The determinants of long-term care expenditure and their interactions

Association between use of different long-term care services and risks of mental disorder and mortality as well as medical utilization

Objective

This study sought to investigate mental disorder and mortality risks and medical utilization among various long-term care (LTC) services and examine the associated factors.

Methods

This retrospective cohort study used data from the National Health Insurance Research Database of the entire population of Taiwan recorded between 2006 and 2017. A total of 41,407 patients using LTC (study group) were identified and propensity score-matched with 41,407 LTC nonusers (control group) at a ratio of 1:1 according to sex, age, salary-based premium, comorbidity index score, and urbanization level. Patients were divided into four groups according to LTC service type. The age distribution was as follows: 50-60 years (10.47%), 61-70 years (14.48%), 71-80 years (35.59%), and 81 years and older (39.45%). The mean age was 70.18 years and 53.57% of female participants were included. The major statistical methods were the Cox proportional hazards model and the general linear model (GLM).

Results

Users of both institutional and inhome LTC services had the highest risk of mental disorder [adjusted hazard ratio (aHR) = 3.2]. The mean mortality rate in LTC nonusers was 46.2%, whereas that in LTC users was 90.4%, with the highest found among the users of both institutional and inhome LTC (90.6%). The institutional LTC users had the shortest survival time (4.1 years). According to the adjusted Cox model analysis, the odds of mortality was significantly higher among institutional LTC users than among inhome LTC users (aHR = 1.02). After the adjustment of covariates, adjusted GLM model results revealed that the annual medical expenditure per capita of LTC nonusers was NT$46,551, which was 1.6 times higher that of LTC users.

Conclusion

Users of both institutional and inhome LTC services have higher risk of mental disorder, shorter survival time, and lower medical utilization.

'Investing' in care for old age? An examination of long-term care expenditure dynamics and its spillovers

We study the dynamic drivers of expenditure on long-term care (LTC) programmes, and more specifically, the effects of labour market participation of traditional unpaid caregivers (women aged 40 and older) on LTC spending, alongside the spillover effects of a rise in LTC expenditure on health care expenditures (HCE) and the economy (per capita GDP). Our estimates draw from a panel of more than a decade worth of expenditure data from a sample of OECD countries. We use a panel vector auto-regressive (panel-VAR) system that considers the dynamics between the dependent variables. We find that LTC expenditure increases with the rise of the labour market participation of the traditional unpaid caregiver (women over 40 years of age), and that such expenditures rise exerts large spillover effects on health spending and the economy. We find that a 1% increase in female labour participation gives rise to a 1.48% increase in LTC expenditure and a 0.88% reduction in HCE. The effect of LTC spending over HCE is mainly driven by a reduction in inpatient and medicine expenditures, exhibiting large country heterogeneity. Finally, we document significant spillover effects of LTC expenditures on per capita GDP.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s00181-022-02246-0.

A qualitative study of senior management perspectives on the leadership skills required in regional and rural Australian residential aged care facilities

BACKGROUND

With increasing recognition of the quality and safety issues in residential aged care, there is an urgent need to better understand what skills senior managers require to deliver on the spectrum of leadership functions in residential aged care facilities. This qualitative study sought to explore the leadership skills that positively influence the quality of care within Australian residential aged care facilities and better understand the professional development needs of senior managers to positively influence care within these complex environments.

METHODS

We conducted semi-structured interviews with 19 senior managers purposively recruited from 14 high-performing non-government residential aged care facilities of varying geographical remoteness in northern Queensland, Australia. Participants held a range of professional roles, including Chief Executive Officer, Director of Nursing and Facility Manager, and had various professional qualifications. We used inductive thematic analysis to identify and categorise senior managers' perspectives on the leadership skills and related strategies to promote quality of care.

RESULTS

Senior managers reported leadership skills in five major domains: i) communication and relationship management, ii) stewardship, iii) professional development, iv) health care knowledge and v) information technology and finance. Most participants highlighted communication and relationship management skills and responding to regulatory change as influential to residential aged care quality performance. Participants with different professional backgrounds often emphasised different skills.

CONCLUSIONS

Participants identified a broad range of skills and strategies required by senior managers in Australian residential aged care facilities. Identifying different skills by differently trained individuals suggests more work is needed to understand and develop sector-specific professional development approaches to better prepare individuals to lead in this complex service environment.

Total care expenditures and their drivers among older adults: A study on health and long-term care expenditures in South Korea

Background

South Korea operates two different national insurance systems: health care insurance covers medical services and long-term care (LTC) insurance covers residential care and home care services. Total care expenditures include benefits from both these insurance schemes and personal payments made for receiving these services. This study aims to identify total care expenditures per older person along with related factors and their effects on care expenditures.

Methods

We analyzed claims data of 2017 for LTC and health care insurance in Korea using multiple regression analysis. Participants were recipients of LTC insurance, aged 60 years or above (n = 650,059). The variables of interest included socioeconomic characteristics, disabilities, chronic diseases, and care needs levels.

Results

The total expenditures were approximately USD 9,808,922,016 for 650,059 older people (USD 15,089.28 ± 8,006.57 per person) in 2017. The benefits of national health insurance accounted for 86.03% of the total, while personal payments accounted for 13.97%. Comparing the expenditure across services, the total amount was found to be much higher for LTC services. The personal payments were similar for the two insurance schemes, and the proportion of expenses by service type (to total expenses) was greater for LTC (LTC versus health care expenditures: 63.25% versus 36.15% of the total expenditures). The total care expenditures differed significantly according to recipient characteristics. Older adults who were women, between 75–84 years old, with higher care needs levels, and who suffered from diseases and lived in the residential facilities were associated with an increase in total expenditures. Moreover, factors such as any type of disability and living alone were related to a decrease in total care expenditures.

Conclusions

The increase in care expenditures should be monitored from an integrated perspective on overall health care and LTC, and to reduce care needs. In addition, we should focus on the factors involved in using (receiving) services for older individuals and complementing the lack of or inadequate services to enhance and sustain the LTC and health care service systems. Older adults receiving full basic livelihood security and living alone should receive greater attention from the perspective of social equity.

Individual and regional determinants of long-term care expenditure in Japan: evidence from national long-term care claims

BACKGROUND

Japan, with the oldest population in the world, faces a financial challenge caused by rising long-term care (LTC) expenditure. For policymakers to address this, it is important that we have a better understanding of how individual and regional characteristics affect LTC expenditure.

METHODS

We linked national LTC insurance (LTCI) claim data, covering the entire population who used LTCI services in Japan, with municipality data on an individual level. Individuals 65 years and older (n=3 876 068) who had used LTCI benefits at least once in the fiscal year (FY) 2016 were included. We examined the associations of individual and municipality characteristics regarding supply and demand of healthcare with the LTC expenditures on facility care, home and community care, and total care (the sum of both types of care), after adjusting for regional differences in LTC extra charges.

RESULTS

The following variables were associated with higher total expenditure; at the individual level: female, a higher care-need level, a lower income (0% co-payments) or a facility service user; at the municipality level: municipalities locating in metropolitan areas, with a higher proportion of single elderly households, more doctors per 1000 citizens, more nursing homes per 100 000 LTC benefit users or more outpatient medical spending per citizen ≥75 years old.

CONCLUSIONS

As we are able to identify several individual and municipality characteristics associated with higher LTC expenditure in Japan, the study offers insights into dealing with the rapidly growing LTC expenditure.

The associations of multimorbidity with the sum of annual medical and long-term care expenditures in Japan

BACKGROUND

The occurrence of multimorbidity (i.e., the coexistence of multiple chronic diseases) increases with age in older adults and is a growing concern worldwide. Multimorbidity has been reported to be a driving factor in the increase of medical expenditures in OECD countries. However, to the best of our knowledge, there is no published research that has examined the associations between multimorbidity and either long-term care (LTC) expenditure or the sum of medical and LTC expenditures worldwide. We, therefore, aimed to examine the associations of multimorbidity with the sum of medical and LTC expenditures for older adults in Japan.

METHODS

Medical insurance claims data for adults ≥75 years were merged with LTC insurance claims data from Kashiwa city, a suburb in the Tokyo metropolitan area, for the period between April 2012 and September 2013 to obtain an estimate of medical and LTC expenditures. We also calculated the 2011 updated and reweighted version of the Charlson Comorbidity Index (CCI) scores. Then, we performed multiple generalized linear regressions to examine the associations of CCI scores (0, 1, 2, 3, 4, or ≥ 5) with the sum of annual medical and LTC expenditures, adjusting for age, sex, and household income level.

RESULTS

The mean sum of annual medical and LTC expenditures was ¥1,086,000 (US$12,340; n = 30,042). Medical and LTC expenditures accounted for 66 and 34% of the sum, respectively. Every increase in one unit of the CCI scores was associated with a ¥257,000 (US$2920); 95% Confidence Interval: ¥242,000, 271,000 (US$2750, 3080) increase in the sum of the expenditures (p < 0.001; n = 29,915).

CONCLUSIONS

Using a merged medical and LTC claims dataset, we found that greater CCI scores were associated with a higher sum of annual medical and LTC expenditures for older adults. To the best of our knowledge, this is the first study to examine the associations of multimorbidity with LTC expenditures or the sum of medical and LTC expenditures worldwide. Our study indicated that the economic burden on society caused by multimorbidity could be better evaluated by the sum of medical and LTC expenditures, rather than medical expenditures alone.

Survival analysis of increases in care needs associated with dementia and living alone among older long-term care service users in Japan

BACKGROUND

Japan is known for its long life expectancy and rapidly aging society that there are various demands of older adults need to be fulfilled with, and one of them is long-term care needs. Therefore, Japan implemented the Long-Term Care Insurance in year 2000 for citizens who are above 65-year old and citizens who are above 40-year old in needs of long-term care services. This study was undertaken to longitudinally examine the influence of dementia and living alone on care needs increases among older long-term care insurance service users in Japan.

METHODS

Long-term care insurance claims data were used to identify enrollees who applied for long-term care services between October 2010 and September 2011, and subjects were tracked until March 2015. A Kaplan-Meier survival analysis was conducted to examine increases in care needs over time in months. Cox regression models were used to examine the effects of dementia and living alone on care needs increases.

RESULTS

The cumulative survival rates before care needs increased over the 4.5-year observation period were 17.6% in the dementia group and 31.9% in the non-dementia group. After adjusting for age, sex, care needs level, and status of living alone, the risk of care needs increases was found to be 1.5 times higher in the dementia group. Living alone was not a significant risk factor of care needs increases, but people with dementia who lived alone had a higher risk of care needs increases than those without dementia.

CONCLUSION

Dementia, older age, the female sex, and lower care needs levels were associated with a higher risk of care needs increases over the study period. Among these variables, dementia had the strongest impact on care needs increases, especially in persons who lived alone.