Measuring Long Term Care Preferences

Objectives: Current policies reorienting long-term care (LTC) delivery from institutional care to home- and community-based services are being made in the absence of crucial evidence on the quality of life associated with these options. Although measuring preferences for different methods of long-term care delivery is essential to policy decisions about the most effective and efficient ways to deliver long-term care, strong preferences for home care are often assumed and have never been quantified.  Prior studies indicate that the shift to home care is generally not cost-saving but may be cost-effective; thus, a rigorous assessment of quality of life is sorely needed in order to evaluate policies incenting home care investment. Time Trade-off (TTO) methods are often used for utility assessments of different health states to measure quality of life (QOL), but have not generally been used to assess social preferences with respect to options for health care delivery, although the need for quantifying those preferences is arguably just as important. 

Methods: Our approach is to extend the traditional TTO method to elicit QOLs associated with the receipt of different modes of LTC services, conditional on health states defined by varying levels of functional and cognitive impairment.  User's LTC preferences are quantified as differential QOL between different LTC options, as well as using Willingness-to-Pay measurement. We focused on individuals “at short-term risk” of needing LTC to best reflect the user’s choice value, consistent with the “informed community values” perspective to balance bias due to adaptation with bias from or lack of being informed about a health condition.

Data: Utility data were collected from patients in a geriatrics clinic in a large urban area in 2013. Eighty-one eligible participants who were age 55 or above and reported some level of having already thought about their own LTC took the survey.

Results: Not surprisingly, we find that people generally prefer receiving LTC at home. Except under the most impaired health state, preferences for home care over institutional care are statistically significant. Home care preference is quantified as 0.27 QOL when people only need help with 1-2 daily living activities and could be translated to a gain of $13,500-$27,000 per year. However, the elicited LTC preferences depend significantly on levels of disability. The preference for home care was weaker or nonexistent once the need for help became greater. In addition, we find that participants with Medicaid or Medicare coverage have stronger home care preferences, relative to the privately insured. Regardless of the LTC preferences, the elicited utilities decreased with the severity of the health conditions, as expected, underscoring the validity of our approach.

Conclusions: Preferences over LTC delivery modes significantly depend on the health states, and people do not consistently prefer home care over institutional LTC as previously assumed. In order to provide cost-effective care, the target population should be identified for different LTC options. The extension of TTO methods to questions of policy appears to be reasonable and provides a promising avenue for more rigorous policy decision-making.