Social security income and the utilization of home care: Evidence from the social security notch

This paper exploits Social Security law changes to identify the effect of Social Security income on the use of formal and informal home care by the elderly. Results from an instrumental variables estimation strategy show that as retirement income increases, elderly individuals increase their use of formal home care and become less likely to rely on informal home care provided to them by their children. This negative effect on informal home care is most likely driven by male children withdrawing from their caregiving roles. The empirical results also suggest that higher Social Security benefits would encourage the use of formal home care by those who would not have otherwise used any type of home care and would also encourage the use of both types of home care services among elderly individuals.     

How do they manage? Disabled elderly persons in the community who are not receiving Medicaid long-term care services

OBJECTIVE: To expand our understanding of how low-income functionally impaired elderly persons are able to remain in the community. DATA SOURCES AND STUDY SETTING: In-person and telephone interviews with 25 elderly individuals who applied for but did not enroll in Connecticut's Home Care Program for Elders (CHCPE). All met the state's nursing home level-of-care criteria. STUDY, DESIGN: In-depth discussions with a small, purposefully selected sample of functionally impaired elderly persons in the community. PRINCIPLE FINDINGS: Many sample members with very high levels of impairment and multiple chronic health conditions remained in the community without CHCPE services because of Medicare home health services combined with extensive levels of informal care. Some sample members, particularly those with more limited informal care networks, did not receive the level of care that they needed. Virtually all were at high risk for medical complications, hospitalizations for acute illnesses, falls, and further loss of functioning. Further, in many cases, informal care networks were overextended, stressed and vulnerable to break down. All but a few of those we interviewed were not receiving services through the waiver program for financial reasons. Most met Medicaid's income criteria but had assets that exceeded Medicaid's $2,000 limit. Several were not participating due to concerns about estate recovery. CONCLUSIONS: Additional formal help is needed to avoid eventual nursing home placement for many sample members. This could be achieved by expanding the availability of case management services and/or relaxing program financial requirements. Further, efforts to reduce Medicare home health expenditures must recognize the heightened vulnerability of many beneficiaries for potentially costly adverse outcomes.     

Effects of the Medicare Alzheimer''s Disease Demonstration on the use of community-based services.

STUDY QUESTION: Did the Medicare Alzheimer''s Disease Demonstration with its case management and community service waivers affect the use of community-based long-term care services among people with dementia and their primary caregivers? DATA SOURCES: Baseline and periodic caregiver interviews. Measures include client and caregiver attributes and self-reported service use. STUDY DESIGN: The demonstration randomly assigned voluntary applicants into treatment and control groups. Treatment group cases were eligible for case management and for up to $699 per month in community care benefits. The actual monthly entitlement varied among the eight demonstration communities due to regional cost and inflation adjustments over time. Analyses are for the year after enrollment. DATA COLLECTION: Analyses are of cases surviving six months or more in the community after enrollment (n = 5,209). Cases received baseline and semi-annual assessments. PRINCIPAL FINDINGS: The intervention of case management and community service reimbursement had a strong, consistent, and positive effect on the likelihood of using home care (including homemaker/chore services, personal care services, companion services) and adult day care. Treatment group clients were at least twice as likely as control group clients to be using any of the four community-based services. A similar, but less pervasive effect was achieved with caregiver training and support group participation. Reimbursement provided by the demonstration''s Medicare waiver was generally not sufficient to exceed the level of control group service acquired through private payment. CONCLUSIONS: Reimbursement levels within the demonstration may have enabled more individuals to purchase some services, but they were not sufficient to increase the average level of use over those in the control group. No consistent differences between demonstration models were found in service use likelihood or average use among users.     

The effects of predetermined payment rates for Medicare home healthcare.

OBJECTIVE: To assess the effects of an alternative method of paying home health agencies for services to Medicare beneficiaries, based on a demonstration program. DATA SOURCES/STUDY SETTING: Primary and secondary data collected on participating home health agencies in five states and their patients during the three-year demonstration period. Primary data included patient surveys at discharge and six months later, and two rounds of interviews with executive staff of the agencies. Secondary data included agencies' Medicare cost reports, quality assurance reviews, Medicare claims data, demonstration claims data, demonstration patient intake forms, and plan of treatment forms. STUDY DESIGN: The 47 agencies volunteering to participate in the demonstration were each randomly assigned to the treatment or control group. Treatment group agencies were paid a predetermined rate based on their inflation-adjusted cost per visit during the year preceding the demonstration; control group agencies were paid under Medicare's conventional cost reimbursement method. Demonstration impacts were estimated by comparing outcomes for the two groups of agencies and their respective patients, using regression models to control for any remaining differences. PRINCIPAL FINDINGS: Agencies paid under prospective rate setting were slightly better at holding per-visit cost increases below inflation than were control group agencies. The change in payment method had no effect on agencies' volume of Medicare visits or quality of care, nor on patients' use of Medicare services or other formal or informal care services. CONCLUSION: Changing from cost-based reimbursement to predetermined payment rates for Medicare home healthcare visits would not lead to large savings for the Medicare program, but would not increase costs to Medicare or adversely affect patients or their caregivers.     

The evaluation of the National Long Term Care Demonstration. 8. The effect of channeling on health and long-term care costs.

Expanded community care for the frail elderly has been advocated based on its potential for financial cost saving. However, the evaluation found that average costs increased: the cost of expanding publicly financed case management and formal community services beyond what already was provided was not offset by reductions in the costs for nursing home care.     

The evaluation of the National Long Term Care Demonstration. 10. Overview of the findings.

The channeling demonstration sought to substitute community care for nursing home care through comprehensive case management and expanded community services. The channeling intervention was implemented largely according to design. Although the population served was, as intended, extremely frail, it turned out not to be at high risk of nursing home placement. The costs of the additional case management and community services--provided in most cases to clients who would not have entered nursing homes even without channeling--were not offset by reductions in the cost of nursing home use. Hence, total costs increased. The expanded formal community care did not, however, result in a substantial reduction in informal caregiving. Moreover, channeling benefited clients, and the family and friends who cared for them, in several ways: increased services, reduced unmet needs, increased confidence in receipt of care and satisfaction with arrangements for it, and increased satisfaction with life. Expansion of case management and community services beyond what already exists, then, must be justified on the basis not of cost savings but of benefits to clients and their caregivers.     

Modelling the effectiveness of financing policies to address underutilization of children's health services in Nepal

OBJECTIVE: To estimate the price responsiveness of utilization of formal children's health-care services in Nepal and to use this information to model the impact on utilization of subsidies or increases in user fees. METHODS: A total of 8112 individual observations (of children aged < 15 years) from 2847 households in 274 communities were obtained from the 1996 Nepal Living Standards Survey. A logit model was applied to determine the net impact of price on a parent or caregiver's decision to seek care for a given instance of illness. The model's coefficients were used to calculate the price responsiveness of utilization decisions. FINDINGS: Parents or caregivers reported that 9.7% of children (788/8112) had been ill or injured in the previous month. Parents reported that they had sought care in 566 (71.8%) of these cases; care was most frequently sought from public providers. The price elasticity of demand for children's health-care services in the formal sector was estimated at -0.16. As prices rise, the demand curve exhibits continuous and declining price elasticity. Overall, a 100% subsidy of user fees would increase current utilization rates by 56%, while a 100% increase in fees would lead to a drop in utilization of only 12%. The differential in utilization across income groups was substantial after changes in fees were implemented. CONCLUSION: While the effect of price on the utilization of children's health-care services in Nepal is statistically significant, the size of the impact is modest. Policies to subsidize fees could increase utilization substantially, while fee increases would lead to modest declines in utilization and generate increased revenue.     

State strategies to support community based long term care for the elderly

States play a principal role in designing and implementing publicly funded long term care programs. They are in a key position to determine what setting, from whom, and under what philosophy of care individuals can access long term care. State long term care systems have evolved over the past 25 years to support increased availability of community based care for older individuals. States have pursued three broad strategies to increase availability. One set of strategies aims to increase capacity through expanding the supply, public funding and eligibility for a wide array of home and community based services (HCBS). A second set of strategies seeks to constrain institutional growth in order to increase the dollars available for HCBS. Managed/capitated long term care is a third strategy that is a hybrid of the other two approaches. Empirically, increased capacity through use of Medicaid and Medicare resources and growth in the supply of community based care providers, combined with moderation of institutional bed supply, are associated with enhanced access and expenditures for community based long term care. The effectiveness of capitated or managed systems of care varies by model and in some cases is still under study. State fiscal resources are key to the ability to support community based care for the elderly. Targeted federal support may be critical to the continued expansion of community based care, given heterogeneity in state resources, coupled with an increasing demand for long term care.     

Obstetric complications: does training traditional birth attendants make a difference?

OBJECTIVE: To assess the effect that a training intervention for traditional birth attendants (TBAs) in Guatemala had on the detection of obstetric complications, the referral of patients with complications to the formal health care system, and, ultimately, those patients' utilization of essential obstetric care services. METHODS: Using a quasi-experimental design, a surveillance system of births was implemented to collect population-based information from 3,518 women between 1990 and 1993. All women were interviewed postpartum by physicians. There were three key independent variables in our study: 1) geographical area (intervention community and non-intervention community), 2) time in relation to the training intervention (before or after), and 3) presence or absence of a TBA at the time of the complication. The key dependent variables for women interviewed were 1) development of an obstetric complication, 2) detection of the problem by the TBA, 3) referral to a health facility, 4) compliance with referral, and 5) use of services. RESULTS: The incidence of postpartum complications decreased after the intervention, controlling for intervention community. On the other hand, after the intervention TBAs were less likely to recognize most maternal complications, and referral rates did not increase significantly. The likelihood of using health care services increased six-fold among women who were not attended by TBAs, and no increase was observed among those who were attended by TBAs. CONCLUSION: Training TBAs may have had a positive effect on the rate, detection, and referral of postpartum complications. However, the evidence is less convincing for overall increases in the detection of complications, in referral to the formal health care system, and in the utilization of essential obstetric services among women attended by TBAs.     

The association between cognitive impairment and community service use patterns in older people living in Australia

Family plays a vital role in supporting individuals with dementia to reside in the community, thus delaying institutionalisation. Existing research indicates that the burden of care‐giving is particularly high for those caring for a person with dementia. Yet, little is known about the uptake of community services by people with a diagnosis of dementia. Therefore, this study aims to better understand the relationship between cognitive impairment and the receipt of community care services. In order to examine the relationship, secondary data collected across Queensland, Australia, from 59,352 home‐care clients aged 65 and over during 2007–2008 are analysed. This cross‐sectional study uses regression analyses to estimate the relationship between cognitive impairment and service mix, while controlling for socio‐demographic characteristics. The dependent variables include formal services, informal care and total home‐care service hours during a 12‐month period. The findings of this study demonstrate that cognitive impairment is associated with accessing more hours of respite and day centre care but fewer hours of other formal care services. Additionally, the likelihood of support from an informal caregiver increases when a client becomes cognitively impaired. Therefore, this study demonstrates that there is an increased need for respite programmes to support informal caregivers in the future, as the population of people living with dementia increases. These findings support the need for investigations of new and innovative respite models in the future.     

Migration and maternal health services utilization in rural Guatemala

This article examines the relationship between migration and the use of formal maternal health-care services among rural women in Guatemala. We identify assimilation, diffusion, and remittances as three potential pathways through which migration can affect health-care service utilization in rural areas. Using data from the 1995 Guatemalan Survey of Family Health and multi-level regression models, we estimate the impact of migration experience at the individual, household, and community level on the use of formal prenatal care and delivery assistance. We find that urban migration experience and having relatives abroad are associated with a greater likelihood of formal prenatal care utilization, after taking account of background characteristics and enabling resources. Migration experience at all levels is also strongly associated with formal delivery assistance; however, this association operates primarily through the positive association between migration and enabling resources. The differential effects of out-migration on maternal health-care service utilization reflect the different barriers to service use that exist for formal prenatal care and delivery assistance. Financial cost and geographic access are the most important barriers to formal delivery assistance, whereas awareness and acceptance remain as important barriers to the use of formal prenatal care in rural Guatemala. Urban migration experience and social ties to urban and international migrants lower the barriers to formal maternal health-care utilization through the acquisition and diffusion of new ideas and practices, and the return flow of financial resources.     

The evaluation of the National Long Term Care Demonstration. 1. An overview of the channeling demonstration and its evaluation.

The channeling demonstration sought to substitute community care for nursing home care to reduce long-term care costs and improve the quality of life of elderly clients and the family members and friends who care for them. Two interventions were tested, each in five sites; both had comprehensive case management at their core. One model added a small amount of additional funding for direct community services to fill the gaps in the existing system; the other substantially expanded coverage of community services regardless of categorical eligibility under existing programs. The demonstration was evaluated using a randomized experimental design to test the effects of channeling on use of community care, nursing homes, hospitals, and informal caregiving, and on measures of the quality of life of clients and their informal caregivers. Data were obtained from interviews with clients and informal caregivers; service use and cost records came from Medicare, Medicaid, channeling, and providers; and death records for an 18-month follow-up period were examined.     

The effects of cost-shifting in the state children's heath insurance program

OBJECTIVES: Many states are increasing the State Children's Health Insurance Program (SCHIP) cost-sharing requirements to induce reductions in enrollment. We examined the effect of increasing SCHIP premiums on both health care use and cost to the public. METHODS: The net cost to the public of increased cost sharing for SCHIP-insured children in a border community was estimated with multivariate methods. The majority (88%) of children were of Mexican origin. RESULTS: We estimated that a $10 increase in monthly premiums would induce 10% of SCHIP children to disenroll, resulting in a 6% increase in public expenditures. CONCLUSIONS: Families that disenroll from SCHIP and become uninsured typically turn to emergency departments for primary care, which increases total health care expenditures through the use of more expensive services.     

Aging in place? Evidence that a state Medicaid waiver program helps frail older persons avoid institutionalization

Long-term care will increasingly shift from institutions to home and community based services. Using data from a Medicaid home care waiver program in South Carolina, the Community Long-Term Care (CLTC) program, we evaluated differences in frailty and service use among CLTC clients between 1995 (n = 3,748) and 2005 (n = 9,157). The expectation was that CLTC clients had become more frail in that period, and had greater access to services in the community, results that might suggest the CLTC program had helped individuals to avoid institutionalization. Frailty measures included acute and chronic conditions, other health conditions, and activities of daily living (ADL). We evaluated the percentage of clients using services, and service use intensity. A large majority of clients in both years were impaired in at least four ADL. In 2005, CLTC clients were significantly more likely to have chronic conditions, including hypertension, chronic obstructive pulmonary disease, Alzheimer's disease, arthritis, diabetes, and renal failure (all p < 0.05). Clients were significantly more likely to receive specific services in 2005, including physical therapy, dialysis, and oxygen (all p < 0.05). Results suggest CLTC participants were more frail in 2005 than in 1995. This may reflect a successful effort to help individuals age in place in the community, delaying institutionalization. States may be able to control increases in Medicaid long-term care costs through home care programs that delay institutionalization.     

Changing the balance of social care for older people: simulating scenarios under demographic ageing in New Zealand

The demographic ageing of New Zealand society, as elsewhere in the developed world, has dramatically increased the proportion of older people (aged 65 years and over) in the population. This has major policy implications for the future organisation of social care. Our objective was to test the effects on social care use, first, of putative changes in the overall disability profile of older people, and second, of alterations to the balance of their care, i.e. whether it was community‐based or residential. In order to undertake these experiments, we developed a microsimulation model of the later life course using individual‐level data from two official national survey series on health and disability, respectively, to generate a synthetic version which replicated original data and parameter settings. A baseline projection under current settings from 2001 to 2021 showed moderate increases in disability and associated social care use. Artificially decreasing disability levels, below the baseline projection, only moderately reduced the use of community care (both informal and formal). Scenarios implemented by rebalancing towards informal care use moderately reduced formal care use. However, only moderate compensatory increases in community‐based care were required to markedly decrease the transition to residential care. The disability impact of demographic ageing may not have a major negative effect on system resources in developed countries like New Zealand. As well as healthy ageing, changing the balance of social care may alleviate the impact of increasing demand due to an expanding population of older people.     

Personal care expectations: Photovoices of Chinese ageing adults in Hong Kong

The increasing ageing population contributes to growing demands for personal care that fulfils ageing adults’ preferences and expectations. This study explored Chinese ageing adults’ expected forms and sources of future personal care and the factors influencing care expectations. A qualitative photovoice research method – which integrated photography, interviews and group discussions – was used for data collection between January and April 2016. Through purposive sampling, 36 community‐residing participants aged 51–80 years took photographs that captured personal care preferences or expectations within individual, familial and societal contexts. Participants described feelings of worry, uncertainty and unpreparedness for future care needs and arrangements. They preferred practicing self‐care for as long as possible and remaining in their homes and communities (“ageing in place”) through support from assistive technologies, family members or home‐based and community services. Institutional care was regarded as the last resort. The findings reflected discrepancies between ageing adults’ care preferences and realities and their ambivalent attitudes towards filial care when switching between roles. Confronted with the increasingly unreliable family care, financial resources and insufficient community services, participants anticipated receiving institutional care that would be less satisfying or that they would dislike. As caregivers, ageing adults displayed strong commitment to filial obligations, whereas when perceiving themselves as care receivers they felt that they could not expect care from their children because of practical considerations. By understanding preferred care forms and sources, actors can devote resources, policies and interventions to support self‐care through proactive planning and technological advancement, foster “ageing in place” through family and community care, and improve institutional care to enable ageing with dignity.     

Immunisation uptake, services required and government incentives for users of formal day care

OBJECTIVES: To determine immunisation uptake in children attending formal day care prior to the introduction of certificates (state) and parent incentives (federal), and to document parent and child carers' attitudes to these strategies. METHOD: In 1997, 60 child care centres and 300 family day carers in suburban Melbourne were randomly sampled. Immunisation dates, service use and preference, and views on government incentives were obtained from parents of children under three years of age. RESULTS: From 2,454 eligible children, information was obtained for 1,779, of whom 84% (95% CI 82-86) were completely immunised. Low income (OR 1.8, 95% CI 1.2-1.9, p < or = 0.001) and larger family size (OR 1.8, 95% CI 1.2-2.7, p = 0.002) and only ever using a doctor (OR 1.6, 95% CI 1.1-2.3) was associated with incomplete immunisation. Main reasons for delaying immunisation were occurrence of minor illness and work commitments. Families would prefer immunisation services at Maternal and Child Health visits (39%), evening sessions (22%) and at day care (22%). Immunisation uptake could increase to 94% if those receiving Childcare Assistance (67%) immunised their children on time but would increase to 87% if these incentive only motivated those for whom Childcare Assistance was essential (15%). While 98% of day care co-ordinators and 71% of family day care co-ordinators documented immunisation status at commencement of child care, only 51% and 33% respectively regularly updated this information. CONCLUSION: Providing client-focused, flexible immunisation services and government incentives and legislation may work together to boost immunisation levels for those in formal child care.     

Modelling the implications of moving towards universal coverage in Tanzania

A model was developed to assess the impact of possible moves towards universal coverage in Tanzania over a 15-year time frame. Three scenarios were considered: maintaining the current situation ('the status quo'); expanded health insurance coverage (the estimated maximum achievable coverage in the absence of premium subsidies, coverage restricted to those who can pay); universal coverage to all (government revenues used to pay the premiums for the poor). The model estimated the costs of delivering public health services and all health services to the population as a proportion of Gross Domestic Product (GDP), and forecast revenue from user fees and insurance premiums. Under the status quo, financial protection is provided to 10% of the population through health insurance schemes, with the remaining population benefiting from subsidized user charges in public facilities. Seventy-six per cent of the population would benefit from financial protection through health insurance under the expanded coverage scenario, and 100% of the population would receive such protection through a mix of insurance cover and government funding under the universal coverage scenario. The expanded and universal coverage scenarios have a significant effect on utilization levels, especially for public outpatient care. Universal coverage would require an initial doubling in the proportion of GDP going to the public health system. Government health expenditure would increase to 18% of total government expenditure. The results are sensitive to the cost of health system strengthening, the level of real GDP growth, provider reimbursement rates and administrative costs. Promoting greater cross-subsidization between insurance schemes would provide sufficient resources to finance universal coverage. Alternately, greater tax funding for health could be generated through an increase in the rate of Value-Added Tax (VAT) or expanding the income tax base. The feasibility and sustainability of efforts to promote universal coverage will depend on the ability of the system to contain costs.     

Reconsidering the effect of Medicaid on health care services use.

OBJECTIVE: Our research compares health care use by Medicaid beneficiaries with that of the uninsured and the privately insured to measure the program's effect on access to care. DATA SOURCES/STUDY SETTING: Data include the 1987 National Medical Expenditure Survey and the Survey of Income and Program Participation for 1984-1988. STUDY DESIGN: We predict annual use of ambulatory care and inpatient hospital care for Medicaid beneficiaries receiving AFDC cash assistance and compare it to what their use would be if uninsured or if covered by private insurance. Comparisons are based on multivariate models of health care use that control for demographic and economic characteristics and for health status. Our model distinguishes among Medicaid beneficiaries on the basis of eligibility to account for the poor health of beneficiaries in some eligibility groups. PRINCIPAL FINDINGS: AFDC Medicaid beneficiaries use considerably more ambulatory care and inpatient care than they would if they remained uninsured. Use among the AFDC Medicaid population is about the same as use among otherwise similar, privately insured persons. Use rates differ substantially among different Medicaid beneficiary groups, supporting the expectation that some beneficiary groups are in poor health. CONCLUSIONS: Although Medicaid has increased access to health care services for beneficiaries to rates now comparable to those for the privately insured population, because of lower cost sharing in Medicaid we would expect higher service use than we are finding. This suggests possible barriers to Medicaid patients in receiving the care they demand. Enrollment of less healthy individuals into some Medicaid beneficiary groups suggests that pooled purchasing arrangements that include Medicaid populations must be designed to ensure adequate access for the at-risk populations and, at the same time, to ensure that private employers do not opt out because of high community-rated premiums.