Long-term Care Financing Research Articles

Where do we draw our last breath? A comparative analysis of factors associated with places of death in European countries

This paper investigates whether a shift towards formal long-term care (LTC), typically associated with increased public spending in LTC, correlates with a lower likelihood of dying in hospitals compared to homes or care homes. Additionally, the study aims to assess how demographic, socioeconomic, and health-related variables are associated with the place of death across European countries. For this purpose, the study employs multinomial logistic regression on the data concerning 16,633 individuals aged 50 and over, who died between 2004 and 2021 in 24 European countries. The countries are grouped in two country groups to control for variations in their LTC systems. The first group consists of countries with more generous public funding for LTC, while the second group includes those where LTC is less funded and structured. Results indicate that the place of death is associated with the country’s healthcare system, demographic characteristics, socioeconomic status, and medical conditions. While hospitals remain the most common setting for death, this trend is shifting as recent years have seen a rise in deaths at home or in care homes across both country groups.

Trends over the past 15 years in long-term care in Switzerland: a comparison with Germany, Italy, Norway, and the United Kingdom

BackgroundThe demographic changes affecting Switzerland and other European countries, including population ageing, will continue to challenge policymakers in building accessible, affordable, comprehensive and high-quality long-term care (LTC) systems. The purpose of this paper is to investigate how Switzerland’s LTC system compares to other European countries, in order to inform how to respond to the increasing need for LTC. We carried out a descriptive study using secondary data from key national and international organizations.MethodsBy comparing the financing, workforce, service delivery and need for LTC in Switzerland, Germany, Italy, Norway and the United Kingdom, we described similarities and differences in these five European countries between 2005-2019. Thirty-three indicators within five domains were analysed: (1) Population statistics and health expenditure, (2) Need for LTC, (3) LTC financing, (4) LTC service delivery, and (5) LTC workforce.ResultsSwitzerland has the highest life expectancy in comparison to the other four high-income countries. However, similarly to other countries, the years lived with disability are increasing in Switzerland. Switzerland’s public expenditure on LTC as a share of GDP is lower than that of Norway and Germany, yet out-of-pocket expenditure on LTC is highest in Switzerland. Switzerland has the highest proportion of persons receiving formal LTC both in institutions and at home. Switzerland has had the most pronounced increase in the proportion of over 65-year-olds receiving LTC at home. Even though more than fourfold more persons receive care at home, Switzerland still has more workforce in LTC institutions than in home-care. In comparison to Germany and the UK, Switzerland has a lower number of informal carers as a proportion of 50-year-olds and over, as well as fewer nationally available services for informal carers compared to Germany, Italy, Norway and the UK.ConclusionsOur comparative study corroborates the importance of improving the affordability of LTC, continuing to support the movement towards home care services, improving the support given to both the professional workforce and informal carers, and improving the amount and quality of LTC data. It also provides a valuable contrast to other European countries to support evidence-informed policymaking.

Quality of life outcomes for informal carers of long-term care service users in Austria, England and Finland

PurposeThe provision and funding of long-term care (LTC) for older people varies between European countries. Despite differences, there is limited information about the comparative performance of LTC systems in Europe. In this study, we compared quality of life (QoL) of informal carers of home care service users in Austria, England and Finland.MethodsInformal carers were surveyed in Austria, England and Finland. The study data (n = 835) contained information on social care-related quality of life (SCRQoL) associated with the ASCOT-Carer measure, and characteristics of carers and care recipients from each country. We applied risk-adjustment methods using a fractional regression model to produce risk-adjusted SCRQoL scores for the comparative analysis. In a sensitivity analysis, we applied multiple imputation to missing data to validate our findings.ResultsWe found that the mean values of the risk-adjusted SCRQoL of informal carers in England were 1.4–2.9% and 0.3–0.5% higher than in Finland and Austria, and the mean values of the risk-adjusted SCRQoL of carers in Austria were 0.8–2.7% higher than in Finland. Differences in the mean values of the country-specific risk-adjusted SCRQoL scores were small and statistically non-significant. English informal carers were less healthy and co-resided with care resipients more often than carers in Austria or Finland.ConclusionSmall differences between the risk-adjusted SCRQoL scores between Austria, England and Finland are consistent with the observation that the countries provide different types of support for informal carers. Our results help local and national decision-makers in these countries to benchmark their informal care support systems.

Public Attitudes for Quality and Funding of Long-Term Care: Findings from an Australian Survey

Public Attitudes for Quality and Funding of Long-Term Care: Findings from an Australian Survey

European long‐term care marketisation: A political economy framework

AbstractThe study of European long‐term care (LTC) marketisation is dominated by institutional and ideational perspectives. In contrast, political economic theoretical frameworks have received little attention. This is paradoxical, because marketisation is an inherently political economic phenomenon. The financialisation of LTC systems, the growth of private for‐profit providers and the rise in cross‐national investments are proceeding apace, yet, they have been neglected by conventional approaches. This paper presents a political economy theoretical framework to study LTC marketisation. In contrast to conventional perspectives, it locates the drivers of marketisation within (neoliberal) capitalism; conceives of the state as significantly aligned with the interests of the business sector; interprets ideology as often originating in the material interests of the latter; examines ‘power struggles’ between, in particular, private providers on one hand and the public/non‐profit sector and care workers on the other hand. These power struggles take place in LTC financing, privatisation, regulation, financialisation and labour flexibility. In those struggles, private providers assert their power (structural, institutional and instrumental) to shape marketisation; however, they can encounter resistance. The framework also examines the outcomes of marketisation and is illustrated empirically by reference to Irish LTC.

Recent innovations in long-term care coverage and financing: a rapid scoping review

ObjectivesTo identify, chart and analyse the literature on recent initiatives to improve long-term care (LTC) coverage, financial protection and financial sustainability for persons aged 60 and older.DesignRapid scoping review.Data sourcesFour...

Medicare skilled nursing facilities' occupancy and payer source: The moderating role of financial performance.

While extensive research has focused on patient outcomes in skilled nursing facilities, a critical gap remains in understanding factors influencing their managerial performance, particularly occupancy rates. This study examines the occupancy rates of skilled nursing facilities and assesses the significance of two important drivers of managerial performance that have not received sufficient attention-the influence of payer mix and total profit margin. Specifically, we focused on the role played by a nursing home's financial performance (as assessed by profit margin) in influencing the relationship between payer mix and occupancy rate among skilled nursing facilities. Data were extracted from the 2019 to 2020 Joint Annual Report of Nursing Homes for a sample of 612 skilled nursing facilities in Tennessee, USA. Regression analysis was performed by fitting a generalized estimating equation of occupancy rate. Compared to skilled nursing facilities in the lowest quartile of profit margin, for example, those in the highest quartile had approximately 18 percentage points higher occupancy rates per unit increase in resident days of care covered by traditional Medicare (β = 0.18, p = 0.0028). Similarly, skilled nursing facilities in the second highest quartile of profit margin had a higher occupancy rate by approximately 23 percentage points per unit increase in Medicare Advantage (β = 0.23, p = 0.0375) when compared to those in the lowest quartile of profit margin. Skilled nursing facilities with stronger financial performance generally have higher occupancy rates, particularly notable in relation to an upswing in payer sources such as traditional Medicare and Medicare Advantage, when compared to skilled nursing facilities with weaker profitability. Given the increasingly larger role of Medicare in long-term care funding, policymakers and nursing home managers may find it useful to consider our findings when evaluating opportunities to enhance managerial performance of skilled nursing facilities.

On the factors determining the health profiles and care needs of institutionalized elders

In many developed countries, population aging raises a number of issues related to the organization and financing of long-term care. While the determinants of the overall burden and cost of care are well understood, the organization of institutionalized long-term care must meet the needs of the elderly. One way to optimize management is to use information on health problems to assess the infrastructure needed, the qualifications of staff, and the allocation of new entrants. In this research, we determine the typical health profiles of institutionalized elderly using novel longitudinal data from nursing homes in the canton of Geneva, Switzerland. Our data contain comprehensive information on health factors such as impairments of psychological and sensory functions, levels of limitations, and pathologies for 21549 individuals covering the period from 1996 to 2018. First, we perform a spectral clustering algorithm and determine the profiles of the institutionalized individuals. Then, we use multinomial logistic regression to study the effects of the factors that determine these health profiles. Our main findings include eight typical health profiles: the largest group consists of the most “healthy” individuals, who, on average, require the least amount of help with their daily needs and who stay in the institution the longest. We show that, in contrast to age at admission and gender, the limitations and the set of pathologies are relevant factors in determining the profile. Our study sheds light on the typical structures of elderly' health profiles, which can be used by institutions to organize their resources and by insurance companies to derive profile-based products that provide additional insurance coverage in case of special needs.

The problems of financing of palliative care and long-term care in the Russian Federation

The article considers problems of financing of palliative care and long-term care in the Russian Federation. The pattern of growth in population's need in care and provision of out-patient and medical services related with demographic changes was revealed. The main problems of accessibility of long-term care associated with reduction of the number of in-patient facilities and unresolved issue of sustainable source of financing for this type of services are demonstrated. The problem of accessibility of palliative care was elaborated. The common problem for two types of medical social services is lacking of integrated management center at the Federal level. The regulation of long-term care is assigned to the Mintrud of Russia and provision of palliative care is assigned to the Minzdrav of Russia that affects effectiveness of management and is expressed in duplication of functions, development of different approaches to determine funding channels.

Utilization of Long-Term Care Services and the Role of Institutional Trust in South Korea

ABSTRACT With population aging, governments have become increasingly involved in the administration, funding, and regulation of formal long-term care (LTC) systems. We examine the association between institutional trust and formal LTC service utilization among older adults aged ≥60 years with care needs in South Korea’s public LTC scheme. Using data from the Korean Longitudinal Study of Aging and hierarchical logistic regressions, we evaluate the respective roles of trust in government and trust in the LTC program on service utilization. Results show that trust in the LTC scheme is significantly associated with service utilization: a unit increase in the level of trust is associated with a 29% increase in the odds of service use on average, controlling for need-related factors (e.g., chronic conditions) and other covariates. Furthermore, the positive relationship between trust and LTC utilization increases in magnitude with age. Older adults who are aged 80 and above, unmarried, with more ADL limitations, with psychiatric disease, or with arthritis are more likely to utilize formal LTC services. Our findings are robust to variations in sample inclusion criteria. Policymakers and health administrators should pay attention to building and maintaining institutional trust in public LTC schemes through good governance and other relevant strategies.

The analysis of problems of supporting long-term nursing of individuals who lost their ability to self-care in Russia

The article considers the issues of social assistance of long-term care of individuals who lost ability to self-care. The comparative analysis of established practices of social assistance of long-term care, of legal and financial support of family members implementing such a care in Russia and European countries is presented. The study was carried out using comparative jurisprudence methodology. The analysis of legislative acts of the European countries revealed possibility of including particular legal provisions concerning financing of long-term care and implementing contractual forms of regulation of employment of family members providing such care, in the Russian social welfare system. The study demonstrated inadequate efficiency of the Russian systems of legal protection and social assistance both individuals seeking long-term care and individuals implementing it, as compared with similar systems in the European countries. To improve these systems, it is necessary to recognize legislatively the care of relative who lost the ability of self-serve as labor function liable to payment based on minimum wage rate. To fix legislatively retention of workplace for caregiver for entire period of caring and/or grant him unpaid vacation for long period. It is necessary to adjust both amount of benefits for care of family member who lost ability to self-care and procedure of calculation of amount of pension benefit of caregiver. The study results can contribute to widening scientific and practical professional discussion in the field of public health, health care organization and social work concerning problems of optimization of means and modes of supporting long-term care of persons who lost ability to self-care. The study results can serve as ground for making amendments to national legislation to harmonize legal support of social welfare system and to improve protection of rights of family members caring relative who lost ability to self-care in conditions of forced loss of income.

Embracing Challenges for Population Aging in China: Building Scientific Evidence to Inform Long-Term Care Policymaking and Practice

ABSTRACT In China, rapid aging of the population is driving up demand for healthcare and long-term care services for older adults. This special issue of the Journal of Aging & Social Policy features a collection of studies that provided timely analyses and fresh insights into a wide range of policy relevant topics concerning long-term care for older adults in China. In this introductory article, we orient readers to these studies organized under four themes: migration, caregiving, and elder care challenges; long-term care service users, frontline workers, and workforce challenges; unmet needs across the care span in healthcare, long-term care, and end of life care; and long-term care financing. We highlight major findings and contributions of each study and provide perspectives on key issues within China’s evolving healthcare and social policy contexts. Collectively, these studies contribute to building scientific evidence where it is lacking and supporting evidence-based long-term care policymaking and practice to meet the mounting challenges of population aging in China.

The Impact of Wages on Care Home Quality in England.

In many countries, a large proportion of long-term care staff are paid at, or near, minimum wage, leading to concerns of negative effects on care outcomes. This study analyzed the effect of staff wages on care home quality ratings in England. A national staffing database of long-term care providers was matched with local-area information on needs and supply to construct a 3-year panel (2016-2018) of English care home observations. Using multiple imputation methods to address missing data provided a data set of 12,055 observations of 5,556 care facilities (both residential and nursing homes). We analyzed the effect of the facility-level average hourly wage of care staff on national regulator quality ratings. A measure of the impact of exogenous changes in the national minimum wage on care facilities was used as an instrument for wage. We find that wages positively affect care home quality ratings. Other things equal, a 10% increase in the average hourly wage of direct care workers would lead to a 7.1% increase in the likelihood that a care home will have a high-quality rating. The wage effect on quality was significant when controlling for staff skill mix, measured as the share of registered nurses in nursing home staff. This study provides important evidence of the positive impact that staff pay can have on the quality of long-term care. Our finding has important implications for appropriate levels of pay and the funding of long-term care.

The LBJ School Experience

I hope that the future public servants who begin their careers in the School will tomorrow be serving effectively not only in the bureaus and departments of the Federal Government and the Congress but also in city halls and court houses and state capitols—not only in Texas but in every region in the country. Above all, I hope that as they master new techniques and disciplines to improve the machinery of government, they will still build their careers of service around a dedication to one of the most cherished principles of our democracy: the greatest good for the greatest number (Lyndon B. Johnson, May 22, 1971). Given high standards of living and modern medicine, there seems to be no inherent limit to how long humans can live. In the United States, the population is rapidly aging, and life expectancy has reached historical highs. By 2040, 20% of individuals will be 65 or older (The Administration on Aging, 2021). Those who reach 65 could live more than 20 years longer (Kochanek et al., 2020). If current trends continue and existing policies and programs are unchanged, the Social Security Trust Fund will be depleted by 2034 (Social Security Administration, 2022); Medicare’s trust fund will go broke by 2028 (Centers for Medicare and Medicaid Boards of Trustees, 2022); and Medicaid’s funding for long-term care for low-income older adults will consume an ever-increasing portion of state budgets (The Commonwealth Fund, 2020). To make matters worse, a lack of personal savings among working-age Americans means that many will be unable to finance their own retirement (Angel, 2018a). Despite early warning signs, these obligations represent a fiscal freight train that is bearing down on families and the state.

Paying for Nursing Home Quality: An Elusive But Important Goal.

Paying for Nursing Home Quality: An Elusive But Important Goal.

Comparative Analysis of Long-Term Care in OECD Countries: Focusing on Long-Term Care Financing Type.

This study aims to examine the characteristics of long-term care (LTC) financing in Organization for Economic Cooperation Development (OECD) countries. To this end, the 26 OECD countries that have introduced LTC systems were classified into three types of models: tax-based, health insurance, and LTC insurance (LTCI) systems. Thereafter, these systems were analyzed using Gilbert and Terrell's policy analysis framework. The results indicated differences in the characteristics of each type of financing in terms of allocation, benefit provision, service delivery, and finance. It is likely that while the LTC insurance model was mainly based on universalism and showed the highest level of coverage, the tax-based and health insurance models adopted selectivism with lower level of benefits per capita. In terms of service delivery, local authorities tended to have the responsibility to decide LTC service users and provide services in many countries, regardless of the type of model. In terms of finance, LTC insurance-based countries had the highest LTC expenditure as a percentage of GDP, followed by countries with tax-based and health insurance systems.

Experience of a demand-side subsidy scheme for residential long-term care: perspectives of elderly and their carers

BackgroundVouchers, which are demand-side subsidies to targeted groups, are a type of consumer-led near-cash social transfer for specified benefits that have been used in education, health and other sectors. To provide better access to residential care services and an additional choice for elderly people in need, a novel means-tested residential care service voucher has been introduced in Hong Kong for elderly people to purchase places in the private sector to enable consumer-directed care. The objectives of this paper are to analyze the perspectives of voucher users and their carers toward the voucher scheme and to identify key elements in the design that will contribute to meeting the scheme’s objectives.MethodsAn exploratory sequential mixed method design was adopted with initial explorative qualitative data collection of the perspectives of elderly people and their carers (Phase 1), which informed the design of the subsequent questionnaire survey (Phase 2). Thirty carers in 5 focus groups and 20 individual interviews with elderly people were conducted between April and May 2018. A total of 401 respondents (373 carers and 28 elderly people) completed the survey questionnaire. Findings from both phases were integrated both narratively and via a joint display.ResultsFive key themes summarized the features in two main elements of the design and implementation of the voucher scheme: awareness, meaning that inadequate knowledge and understanding of voucher schemes hinder participation; service needs and types, indicating that the urgent need for residential care services is the key reason for participation; shared responsibility, meaning that a high copayment level discourages participation; choice and flexibility, reflecting appreciation of the additional choices provided by voucher schemes although the availability of residential care beds limits choices; and service quality, indicating mixed perceptions of service quality and the impact of the voucher scheme. Voucher users believe that the voucher scheme is more helpful for relieving the financial burden (98.7%), reducing carers’ stress (97.0%) and reducing the waiting time for subsidized homes for elderly people (89.0%) than for increasing choice and flexibility (78.1%) and improving service quality (62.1%).ConclusionsThis study demonstrates how the design of a voucher scheme affects its take-up by targeted beneficiaries. When a voucher scheme is implemented in a long-term care system, it must consider the congruence with existing policies in long-term care provision and financing. The voucher scheme in Hong Kong has been able to generate the utilization of nonsubsidized places in homes for elderly people that were underutilized, but its effectiveness is limited by inadequate knowledge and understanding of the voucher scheme and the availability of residential care places. Giving the purchasing power and choice of providers to beneficiaries has the potential to enhance the quality of services, which will contribute to meeting the objectives. The study findings carry significant implications for long-term care policies and provide insights into the key features of the voucher scheme for residential care services and how to best design and implement a voucher scheme for elderly people in the context of policy objectives and a long-term care policy.

FEDERAL ACTIONS TO SUPPORT FAMILY CAREGIVERS UNDER THE BIDEN ADMINISTRATION

Abstract Family caregivers are the glue holding together the delivery and financing of long-term care. Replacing family care with paid care would cost roughly $470 billion each year. But family caregivers are struggling. They face many challenges – most notably the financial stress and the need for services and supports. Other challenges include lack of respite care, need for caregiver training, and lack of access to quality paid workforce. In order to address these challenges, Congress authorized the RAISE Family Caregiving Advisory Council. The RAISE (Recognize, Assist, Include, Support and Engage) Family Caregivers Act directs the Secretary of Health and Human Services to develop a national family caregiver strategy. This session presents the findings of two years of focus groups and interviews with family caregivers and hundreds of stakeholder organizations that support them, providing concrete input to the Biden administration on how to deliver on the broad objectives of the RAISE Act.

Trust in the publicly financed care system and willingness to pay for long-term care: A discrete choice experiment in Denmark

Aging populations put pressure on the provision and financing of long-term care (LTC) services in many countries. The projected increase in LTC expenditures may in particular constitute a threat to the future sustainability of public budgets in welfare states, where LTC is financed through taxes. To accommodate the increasing number of 80+ year-olds in society, policy-makers and service administrators need a better understanding of care preferences among future older adults: What types of services do older citizens prefer most, and which factors shape their LTC preferences? A discrete choice experiment (DCE) was administered to a representative sample of the Danish population aged 54–64 from May to July 2019 (n = 1154), investigating which factors shape individuals' preferences and willingness-to-pay (WTP) for their future LTC. Our results reveal that respondents are willing to make additional out-of-pocket payments to supplement the care provided for free by the municipality. The WTP was highest for services such as receiving help from a regular care team ($129 per month) and an extra shower a week ($116 per month). Moreover, we find heterogeneous care preferences, with three user characteristics associated with higher WTP for services: higher education, high wealth, and a low trust in the publicly financed care system. Our results raise concerns that inequalities between relatively more- and less-resourceful older adults may increase in Scandinavian-type welfare states in the future. Such increasing inequality in service provision may undermine citizens’ trust in and support of the publicly financed care system.

Modelling the burden of long-term care for institutionalised elderly based on care duration and intensity

AbstractThe financing of long-term care and the planning of care capacity are of increasing interest due to demographic changes and the ageing population in many countries. Since many care-intensive conditions begin to manifest at higher ages, a better understanding and assessment of the expected costs, required infrastructure, and number of qualified personnel are essential. To evaluate the overall burden of institutional care, we derive a model based on the duration of stay in dependence and the intensity of help provided to elderly individuals. This article aims to model both aspects using novel longitudinal data from nursing homes in the canton of Geneva in Switzerland. Our data contain comprehensive health and care information, including medical diagnoses, levels of dependence, and physical and psychological impairments on 21,758 individuals. We build an accelerated failure time model to study the influence of selected factors on the duration of care and a beta regression model to describe the intensity of care. We show that apart from age and gender, the duration of stay before death is mainly affected by the underlying diseases and the number of different diagnoses. Simultaneously, care intensity is driven by the individual level of dependence and specific limitations. Using both evaluations, we approximate the overall care severity for individual profiles. Our study sheds light on the relevant medical, physical, and psychological health indicators that need to be accounted for, not only by care providers but also by policy-makers and insurers.