing Homes “A growing movement, known as ‘culture change’ or ‘resident-centered care,’ is “How effective has the ‘culture change’ or ‘resident-centered care’ movement been working to deinstitutionalize long-term care and radically transform the nursing in improving the quality of care in nursing homes?*” home environment. In a culture change model, seniors enjoy much of the privacy and choice they would experience if they were still living in their own home. Very effective Nursing home residents are given greater control over their daily lives (e.g., daily 20% schedules, food choices, other decisions) and there is a living environment that Not sure is designed to be a home rather than an institution. How familiar are you with 28% the culture change or resident-centered care movement in nursing homes?” Effective 20% Not sure 1% Very familiar 17% Not at all effective 5% Somewhat effective Not familiar 28% 33% *Asked of those familiar with culture change/resident-centered care. Familiar Source: Commonwealth Fund Health Care Opinion Leaders Survey, June 2008. 21% sus that ad campaigns cannot adequately address the Somewhat complex issues involved in such crucial family decisions. familiar 28% Source: Commonwealth Fund Health Care Opinion Leaders Survey, June 2008. The Culture Change Movement Over the last decade, a growing movement within the nursing home industry known as “culture change” has term care system. Nearly three-fourths of health care been seeking to radically transform the nursing home opinion leaders (74%) thought that formal care coordi- experience. In nursing homes that adopt the principles nation services that explicitly link people to appropri- of culture change, residents are given greater control ate long-term care options would be effective or very over their daily lives, and nurse’s aides—the frontline effective (Figure 6). A similar proportion thought that workers responsible for day-to-day, hands-on care— counseling services that help people navigate available are given greater autonomy to care for residents. In service options when long-term care is needed would addition, the physical and organizational structure of be effective. such facilities has been designed to feel more like a In addition, more than two-thirds (68%) of home than an institution. health care opinions leaders think that having a “medi- Survey participants were asked about their cal home”—defined as a patient-centered primary care familiarity with the culture change movement and practice designed to offer accessible, continuous, and what effect, if any, culture change has had on nursing coordinated care—would be effective in linking fami- home quality. Over a third of respondents said they lies to services and helping families with long-term were familiar with the culture change movement, care decision-making. To be effective medical homes, while another 28 percent were somewhat familiar however, physician practices would themselves need (Figure 7). One-third of opinion leaders were not better information and access to resources within their familiar with the movement. Among leaders who were community than is currently generally available. at least somewhat familiar with culture change, about Few leaders saw general public-information one of three (28%) said it has been effective in its goal campaigns as an effective strategy for helping people of improving the quality of care in nursing homes, and make choices either for themselves or for relatives. another 38 percent indicate it has been somewhat More than likely, this lack of support reflects a consen- effective (Figure 8). Of those who were at least some- 6T he  C ommonwealth F und what familiar with this movement, 28 percent were Figure 9. Opinion Leaders Believe It Is Important That the not sure whether it has had any impact on nursing Health Reform Plans of the Presidential Candidates Address Quality and Financing of Long-Term Care home performance. “Thinking about the health reform plans of the presidential candidates, These findings suggest that evidence about the how important is it that their plans address the quality and financing of long-term care?” benefits of implementing culture change and resident- Not Not sure centered care need to be more widely disseminated. important 2% Findings from The Commonwealth Fund’s National 7% Survey of Nursing Homes show that in facilities that incorporate some aspects of culture change, substantial Somewhat Very important important benefits accrue to residents and to nursing homes 23% 41% themselves in the form of better staff retention, higher occupancy rates, better competitive position, and 7 improved operational costs. As awareness of these Important 28% and other advantages grows, it is likely that many Source: Commonwealth Fund Health Care Opinion Leaders Survey, June 2008. more nursing homes will begin to make the changes in human resource management, physical environment, and care delivery that are the hallmarks of resident- can have serious detrimental effects on the physical centered care. and mental well-being of frail elderly adults. Quality is also highly variable across geo- The Need for National Leadership graphic regions. In the top tenth of states, the rate of Not since the days when Florida congressman Claude pressure sores among high-risk nursing home residents Pepper championed the interests of the elderly has the averages 7 percent, compared with 17 percent within issue of long-term care policy risen to the level of a the bottom tenth. And the use of physical restraints 8 public priority. Yet, seven of 10 (69%) opinion leaders ranged from 2 percent of all residents in the top tenth agreed that the presidential candidates should address of states to 12 percent in the bottom tenth, with a in their health reform plans the quality and financing of national average of 6 percent. long-term care (Figure 9). If real progress is to be Increasing nursing homes’ retention of trained made in securing financing and improving quality, and qualified certified nurse’s aides is an effective long-term care must be made a focus of national strategy for improving the quality of resident care. policy debate. Currently, turnover rates are high, ranging from 38 The Commonwealth Fund Commission on a percent of aides in the top-performing group of states High Performance Health System has documented the to 119 percent in the worst-performing group, with an 10 need for action to improve both the quality and effi- average of 71 percent. Working on ways to improve ciency of long-term care. Its 2008 National Scorecard job satisfaction and creating incentives for nursing on U.S. Health System Performance found that quality homes to retain their qualified staff are ways to reduce of care and transitions in care between nursing homes turnover and improve care. and hospitals are highly variable across states and 9 across nursing homes. For example, the proportion of long-stay nursing home residents who are hospitalized As Hubert Humphrey famously said, “The ranges from 12 to 27 percent in the bottom and top 10 moral test of government is how that government percent of states, respectively, with a national average treats those who are in the dawn of life, the children; of 19 percent. Potentially avoidable hospitalizations those who are in the twilight of life, the elderly; and not only lead to higher health care costs, but they also those in the shadows of life—the sick, the needy, and H ealth C are O pinion L eaders ’ Views on the F uture of L ong -Term C are 7 11 the handicapped.” Guaranteeing that all Americans have access to high-quality long-term care when they require it must become a top priority of the nation, as must raising the performance of the long-term care system overall. If we fail to plan now for the long-term care needs of our aging population, we run the risk that we will run out of alternatives for ensuring a good quality of life at the end of life. 6 N otes M. J. Koren, Caring for an Aging America. 7 1 M. M. Doty, M. J. Koren, and E. L. Sturla, Culture U.S. Census Bureau, 2004, “U.S. Interim Projections by Change in Nursing Homes: How Far Have We Come? Age, Sex, Race, and Hispanic Origin,” http://www.cen- Findings From The Commonwealth Fund 2007 National sus.gov/ipc/www/usinterimproj/. Survey of Nursing Homes (New York: The 2 D. G. Stevenson, “Planning for the Future: Long-term Commonwealth Fund, May 2008). Care and the 2008 Election,” New England Journal of 8 D. Durenberger, The U.S. Long Term Care System: Ripe Medicine, May 2008 358(19):1985–87. for Reform, commentary, The Commonwealth Fund, 3 M. J. Koren, Caring for an Aging America, Invited Dec. 29, 2005. Testimony: U.S. House of Representatives Committee on 9 The Commonwealth Fund Commission on a High Appropriations Subcommittee on Labor, Health and Performance Health System, Why Not the Best? Results Human Services, Education, and Related Agencies from a National Scorecard on U.S. Health System Hearing on Health Care Access and the Aging of Performance, 2008 (New York: The Commonwealth America, Feb. 15, 2007. Fund, July 2008). 4 U.S. House of Representatives Committee on 10 M. J. Koren, Caring for an Aging America (accompany- Appropriations Subcommittee on Labor, Health and ing chartpack); The Commonwealth Fund Commission Human Services, Education, and Related Agencies on a High Performance Health System, Why Not the Hearing on Health Care Access and the Aging of Best?. America, Feb. 15, 2007. 11 5 From his remarks dedicating the Hubert H. Humphrey A. Shih, D. M. Dewar, and T. Hartman, “Medicare’s Building (the headquarters of the U.S. Department of Quality Improvement Organization Program Value in Health and Human Services) in Washington, D.C., Nov. Nursing Homes,” Health Care Financing Review, Spring 1, 1977. Hubert H. Humphrey Quote Page, http://home. 2007 28(3):109–16. att.net/~howington/hhh.html. 8T he  C ommonwealth F und Table 1. SUPPORT FOR STRONGER REGULATION OF LONG-TERM CARE INSURANCE INDUSTRY “Long-term care insurance has come under scrutiny for failing to deliver needed coverage. For example, protracted approval processes, denial of payments for services already received, and other problems weaken public confidence in purchasing coverage. One proposal is to have stronger regulation of the long-term care insurance industry in light of alleged abuses. Please indicate your level of support for this proposal.” Total Academic/ Health Care Business/ Government/ Labor/ (n=196) Research Delivery Insurance/Other Consumer Advocacy Institution (n=42) Health Care (n=33) (n=101) Industry (n=53) % % % % % Strongly favor 45 46 45 43 48 Favor 46 46 43 45 42 Oppose 3 1 5 8 3 Strongly oppose 1 2 --- --- --- Not sure 3 4 5 2 3 Base: 196 respondents. Note: Percentages may not add up to 100 percent due to rounding or no response. H ealth C are O pinion L eaders ’ Views on the F uture of L ong -Term C are 9 Table 2. support for policy mechanisms to address paying for long-term care “Below are three broad policy mechanisms that have been proposed to address paying for long-term care. Please indicate your level of support for each one.” Business/ Government/ Academic/ Insurance/ Health Care Labor/ Total Research Other Delivery Consumer (n=196) Inst. Health Care (n=42) Advocacy (n=101) Industry (n=33) (n=53) % % % % % Strongly favor/ 79 79 78 81 81 Favor (Net) Strongly favor 39 39 38 43 45 Add a long-term care Favor 40 40 40 38 36 benefit to Medicare, financed by a premium Oppose 7 6 7 8 3 Strongly oppose 8 8 7 9 9 Not sure 5 7 5 2 6 Strongly favor/ 64 61 62 72 54 Favor (Net) Strongly favor 27 26 26 42 18 Provide tax incentives for individuals to Favor 37 35 36 30 36 purchase private long-term care insurance Oppose 25 27 24 19 36 Strongly oppose 5 7 5 4 3 Not sure 4 4 5 2 3 Strongly favor/ 63 64 60 55 72 Favor (Net) Strongly favor 27 32 36 17 24 Transfer the responsibility for Favor 36 32 24 38 48 Medicaid long-term care from states to the Oppose 20 19 29 28 18 federal government Strongly oppose 4 5 2 6 - Not sure 12 12 10 9 6 Base: 196 respondents. Note: Percentages may not add up to 100 percent due to rounding or no response. 10T he  C ommonwealth F und A bout T he H ealth C are O pinion L eaders S urvey The Health Care Opinion Leaders Survey was conducted online by Harris Interactive on behalf of The Commonwealth Fund among 196 U.S. opinion leaders in health policy and innovators in health care delivery and finance between June 2, 2008, and June 30, 2008. Harris Interactive sent out individual e-mail invitations to the entire panel containing a password-protected link, and a total of four reminder e-mails were sent to those who had not responded. No weighting was applied to these results. The initial sample for this survey was developed using a two-step process. The Commonwealth Fund and Harris Interactive jointly identified a number of experts across different professional sectors with a range of perspectives based on their affiliations and involvement in various organizations. Harris Interactive then conducted an online survey with these experts, asking them to nominate others within and outside their own fields whom they consider to be leaders and innovators in health care. Based on the result of the survey and after careful review by Harris Interactive, The Commonwealth Fund, and a selected group of health care experts, the sample for this poll was created. The final list included 1,246 individuals. In 2006, The Commonwealth Fund and Harris Interactive joined forces with Modern Healthcare to add new members to the panel. The Commonwealth Fund and Harris Interactive were able to gain access to Modern Healthcare’s database of readers. The Commonwealth Fund, Harris Interactive, and Modern Healthcare identified readers in the database that were considered to be opinion leaders and invited them to participate in the survey. This list included 1,467 people. At the end of 2006, The Commonwealth Fund and Harris Interactive removed those panelists who did not respond to any previous surveys. In 2007 recruitment for the panel continued, with Modern Healthcare recruiting individuals through their Daily Dose newsletter. In addition, Harris Interactive continued to recruit leaders by asking current panelists to nominate other leaders. The final panel size for the Health Care Delivery System Reform survey included 1,078 leaders. With a pure probability sample of 196 adults (for a response rate of 18%), one could say with a 95 per- cent probability that the overall results have a sampling error of +/– 7.0 percentage points. However, that does not take into account other sources of error. This online survey is not based on a probability sample and there- fore no theoretical sampling error can be calculated. The data in this brief are descriptive in nature. It represents the opinions of the health care opinion lead- ers interviewed and is not projectable to the universe of health care opinion leaders. H ealth C are O pinion L eaders ’ Views on the F uture of L ong -Term C are 11 A bout T he A uthors Michelle McEvoy Doty, Ph.D., director of survey research, is responsible for research, survey develop- ment, and analysis at The Commonwealth Fund and conducts research examining health care access and qual- ity among vulnerable populations and the extent to which lack of health insurance contributes to barriers to health care and inequities in quality of care. She received her M.P.H. and Ph.D. in public health from the University of California, Los Angeles. She can be e-mailed at mmd@cmwf.org. Mary Jane Koren, M.D., M.P.H., assistant vice president, joined the Fund in 2002 and leads the Picker/ Commonwealth Program on Quality of Care for Frail Elders. Dr. Koren is also chair of the Advancing Excellence in Americas Nursing Homes campaign Steering Committee for 2008. Dr. Koren, an internist and geriatrician, has practiced in both nursing home and home care settings and was the associate medical director of the Montefiore Home Health Care Agency. Later, she was appointed director of the New York State Department of Health’s Bureau of Long Term Care Services, where she ran the nursing home survey and certi- fication programs, led the state’s implementation of OBRA’87. She can be e-mailed at mjk@cmwf.org. Karen Davis, Ph.D., is president of The Commonwealth Fund. She is a nationally recognized economist with a distinguished career in public policy and research. In recognition of her work, Ms. Davis received the 2006 AcademyHealth Distinguished Investigator Award. Before joining the Fund, she served as chairman of the Department of Health Policy and Management at The Johns Hopkins Bloomberg School of Public Health, where she also held an appointment as professor of economics. She served as deputy assistant secretary for health policy in the Department of Health and Human Services from 1977 to 1980, and was the first woman to head a U.S. Public Health Service agency. A native of Oklahoma, she received her doctoral degree in economics from Rice University, which recognized her achievements with a Distinguished Alumna Award in 1991. Ms. Davis has published a number of significant books, monographs, and articles on health and social policy issues, including the landmark books Health Care Cost Containment; Medicare Policy; National Health Insurance: Benefits, Costs, and Consequences; and Health and the War on Poverty. She can be e-mailed at kd@cmwf.org. The mission of The Commonwealth Fund is to promote a high performance health care system. The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff.