Long-term care goes to market: Managed competition and Ontario's reform ofcommunity-based services

A shift in emphasis from institutions to community poses important challeng es for providers and policy makers, key among them being the challenge of p roviding a sufficient volume of high quality community-based services to me et consumer needs. This challenge is particularly evident in community-base d long-term care (LTC) due to the complexity and diversity of the field, th e vulnerability of the population served, and the current wave of demand fo r services generated by hospital downsizing. The most recent reform of long -term care in Ontario is of particular interest in this context because, as suggested by the provincial government's maxim "highest quality, best pric e," it promises cost-efficiency while maintaining or improving quality. To do this it employs a "managed competition" model in which for-profit and no t-for-profit providers compete for service contracts under the auspices of local Community Care Access Centres (CCACs) run by volunteer boards. In thi s paper we draw on the comments of senior government officials and represen tatives of provider organizations, as well as published documents, to highl ight issues and problems posed by the province's latest reform. We argue th at, particularly under conditions of capped budgets and increasing demands, the managed competition process may result in the subordination of service quality and consumer choice to pressures for cost-containment.