Periodic Reporting for period 1 - LTCpolicies (Optimizing access to long-term care? Impact of long-term care policies on use, health and equity among the elderly)
Periodo di rendicontazione: 2020-09-01 al 2022-08-31
OECD countries face the aging of their population, a demographic trend
that will amplify in the next decades. This causes a substantial
increase in the number of the disabled elderly, who require
assistance with activities of daily living. Reconciling the societal
concern for ensuring appropriate long-term care (LTC) to the disabled
elderly and the pressure on public spending is a major challenge that
all OECD countries struggle with. Governments aim at containing
rising costs of formal LTC by setting eligibility criteria and
cost-sharing rules, and encourage the provision of LTC by relatives
(informal care). Such measures may however impact the efficiency and
equity of LTC policies.
How does the design of LTC policies affect LTC use? What are the
downstream effects LTC use may have on health and health care use? To
what extent are informal caregivers involved alongside formal
caregivers? And how does the aggregate value of informal care compare
with that of formal LTC?
This project provides robust empirical evidence on these questions by
making use of conceptual and empirical tools from applied economics.
Identification of causal relationships is achieved by exploiting
exogenous variation (e.g. induced by a reform). Furthermore, the
project leverages high-quality, individual-level data, which combine
surveys and administrative sources. It relies on data, policies and
institutional contexts from France and the Netherlands.
that will amplify in the next decades. This causes a substantial
increase in the number of the disabled elderly, who require
assistance with activities of daily living. Reconciling the societal
concern for ensuring appropriate long-term care (LTC) to the disabled
elderly and the pressure on public spending is a major challenge that
all OECD countries struggle with. Governments aim at containing
rising costs of formal LTC by setting eligibility criteria and
cost-sharing rules, and encourage the provision of LTC by relatives
(informal care). Such measures may however impact the efficiency and
equity of LTC policies.
How does the design of LTC policies affect LTC use? What are the
downstream effects LTC use may have on health and health care use? To
what extent are informal caregivers involved alongside formal
caregivers? And how does the aggregate value of informal care compare
with that of formal LTC?
This project provides robust empirical evidence on these questions by
making use of conceptual and empirical tools from applied economics.
Identification of causal relationships is achieved by exploiting
exogenous variation (e.g. induced by a reform). Furthermore, the
project leverages high-quality, individual-level data, which combine
surveys and administrative sources. It relies on data, policies and
institutional contexts from France and the Netherlands.
WP1 and WP2 were combined to answer the following questions: is it so
that when older adults are required to pay more for a stay in a
nursing home, their admission to a nursing home is postponed? If so,
do they use more home care as a substitute? And has this any adverse
health consequences? We leverage a reform of cost sharing
on LTC that was implemented in the Netherlands. We
find that a higher price for nursing home stays does reduce the time
spent in a nursing home. The offsetting increase in home care use is
small and there is no overall effect on mortality. Because some
people end up staying many years in a nursing home, even a limited
increase in the monthly out-of-pocket payment induces a substantial
rise in the total amount older adults may face over their retirement.
It is often claimed that the help provided to older adults by their
relatives can delay or altogether avoid their nursing home admission.
Is it so? WP8 tackles this question, making use of a unique large
health survey linked with administrative data. We find
that the chance of a nursing home admission is reduced
with informal care for individuals with mild limitations, while it is
increased for individuals with severe limitations. For the latter,
although informal care increases formal care costs, it also results
in lower post-acute care use and mortality.
Following the outbreak of the COVID pandemic, WP9 was initiated. It stems from
the following puzzle: in economics, it is generally assumed that
informal care substitute with home care but vanishes when an
older adult enters a nursing home. Yet, the visit restrictions
imposed on nursing home residents in the early months of the pandemic
seemed to trigger major effects on their daily life.
We show that a majority – over 75% - of residents do receive informal
care. Caregivers are mostly involved in helping with administrative
tasks and mobility within and outside the residence.
WP10 provides an assessment of the aggregate monetary value of the
informal care provided to older adults in France. In this study, we
additionally answer the following question: Are nursing home
residents more likely to receive informal care than older adults in
the community because both populations have different
characteristics, and/or because the determinants of informal care
receipt differ at home versus in nursing homes? We show that both channels are equally relevant
empirically. In the aggregate, informal care for people in the
community remains quantitatively dominant because nursing home
residents represent a limited proportion of all older adults with
care needs and they receive less hours of informal care on average.
Finally, WP11 investigates into options for the financing of long-term care
that have been recently developing in the Netherlands. These options
aim at encouraging ageing-in-place. Has this goal been achieved? Have
these care options played a role in the sustained development of
private nursing homes? How can they contribute to or challenge the
equity in access to long-term care and in its financing in the
Netherlands? Th aim of WP11 is to describe these options and show how
they are being used by older adults, based on aggregate statistics as
well as individual-level data.
that when older adults are required to pay more for a stay in a
nursing home, their admission to a nursing home is postponed? If so,
do they use more home care as a substitute? And has this any adverse
health consequences? We leverage a reform of cost sharing
on LTC that was implemented in the Netherlands. We
find that a higher price for nursing home stays does reduce the time
spent in a nursing home. The offsetting increase in home care use is
small and there is no overall effect on mortality. Because some
people end up staying many years in a nursing home, even a limited
increase in the monthly out-of-pocket payment induces a substantial
rise in the total amount older adults may face over their retirement.
It is often claimed that the help provided to older adults by their
relatives can delay or altogether avoid their nursing home admission.
Is it so? WP8 tackles this question, making use of a unique large
health survey linked with administrative data. We find
that the chance of a nursing home admission is reduced
with informal care for individuals with mild limitations, while it is
increased for individuals with severe limitations. For the latter,
although informal care increases formal care costs, it also results
in lower post-acute care use and mortality.
Following the outbreak of the COVID pandemic, WP9 was initiated. It stems from
the following puzzle: in economics, it is generally assumed that
informal care substitute with home care but vanishes when an
older adult enters a nursing home. Yet, the visit restrictions
imposed on nursing home residents in the early months of the pandemic
seemed to trigger major effects on their daily life.
We show that a majority – over 75% - of residents do receive informal
care. Caregivers are mostly involved in helping with administrative
tasks and mobility within and outside the residence.
WP10 provides an assessment of the aggregate monetary value of the
informal care provided to older adults in France. In this study, we
additionally answer the following question: Are nursing home
residents more likely to receive informal care than older adults in
the community because both populations have different
characteristics, and/or because the determinants of informal care
receipt differ at home versus in nursing homes? We show that both channels are equally relevant
empirically. In the aggregate, informal care for people in the
community remains quantitatively dominant because nursing home
residents represent a limited proportion of all older adults with
care needs and they receive less hours of informal care on average.
Finally, WP11 investigates into options for the financing of long-term care
that have been recently developing in the Netherlands. These options
aim at encouraging ageing-in-place. Has this goal been achieved? Have
these care options played a role in the sustained development of
private nursing homes? How can they contribute to or challenge the
equity in access to long-term care and in its financing in the
Netherlands? Th aim of WP11 is to describe these options and show how
they are being used by older adults, based on aggregate statistics as
well as individual-level data.
The project extends the scientific literature, in the following main
ways: it sheds light on the role of out-of-pocket payments and
informal care in nursing home entry decisions. Evidence on their role
mainly comes from the United States, whose health care system differs
radically from those of European countries. Recall bias in the timing
of admissions is eliminated thanks to the use of administrative data;
those additionally allow to map out the use of substitute home care
and potential health effects (WP1/2 and WP8). The project provides a
quantitative assessment of informal care receipt by nursing home
residents, which had been left aside by the economic literature.
Compared with studies from other fields, the project relies on a
representative and high-quality survey that minimizes the risk of
selection biases (WP9 and WP10). By gathering and making openly
accessible dedicated information on co-payments on long-term care in
the Netherlands, the project can facilitate further research (WP1/2).
The description of novel options for the financing of long-term care
(WP11) intended to a non-Dutch audience may foster interest for
comparative research.
The project delivers a set of policy implications. When designing
cost-sharing rules for long-term care systems, policy makers should
not only look at budgetary savings but also aim at minimizing welfare
losses. A cap on lifetime co-payments would limit the associated
financial risk while preserving the incentive to postpone an
admission (WP1/2). Flexible options for LTC financing of prove necessary to bridge the gap between intensive care
provided in nursing homes and less comprehensive
and lighter care delivered at home. The options that have been
developing along these lines in the Netherlands may however fuel the
growth of fully private residential care admissions and may have
unwarranted consequences on equity in access to care and in its
financing (WP11). Promoting informal care systematically cannot be expected to systematically
result in lower institutionalization rate and care costs. Still,
informal support can well be welfare-enhancing: a timely admission
may come along with benefits in terms of well-being and survival that
may outweigh additional costs (WP8). Loss of informal care due to visiting restrictions may negatively affect
the health and wellbeing of nursing home residents. Policymakers should factor in the role of informal
caregivers when assessing the benefits and costs of visiting
restrictions in nursing homes (WP9). Ignoring nursing homes leads to underestimate the aggregate value of
informal care provided to older adults in France by 5%. When informal
care is taken into account, households are found to bear 80% of LTC
costs (WP10).
ways: it sheds light on the role of out-of-pocket payments and
informal care in nursing home entry decisions. Evidence on their role
mainly comes from the United States, whose health care system differs
radically from those of European countries. Recall bias in the timing
of admissions is eliminated thanks to the use of administrative data;
those additionally allow to map out the use of substitute home care
and potential health effects (WP1/2 and WP8). The project provides a
quantitative assessment of informal care receipt by nursing home
residents, which had been left aside by the economic literature.
Compared with studies from other fields, the project relies on a
representative and high-quality survey that minimizes the risk of
selection biases (WP9 and WP10). By gathering and making openly
accessible dedicated information on co-payments on long-term care in
the Netherlands, the project can facilitate further research (WP1/2).
The description of novel options for the financing of long-term care
(WP11) intended to a non-Dutch audience may foster interest for
comparative research.
The project delivers a set of policy implications. When designing
cost-sharing rules for long-term care systems, policy makers should
not only look at budgetary savings but also aim at minimizing welfare
losses. A cap on lifetime co-payments would limit the associated
financial risk while preserving the incentive to postpone an
admission (WP1/2). Flexible options for LTC financing of prove necessary to bridge the gap between intensive care
provided in nursing homes and less comprehensive
and lighter care delivered at home. The options that have been
developing along these lines in the Netherlands may however fuel the
growth of fully private residential care admissions and may have
unwarranted consequences on equity in access to care and in its
financing (WP11). Promoting informal care systematically cannot be expected to systematically
result in lower institutionalization rate and care costs. Still,
informal support can well be welfare-enhancing: a timely admission
may come along with benefits in terms of well-being and survival that
may outweigh additional costs (WP8). Loss of informal care due to visiting restrictions may negatively affect
the health and wellbeing of nursing home residents. Policymakers should factor in the role of informal
caregivers when assessing the benefits and costs of visiting
restrictions in nursing homes (WP9). Ignoring nursing homes leads to underestimate the aggregate value of
informal care provided to older adults in France by 5%. When informal
care is taken into account, households are found to bear 80% of LTC
costs (WP10).