PHILADELPHIA, May 6, 2025 – The American College of Physicians (ACP) has published a new paper addressing the challenges and ethical implications of current long-term care services and business models, calling for more research into meeting vulnerable patient interests and scrutiny into the business practices. "Optimizing Ethical Care, Quality, and Safety in Long-Term Services and Supports: A Position Paper from the American College of Physicians" was published today in Annals of Internal Medicine.
Long-term care encompasses a wide variety of facilities and services for individuals who can no longer independently care for themselves due to cognitive decline, functional limitations, chronic illness, or the consequences of such conditions. These services are delivered in institutional and non-institutional settings such as nursing homes, assisted living facilities, home and community-based programs, and hospice.
Eight million people receive long-term care services, but despite its prevalence, the substantial challenges that the long-term care system in the United States faces has received limited attention. With 90 percent of current nursing home residents aged 65 or older, and the U.S. population of persons older than 65 years expected to double by 2030, addressing these challenges has become urgent. Facilities grapple with inadequate staffing, and the complexity of systems and business models has resulted in inconsistent regulations and oversight. The majority of individuals receiving long-term care have Medicaid or Medicare as their primary payer, but growing budget pressure on states and the federal government may further limit continued coverage.
The COVID-19 pandemic “lifted the veil” over systemic issues in long-term care, exposing U.S. financing, delivery, and regulation of nursing home care as “ineffective, inefficient, fragmented, and unsustainable”, per a 2022 report from the National Academies of Sciences, Engineering, and Medicine cited in the paper. Because of inadequate infection control in care facilities such as nursing homes, and the undervaluing and misrepresentation of their residents, COVID-19 related deaths resulted in a 13% decrease in the total number of nursing home residents nationally.
Quality of care is inconsistent across long-term care business models, and can fluctuate among for-profit, nonprofit, government-owned, and private equity-owned. The latter business model is linked to higher rates of hospitalization, practices that can endanger residents, and reduced staffing levels of registered nurses. Such models can put profits before patient wellbeing, leaving a vulnerable population at risk.
The paper, developed by ACP’s Ethics, Professionalism and Human Rights Committee, outlines four positions from an ethical, patient-centered perspective.
- Long-term care professionals and facilities, its associated legislative policy, and business practices should incentivize and promote ethical evidence-based use of resources. This approach should optimize care quality and plans, patient preferences, and decision-making while prioritizing the safety of persons across lifespans residing in various settings in the community.
- Long-term care professionals and facilities must respect the dignity, autonomy, and uniqueness of each individual and they have an ethical duty to do so. Individuals receiving long-term care can be vulnerable because of cognitive impairments, physical disabilities, and a limited social support network, and may lack advocates to speak on their behalf. Care should be patient-centered, not institution-centered, and tailored to individual needs rather than organizational efficiency or profit.
- Long-term care professionals and facilities must prioritize health equity in long-term care and undergo efforts to improve access to care and overcome stereotypes and prejudice based on race, ethnicity, age, and income. Ageism has a significant influence on long-term care. ACP recommends improved education of health care professionals and the public about the value of older adults in our society and the harms of prejudice against them.
- Patients and families have the right to hold responsible parties accountable for the quality of long-term care, and this requires increased transparency and accountability. Information about those with a stake in management, operations or facility of long-term care should be readily accessible and easily interpretable so patients and families can evaluate quality, standards of care, and potential competing interests.
“A physician’s ethical responsibility to the wellbeing of their patient extends throughout the patient’s lifetime. For many older adults who depend on long-term care, it is more important than ever that their interests and their health be prioritized, even if they have no way to advocate for themselves,” said Jason M. Goldman, M.D., FACP, President, ACP. “ACP believes that an ethical, evidence-based and collaborative approach is the way to improve long-term care and create a compassionate, equitable system. Collaboration among health care systems, policymakers, owners and operators of long-term care facilities, and caregivers can ensure individuals receive safe, quality care across their lifespan.”
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About the American College of Physicians
The American College of Physicians is the largest medical specialty organization in the United States with members in more than 172 countries worldwide. ACP membership includes 161,000 internal medicine physicians, related subspecialists, and medical students. Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness. Follow ACP on X, Facebook, Instagram, Threads, and LinkedIn.