The effect of public provision of home care on living and care arrangements: evidence from the channeling experiment.
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Aged↗
Biomedical subjects
P Kemper
Publications and source records attributed to P Kemper.
Designing home care benefits: the range of options and experience.
This article presents a framework identifying important home care benefit design decisions and reviews existing designs that have been adopted in practice. Four basic designs were identified, based on a review of 55 home care benefits drawn from public programs in the United States and foreign countries, and from private long-term care insurance policies in the United States. Three of these designs-service entitlements, managed-service benefits, and cash disability allowances--have each been adopted by public programs in the United States and abroad, and by private insurance policies in the United States. A fourth design--individualized cash benefits--has been adopted in only one experimental program. The designs observed in practice are remarkably varied, providing evidence that many alternative designs are feasible. Experimentation, particularly with cash disability allowances, is needed to determine the relative costs and benefits of various designs.
Aged↗
The design of the community tracking study: a longitudinal study of health system change and its effects on people.
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Community Health Planning↗
Lifetime patterns of payment for nursing home care.
Although much is known about who pays the annual aggregate nursing home bill, relatively little is known about payment-source patterns of individuals during their lifetimes. In this article, lifetime payment-source patterns are analyzed for elderly nursing home users, particularly the extent to which they spend down assets to become eligible for Medicaid. During their lifetimes, 44% of persons who use nursing homes after 65 years of age start and end as private payers, 27% start and end as recipients of Medicaid benefits, and 14% spend down assets to become eligible for Medicaid benefits. Although still a relatively small proportion, the asset spend-down estimate based on lifetime data is 2.5 times previous national estimates based on data for single nursing home stays. The projected risk of spending down assets in nursing homes for all persons who turn 65 years of age in 1995, including users and nonusers of nursing homes, is slightly more than 6%. Equally or more important for policy is that 17% of all persons who turn 65 years of age can expect to end up using a nursing home and receiving Medicaid reimbursement. Of those, more than 3 in 5 will have entered the nursing home already eligible for Medicaid benefits.
Black or African American↗
Risky business: long-term care insurance underwriting.
Private insurance is one strategy for financing the large and growing cost of long-term care. Little is known, however, about the extent to which medical underwriting may limit the potential of private insurance to cover nursing home care, or whether the underwriting criteria used in this relatively new market successfully identify high-cost groups. This paper uses data from the National Mortality Followback Survey to address these two questions. We estimate that between 12% and 23% of the population would be rejected for private long-term care insurance because of their health if everyone applied at age 65. These figures rise to between 20% and 31% at age 75. Our simulation results suggest that long-term care insurance underwriting criteria identify individuals who vary substantially in the financial risk they pose to insurers. In most cases, whether a criterion identifies a high-cost group is sensitive to the policy individuals are assumed to buy.
Activities of Daily Living↗
[Effect of a face mask on work of breathing in patients with chronic obstructive respiratory disease].
Resistive loading associated with breathing through a face mask (surgeons' paper mask) increases work of breathing significantly after a prolonged period of wearing. The additional resistive breathing due to a face mask may be intolerable for patients with preexisting overloaded respiratory muscle pump and contribute to inspiratory muscle fatigue.
Adult↗
Altered tissue distribution of viral replication and T cell spreading is pivotal in the protection against fatal lymphocytic choriomeningitis in mice after neutralization of IFN-alpha/beta.
IFN-alpha/beta have been shown to play a central role in the development of lymphocytic choriomeningitis and increasing attention has been focused on this group of cytokines as early regulatory factors directing T lymphocyte responses. In the present study, injection of antiserum to IFN-alpha/beta prevented the development of lymphocytic choriomeningitis, was associated with the absence of detectable expression of early 2'-5' oligo-adenylate synthetase mRNA and coincided with viremia of lymphocytic choriomeningitis virus (LCMV) followed by establishment of a persistent infection. The LCMV-specific cytotoxic T lymphocyte response was unchanged in cervical lymph nodes but decreased in the spleen of anti-IFN-alpha/beta-treated animals. The expression of cytokine mRNA (particularly IFN-gamma) in organs of LCMV-infected mice treated with anti-IFN-alpha/beta coincided with infiltration of lymphocytes and tissue destruction. Furthermore, a reduced number of infiltrating leukocytes in the brain and cervical lymph nodes and a low expression of cytokine mRNA in the brain was observed in anti-IFN-alpha/beta-treated animals. In total, the findings support the view that neutralization of IFN-alpha/beta leads to extensive LCMV replication in the viscera. The therapeutic effects of anti-IFN-alpha/beta antiserum seem to be independent of the functional capacity of T cells but probably result in a dispersion of activated T cells throughout the body of LCMV-infected mice. Absence of IFN-alpha/beta expression in the central nervous system is proposed as the mechanism behind the IFN-alpha/beta-dependent targeting of T cells to the brain.
2',5'-Oligoadenylate Synthetase↗
Cerebral expression of multiple cytokine genes in mice with lymphocytic choriomeningitis.
The simultaneous expression of multiple cytokine genes was examined within the brain and peripheral organs of euthymic and congenic athymic mice during the course of lymphocytic choriomeningitis (LCM) induced by the intracranial inoculation of LCM virus. In euthymic mice, levels of TNF-alpha, IL-1 alpha, IL-6, and IL-1 beta mRNA in the brain increased early in infection and further increased with the progression of disease; the level of IFN-gamma mRNA was expressed at high levels late in infection and correlated with the onset of clinical disease. In the peripheral organs, TNF-alpha, IL-1 alpha, and IL-1 beta gene expression predominated early and then declined late in disease. In athymic mice (which do not develop LCM), expression of TNF-alpha, IL-1 alpha, IL-6, and IL-1 beta mRNA increased progressively in brain and peripheral organs from days 3 to 6 postinfection. The levels of these transcripts were significantly lower than those in infected euthymic animals. In euthymic mice, in situ hybridization revealed IFN-gamma-, TNF-alpha-, and IL-1 alpha-expressing cells throughout the inflammatory cell infiltrates associated with areas of LCMV nucleic acid. Therefore, in mice with LCM there is simultaneous expression of multiple cytokine genes, the pattern of which is distinct for brain vs peripheral organs and for euthymic vs athymic mice. The close spatiotemporal relationship between expression of cytokine genes and evolution of disease in brain implicate cytokines are not only key coordinators of the host response but also as possible mediators of neuropathology in LCM.
Animals↗
Disability and cognitive impairment criteria: targeting those who need the most home care.
Proposed federal long-term care reforms include eligibility criteria based on disability and cognitive impairment. This article illustrates the process of evaluating alternative eligibility criteria based on one possible targeting goal--serving those who need the most care. Channeling data are used to construct a measure of total care needs which is used to evaluate success at meeting the targeting goal. Results indicate the difficulty of establishing eligibility cutoffs that are equitable and meet the targeting goal.
Activities of Daily Living↗
Activation of cerebral cytokine gene expression and its correlation with onset of reactive astrocyte and acute-phase response gene expression in scrapie.
The pathogenesis of scrapie, a transmissible subacute spongiform encephalopathy, is unclear. However, certain aspects of the known cellular and molecular neuropathology in scrapie led us to hypothesize that cytokines could mediate cerebral pathological changes in this neurodegenerative disease. Therefore, expression of multiple cytokine genes in the brain and peripheral organs of scrapie-infected mice was examined. Late in the course of scrapie, expression of tumor necrosis factor alpha (TNF-alpha), interleukin-1 alpha (IL-1 alpha), and IL-1 beta mRNA was markedly increased in the brain but not the spleen, kidneys, or liver. In time course studies, scrapie-infected mice exhibited increased cerebral expression of the TNF-alpha, IL-1 alpha, and IL-1 beta mRNAs by week 15 postinoculation--a time point that coincided with the onset of clinical symptoms. Thereafter, the levels of these cytokine transcripts increased progressively to the terminal stages of of the disease (week 25). To determine the relationship of the increased cerebral expression of the cytokine mRNAs to the development of pathological changes in scrapie, we examined the expression of the glial fibrillary acidic protein gene (a marker for astrocytosis) and the murine acute-phase response gene homologous to the alpha 1-antichymotrypsin gene (designated EB22/5.3). Markedly increased expression of both the glial fibrillary acidic protein and EB22/5.3 mRNAs was observed in the brain but not the peripheral organs of scrapie-infected mice. The increased expression of both these gene products also occurred at week 15 of infection and, thereafter, increased progressively to the terminal stages of the disease. Therefore, infection of mice with scrapie resulted in significant increases in the expression of the TNF-alpha, IL-1 alpha, and IL-1 beta gene products, whose pattern correlated with the onset and development of molecular and clinical pathological changes. Since scrapie is known not to evoke an immune response, the present findings strongly suggest the existence of a localized cerebral host response to the agent during which proinflammatory cytokines could be key pathogenic mediators.
Acute-Phase Reaction↗
Nursing home financing reform: how would it affect expenditures for nursing home care?
There are a number of proposals to expand substantially public financing of nursing home care. Included among the major elements of these proposals are front-end benefits limited to three or six months, back-end benefits with waiting periods of one or two years, and coverage of all nursing home days with or without substantial income-related cost sharing. Using data from the 1987 National Medical Expenditure Survey, this paper simulates the effect of these proposed changes in nursing home financing on public expenditures, Medicaid expenditures, and private expenditures (in total and by marital status and income group). The incentive for increased use of nursing home care also is examined. A short front-end benefit, the least expensive option in terms of public expenditures, increases public expenditures by $1 billion to $2 billion in 1987. Comprehensive coverage of all nursing home days increases public costs by $9 billion to $10 billion dollars, depending on the cost-sharing arrangement. There is wide variation in the range of plausible estimates because of uncertainty about the effect of increased public coverage of nursing home care on utilization.
Costs and Cost Analysis↗
Neurologic disease induced in transgenic mice by cerebral overexpression of interleukin 6.
Cytokines are thought to be important mediators in physiologic and pathophysiologic processes affecting the central nervous system (CNS). To explore this hypothesis, transgenic mice were generated in which the cytokine interleukin 6 (IL-6), under the regulatory control of the glial fibrillary acidic protein gene promoter, was overexpressed in the CNS. A number of transgenic founder mice and their offspring exhibited a neurologic syndrome the severity of which correlated with the levels of cerebral IL-6 expression. Transgenic mice with high levels of IL-6 expression developed severe neurologic disease characterized by runting, tremor, ataxia, and seizure. Neuropathologic manifestations included neuro-degeneration, astrocytosis, angiogenesis, and induction of acute-phase-protein production. These findings indicate that cytokines such as IL-6 can have a direct pathogenic role in inflammatory, infectious, and neurodegenerative CNS diseases.
Animals↗
A double-blind study of two dosage regimens of lomefloxacin in bacteriologically proven exacerbations of chronic bronchitis of gram-negative etiology.
Lomefloxacin has been shown to produce high and sustained concentrations in serum and bronchial mucosa after once-daily administration. This study was designed to assess whether a dose response exists for 400 mg lomefloxacin given once daily or twice daily for 10 days in the treatment of acute bacterial exacerbations of chronic bronchitis of gram-negative etiology. A total of 100 adult patients with acute exacerbations of chronic bronchitis were enrolled at 10 study sites in Germany. Patients with confirmed bacterial pathogens in the baseline sputum culture (once-daily group n = 49, twice-daily group n = 47) were eligible for analysis of bacteriologic and clinical efficacy. The eradication rates for the most frequently isolated baseline pathogens, Haemophilus influenzae, Pseudomonas aeruginosa, and Klebsiella pneumoniae, were at least 75% for both treatment regimens. Overall, once-daily treatment eradicated baseline pathogens in 42 of 49 (85.7%) patients, while twice-daily treatment eradicated pathogens in 43 of 47 (91.5%). This difference was not statistically significant (p = 0.226). Clinically, 47 of 49 (95.9%) patients in the once-daily group and 46 of 47 (97.9%) in the twice-daily group were cured or improved (p = 0.307). Both regimens were well tolerated; there were no differences in the incidence (six patients in each group), types, or severity of adverse events, nor was there clinical evidence of theophylline interaction. The results of this study demonstrate that once-daily treatment with 400 mg lomefloxacin is as effective as twice-daily dosing with 400 mg in patients with acute bacterial exacerbations of chronic bronchitis.
Adult↗
Long term care arrangements for elderly persons with disabilities: private and public roles.
When private resources are defined broadly to include informal care as well as private expenditures, 73 percent of the elderly long term care population rely entirely on private resources for their care. The emphasis of current programs on institutional care directs public resources toward those with more serious disability and less family to care for them. Among those with four or five disabilities in ADLS, 35 percent of those without a spouse or children currently receive no public support, compared with nearly 80 percent of those with both a spouse and children. Thus, even if restricted to seriously disabled persons, a new program expanding public long term care financing would increase eligibility for public benefits disproportionately among those with greater informal care resources.
Activities of Daily Living↗
The use of formal and informal home care by the disabled elderly.
Using data from the Channeling experiment, this article analyzes the factors associated with the amount of formal and informal home care received by the disabled elderly. The amounts of formal and informal home care used increase with disability, as well as with other measures of need for care. The use of formal care increases, and the use of informal care decreases, with income. The availability of immediate family increases reliance on informal care and reduces reliance on formal care. The findings have implications for the design of proposed programs to expand publicly financed home care for the disabled elderly.
Activities of Daily Living↗
Public and private responsibility for financing nursing-home care: the effect of Medicaid asset spend-down.
Data from a nationally representative sample of nursing-home residents at the beginning of 1987 are used to assess the interaction of Medicaid asset spend-down, the distribution of nursing-home days by payment source, and the effect of proposed changes in public financing of nursing-home care. Three out of five nursing-home residents were covered by Medicaid in January 1987; nearly all of the remainder were private-pay. Most Medicaid recipients were covered by Medicaid when they entered the care facility at the start of an episode, but 18 percent had spent down and were originally admitted as private-pay. A universal nursing-home benefit that insured the first six months of each nursing-home episode would cover 16 percent of the people in nursing homes on a given day, disproportionately those who are private-pay. A universal benefit with a 24-month waiting period would cover 56 percent of nursing-home residents on a given day, and would tend to favor those financed by Medicaid.
Financing, Government↗
Lifetime use of nursing home care.
BACKGROUND AND METHODS: Despite the growth in the number of Americans in nursing homes, there are only limited data on the total amount of time that people spend in such facilities. We estimate the amount of time the average person spends in nursing homes over his or her lifetime (lifetime nursing home use), using data from the National Mortality Followback Survey of the next of kin of a sample of persons 25 years of age or older who died in 1986. On the basis of these data, we estimated the likelihood that Americans will use nursing home care during the course of their lifetimes and the total duration of such care. Current data on life expectancy were then used to reweight the sample to project lifetime nursing home use for those who became 65 years old in 1990. RESULTS: Of those who died in 1986 at 25 years of age or older, 29 percent had at some time been residents in a nursing home, and almost half of those who entered a nursing home spent a cumulative total of at least one year there. The probability of nursing home use increased sharply with age at death: 17 percent for age 65 to 74, 36 percent for age 75 to 84, and 60 percent for age 85 to 94. For persons who turned 65 in 1990, we project that 43 percent will enter a nursing home at some time before they die. Of those who enter nursing homes, 55 percent will have total lifetime use of at least one year, and 21 percent will have total lifetime use of five years or more. We also project that more women than men will enter nursing homes (52 percent vs. 33 percent), and among them, more women than men will have total lifetime nursing home use of five years or more (25 percent vs. 13 percent). CONCLUSIONS: Our projections indicate that over a lifetime, the risk of entering a nursing home and spending a long time there is substantial. With the elderly population growing, this has important implications for both medical practice and the financing of long-term care.
Adult↗
A lifetime perspective on proposals for financing nursing home care.
In this paper data from the National Mortality Followback Survey and the National Nursing Home Survey are used to estimate the lifetime cost of nursing home care. The expected discounted cost for persons turning 65 in 1990 is $27,600. However, variation around this average is high. The 9% of persons expected to use at least 5 years of nursing home care will account for 64% of aggregate cost for the cohort; the 68% using less than 3 months of care will account for only about 1% of cost. The percentage of costs covered under alternative financing strategies also varies widely. An entitlement covering the first 3 months of care subject to 30% coinsurance would cover 5% of aggregate cost; an entitlement with a 2-year deductible and the same coinsurance would cover 41% of cost.
Aged↗