A prospective budgeting model for home- and community-based long-term care.

Home- and community-based long-term care services offered in more than two dozen controlled experiments conducted in the past 30 years are subjected to a "break-even" analysis. We found that health care costs for the treatment group averaged only about 14% more than the control group across all studies and a similar amount among the subset of studies evaluated since 1980. Because patient benefits were so minimal, they would have to be valued at an exceedingly high rate to break even from a social cost perspective. On the other hand, improved operating efficiency might make cost-accounting break-even an almost achievable goal. Improvements needed include better targeting of high-risk patients and better utilization controls on home and community care services. A prospective budgeting model with performance goals may be helpful.