Inancing aged care: Swimming against the tide? F inancing aged care: Swimming against the tide? Toni...
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Transcript of Inancing aged care: Swimming against the tide? F inancing aged care: Swimming against the tide? Toni...
Financing aged care: inancing aged care: Swimming against the tide?Swimming against the tide?
Toni AshtonSusan St John
“Older people with high and complex health and disability support needs will have access to flexible, timely and co-ordinated services and living options that take account of family and whanau carer needs.”
Health of Older People Strategy 2002
The VisionThe Vision
Financing of residential careFinancing of residential careTax funded + patient contributions
Subsidy is income and asset-tested
To be eligible for subsidy must
– Be NZ permanent resident aged 65 +
– Be assessed as in need of care
– Have assets less than $150,000
Top-upsubsidy
Statepension
SubsidyOther
Income
Statepension only
High income
Statepension
Statepension
Otherincome
Subsidy
Some other income
Sources of fundsSources of funds
DHBContractprice forrest homes
The Asset TestThe Asset Test
Years Single person
Married couple with one in care
Married couple,
both in care
1998 – 2005 $15,000 $45,000 + house etc $30,000
From July 2005
$150,000 $55,000 + house etc
or
$150,000 total
$150,000
Raising the threshold is Raising the threshold is popular with voters but…..popular with voters but…..
How about a divorce,
honey?All this
And $55,000
too!
….Favours non-income-earning assets
Costly…so less funds available for Costly…so less funds available for increasing the price of servicesincreasing the price of services
900
950
1000
1050
1100
1150
1200
' 95 ' 96 ' 97 ' 98 ' 99 ' 00 ' 01 ' 02 ' 03 ' 04 ' 05
CPI
Hospital
Homecare
Source: Max Robins, HealthCare providers, NZ
Ministry of Health 2005Ministry of Health 2005
“Providers consider funding has consistently and increasingly lagged behind costs …. leading to business failures, service cuts, suppression of wage rates, high labour turnover, inadequate return for risk and investment, and inadequate investment in workforce development. The problems are of such a magnitude that they cannot be resolved by small injections of funding.”
The demographic tidal wave is The demographic tidal wave is approaching………approaching………
2005
Is “ageing in Is “ageing in place” the place” the solution?solution?
2005
ResidentialCare62.6%
CarerSupport 4%
Environmental Support 3.1%
CarerSupport 2.4%
ResidentialCare54.7%
HomeCare9.4%
HomeCare11.1%
Environmental Support 5.5%
NASC 1.5%Respite care 1.4%
Government expenditure on Government expenditure on long term carelong term care 1998/99 2003/041998/99 2003/04
Assessment & rehab 11.2%
Other12.3%
Assess & rehab 21%
Other 9.4%
Expenditure on home care services increased from 15% to 21%
0
1
2
3
4
5
6
7
8
1966 1976 1986 1991 1996 2001
L/S hospital
Rest home
% of people in aged 65+ in % of people in aged 65+ in long term residential carelong term residential care
4.3 4.0 2.21.5
1.9
1.92.6
3.74.7
4.8
1.4
5.1
Current obstaclesCurrent obstacles
Level of home support services currently inadequate and make clients devalued (Parsons, Dixon et al, 2004)
Low paid, unskilled workforce Problems of isolation, elder abuse Lack of adequate support for carers Difficult to monitor quality of home care Home care not cost-effective for levels of
dependency
Cost-effectiveness of hospital Cost-effectiveness of hospital care versus hospital-at-homecare versus hospital-at-home
Objective: To compare: (a) Usual hospital care
(b) Early discharge + intensive home management by Quick Response Team (QRT)
Harris, Ashton, et al. The effectiveness, acceptability and costs of a hospital-at-home service compared with acute hospital care. Journal of Health Services Research and Policy, 2005.
MethodMethod
Quick response team of – 4 - 6 registered staff nurses, medical registrar,
social worker,home support workers, other health professionals as required
– Provided intensive home support and rehab, inc up to 10 hrs nursing, 7 days per week
285 patients randomised to receive either standard hospital care or hospital-at-home care
Patients assessments at 10 days, 30 days and 90 days
Measures of effects Measures of effects and costs and costs
Costs Hospital costs
– individual treatments– per day hospital costs– overheads
Community services– Quick Response Team – GPs, meals-on-wheels, community
health services, home agency services, etc
Patient costs– GP and other fees– carer’s lost income
Effects Measures of patient health
– SF36– cognitive function– daily activities, etc. etc
Patient satisfaction Carer’s satisfaction GP satisfaction
ResultsResults
Effectiveness: No significant difference
in almost all of the measures of health outcome
Scores for patient satisfaction, relative satisfaction and carer strain index generally favoured QRT.
Average episode
costs:
Hospital care = $3,498
Hospital-at-home =
$6,904!!
Why was the hospital-at-home Why was the hospital-at-home so costly?so costly?
New service – operating below full capacity – conservative approach
Very comprehensive service inc. 24 hr cared if needed
Some patients had high readmission rates – inappropriate placement??
Study conclusionStudy conclusion
Hospital-at-home services can be safe and effective BUT….
Can be very costly for highly dependent patients
Further work required to examine how costs of these services can be reduced without undermining safety and acceptability
Swimming against the Swimming against the demographic tide…demographic tide…
Demand is increasing– Larger percent of
residents now eligible for subsidies
– Cost to government of raising asset threshold will increase
BUT….Supply is decreasingBUT….Supply is decreasing
Cost of service provision is increasingProviders are leaving residential sectorCare facilities concentrated in high
income urban areasHome care services currently
inadequateSmaller DHBs likely to have difficulty
managing funding pressures
ConclusionConclusion
Tax-funding alone for long term unlikely to be sustainable
Recent changes to asset test have exacerbated the problem
The “Vision” of the Health of Older People Strategy unlikely to be achieved
Proposed government review should include:– Inequities in asset testing– Funding options that spread costs more widely
across working and older population– Comprehensive review of funding across whole
spectrum of long term care
Thank you!Thank you!