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Preferences for long-term care services: willingness to pay estimates derived from a discrete choice experiment
- Authors:
- NIEBOER Anna P., KOOLMAN Xander, STOLK Elly A.
- Journal article citation:
- Social Science and Medicine, 70(9), May 2010, pp.1317-1325.
- Publisher:
- Elsevier
Ageing populations increase pressure on long-term care. Optimal resource allocation requires a mix of care services based on costs and benefits, and requires knowledge of how individuals place value on particular aspects of long-term care. This study elicits preferences in the elderly population for long-term care services for varying types of patients. A discrete choice experiment was conducted in a general population subsample of 1082 people aged 50–65 years drawn from the Dutch Survey Sampling International panel. To ascertain relative preferences for long-term care and willingness to pay for these, participants were asked to choose the best of 2 care scenarios for 4 groups of hypothetical patients: frail and demented elderly, with and without partner. The scenarios described long-term care using 10 attributes: hours of care, organised social activities, transportation, living situation, same person delivering care, room for individual preferences, coordination of services, punctuality, time on waiting list, and co-payments. Overall, the results showed that long-term care services were thought to produce greatest well-being for the patients without a partner and those with dementia. Individuals combining these 2 risk factors were thought to benefit the most from all services except transportation which was considered more important for the frail elderly. The results support the notion that long-term care services represent different value for different types of patients and that the value of a service depends upon the social context. Policy-making would profit from allocation models in which budgetary requirements of different services can be balanced against the well-being they produce for individuals.
Caring for the very old: public and private solutions
- Author:
- GLENNERSTER Howard
- Publisher:
- London School of Economics. Suntory-Toyota International Centre for Economics an
- Publication year:
- 1996
- Pagination:
- 29p.,bibliog.
- Place of publication:
- London
Governments in many countries are responding to the growing numbers of very old people in their populations ineffectively. Neither existing funding mechanisms nor the private market seem able to provide a solution either. This paper explores some of the reasons for this.
Crossing the threshold: the implications of the Dilnot Commission and Law Commission reports for eligibility and assessment in care and support
- Authors:
- SOCIAL CARE INSTITUTE FOR EXCELLENCE, HENWOOD Melanie
- Publisher:
- Social Care Institute for Excellence
- Publication year:
- 2012
- Pagination:
- 81p.
- Place of publication:
- London
This scoping report, commissioned by SCIE from Melanie Henwood Associates, explores the implications of key Dilnot and Law Commission proposals in respect of assessment and eligibility for publicly funded adult social care. The report draws on a range recent literature to highlight key issues in the current debate. Interviews were also conducted with 11 key stakeholders which explored their perceptions of and response to the key proposals for changing the approach to assessment and eligibility for adult social care in England. The report identifies three central issues: how people are assessed for their care and support needs; the implications of establishing a national eligibility threshold for care and support; and how a cap on lifetime care costs could work in practice. Although the recommendations from the Dilot Commission and Law Commission are welcome, the report concludes that they raise many complex issues that will need considerable policy and practice attention if they are to be successful.
Reimagining financing and payment of long-term care
- Authors:
- WERNER Rachel M., KONETZKA R. Tamara
- Journal article citation:
- Journal of the American Medical Directors Association, 23(2), 2022, pp.220-224.
- Publisher:
- Elsevier (for the American Medical Directors Association)
The COVID-19 pandemic revealed fundamental problems with the structure of long-term care financing and payment in the United States. The piecemeal system that exists suffers from several key problems, including underfunding, fragmentation across types and sites of care, and substantial variation in payment across states and populations. These problems result in inefficient allocation of resources, limited access to care, substandard quality, and inequities in both access and quality. The researchers propose a new federal benefit for long-term care, most likely as part of the Medicare program. Essential features of this benefit include taxpayer subsidies, along the lines of other Medicare benefits, and coverage across the range of long-term care services, including both residential and home- and community-based care. A new federal benefit has the most potential to break down administrative barriers and improve resource allocation, to ensure adequate payment rates across all states, to expand access to care by spreading risk across the entire Medicare population, and to improve equity by extending coverage to all Medicare beneficiaries who want it. A new federal benefit is politically challenging, requiring bold action by Congress, and entails the risks of administrative challenges and unintended consequences. However, in this case, retaining the status quo remains the far greater risk. (Edited publisher abstract)
Multitasking in nursing homes: differences between for-profit and nonprofit quality outcomes
- Authors:
- GAUDET Hefele Jennifer, et al
- Journal article citation:
- Gerontologist, 59(6), 2019, pp.1034-1043.
- Publisher:
- Oxford University Press
Background and Objectives: Nursing homes (NHs) in the United States face increasing pressures to admit Medicare postacute patients, given higher payments relative to Medicaid. Changes in the proportion of residents who are postacute may initiate shifts in care practices, resource allocations, and priorities. This study sought to determine whether increases in Medicare short-stay census have an impact on quality of care for long-stay residents. Research Design and Methods:This study used panel data (2005–2010) from publicly-available sources (Nursing Home Compare, Area Health Resource File, LTCFocus.org) to examine the relationship between a 1-year change in NH Medicare census and 14 measures of long-stay quality among NHs that experienced a meaningful increase in Medicare census during the study period (N = 7,932). This study conducted analyses on the overall sample and stratified by for- and nonprofit ownership. Results: Of the 14 long-stay quality measures examined, only one was shown to have a significant association with Medicare census: increased Medicare census was associated with improved performance on the proportion of residents with pressure ulcers. Stratified analyses showed increased Medicare census was associated with a significant decline in performance on 3 of 14 long-stay quality measures among nonprofit, but not for-profit, facilities. Discussion and Implications: The findings suggest that most NHs that experience an increase in Medicare census maintain long-stay quality. However, this may be more difficult to do for some, particularly nonprofits. As pressure to focus on postacute care mount in the current payment innovation environment, the findings suggest that most NHs will be able to maintain stable quality. (Edited publisher abstract)
Exploring the feasibility and validity of a pragmatic approach to estimating the impact of long-term care: The 'expected' ASCOT method
- Authors:
- MALLEY Juliette, et al
- Journal article citation:
- Journal of Long-Term Care, April 2019, pp.67-83. Online only
- Publisher:
- King's College London
- Place of publication:
- London
Context: Measuring the impact of long-term care (LTC) is essential if we are to allocate limited resources effectively. Objectives: This study explored the feasibility and validity of a pragmatic approach to evaluation, known as the counterfactual self-estimation of programme participants (CSEPP). CSEPP forms part of the Adult Social Care Outcomes Toolkit (ASCOT), and is referred to as the ‘expected’ method since participants estimate their expected quality of life (QoL) in the absence of services. Methods: This study used survey data from interviews with 748 LTC users in 22 English local authorities, which included questions on self- and interviewer-assessed understanding of the ‘expected’ questions. This study used these data to assess feasibility. Construct validity was assessed by examining hypothesised associations between the expected score and individual characteristics. Bias was assessed by comparing the CSEPP impact estimate to one produced using the instrumental variables approach used by Forder et al. (2016, 2018) on the same dataset. Findings: This study found evidence that the CSEPP/‘expected’ method was feasible and the self-estimated counterfactual outcome scores valid. There were indications that the method is less appropriate for some groups and that it may slightly overestimate the impact of LTC. Limitations: The main limitation is that the between methods comparison assumes that the instrumental variables approach provides a largely unbiased estimate of the effect of LTC, which is unlikely to be the case. Implications: The CSEPP/‘expected’ method is a useful tool in the LTC context, but more research is needed to understand potential sources of bias and its feasibility with certain groups. (Edited publisher abstract)
Priorities for long-term care resource allocation in England: actual allocation versus the views of directors of service and older citizens
- Authors:
- CLARKSON Paul, et al
- Journal article citation:
- Journal of Long-Term Care, September 2018, pp.13-23. Online only
- Publisher:
- King's College London
- Place of publication:
- London
Context: Decisions about resource allocation in long-term care are a perennial issue. The basis for deciding between different needs in prioritising allocation is contested. In England, this debate has crystallised with the advent of selfdirected support, where individuals’ expressed preferences drive resources. Objectives: To compare perceptions of the priority given to needs for resource allocation in long-term care of older people by two stakeholder groups, compared with actual resource allocation. Methods: Survey data, eliciting perspectives of senior service managers and older citizens, were used to rank the perceived importance of eight needs-related outcomes. Actual resource allocation from 17 local authorities was also modelled against these outcomes. A variable importance metric was used to rank the importance of these outcomes in determining actual resource allocation. Findings from each data collection were compared. Findings: Differences in prioritisation of needs emerged between stakeholders compared with actual allocation. Older citizens and actual allocation prioritised basic and instrumental activities of daily living (ADLs). Directors’ rankings were more distinct, still prioritising basic ADLs, but ranking psychological well-being higher and instrumental ADLs lower. Limitations: The model of actual allocation could not account for political and bureaucratic factors influencing resource allocation, nor the complexity of certain needs that might incur greater resources. Implications: Discretion continues to influence resource allocation, which remains a contested area. Directors must account for overall spend and other extrinsic factors to maintain sustainability, whereas older citizens prioritise instrumental ADLs, despite these being considered lower priority in eligibility decisions. Overall, ADLs remain important drivers of allocation. (Edited publisher abstract)
Using a 'wellbeing' cost-effectiveness approach to improve resource allocation in social care
- Authors:
- FORDER Julien, FERNANDEZ Jose-Luis
- Publisher:
- Quality and Outcomes of Person-centred Care Policy Research Unit
- Publication year:
- 2015
- Pagination:
- 22
- Place of publication:
- Canterbury
The main aim of this paper is to contrast a needs-led social care resource allocation system with one using a maximising wellbeing approach; that is, one based on: measuring the wellbeing consequences of using services and applying the principles of cost-effectiveness and opportunity cost. The promotion of wellbeing is the newly-stated guiding principle for the long-term care (social care) system in England. It signals a shift away from a focus on care need ‘deficits’ approach. Such a change in perspective has the potential to substantially alter how public care systems operate. The practical challenges are significant, both in the interpretation of wellbeing goals and in determining how the care system might be configured to achieve them. The paper describes how a maximising wellbeing approach might be applied in the case of long-term care. It argues that in theory a maximising wellbeing approach with full information will produce greater total wellbeing improvement for the same budget than a needs-based system. In practice, the comparison will depend on: (a) whether it is possible to actually measure wellbeing in a way that is consistent with the policy goals; (b) the availability of cost-effectiveness information; and (c) the decision rules used to implement a maximising wellbeing approach. (Edited publisher abstract)
Long-term care in the European Union
- Author:
- EUROPEAN COMMISSION. Directorate-General for Employment, Social Affairs and Equal Opportunities
- Publisher:
- European Commission. Directorate-General for Employment, Social Affairs and Equal Opportunities
- Publication year:
- 2008
- Pagination:
- 35p.
- Place of publication:
- Brussels
The demands for and costs of long-term care provision in the EU will rise significantly by 2050, according to a report presented by the European Commission on 28 April 2008. Meanwhile, the vast majority of Europeans (almost nine out of ten) favour home- or community-based care over care in an institutional setting. The projected growth in demand for long-term care services presents a major challenge for national governments. But the report also shows that Member States are striving to guarantee access for all to quality care by providing adequate resources to meet this demand. The Commission's report analyses the main challenges Member States face in the field of long-term care, their strategies for tackling them and presents possible solutions. It draws on the national reports submitted as part of the EU's system of common objectives, assessment and reporting for social protection and inclusion – the 'Open Method of Coordination'.
Improving equity and sustainability in UK funding for long-term care: lessons from Germany
- Author:
- GLENDINNING Caroline
- Journal article citation:
- Social Policy and Society, 6(3), July 2007, pp.411-422.
- Publisher:
- Cambridge University Press
This paper argues for a transformation of arrangements for accessing and allocating public resources for long-term care in the UK. Currently these arrangements are fragmented, inequitable and not always well targeted. Different arrangements exist in Scotland and England; Wales has also debated the introduction of free personal care. While not necessarily advocating a social insurance approach, the experience of Germany nevertheless shows how simplicity, transparency and equity of access can be combined with strong cost control levers and political sustainability. An opportunity to transform ways of accessing and distributing public resources for long-term care arises with the piloting of ‘individual budgets’ in 13 English local authorities from 2006. The paper argues that the principles underpinning individual budgets should be extended, with the UK government taking a strong national lead.