ACCOUNTING AND MAPPING OF LONG-TERM CARE EXPENDITURE UNDER SHA 2011 · 1. Accounting for long-term...

ACCOUNTING AND

MAPPING OF LONG-TERM

CARE EXPENDITURE UNDER

SHA 2011

December 2012

Health Division

www.oecd.org/health

Directorate for Employment, Labour and Social

Affairs

Contact [email protected]

http://www.oecd.org/health

mailto:[email protected]

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ACKNOWLEDGEMENTS

The authors wish to thank the following for their cooperation in undertaking this study

Kaisa Ahola (Statistics Sweden), Marie Glanzelius (Statistics Sweden), Vladimira Kalnicka (Czech

Statistical Office), Cristina Liwendahl (Statistics Sweden), Stane Marn (Statistical Office of the Republic

of Slovenia), Naohiro Mitsutake (Japanese Institute of Health Economics and Policy), Vincent van Polanen

Petel (Statistics Netherlands), Raymond Rossel (Federal Statistical Office Switzerland), Tomas Roubal

(Czech Ministry of Health). Valuable comments were also received from Eurostat, WHO and the

participants of the 14th Meeting of National Health Account Experts.

This project was funded under EU contribution agreement 2011 53 01.

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TABLE OF CONTENTS

Background .................................................................................................................................................. 4 Analysis of Country Reports ........................................................................................................................ 5

Data and methodology used by countries ................................................................................................. 6 Split between ADL and IADL.................................................................................................................. 7 Results ...................................................................................................................................................... 8 Back recalculation of time-series ........................................................................................................... 10

Further clarification of long-term care under SHA 2011 ........................................................................... 10 Application of the majority criterion and the split between ADL and IADL ......................................... 10 Split between assistance care services (HCR.1) and social services outside of the SHA boundary ...... 11 Informal care (unpaid) ............................................................................................................................ 11 Long-term care providers ....................................................................................................................... 12

Conclusions and next steps ........................................................................................................................ 12

ANNEX 1: ADDITIONAL GUIDANCE ON LTC SERVICES .................................................................. 13

ANNEX 2: ADDITIONAL SOURCES OF INFORMATION ..................................................................... 21

ESSPROS ............................................................................................................................................... 21 SOCX ..................................................................................................................................................... 22

Tables

Table 1 Changes in reporting of long-term care expenditure ...................................................................... 9

Figures

Figure 1 Comparability issues around the estimation of long-term care expenditure in OECD countries .. 5

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Background

1. Accounting for long-term care under the System of Health Accounts framework has long been

recognised as one of the major issues affecting the overall comparability and usefulness of international

health expenditure data. The comparability of long-term care and, therefore, total health care expenditure

figures has been limited since SHA 1.0 allowed for multiple interpretations of the definition and boundary

of long-term care. Much of this variance is triggered from the different national notions of long-term care –

e.g. which ministry has responsibility for long-term care, or how long-term care is financed, etc.

2. A number of steps have been taken in order to reduce the apparent discrepancies between

reporting practices in this field. In 2006, long-term care guidelines for the Joint Health Accounts

Questionnaire (JHAQ) were drafted1. These guidelines are still applicable for current JHAQ submission

rounds. They clarified the split of long-term care into a health component and a social component, with

only the health part is also an element of the aggregate of total health expenditure. The boundary centred

on a theoretical separation of the services related to ADL (Activities of Daily Living) and IADL

(Instrumental Activities of Daily Living). A subsequent in-depth study of long-term expenditure and

potential data sources of OECD and EU countries in 20072 recommended this approach be maintained.

However, in view of the ongoing revision of the SHA manual, the guidelines left the door open for

countries to continue with their established accounting practices. Thus, although there has been a general

convergence of data on long-term care expenditure, there remain some limitations in international

comparability, as can be seen in Figure 1.

3. The figure highlights two issues. First, there is a problem in common with other parts of the

health accounts – related to data gaps. In this case, there are significant information gaps concerning

private financing of long-term care as well as the reporting of long-term care services outside the health

care boundary (i.e. long-term (social) expenditure). Coupled with this are the different boundaries applied

to separate long-term care into the health and social components.

4. As mentioned before, the main issue around this separation is the allocation of personal care

services – also known as services related to activities of daily living (ADL) which include help with eating,

bathing, dressing, moving around, management of incontinence – and assistance care services – also

known as instrumental activities of daily living (IADL) which include help with shopping, cleaning,

cooking, using the telephone etc. Currently, some countries include neither of the two types of services in

their long-term care (health) expenditure figure while other countries include both.

5. SHA 2011 is now more precise on where to draw the boundary between long-term care (health)

and long-term care (social)3. However, it is important to note that the definitions and boundaries presented

in SHA 2011 are basically re-enforcing the split suggested in the 2006 long-term care guidelines, such that

in the theoretical sense:

1 Guidelines for estimating long-term care expenditures in the Joint 2006 SHA Data Questionnaire

2 Conceptual Framework and Methods for Analysis of Data Sources for Long-term care expenditure

http://www.oecd.org/els/healthpoliciesanddata/Conceptual%20Framework%20and%20Methods%20for%2

0Analysis%20of%20Data%20Sources%20for%20Long-Term%20Care%20Expenditure.pdf

3 The most relevant definitions and paragraphs can be found in Chapter 5 of the SHA 2011 manual.

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Figure 1 Comparability issues around the estimation of long-term care expenditure in OECD countries

Source: Source: OECD Health Data 2012

Personal care services (ADL) should be considered as long-term care (health)

Assistance care services (IADL) should be considered as long-term care (social)

6. As SHA 2011 explains, such a conceptual division has to be further qualified according to the

mode of provision. Thus, in the same way that curative in-patient care consists of a „package‟ of services

of varying care intensity, long-term care in an institutional setting needs to be treated accordingly.

7. The OECD invited member countries to test the feasibility of accounting of long-term care under

SHA 2011. Each participating country provided a short report and engaged in bi-lateral correspondence

with the OECD on certain aspects arising from the reports. The findings and recommendations are

summarised in the remainder of this paper.

8. In addition, the OECD drew up further guidance and clarifications on particular issues to

complement the SHA 2011 Manual. Specific long-term care services are described and accounting

recommendations are presented (Annex 1). Finally, the OECD assessed the suitability of closely-related

international statistical systems like ESSPROS and SOCX as possible data sources for the purposes of

SHA (Annex 2). The final report also took into account the discussions from the 14th Annual Meeting of

OECD Health Accounts experts and subsequent feedback to the preliminary draft report.

Analysis of Country Reports

9. The participating countries were asked to document the data sources currently used and/or

planned to be used for the accounting of the various long-term care components under SHA 2011 and to

provide a short description of the overall methodologies applied for the calculation of the different

components of long-term care.

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Data and methodology used by countries

Netherlands

10. Health Accounts in the Netherlands are primarily constructed from a provider perspective. The

most important data source for the calculation of total expenditure of long-term care providers are the

obligatory annual documents submitted including the annual financial reports. Based on these, the output

of each provider is condensed to several “products”. In a further step, the financing agents/schemes of

these products are analysed. Three main schemes that finance the different products of long-term care

providers could be identified. For those schemes, 53 packages and 11 support functions including different

long-term care components and aimed at different dependent population groups could be distinguished. As

several packages comprise a product, the packages are cost-weighted and each package and support

function was grouped into either long-term care (health) or long-term care (social) based on its dominant

character. As a result, they construct different distribution keys for each product of the long-term care

providers (the keys can deviate between the same product of different providers). Applying the distribution

keys to the products they arrive at individual functional splits between the health and social part of long-

term care reflecting the different focus of each relevant long-term care provider.

Switzerland

11. Switzerland also starts its analysis from the side of the health care provider, identifying relevant

in-patient and out-patient long-term care institutions that provide some services of long-term care and then

calculating their expenditure based on data gained from business registries. The expenditure of private

households, in this approach, is estimated as a residual value after deducting the expenditure of all known

financing schemes of long-term care. Analysis of the different long-term care components is done by

scrutinising the long-term care providers and not the available benefit package from different financing

schemes. Based on expert estimations some long-term care providers were classified as predominantly or

exclusively social care providers. All of their expenditure was subsequently allocated to long-term care

(social). For three types of long-term care providers that potentially provide ADL and IADL services

different methods of demarcating the long-term care services were analysed, among them type of skill and

level of education of staff, input components (such as costs for accommodation, nursing cost,

pharmaceuticals, devices), the function of employees (personnel with focus on care, therapy administration

and technical personnel) or the revenue side from the providers (health insurance, other programs or

private households). The resulting distribution keys to assess the health and social part of the total output

of these long-term care providers can vary enormously depending on the variables used for the

construction of the keys.

Sweden

12. Sweden on the other hand identifies long-term services using the detailed summary accounts of

the two financing agents that are largely responsible for financing long-term care: the municipalities and

county councils. The summary accounts (financial results) of these schemes are analysed and the items

containing one or more long-term care components identified. Generally, costing data that would allow for

a cost-weighted split of the long-term care items in the summary accounts does not exist. For some

significant long-term care items data exists on interventions from secondary sources which are used as a

proxy. Expenditure of those long-term care items where intervention data exists are split – using identical

cost-weights of interventions – into a long-term care (health), a long-term care (social) and a non-SHA-

relevant social care component. For long-term care items where secondary statistics do not exist

expenditure is attributed using the majority criterion based on expert estimation. In a further step, the long-

term care functions are allocated to the corresponding health care provider.

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Japan

13. Japan is using a near-identical approach to Sweden. They analyse the composition of the major

scheme financing long-term care: the public long-term care insurance scheme. The accounting results

contain around 40 different benefit packages. The content of each package is assessed and attributed to one

of the different service components: medical or nursing care, personal care, assistance care services and

other social care. According to this analysis, expenditure of the accounting items is attributed to the

corresponding long term care (health) and social functions and providers respectively.

Czech Republic

14. Data from the Czech Republic on long-term care expenditure is limited to public financing since

there appears to be a lack of a viable data source to estimate private expenditure. Public long-term care

expenditure is financed via three channels: the health insurance funds, transfers from the public sector and

a newly introduced attendance allowance scheme. For the tracking of long-term care expenditure financed

by the health insurance funds the individual provider identification number is used. This identification

number is needed to process all claims from providers towards the health insurance funds. After analysing

the full list of registered health care providers, those providers that are predominantly involved in long-

term care provision can be identified. In the absence of data permitting a split between ADL and IADL

services, all expenditure of those providers were attributed to long-term care (health). It is assumed that the

“over reporting” of ADL for the identified providers is compensated with the “underreporting” of personal

care services delivered by social service providers that were not identified as long-term care providers but

who incidentally render ADL services. Transfers from the public sector can be attributed to long-term care

providers and functions using detailed budget information. For the newly established attendance allowance

paid directly to dependent persons, different long-term care activities can be identified and split - based on

expert estimations - between nursing care and ADL services on the one side and IADL and other social

services on the other.

Slovenia

15. Although there are plans to establish an integrated system for long-term care services in Slovenia,

they are currently financed and provided by a multitude of actors. For the purpose of this project, long-term

care services were first divided into the “home care/community care”, “semi-residential care” and

“residential care”. In a subsequent step, all long-term activities financed by either pension and disability

insurance, health insurance, insurance for parental care and social assistance that fall into the different

areas were identified. The split into long-term care (health) and long-term care (social) was done by either

analysing the legal requirements and based on the dominant character or using secondary data such as

number of interventions. During the course of the project Slovenia was able to identify numerous long-

term care activities, particularly in the field of long-term care (social), where the data acquisition has not

been finalised. The impact of the change in reporting is therefore preliminary.

Split between ADL and IADL

16. Although using different estimation techniques, all countries were able to identify the different

services from the various long-term care activities that exist in their respective countries. In some cases,

simplified techniques were applied. Estimating the share of the different components related to long-term

care (medical or nursing care, personal care services, assistance care services, other social care services)

within one long-term care activity is more challenging. Cost weights of the different components within an

activity are frequently not available. Data from secondary data sources are then used to estimate the shares

and the dominant character of the package: long-term care (health), long-term care (social) or services

considered outside of SHA boundaries. Data sources used by the countries to evaluate the shares of long-

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term activities include data on the number of interventions, data on the education and qualification of the

staff performing these activities, legal requirements defining the basis of entitlement or expert estimations.

Results

Level of detail reported

17. On a disaggregated level all participating countries were able to report expenditure on:

In-patient long-term care (health) HC.3.1

Home-based long-term care (health) HC.3.4

Long-term care (social) HCR.1

Only some countries were able to identify expenditure on:

Day long-term care (health) HC.3.2

which are usually included in in-patient long-term care (health) for those countries that cannot report this

function separately.

18. Depending on the various institutional arrangements in countries, the reported long-term care

services are predominantly provided in Hospitals (HP.1), Residential long-term care facilities (HP.2),

Providers of home health services (HP.3.5), Households as providers of home health care (HP.8.1) and all

other industries as secondary providers of health care (HP.8.2).

19. Reporting on HC.3.3, out-patient long-term care (health) would only seem viable for a few

countries at present. As noted in the SHA 2011 manual, long-term care provided in an out-patient setting is

still innovative and evolving and as such reporting of these services would most likely require patient-

specific data which is rarely available. At this point it is worth bearing in mind that for a service to be

classified as long-term care, the service must be

1. Either medical/ nursing care, personal care or assistance care;

2. Aimed at the dependent population like the elderly or physically or mentally disabled people

suffering from chronic conditions with functional or cognitive limitations that are not of

temporary nature only.

20. The lack of patient-specific data can be circumvented by either applying legal requirement of

benefits of certain schemes (e.g. by law, a patient has to fulfil some dependency requirements to be eligible

for services of the long-term care insurance scheme in Japan) or by making the basic assumption that some

service rendered by specialised providers can only be aimed at dependent people. These second-best

options are usually feasible in the case of in-patient long-term care, day cases of long-term care, home

based long-term care and social long-term care. In the case of out-patient long-term care which is provided

either by medical practitioners or nurses the situation is somehow different as these providers usually focus

on the provision of curative or rehabilitative services. As a proxy, Slovenia classified out-patient

ambulatory centres in homes for the elderly as HC 3.3.

21. To identify expenditure of out-patient long-term care, a combination of billing data from out-

patient doctors and nurses with the dependency status of the treated patient would be required. In the

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absence of patient-specific data, out-patient services for long-term care dependent people are usually

recorded as curative-rehabilitative (HC.1/HC.2) by countries.

22. In summary, based on the experiences of the participating countries, the implementation of the

recommendations of SHA 2011 in the field of long-term care seems generally feasible.

Changes in Reporting

23. Participating countries compared their reporting of long-term care expenditure which they

currently submit under SHA 1.0 (JHAQ) with what they would report if closely adhering to the definitions

of long-term care under SHA 2011, for a single reference year. The figures are presented in Table 1. The

changes are significant for those countries that previously applied a narrow definition of long-term care

(health), e.g. the Netherlands4, Japan and Sweden. Their share of HC.3 within Current Health Expenditure

increases by about 10 percentage points. In Switzerland, on the other hand, this share may decline slightly

– subject to different scenarios – as they were able to identify some IADL services that have been moved

to long-term care (social). Importantly, in applying the clear SHA 2011 definitions, these shares now look

more comparable than before.

24. The re-allocation of personal care services to long-term care (health) has also an impact on the

aggregated figure Current Health Expenditure. The share of Current Health Expenditure to GDP which is

one of the main indicators of SHA 2011 will rise about 1 percentage point for the Netherlands, Japan and

Sweden.

Table 1 Changes in reporting of long-term care expenditure

SHA 1.0 SHA 2011

share HC3/CHE

share CHE/GDP

TOTAL LTC/GDP

share HC3/CHE

share CHE/GDP

TOTAL LTC/GDP

NDL (2009) 13.5% 10.0% 3.9% 23.9% 11.1% 3.9%

JPN (2008) 8.9% 8.4% 1.2% 17.1% 9.4% 1.7%

SWE (2010) 7.5% 9.1% 3.7% 20.5% 10.5% 3.4%

CHE (2010)* 19.8% 11.4% 2.2% 13.5-19.1% 10.5-11.3% 2.8%

SVN (2010)** 8.6% 8.6% 1.3% 13.8% 9.2% 1.3%

* For SHA 2011 range of possible scenarios

** Preliminary results

25. Finally, the indicator total long-term care to GDP has also increased for most countries reflecting

the fact that countries not only made the effort to regroup “existing” long-term care activities between the

health and social part but also looking into data to report new elements of long-term care (social)

expenditure. The data available under SHA 2011 still hint at some differences in reporting practices,

specifically in long-term care (social) expenditure. Countries are encouraged to further investigate their

accounting practice in this area. Nevertheless, compared to data reported under SHA 1.0, progress towards

more comparability can clearly be seen. Increased harmonisation as to the contents of the social part of

long-term care could be expected to reduce the discrepancies even further.

26. Summarising the findings of the country studies, they appear promising for increased

comparability of the long-term care (health) spending between countries. Concerning long-term care

4 The Netherlands have already implemented SHA 2011 in their current reporting of JHAQ.

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(social) spending, there remain some discrepancies which might be due to unclear demarcations between

activities that can be considered long-term care and social activities that are outside of the SHA

framework.

Back recalculation of time-series

27. Participating countries reported that they would be in a position to recalculate their long-term

care expenditure applying the SHA 2011 recommendations for several years. A consistent medium-term

time series for analysis is therefore warranted.

Further clarification of long-term care under SHA 2011

28. In the light of the results from the country implementation exercises, this report further clarifies

some outstanding issues which have arisen.

Application of the majority criterion and the split between ADL and IADL

29. As detailed in SHA 2011, the approach taken to define the boundaries between long-term care

(health) and long-term care (social) is a functional approach based on the type of services linked to

personal care services (ADL) – which are considered part of long-term care (health) - and assistance care

services (IADL) – accounted as long-term care (social) services. SHA 2011 provides recommendations as

to how this principle should be applied in practical terms.

30. In reality, long-term care is frequently provided in a package comprising both the health and

social components. Generally, an effort should be made to analyse all components of any LTC services

package.

If provided in a package in a home care setting

personal care services and assistance care services that are provided together but can be

identified separately should be split.

personal care services and assistance care services that are provided together but cannot be

identified separately should be accounted for based on the dominant character of the service

package, that means, if nursing care or personal care dominates it should be accounted for as

long-term care (health) and if assistance care service services dominate it should be accounted

for as long-term care (social).

If provided in a package in an in-patient setting

personal care services and assistance care services that are provided together - irrelevant

whether they can identified separately or not - should be accounted for based on the dominant

character of the service package, that means if nursing care or personal care dominate, it

should be accounted for as long-term care (health) and if assistance care services dominate, it

should be accounted for as long-term care (social).

31. The reasoning why, according to this rule, some incidental IADL services should be included in

long-term care (health) is to account for service packages in a consistent way across in-patient service

providers5.

5 E.g. all services are bundled together and included in curative in-patient hospital care

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Split between assistance care services (HCR.1) and social services outside of the SHA boundary

32. The split between assistance care services (HCR.1) and social services outside of the SHA

framework has not been as clearly established in SHA 2011 as the split between long-term care (health)

and long-term care (social) because boundaries in the social area seem even more difficult to define.

Moreover, countries also reported some problems aligning Figure 5.3 of the manual with the definitions of

long-term care (social) under HCR.1.

33. For the demarcation of assistance services and other social services we recommend to follow the

definitions and examples of assistance care services that should be considered as HCR.1:

Services for people with IADL functional limitation such as shopping, cleaning, cooking;

Meals on wheels;

Subsidies to residential services and expenditure on accommodation in assisted living

arrangements and other kinds of protected housing for persons with functional limitations;

Day-care social services for dependent people;

Transportation to and from day care facilities for dependent persons.

34. By definition, all other social services that do not belong to the above mentioned group are

outside of the scope of health accounting. SHA 2011 explicitly excludes special schooling for disabled

people and vocational rehabilitation. Such services are considered for the purpose of social integration

rather than health-related and are therefore beyond the scope of SHA.

35. Annex A2 includes some further specific examples to make this split more operational.

Informal care (unpaid)

36. Generally, for a service to be accounted for in SHA there must exist a transaction, e.g. a transfer

of funds (payment) in exchange for a service. The only mentioned exception is the case of care allowances.

In these cases, financing schemes make unrequited payments to dependent persons that, in turn, are obliged

to organise the long-term care services they need themselves irrespective of the provider6. These transfers

are to be considered in SHA (either as HC.3 or HCR.1). They are treated as a proxy for a transaction and

must be distinguished from monetary transfers to dependent people that replace the loss of income7.

37. The provision of unpaid long-term care services by family member where no care allowance is

disbursed is considered unpaid household production as there is no transaction. These services should not

be considered in SHA. Measuring and valuing these services might be interesting for different types of

analysis but are beyond the scope of SHA, e.g. measurement of household‟s production.

6 The provider in cases of care allowances are often family members or friends of the care allowance recipients.

7 In some countries it may be difficult to monitor whether dependent persons actually use the funds received as care

allowances to pay for their provision of long-term care services. In that case, it is recommended to account the care

allowance as long-term care expenditure when there is a legal requirement to use those funds for the own-

organization of care. If there is no legal obligation then these transactions should be treated as cash-benefits and

considered in SHA.

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Long-term care providers

38. SHA 2011 introduced some minor changes in the classification of providers of health care

(ICHA-HP). With regards to long-term care services the following combinations of functions and

providers seem to be typical for many countries:

In-patient services of long-term care (health) are typically provided in “Hospitals” (HP.1) or

“Residential long-term care facilities” (HP.2).

Home-based long-term care (health) is frequently provided by “Providers of home health care

services” (HP.3.5) and “Households as providers of home health care” (HP.8.1).

Other providers belonging to the category “Rest of the Economy” (HP.8) can also qualify as

long-term care providers:

Long-term care (health) services can be attributed to “All other industries as secondary

providers of health care“ (HP.8.2) if they constitute a minority share of the output value of

this provider. This means, that the provider in question must focus on the delivery of non-

health care services, e.g. long-term care (social).

By convention, the category “Other industries n.e.c.” is reserved to providers that exclusively

deliver health care related services, such as long-term care (social). Therefore, an assisted

living facility without any incidental long-term care (health) services has to be classified in

this category.

39. Of course, other combinations of long-term care services and health care provider are also

feasible, particularly in countries where long-term care provision follows a more integrated approach.

Conclusions and next steps

40. The responses received so far indicate that the implementation of SHA 2011 is feasible in the

field of long-term care. However, the exercise has highlighted certain areas and examples where additional

guidance has been necessary. As such, this report has sought to clarify these areas and provides some

specific case types with allocation rules between long-term care (health), long-term care (social) and

services outside the boundary of SHA (see Annex 1).

41. The aim of this additional guidance is to provide health accountants with a comprehensive set of

common activities in the realm of long-term care and corresponding accounting recommendations. The

additional guidance draws on the draft guidance provided to participating countries, comments in country

reports, subsequent feedback from 2012 health accounts meeting and the “old” LTC guidelines of 2006.

There may be additional refinements to this guidance through the piloting JHAQ process in 2013.

42. The final report on the feasibility of the implementation of long-term care applying the SHA

2011 boundaries, classifications and accounting rules also reflects feedback from the 2012 Health

Accounts meeting and subsequent comments to the preliminary draft report.

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ANNEX 1: ADDITIONAL GUIDANCE ON LTC SERVICES

43. The following are examples of services with recommended accounting practice which aim to

complement the paragraphs on long-term care in SHA 2011.

Nature of the service HC Reasoning

Medical treatment, examinations and diagnosis (typically done by doctors) related to the underlying condition of the patient causing dependency with LTC services in hospitals/ nursing homes/ hospices/ out-patient practices/ arranged living facilities/ homes of the patients

HC.3 These services should be part of the long-term care (health) as they are related to the condition causing the dependency

Medical treatment, examinations and diagnosis (typically done by doctors) for another disease or condition unrelated to the condition of the patient causing dependency with LTC services in hospitals/ nursing homes/ out-patient practices/ arranged living facilities/ homes of the patient

HC.1 or HC.2

These services do not pertain to the LTC-dependency of the patient and should be accounted for separately as curative or rehabilitative care

Nursing care (wound dressing, monitoring of medication, giving injections etc…) typically provided by qualified nurses related to the condition of the patient causing dependency with LTC services in hospitals/ nursing homes/ hospices/ out-patient practices/ arranged living facilities/ homes of the patients


Nursing care (wound dressing, monitoring of medication, giving injections etc…) typically provided by qualified nurses for another disease unrelated to the condition of the patient causing dependency with LTC services in hospitals/ nursing homes/ hospices/ out-patient practices/ arranged living facilities/ homes of the patients

HC.1 These services do not pertain to the LTC-dependency of the patient and should be accounted for separately as curative or rehabilitative (e.g. could be related to a surgical procedure)

Personal care services (washing, bathing, helping out of bed etc..) that provide help with activities of daily living (ADL) by qualified nurses and relate to the condition of the patient causing dependency in hospitals/ nursing homes/ hospices/ out-patient practices/ arranged living facilities/ homes of the patients


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Personal care services (washing, bathing, helping out of bed etc..) that provide help with activities of daily living (ADL) by lesser-qualified caregivers (e.g. family members) and relate to the condition of the patient causing dependency in the home of the patient, under the condition they receive some kind of payment or allowance.

HC.3.4 These services should be part of the long-term care (health) as they are related to the condition causing the dependency. The nursing allowance is treated as a proxy for the payment of the service, though it might be well below the typical country-specific wage for nurses

Personal care services (washing, bathing, helping out of bed etc..) that provide help with activities of daily living (ADL) by lesser-qualified caregivers (e.g. family members) and relate to the condition of the patient causing dependency in the home of the patient, under the condition that it is unpaid

Not included

As there is no transaction, it is unpaid household production. As such it should go unaccounted for in SHA

Assistance services (meal preparation, shopping, housework etc…) that provide help with instrumental activities of daily living (IADL) by qualified nurses or lesser-qualified caregivers (if there exists an allowance for the provision of these services) in any kind of living arrangement (as opposed to institutional care)

HCR.1 If these assistance services are provided separately they should be reported as HCR.1.

If the assistance services by lesser-qualified care takers (e.g. family members) are not remunerated via an allowance they should be considered as unpaid household production

Personal care services (washing, bathing, helping out of bed etc..) that provide help with activities of daily living (ADL) in combination with assistance services (shopping, housework etc…) by qualified nurses or lesser-qualified caregivers (e.g. family members) in any kind of living arrangement

HC3 if ADL dominant

HCR.1 if IADL dominant

An effort should be made to identify the components of the services package and account for them separately. If a separation is not feasible and the health part (ADL) in this integrated service package is dominating the whole package should be recorded as HC.3. If the social part (IADL) is dominating the whole package should be recorded as HCR.1

Nursing care, personal care and assistance services provided by caregivers (that may or may not be qualified) that are employed informally (illegally) by the dependent.

HC3 if ADL dominant

HCR.1 if IADL dominant

The same accounting rules should apply as for legal or formal employment. It is one aim of SHA 2011 to also include activities of the non-observed economy.

Pharmaceuticals provided to patients requiring LTC services when they are a component of a service package (most common in an in-patient or home-care setting)

HC.3 Follows the same logic as pharmaceuticals dispensed in hospitals where they are part of curative care (HC.1) [Pharmaceuticals are additionally considered as a factor of health care provision in the ICHA-FP classification]

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Pharmaceuticals provided to patients requiring LTC services when they are not a component of a service package (e.g. patient has to acquire medication from pharmacy on his own or has it delivered to him or his nursing care facility)

HC.5 The acquisition of medication as a separate transaction should be reported as such. It follows the same logic as in the case of pharmaceuticals used for curative purposes in in-patient (HC.1) or out-patient setting (HC.5)

LTC services provided in day care (or night care) centres. These facilities can be dedicated to the elderly or to the physically or mentally disabled of all ages. Day (night care) means that the patient is being take care of in these facilities for some hours during day time (night time). The rest of the time they usually spend in their home, possibly under the care of family members

HC.3.2 If the dominant character of these institutions is the provision of nursing care and ADL services they should be recorded as HC.3. If their focus is more of a social nature they should be recorded as HCR.1 (except for the ADL part that should be reported – if possible – as HC.3)

Respite care for families with dependent person requiring LTC services. Some schemes in countries allow family members to take a break from their care obligations for the elderly or physically or mentally disabled relatives. During this time (either once a year for a longer period or shorter periods every quarter of month) the LTC dependent will typically be cared for full-time in an in-patient setting, e.g. a nursing home specialised in short-term stays.

HC.3.2 Though respite care is typically provided in an in-patient setting, the short-term nature of the care justifies the classification as HC.3.2

Summer camp for disabled people and/or for whole families with disabled children

HCR.1 (or HC.3.2)

Included in HC.3 if the whole ‘package” has a significant nursing and/or personal care component. If the social component is the main purpose, should be considered as HCR.1, with the exception of and health services which should be – if possible – be reported as HC.3

Home adjustment measures are construction works in the home of the LTC patient. The aim of these works is to enable the patient to stay in his familiar surrounding as long as possible and to avoid a move into a usually much more expensive nursing home. The works typically include disability-adapted construction works of the house, like the widening of door thresholds or the installation of technical devices like stair case lifts.

Capital Account These transactions should be considered as an investment rather than final consumption; it should therefore be included in gross fixed capital formation in the capital account.

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Support services for informal carers (e.g. family members) that provide ADL services (paid or unpaid). The support services could include counselling and basic training lessons in LTC provision. Note that the cost of social protection of carers (e.g. insurance and pension payments) may also be included – see also Care allowance below).

HC3.4 or HCR.1

Support services should be considered as HC.3 if the support informal carers that provide help with ADL. Following the logic of this chapter eventual support services for informal carers providing solely help with IADL should be recorded as HCR.1

Telematic services are becoming increasingly popular in the whole health care sector. The idea behind them is to use modern ICT equipment to enable patients to stay in their familiar surroundings and avoid costly institutionalisation. In connection with LTC services these telecare services could include emergency call infrastructure within their homes, remote monitoring systems of medication intake and vital parameters.

HC.3.3 If the telematic services are part of a LTC-service package (usually provided by a scheme) it should be reported as HC.3. The own-account acquisition of telematic equipment itself should be recorded under HC.5.2.9

Care allowance are funds provided by financing schemes to dependent people with LTC needs and oblige them to organise their nursing and/or personal care themselves (typically by informal care takers like family members).

HC.3.4 Care allowances paid out for the organisation of nursing care or personal care services should be recorded as HC.3.

Long-term social care cash-benefits are allowances to dependents or family members to cover informal care service of a social nature (or help with IADL)

HCR.1 Long-term social care cash-benefits for the organisation of help with IADL services or to cover the cost of other social services should be recorded as HCR.1. If these services have a nursing or personal care component, this part should be – if possible – reported separately under HC.3

Cash benefits can be granted to people with sickness, disability or dependency. The main purpose is income protection. There is no direct relationship to nursing care, personal care or IADL services.

Not included Cash benefits are not considered as a substitute for long-term services if there is no obligation to organise the care with this money.

Special schooling programmes for children suffering from a mental or physical handicap and who are thus requiring some elements of LTC services are provided in most countries

Not included The primary purpose of special schooling lies in social integration and has no health care purpose. If there are components of ADL or IADL services that can be identified separately, they should be accounted for as HC.3 or HC.R.1 respectively.

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Vocational programmes in sheltered workshops specifically dedicated to mentally or physically disabled exist in many countries. The aim of these programmes is to integrate the disabled people into regular work life to the greatest extent possible. The challenges of their tasks vary depending on the degree of their disabilities. The sheltered workshops are usually subsidised by the government.

Not included The primary purpose of vocational programmes lies in social integration and has not health care purpose. If there are components of ADL or IADL services that can be identified separately, they should be accounted for as HC.3 or HC.R.1 respectively.

Social day centres for the physically and mentally disabled are typically for those who are not fit to work. The purpose is more the delivery of social and leisure activities.

HCR.1 (HC.3.2)

If the primary purpose lies on social activities it should be recorded as HC.R.1. If there are also LTC services provided that can identified as such, those should be recorded as HC.3.2

Social day care centres for the elderly can provide a vast range of predominantly social activities. They are usually different from those of physically and mentally disabled. However, they have in common that their focus is typically not that of health care.

HCR.1 (HC.3.2)

As most of the services provided focus on social activities they should be recorded as HC.R.1 or even outside of SHA. Incidental provision of ADL services should of course be recorded as HC.3.2

Case Management is provided by government agencies or health insurance schemes in various countries. For dependent people case managers usually help with the administrative paperwork, provide for counselling of family members, coordinate nursing and personal service which can be provided from different organisations or contact nursing homes or health professionals. Depending on the country the organisational setting of case managers or their tasks can differ.

HC.3.1 or HC.3.4 Though the services provided by the case manager are more of an administrative nature, they should be recorded as HC.3 as there is a very close relationship to the dependent people and these services are usually provided outside of the typical administrative bodies of the financing schemes.

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Medical assessment of applicants for LTC benefits is required in most countries. These assessments are based on medical criteria to evaluate the functional limitations and the overall condition of the patient. As a result the dependent will be grouped into a dependency class that qualifies for the delivery of services or the application is disapproved if the functional limitations are not severe enough. The medical assessment are conducted by professional staff (nurses or doctors)

HC.3.1 or HC.3.4 This administrative procedure is the assessment of the health status of dependent people and should therefore be accounted for as HC.3

Supported living arrangements for the elderly are barrier-free apartments used by patients who can no longer live in their own houses but who are still too independent to live in nursing homes. Typically the residents require some sort of nursing or personal care provided by qualified nurses having an office on the premises or coming to the premises frequently. Meals are usually available on-sight but residents can also choose to cook if their condition allows them to do so. Cleaning services and additional services are usually also available.

Depends HCR.1 or HC.3.4

The nursing care and personal care component of the services provided in supported living arrangements should be accounted for as HC.3 (most commonly as HC.3.4 since they are considered as the person’s home). The residential services like cleaning, meals etc. should be accounted for as HC.R.1. Also, subsidies to the residential services and the costs of accommodation should be accounted for as HC.R.1 There exists a broad range of supported living facilities in many countries that differ in level of dependency of the residents. If the above mentioned services are provided together and cannot be separated they should be classified as HCR.1 or HC.3 based on the dominant character of the facilities

Supported living arrangements for the physically or mentally handicapped are typically different from those for the elderly as they are generally aimed at a younger population with other limitations. These residences can vary according to the need of their residents. Some might focus on the provision of nursing and ADL services, some of them will only provide lower level of care and have basically a social focus.

Depends HCR.1 or HC.3.4

The nursing care and personal care component of the services provided in supported living arrangements should be accounted for as HC.3.4 The residential services like cleaning, meals etc. should be accounted for as HC.R.1. Also, subsidies to the residential services and the costs of accommodation should be accounted for as HC.R.1 There exists a broad range of supported living facilities in many countries that differ in the level of dependency of the residents. If the above mentioned services are provided together and cannot be separated they should be classified as HCR.1 or HC.3 based on the dominant character of the facilities

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Homecare companies are supplying patients with a variety of medical products at their homes. These products can include

Ostomy care

Continence care

Wound Care

Enteral nutrition They are not exclusively aimed at LTC patients. In addition to the supply, field staff may also provide basic advice in their usage.

HC.5 (HC.3.4 or HC.1)

Medical products in an out-patient setting should be classified as HC.5. If these products are provided as an integral part of a LTC service package they should be considered as HC.3.4 If the products are part of a service package aimed at patients with no LTC dependency they should be accounted for as HC.1

Transportation of LTC dependents to day care nursing facilities can be provided by governmental or insurance programmes in the case of day care or respite care

HC.3.2 or HC.4.3 or excluded

Transportation services should be accounted as HC.3.2 if part of a LTC-service package funded by a scheme. If costs are borne separately and transportation is based on medical recommendation, they should be reported as HC.4.3 If the households have to provide the transportation service themselves, they should not be accounted for (unpaid household production)

Transportation of LTC dependents to day care facilities with a social focus

HCR.1 or excluded

Transportation services should be accounted for as HC.R.1 if they are part of a package funded by a scheme or borne separately If the households have to provide the transportation service themselves, they should not be accounted for (unpaid household production)

Transportation of mentally or physically disabled children to special schools or summer camps or adults to sheltered workshops

Not included if the services in these institutions are outside the scope of SHA (see above), so should be the transportation service.

Investment surcharges or direct investment payments refer to the situation in some countries where LTC recipients are required to pay for the capital expenses that long-term care provider separately. These capital expenses borne by the providers to ensure the delivery of LTC services. In most countries capital expenses are an inherent component of the price of the LTC services and are a not accounted for separately.

HC.3 or HC.R.1 By convention private household cannot engage in capital formation. The health care providers are the ones making the decision to acquire or dispose of assets. Those transactions should be captured in the capital account. The investment surcharge payable by LTC recipients should be treated for as an ordinary price component of the service provided, even if billed separately. In the case of a long-term care institution with a focus of nursing/personal care these payments should be accounted for as HC.3. In the case nursing institution with a focus of residential care or IADL services the payments should be accounted for as HCR.1.

Medical treatment, nursing care and personal care services for dependent persons with mental conditions in mental health and substance abuse facilities (HP2.2) or mental health hospitals (HP1.2) where the focus is on room and board and protective supervision.

HC.3.1 These services should be considered as long-term care (health) when the focus is on nursing care and personal care services. Depending on countries’ organisation of care these services can be delivered in mental health facilities (HP2.1) or mental health hospitals (HP1.2).

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Medical treatment, with less frequent incidental nursing care and personal care services for patients with mental conditions in mental health hospitals (HP1.2) where the focus is on diagnostic and medical treatment as well as counselling with the principal intent to relieve symptoms of the illness or to reduce its severity.

HC.1.1 These services relate to curative care and not to long-term care.

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ANNEX 2: ADDITIONAL SOURCES OF INFORMATION

44. Two closely-related international statistical systems exist in the field of social care whose

information might serve as an input to health accountants in setting up comprehensive long-term care

accounting. One of them is the European System of Social Protection Statistics (ESSPROS) which is

managed under the auspices of the European Union and the other one is the OECD Social Expenditure

Database (SOCX) for OECD countries.

ESSPROS

45. ESSPROS aims to provide a comprehensive and coherent description of social protection

interventions performed by both public and private bodies that intend to relieve households and individuals

of the burden of a defined set of risks or needs, provided that there is neither a simultaneous reciprocal nor

individual arrangement involved. In practice, various bodies, both government-controlled schemes and

those not controlled by government, can be included in the countries‟ list of social protection schemes; the

most frequent of these include

Social security funds;

Central, state and local government agencies;

Insurance companies (in Denmark, the pension funds running labour market pensions can

delegate the administration of these pensions to insurance companies);

Mutual benefit societies;

Public or private employers that provide benefits to their current and former employees directly;

Private welfare assistance institutions and charitable organisations (for instance, the Red Cross).

46. Social benefits are broken down by ESSPROS function and by type. The function of a social

benefit refers to the primary purpose for which social protection is provided, irrespective of legislative or

institutional provisions. In other words, the functional breakdown of social benefits reflects all

interventions of social protection schemes by grouping them according to the eight types of risks, i.e.

sickness/health care, disability, old age, survivors, family/children, unemployment, housing and social

exclusion. The type of benefit refers to the form in which the protection is provided. These can take many

forms; however, in the core ESSPROS system these are limited to benefits in cash, i.e. cash payment to

protected people, and benefits in kind that include reimbursements of expenditure made by protected

people and goods and services directly provided to protected people.

47. Transaction that could be of interest for health accountants to capture health expenditure in the

field of long-term care are potentially recorded in ESSPROS under the functions

Sickness/Health care

Disability

Old age

Social exclusion not elsewhere classified

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48. Annex A of SHA 2011 presents a correspondence between health care functions (ICHA-HC) and

ESSPROS. In the field of long-term care (HC.3 plus HCR.1), transactions which might be worth

investigating include:

Function: Sickness/Health Care Code: 1111211




Function: Disability Code: 1121201


Function: Old Age Code: 1131200














49. It is not advisable to use the data of these aggregates directly for long-term care accounting under

SHA as the demarcation between health and social differs between SHA and ESSPROS. We would rather

recommend analyzing the data sources that are used to compile the above mentioned ESSPROS figures.

They might constitute a valuable data source for SHA as well. ESSPROS data is published on the

EUROSTAT homepage. Data Correspondents for ESSPROS usually come from Ministries of Social

Affairs.

SOCX

50. The OECD SOCX (SOCial eXpenditure) database provides internationally comparable statistics

on public and (mandatory and voluntary) private social expenditure at a programme level. It is related to

ESSPROS – in fact for European countries, ESSPROS is the prime data source for SOCX – but there are

differences in the classifications, e.g. displaying the category of active labour market programmes. In the

field of long-term care, SOCX is of limited use for health accountants because for the category “Health”

SOCX is using the aggregate Current Health Expenditure out of OECD Health Data. That means all long-

term care (health) expenditure will be included there. However for long-term care (social) SOCX might be

a useful data source. Relevant programmes could be included in the categories old age, incapacity-related

benefits and other social policy areas. As with ESSPROS we would recommend analyzing the data sources

(particular schemes) that are used to compile the SOCX figures rather than using the outright values for

SHA reporting.

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