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Cross-cultural comparisons of long-term care practices: modifications to financing and delivery approaches in seven countries

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Cross-cultural comparisons of long-term care practices: modifications to financing and delivery approaches in seven countries

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Content CROSS-CULTURAL COMPARISONS OF LONG-TERM CARE PRACTICES:
MODIFICATIONS TO FINANCING AND DELIVERY
APPROACHES IN SEVEN COUNTRIES
by
Kirsten Heide Thorstenson
A Thesis Submitted to the
FACULTY OF THE SCHOOL OF GERONTOLOGY
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degrees
MASTER OF SCIENCE IN GERONTOLOGY AND
MASTER OF PUBLIC ADMINISTRATION
May 1995
Copyright 1995 Kirsten Heide Thorstenson
UNIVERSITY OF SOUTHERN CALIFORNIA
LEONARD DAVIS SCHOOL OF GERONTOLOGY
University Park
Los Angeles, CA 90089
This thesis, written by
K irsten H eide T horstenson
under the director of hf£ Thesis Committee and approved by all its
members, has been presented to and accepted by the Dean of the Leonard
Davis School of Gerontology and the Dean of: P u b lic A d m in istra tio n
in partial fulfillment of the requirements for the degree of
Master o f S c ie n c e in G erontology and M aster o f P u b lic A d m in istra tio n
Dean
Dean
Date Z W / / I t S
THESIS COMMITTEE
(Q k l //. L
/ & J / / . A t
Chairman
Dedication
This paper is dedicated to my grandparents:
Elisabeth Hess, my Oma, my grandmother, whose smile is like a sunshine filled
daydream and
Henry Alfred Hess, my Opa, my grandfather, who is as resilient as a branch of
an orange tree bending from the weight of fruit.
Acknowledgments
I would like to thank Eric Anderson and Dr. Kate Wilber for their insight,
guidance, encouragement, and review of this project. I appreciate Dr. Dave
Peterson’s willingness to review the paper as a result of unforeseen
circumstances. Additionally, I would like to recognize Steven Lutzky for the
literature review that he conducted on Israel, Japan, and the Netherlands during
the summer of 1992. Finally, thank you to Sandra Welfeld for editing and
formatting the final version of this paper.
Table of Contents
Abstract................................................................................................................................ v
Introduction..........................................................................................................................1
The Context: Current LTC Issues and Innovations in the U.S...................................3
Methods...............................................................................................................................8
Overview of Other Countries' Approaches to Delivering and Financing LTC 10
Demographics...................................................................................................... 10
Acute Health Care System................................................................................ 11
LTC Eligibility....................................................................................................... 12
LTC Service Delivery..........................................................................................12
LTC Financing......................................................................................................17
Other Countries' Efforts to Serve People in Need at Home and Contain Costs .18
Serving People in Need at Home.....................................................................19
Revising Eligibility Criteria....................................................................20
Expanding Service Options.................................................................. 21
Promoting Informal Caregiving.............................................................24
Containing Costs................................................................................................. 26
Changing the Administrative Structure............................................... 27
Targeting Public Resources................................................................. 29
Implementing Global Budgeting or Budget Caps............................. 31
Conclusion........................................................................................................................ 33
Bibliography...................................................................................................................... 36
iv
Cross-Cultural Comparisons of Long-Term Care Practices: Modifications to
Financing and Delivery Approaches in Seven Countries
Introduction
As chronic disability becomes more prevalent among the aging population
in the United States and the need for long-term care (LTC) increases, it is useful
to review systems of financing and delivering long-term care in other countries.
Many people in the United States often incorrectly assume that other developed
countries effectively and efficiently provide "cradle to grave" medical and social
services. This vision includes an image of well- developed, publicly funded,
universal, coordinated, and integrated acute and long-term health and social
service programs available to persons of all ages. This, however, is not the
case. Like the United States, fragmented service delivery and welfare-based
financing approaches are common to LTC in many countries (GAO, 1994).
Furthermore, facing cost and demographic challenges, which are similar to the
United States, other countries are modifying their LTC systems.
Therefore, comparing and contrasting approaches to financing and
delivering long-term care in other countries may be useful in this country's
debate over long-term care reform. Although they have different cultures,
traditions, political and economic history, and government structures, other
countries that are modifying their long-term care systems are using ideas and
methods that may be transferable to the United States. Examining the
1
characteristics of long-term care programs in other countries might help U.S.
policy makers identify the best practices and approaches to inform long-term
care financing and delivery in this country.
Current comparative research focuses predominately on industrialized
nations such as Sweden, Germany, Great Britain, and Canada (GAO, 1994,
Davies, 1992, Doty, 1993, Doty, 1990, Tilly & Stucki, 1991, Kane & Kane, 1989,
Kane & Kane, 1985). These countries finance highly socialized acute care
programs, but are recognizing and addressing long-term care financing and
delivery issues. In addition, other countries which have not received as much
attention in the research including Israel, Japan, and the Netherlands also are
addressing increasing demands for long-term care. The goal in all these
countries is to design a set of services that can be effectively and efficiently
administered and delivered to individuals in need. Furthermore, several
countries are attempting to reduce the institutional bias currently found in their
long-term care systems by increasing the availability of home and community
based services. This thesis explores the common access, delivery, and
financing concerns among eight nations - Canada, Germany, Israel, Japan, the
Netherlands, Sweden, the United Kingdom, and the United States. This thesis
also discusses current system modifications for people age 65 and over as these
nations attempt to deal with the increasing demand and rising costs associated
with financing and delivering long-term care.
2
The Context: Current LTC Issues and Innovations in the U.S.
An aging population, particularly increasing numbers of frail elderly age
80 and over, and an associated increase in the demand for long-term care
characterize the current demographic situation in the United States. In 1990,
12.5 percent of the population in the U.S. was age 65 and over and 3.6 percent
of the population who were age 80 and over (GAO, 1994). According to the U.S.
Bureau of the Census, more than 12 million Americans are estimated to need
long-term care. The majority of those who need LTC (about 7.3 million or three-
fifths of the long-term care population) are age 65 and over. Concurrently, the
availability of informal caregivers including family and friends is expected to
decrease. This trend is caused by increased workforce participation by women
and broader dispersion of families throughout the country. Therefore, people in
need of long-term services are anticipated to turn to public and private programs
that provide these services.
Similar to many other countries, publicly financed long-term care in
the United States is costly, biased towards institutional care, and characterized
by fragmented administration and delivery systems. In 1993, individuals and
their families, as well as federal, state and local government programs, spent
more than $100 billion on long-term care (GAO, 1994). As seen in table 1,
currently, six federally based programs fund long-term care services: Medicare,
Medicaid, the Social Security Block Grant (SSBG)), the Older Americans Act
3
(OAA), the Supplemental Security Income (SSI), and the Department of
Veterans Affairs (DVA). Each program has different eligibility criteria, services,
and financing mechanisms resulting in a complex, overlapping, incomplete web
of services and protection for persons in need of long-term care.
In addition to the fragmentation of programs which support LTC, out-of-
pocket costs of care are high. As seen in figure 1, Medicaid and out-of-pocket
expenditures each funded approximately 45 percent of nursing home care in
1990. Costs that cannot be calculated, however, are the personal costs incurred
by family and friends who provide unpaid caregiving. About 95 percent of
people with one to five limitations in activies of daily living receive some informal
care (Jackson, 1992).
FIGURE 1 . Sources of Funding for Nursing Home Care, 1990
Total Spending - $3 3 .1 billion
Other
Oowmment
* * Medicare
2 %
loom: H ftiro p n F m d bjre o C en tM a ^a allle M n h lO T O M h a a d iiiM afta a O a e *
cttm Aotmiy. Onrtneoof Nniwnl C l E n l i —.
4
Tablg 1. M^Jor F id a ril Proorams Supporting Long-Tarm
Cara 8 arvlca« for tha Eldarty and Diaablad*
Program Obtectlvee Eligibility Requirements Administration Long-Term Care Services
M adi caram tta
XVM o f tha S ocial
S e cu rity A ct
Fodaral spendi ng,
1903:
$15. 51 but t on
(U.S. Comml tt ao
on Ways and
Maane. 1094)**
To pay tar aout a
medi cal care for
thaagadand
M tocted d lu b M
Paraona ago 8 6 and over, par aona
undar s q b 0 6 anUt t sd to fact ors!
dt aabkky benefi ts. oertal n paraona wkh
End-Staga Ranai Ot oeaae
Federal : Heal t h Cara
Fi nanol ng
e j - . r „ i . i . . . n * n i n
A G m ilN Q lD O fV n n a
State: N/ A
Home haakh vi aks, ext ended
hoapkal ateya, kmked st oked
nursi ng f ackky cere
M adtoai dm Ua XIX
o f th a S ocial
S e curity A ct
Federal and Stat a
LTC Expendi tures,
1903:
$42.13 bi llion ***
(Hardwi ck at a l.,
1004)
To pay fo r medi cal
a n tta n o * tor
certai n t ow i ncome
paraona
Aged, b in d, dt aabi ed paraona
m eshi ng cash ooet at anoa under SSI ;
Ot hara reoeMng oaah aaat otanoe
under AFDC at ot ata opti on; Paraona
iwh o qual ify aa “M edi cal l y Needy at
■l ate opti on
Fodaral : Haakh Care
Fi nanci ng
Admi nl at r adOf VHHS
State: State Medi cai d
Agency
Nursi ng home cars, home and
communky baaed haakh and
soci al servi ces, out-pati ent care,
f acUkt oe for the mental l y
retarded, chroni c care hospi tal s
S ocial Servl cee
B lock O rant/TM e
XX o f th e S ocial
S e curity A ct
Federal Grant,
1903:
$2.77 bt oi on
(U.S. Bureau o f t ha
Conoua, 1904)
To aaai at fam i l i es
and i ndMduat o i n
m al nl ai ni ng aoif-
suffl ctoncy and
i ndependence
No federal requi rements, state may
requi re meena teat
Federal : O ffi ce of Human
Devel opmant
Servi cee/HHS
State: State soci al
earvi cea or human
raeourcee agency, other
state agonct as may
admi nt ot ar part o f Tkto X X
f unda for certai n groups;
e.g. State Agency ta r the
Bl i nd
Servi ces provi ded at the states’
di screti on, may Incl ude l ong
t erm care
O lder Am eri cana
A ct
Federal Grant,
1004, Ti bs III and
Ti de VII programa:
$8. 11 m i l l i on
(Adm i ni strati on on
Agi ng. 1904)
Foot er tha
devel opment of a
oomprehonet oo and
coordi nated servi ce
ayat om to aarva t ha
el derl y
Paraona ago 80 and over; no maana
teal, but servi ces are targeted to those
wkh graataat aoct at or economi c need
Fodaral : Adm i ni strati on
on Agi ng/ HHS
Stata: Stata agency an
agi ng
N utri ti on servi ces, homo and
communky baaed soci al
servi ces, protecti ve servi ces,
l ong-term care ombudsman
Supplam ontal
S e curity
Incom e/Ti de XVI
o f th a S ocial
S acurtty A ct
Federal Banal Ba,
1003:
$20.72 bi t oon
(U.S. Commut es
on W ayaand
Maana, 1904)
To promot e an
I nooma floor for
needy aged, b N n d
and dt aabi ed
parsons
Aged, bl i nd, dt aabi ed paraona who
rmm n o m jriiiiD V in N noomv m o
resource raqui raments. States may
make peymant a to other state-defi ned
eNgtoMty groups
Federal : Soci al Securi ty
i r i- i ___
AammMi rmon
State: s ta r
Suppt omant al Payment
Program may ba atato or
rao an iy im i« M v rM
SSI awards to persons i n
koenaed root homes and nursi ng
homes may bo retai ned by
provi ders to hel p offset l ong
t erm care coots
Departm ent o f
Vetarane A ffa ire
Program
Expanses,
1909:
$1.68 b illo n
(OMB, 1906)****
To pay tar nurol ng
home and
domt oHl ar y oara tar
vat arana
Vat arana reoai ve oarvi caa baaed on
l evel of care needed and pr ograma
unct or whl oh o o fs t o pi ovl dod! m m i
tost t o a p p M a d tar domt catory care,
modl oal need tar NH care, state
dtaoratl on tar atato vatarana homes
Federal : Vot erana
Admi ntotratton
State: N/ A
Nursi ng homes and
doml cktarl ee owned and
operated by tha VA, communi t y
nursi ng homes that contract wkh
tha VA to pnot f de care, and state
veterans’ homes avwi ed and
operated by 40 states
Thi s tabl e to adapt ed from an Internal GAO worki ng documanl .
Sum of spendi ng fo r sl dted nursi ng faototy, homa haakh. and haapt oa cam.
Sum of HCBS awp enci ki asa (homa haakh, HCBS wai vers, and paraonal cam), and Insti tuti onal expendkurae (nursi ng
f actory and ntanei va cam faotat y/ment aky retarded)
Sum o f tha mai ntenance and opar adnq ai y anaaa for tha f okovdng programa: VA factory nursi ng homa and doml cdt ory
cam, confractad communi ty numl ng homa oars, and gmnl a (or S tata doml cktary and nursi ng homa care.
5
Even though chronic and acute conditions require different types of
services, they are inextricably intertwined. People with acute conditions pursue
curative treatments versus maintenance care which is traditionally required by
persons with chronic conditions. Furthermore, a lack of coordination or
integration of acute and long-term care financing and delivery systems
compounds an individual’s problems with access to services and receiving
appropriate levels of care. The United States has not yet developed a health
care system at the federal or state level that provides all individuals access to a
broad set of flexible services designed to meet the needs of people with both
acute and long-term conditions.
In the absence of federal reform, some states are experimenting with
innovative systems of financing and delivering long-term care to potentially curb
health care costs and provide a broader range of services. Their efforts
potentially will change the way people view the financing and delivery of primary,
acute, and long-term care. For example, Maine recently applied for and
received permission from the U.S. Health Care Financing Administration (HCFA)
to begin a Medicaid managed care demonstration project. The project will
demonstrate integrated models for the financing and delivery of managed care
and social services for Medicaid eligible elderly and physically disabled persons
throughout the state. The project seeks to promote the development of regional
service delivery networks or health plans, particularly in rural areas of the state,
that are responsible for the management, coordination, and integration of
6
services and that include multi-disciplinary approaches to care planning and
service delivery. The demonstration will provide a comprehensive package of
primary, acute, and institutional and community based long-term care services
as part of a prepaid capitated health plan for the target populations. Despite
using a welfare program for reform, Maine’s goals of integrating acute and long
term care funding and provision of services, administering services at the local
level, and fixing costs are similar to some of the innovations found in other
countries including Israel, Germany, the United Kingdom, the Netherlands,
Sweden, and the Canadian provinces.
Some other local, state, and federal efforts to finance and deliver long
term care that are more incremental in nature than Maine's managed care
demonstration are currently being evaluated. These include: the Social Health
Maintenance Organization (SHMO) which integrates acute and long-term care
financing and delivery systems and On Lok and its replication, (PACE) models,
which coordinate financing and delivery of long-term care. These models
emphasize home and community based care, supporting the preferences of
older persons; 95 percent of the disabled elderly living in the home would prefer
to stay out of a nursing home for as long as possible (Rivlin, Wiener, Hanley, &
Spence, 1988). Further promoting expansion of services to the home and
community, 40 states operated 53 1915(c) Medicaid waivers serving the
aged/disabled in FY1991 (Congressional Research Service, 1993).
7
Some states like Oregon are using their nurse practice acts to allow
nurses to delegate the provision of medical tasks by non-credentialed individuals
in the home. A 1990 survey of state provisions for the elderly identified programs
in 35 of the 50 states that made some form of financial payment to relatives and
other informal caregivers for the provision of homemaker, chore, personal or
attendant care (Stone & Keigher, 1994). Of the 35 states that allowed family
caregiver compensation, numbers served ranged from very few to approximately
13,000 care recipients in Michigan and over 100,000 in California (Stone &
Keigher, 1994). Demonstrations and state level initiatives are modifying existing
LTC systems. In addition to studying mechanisms of financing and delivering
long-term care in other countries, states can learn practices and approaches
from one another.
Methods
This thesis builds upon a larger 1994 GAO study, Other Countries
Tighten Budgets While Seeking Better Access, which reviewed the provision of
long-term care services in Canada, Germany, Sweden and the United Kingdom.
In that study, the GAO examined two issues: 1) the financing and cost-
containment measures those countries use to control public spending for long
term care and the 2) administrative and delivery approaches the countries use to
expand the range of and access to services. The GAO's review included data
8
and information obtained from Canada (particularly the provinces of British
Columbia and Ontario), Germany, Sweden, and the United Kingdom. They
interviewed officials and experts in each country, including government officials,
providers of long-term care, consumer advocates, and embassy officials. In
addition, they participated in several meetings of domestic and international
health and long-term care experts and obtained information from representatives
of the Organization for Economic Cooperation and Development in the United
States and Europe.
I expanded upon GAO’s analysis of Canada, Germany, Sweden and the
United Kingdom by adding three countries including Israel, Japan, and the
Netherlands. I further investigated how other countries were modifying their LTC
programs to serve a larger number of people in need of LTC at home while
controlling costs. The information on Israel, Japan, and the Netherlands was
collected from embassy officials and an extensive literature review was
conducted during the summer of 1992. Embassy officials also collected
literature and responded to a written survey (designed by the GAO) that used
open ended questions about the financing and delivery of health and long-term
care in their respective countries. During the summer of 1993, I synthesized and
analyzed the survey responses and literature about Israel, Japan, and the
Netherlands. After an extensive literature review conducted to collect additional
information about Canada, Germany, Sweden, and the United Kingdom during
the summer of 1994,1 completed the secondary data analysis.
9
Overview of Other Countries’ Approaches to Financing and Delivering LTC
Like the United States, fragmentation of both public and private long-term
care financing and delivery systems exists in Canada, Germany, Israel, Japan,
the Netherlands, Sweden, and the United Kingdom. Despite maintaining
nationalized acute health care systems, only limited LTC services are included
within these health care delivery systems. Due to an acute medical care
orientation, long-term care services covered under these plans are usually
medically oriented. Unlike acute care policy which is highly structured and
organized, LTC policy has evolved from a wide array of public, private, and
voluntary efforts (GAO, 1994). Thus, complex and overlapping health and social
services with differing service levels and eligibility criteria are the norm. Prior to
discussing LTC financing and delivery modifications, it would be useful to
explain briefly the demographic characteristics, acute health care system, LTC
eligibility, LTC service delivery, and LTC financing. The following discussion
relies on information found in Table 2.
Demographics
In 1990, several countries including Canada (11.5 percent), Japan (11
percent), and Israel (9 percent) had smaller proportions of their population age
65 and over than the United States (12.5 percent). Japan, however, is one of
the most rapidly aging countries in the world with its elderly population expected
to almost double between 1990 and 2010 (GAO, 1993). Israel also has a unique
demographic profile. Although the proportion of Israelis age 65 and over is
increasing at a slower rate than the countries examined, nearly 41 percent of
persons age 65 and over is age 75 and over (GAO, 1993). Sweden and
Germany had the greatest percentages of their populations who were elderly in
1990 at 18 and 15 percent respectively (GAO, 1994).
Acute Health Care System
Although the degree of government involvement in financing and
delivering acute care services varies among countries, all of these countries
require individuals to have some type of medical coverage. Citizens in
Germany, Japan, and Israel receive coverage from sickness funds that are
regulated by the government; eligibility is related to an individual’s occupation.
In the Netherlands, two-thirds of the population (comprised of people with
incomes under $25,000) is covered under mandatory health insurance; the
remaining one-third is covered on a voluntary basis by private, for-profit
insurance companies (GAO, 1993). And, in Sweden, Canada, and the United
Kingdom all citizens are covered by national health insurance.
11
LTC Eligibility
No uniform eligibility criteria exist for long term care. Eligibility criteria for
institutional and home and community based services vary according to the type
of service and the country. Except for Sweden, all of the countries examined
use a means test to determine eligibility for either institutional or home and
community based services. Germany, Japan, and the Netherlands require a
physician's assessment and request on behalf of the client. However, in Canada
and some programs in Israel, functional assessments are used to determine an
individual's need for services. Israel further refines its eligibility criteria by
administering a social support assessment concurrently with the functional
assessment.
LTC Service Delivery
Currently, an institutional bias exists in each country examined in this
thesis. Compared to institutional care, home and community based services are
less well developed and funded (GAO, 1994). Thus, most families and
individuals in need turn to institutional care for services. Yet, quality institutional
care is costly. In addition, an institutional bias may result in unnecessary
institutionalization in which individuals receive services that do not effectively
1 2
Table 2. LTC Financing and Delivery Approaches in Seven Countries and the United States*
LTC Eligibility LTC Service Delivery LTC Financing Modifications Demographics
Canada___________
In 1990,11.5 percent of
the population was age
65 and over and 2.4
percent was age 80 and
over. By 2010, the
elderly population is
expected to increase to
14.3 percent for age 65
and over and 4.1
percent for age 80 and
over.
Acute Health Care
System
All Canadians receive
complete health
insurance coverage for
basic hospital and
physician services
without co-payments.
The central government
distributes block grants
to the provinces.
Since the late 1970s,
coverage for a broad
range of LTC services
has been provided as
a universal benefit in
most Canadian
provinces. Eligibility
for covered services
is based on functional
need.
In some Canadian
provinces, responsibility
for LTC is fragmented
among multiple
agencies and providers
(Ontario), while others
have long histories of
coordinated and
integrated systems of
LTC (British Columbia).
Canadian provinces
finance LTC from a
variety of sources
mostly supported by
general tax revenues
Most provinces, using
incremental efforts,
have developed long
term care as a
universal benefit
program
Germany
In 1990, 15 percent of Most Germans obtain
the population was age their health insurance
65 and over and 3.8 from one of
percent age 80 and approximately 1,200
over. By 2010, this government regulated
population is expected to payers called sickness
increase to 20.4 for hinds. These funds
people age 65 and over provide a
and 5.2 percent for comprehensive benefits
people age 80 and over, package covering most
health costs with little or
no copayment.
Germany's welfare Currently in Germany,
system for providing public welfare funds
LTC benefits requires institutional care, and
means testing. To several charitable
qualify for public organizations provide
assistance, individuals support for most home
must exhaust and community based
personal income and services,
assets, and family
members, such as
adult children are
legally obligated to
contribute as well.
Until Germany's Changes will make
change is fully long-term care
implemented in 1996, services standard
means tested welfare benefits to be
will remain the provided through
primary mechanism of national health
public financing for insurance. An
long term care. Local increase in the
welfare offices grant government mandated
public benefits only payroll tax shared
after strict financial equally by workers
requirements are met. and their employers
will finance the
system.
Table 2 (continued)
Demographics Acute Health Cara
System
LTC Eligibility LTC Service Delivery LTC Financing Modifications
Israel
The percentage of
people age 65 and over
increased from 7 percent
in 1970 to 0 percent in
1990. About 41
percent of the elderly
population is 75 or over
which is about 4 percent
of the total population.
Four health funds,
similar to HMOs in the
United States insure and
provide health care to
their members. The
funds generally do not
cover dental services or
geriatric or psychiatric
LTC.
HCBS based on
functional ability and a
slight means test.
The individual is
required to live in the
community. Eligibility
for institutional care is
determined by
functional ability,
social assessment,
and a means test.
Home and community
care is coordinated
through one agency and
delivered by case
management teams.
Institutional care is
fragmented among
multiple agencies.
LTC is financed by
general taxes, payroll
taxes, local taxes, and
out-of-pocket
payments. Welfare
based financing with
stringent income and
asset requirements is
used for institutional
care and was used for
HCBS prior to
changes.
Long Term Care
Insurance (LTCI)
implemented in 1988,
provides universal,
almost completely
non-means tested
coverage for disabled
individuals living in
the community. The
primary goal of this
effort is to consciously
bias LTC financing
towards HCBS.
Japan___________
Japan is one of the
world’s most rapidly
aging countries. In
1990,11 percent of the
population was over age
65. By the year 2010,
20 percent of the
population is expected to
be elderly.
Japan has a universal,
comprehensive health
care system. People
over age 70 receive
nearly free medical
services despite a small
copayment.
Eligibility varies
according to the type
of service accessed.
Criteria used to
determine eligibility
include: physician's
request, means
testing, lack of social
support, and
functional ability.
Service delivery is
heavily biased towards
using acute hospital care
beds for chronic care
services. A limited
number of publicly
owned nursing homes
exist. Some home care
services are provided
through the Gold Plan, a
current effort to expand
HCBS.
Nursing home
residents pay on a
sliding fee scale. If
the are unable to pay,
the welfare office will
completely cover
expenses. Until 1982,
acute health
insurance covered
hospital costs
completely for
individuals age 70 and
over.
The Gold Plan aims to
increase HCBS
including the use of
geriatric rehabilitation
clinics and the
number of visiting
homemakers, respite
care centers, and day
nursing homes. The
ten year plan will
reduce acute hospital
care at a cost of 543
billion.
Table 2 (continued)
Demographics Acute Health Cara
System
LTC Eligibility LTC Service Delivery LTC Financing Modifications
The Netherlands
The percentage of
people over age 65 will
rise from 13 percent in
1993 to 18.8 percent in
2020 and 23.4 percent in
2025. The Dutch
population will remain
around 16 million.
Two-thirds of the
population is covered
under mandatory health
insurance. Eligibility Is
based on income
(people earning under
$25,000). One-third of
the population is
covered on a voluntary
basis by private, for
profit insurance
companies.
Nursing home Home nursing and home
admission is help are administered
authorized by a regionally by local
physician. Homes for welfare agencies to
the aged assess which the client must
individuals based on belong,
functional ability and a
means test.
To receive
institutional care, the
client must contribute
most of income and
pension towards the
cost of care. Other
financing mechanisms
include: taxation,
fees-for-service, and
mandatory insurance.
Regulation of health
care supply and
demand will be shifted
from the government
to semi-public sick
funds. Distinction
between government
or private insurance
will be dissolved. All
LTC provisions will be
included in the basic
health plan.
Sweden
Sweden has a great A national health
number of elderly people insurance system covers
with 18 percent of its
population over age 65
and approximately 4
percent over age 80.
each citizen. The
System relies on the
principle that a H citizens
are entitled to good
health and equal access
to health and medical
care.
Because Swedes
have traditionally
enjoyed universal
access to care,
eligibility on the basis
of financial need has
not been a feature of
the system.
Because municipalities
finance most LTC, they
also control the supply
of services in hospitals,
nursing homes, and the
home and community.
Sweden has
historically financed
LTC as a socially
insured benefit that is
paid for through taxes.
Services are funded
primarily by local
governments; the
national governments
share of spending is
less than 10 percent.
Cost sharing is
increasing.
Legislation, the 1992
Adel Reform, shifts
resources and taxing
authority to
municipalities, making
them fully responsible
for administering long
term care services.
Table 2 (continued).
Demographics Acute Health Care
System
LTC Eligibility LTC Service Delivery LTC Financing Modifications
United Kingdom
In 1090,15.7 percent of
the population was age
65 and over and 3.7
percent of the
population was age 80
and over. These
percentages are
expected to increase to
17.1 and 5.1 for age 65
and over and age 60
and over respectively by
2010.
The National Health
Service which is
controlled by the central
government provides a
comprehensive range of
medical services
available to all residents
irrespective of income.
Prior to 1903,
eligibility for
institutional care and
HCBS provided by
local authorities was
means tested.
Residential care
funded by the Social
Security System was
als means tested with
a limited gatekeeper
role by the physician.
Prior to 1993, LTC
modifications,
responsibility for
administering LTC was
fragmented among
multiple agencies and
levels of government.
No single entity was
responsible for
determining the
population's need for
care or for allocating
resources.
Public funding for LTC
is financed from
national welfare
funds, which are
transferred to local
authorities.
Approximately 57
percent of nursing
home residents were
dependent on welfare.
The 1990 Community
Care Act was
implemented in 1993.
The act grants local
authorities strict global
budgets for long-term
care services.
The United States
In 1090,12.5 percent of
its population was over
age 65 and 2.8 percent
was over age 80. By
2010,13.3 percent will
be over age 65 and 3.8
percent will be over age
80.
Individuals or their
employee purchase
coverage from private
insurance companies.
Coverage varies
according to the plan.
Poor women and
children, the blind and
disabled receive
coverage from public
programs.
Eligibility for LTC Service delivery is
services is primarily distributed among many
based on means federal, state, and local
testing. However, agencies. Responsibility
some programs use for service delivery
age as a depends on the
determination of need, distribution of specific
program funds.
Means tested welfare
is the primary
mechanism for public
financing of LTC.
Families pay for a
large portion of the
costs of LTC. Private
insurance plays little
to no role in the
financing of LTC.
Many states are
planning or
implementing
incremental changes.
The efforts vary on a
state by state basis.
* InfomwWon about Canada, Gar many, Swaden, and the Uni t ed Ki ngdom it adapt ed f rom GAO, 1994.
match their needs. For instance, in Japan, service delivery is heavily biased
towards using acute hospital care beds for chronic care services.
LTC Financing
As shown in table 2, public funding for long-term care in Germany, Israel,
the United Kingdom, the Netherlands and Japan has traditionally relied on
welfare-based financing. Over time, the welfare systems, intended to serve as
financial safety nets for the poor, began financing services for people with
moderate incomes in need of long-term care, resulting in dramatic increases in
public costs (GAO, 1994). Prior to modifications, in the countries with welfare-
based LTC systems, individuals were generally required to contribute portions of
their income and assets before becoming eligible for services. In Sweden,
however, LTC has long been provided as a non-means tested social insurance
benefit. And, most Canadian provinces began to move away from welfare-based
financing for long-term care in the 1970s (GAO, 1994).
As in the United States, private insurance contributes little to the financing
of long-term care in the countries reviewed. And, none of these countries has
actively promoted the development of a private insurance market. In Canada,
Sweden, the Netherlands, Japan, and Israel, little or no private insurance exists.
In Germany, the private insurance industry began offering long-term care
policies in 1986. To date about 133,000 private policies, representing less than
17
one percent of the total population, have been sold (GAO, 1994). In the United
Kingdom, the first policies were sold in 1991; as of 1992 seven insurers reported
offering some long-term care coverage (GAO, 1994).
In response to aging populations, service delivery, and financing
concerns, these countries are modifying their long-term care programs. Not
surprisingly, the most comprehensive alterations are occurring in Sweden and
Germany, the countries with the highest percentages of their populations who
are elderly. Nonetheless, other countries with a smaller percentage of their
population who are elderly are implementing changes to address the expected
increases in demand and cost for services. Most significantly, these countries
have begun modifications by asking and answering questions relevant to
addressing the issue of financing and delivering long-term care including: 1)
Who will be eligible to receive services?; 2) What services will be provided?; 3)
How will services be delivered and administered?; and 4) How will LTC be
financed and the cost of care controlled?
Other Countries' Efforts to Serve People in Need of LTC
At Home While Controlling Costs
In an effort to allow older people to remain as independent as possible,
many countries are trying to expand service options which allow people to stay
in their own homes and communities. To achieve this goal, countries are
redefining eligibility criteria, funding new service options, and supporting
18
informal caregivers. The shift in eligibility criteria and the setting where services
are provided attempts to give people a better quality of life during their last
years. Nonetheless, each country must address how they will ensure quality
care. Organizing funding and administrative responsibility through local
agencies brings responsibility and accountability to people at the local level who
are more directly in contact with people in need of LTC in their community. By
effectively targeting public resources and negotiating fees with providers, local
agencies working within fixed budgets must manage their costs efficiently to
provide services to a greater number of people.
Serving People in Need at Home
Almost all people in need of LTC would prefer to stay at home rather than
enter a nursing home. However, staying at home requires extensive assistance
from family and friends or reliance on paid care which many people cannot
afford. As the severity of disability increases over time, so does the need for
informal care. Through modifications of their systems, by revising their eligibility
criteria, expanding services options, and promoting informal caregiving, other
countries are attempting to restructure and rationalize their delivery systems to
support informal caregivers who provide services in the home to people in need.
19
Revising Eligibility Criteria
Program modifications currently being implemented in Germany and
Canada reduce or eliminate income as an eligibility criterion. The changes in
eligibility requirements, based primarily on functional need rather than the ability
to pay, remove social stigmas surrounding income related, welfare-based
systems. The number of people eligible for LTC services and associated costs
could be expanded or limited based on how functional ability is defined and how
many limitations are used to determine need for services. Nonetheless, a
person’s need is based on the ability to perform functions not on an individual's
ability to pay for services.
Germany. In July 1992, Germany passed legislation to eliminate most
welfare financing for long-term care and created a new social insurance benefit
for persons in need of long-term care (GAO, 1994). Beginning in 1996,
coverage for both institutional and community-based long-term care will be
provided through Germany's mandatory private health insurance system
compiled of 1,200 local sickness funds. Eligibility criteria will be based on the
client’s ability to perform self-care functions and will be related to physical and
cognitive impairments. In response to change in eligibility criteria, the German
government has allocated over 7 billion dollars per year in combined sickness
funds and government programs (GAO, 1994).
20
Canada. In the Canadian provinces of British Columbia and Manitoba,
assessment of functional need determines eligibility for nursing home coverage.
In Manitoba, no copayments were required for home support services.
However, residents of British Columbia paid for portions of the home support
visit up to a maximum of the entire cost of the visit (Miller, 1993).
Although measures of functional ability appear to offer an improvement
over age as a measure of need, such measures have some limitations. For
example, using questions and tests as measures to determine the level of
functional ability without the use of additional measures of social support will
skew the level of the individual's need. People may respond that they do not
need assistance with dressing when in fact their spouse assists them with
dressing every day. People may not correlate their spouse’s help with needing
assistance. Furthermore, the number of ADLs used as a benchmark for
receiving services will determine the number of people eligible for the program
and associated costs. A liberal definition expands access to available services
which contrasts with a more restrictive definition that limits the number of people
eligible for services.
Expanding Service Options
In many countries, public long-term care spending is disproportionately
directed towards nursing home care with comparatively little funding for home
and community based services. The development and funding of services
21
offered in the home or community settings is expected to provide several
benefits. Expanded home and community based services has the potential for
addressing a continuum of needs and allowing people to remain in their homes
and communities. Furthermore, home and community based services can be
designed to include informal caregivers as resources to help implement
treatment plans.
Israel. In 1988, Israel began a national public program, Long Term Care
Insurance (LTCI), to provide home and community based services. LTCI is
financed by employer and employee taxes deducted from an individual’s income.
Employee and employer contributions of .2 percent relieved the Treasury from
any fiscal responsibility. These insurance fund taxes total about $15 million per
year. This amount seems quite small, (about .7 percent of the total state
budget); nonetheless, it serves about 10 percent of the population (Cohen,
1988). By maintaining control over eligibility criteria based on functional ability,
the national government can measure the size of the eligible population and
related costs.
Japan. In an effort to decrease utilization of the acute care system for
long-term services, Japan’s Ministry of Health and Welfare inaugurated a ten
year plan, the Gold Plan, to reduce hospital care costs by $43 billion. At that
time, five percent of the age 65 and over population was bedridden. Specifically,
about 42 percent were in hospitals, about 20 percent in nursing homes, and
about 36 percent at home (Dentzer, 1991). The Gold Plan aims to adjust those
percentages to about 12 percent in hospitals, about 24 percent in skilled nursing
facilities, and about 35 percent at home with the remaining 28 percent in newly
created geriatric rehabilitation centers (Dentzer, 1991). The plan significantly
increases the numbers of visiting homemakers, respite care centers, and day
nursing homes. By 1999, the number of visiting homemakers is expected to
increase from 40,000 to 100,000. Some question the adequacy of the increase.
Because Japan had few home services existing prior to this legislation and the
most rapidly aging population in the world, experts believe that the numbers are
not sufficient. In addition, with tight immigration laws, more women in the
workforce and a declining birthrate, the question remains, who will ftll these
socially and economically low status positions of homemakers?
Home and community based services in total are not necessarily less
costly than nursing homes because they serve a larger number of people.
However, the substitution of home and community based services for nursing
home care does reduce the rate of growth of the cost of nursing home care. In
addition, since studies indicate that people prefer to receive care in their own
homes, expansion of home care services would result in greater consumer
satisfaction. Ultimately, the cost of providing long-term care will drive reform
efforts. Therefore, financing systems will determine the eligibility criteria, service
delivery structure, and the types of services provided. The challenge for policy
makers lies in developing a cost-effective, efficient, and equitable system of
financing and delivering long-term care.
23
Promoting Informal Caregiving
Informal care provided by family and friends is the most prevalent form of
LTC and will continue to be so in the future. Formal care that complements
informal care becomes more important as the severity of the disability and care
needs increase. A system of formal services including home and community
based options should supplement not supplant care already provided by family
and friends (Morginstin, 1988). Sweden, Germany, and Israel have chosen to
support informal caregivers through various methods including direct cash
payments, paid leave for caregivers, and including caregivers as part of the
overall care plan.
Sweden. Sweden provides a high level of support for informal caregivers
through direct government payments and requirements for employers. Public
funds are spent as salaries paid to family caregivers for whom caregiving is a
regular full-time or part-time job. Employers must grant up to 30 days of paid
leave for individuals to provide care for elderly or disabled family members. As
part of the legislation passed in 1992, municipalities will receive greater
administrative responsibility and additional national funds to pay for caregivers.
Germany. People in need of home care may choose cash benefits which
can be used to pay informal caregivers given that adequate home care is being
provided. Relatives, friends, or neighbors who provide care on a regular basis
will also be entitled to most regular employment benefits such as public pension
credits and insurance coverage. Informal caregivers will receive four weeks of
24
vacation per year during which time the sickness funds will pay for professional
home care services to relieve the caregiver of responsibilities.
Israel. Implemented in 1986, the Long Term Care Insurance (LTCI)
program provides universal, almost completely non-means tested coverage for
disabled individuals living in the community. To receive benefits under LTCI, the
individual must live in the community and not in a nursing home. Individuals or
their families apply for coverage exclusively to one of 17 national offices. A
claims officer at one of the local branches verifies the application information
and arranges for an in-home functional dependency evaluation administered by
a specially trained nurse. Functional dependency is measured using an
Activities of Daily Living (ADL)test that includes personal care activities such as
eating, bathing, dressing, toileting, and transferring from a bed to a chair. The
results from the test is applied to a uniform set of criteria to determine eligibility
for services. Additionally, a means test is applied to the income of the elderly
person and the spouse; however, few people are denied benefits based on their
income. The family is included in the resulting treatment plan so that an
appropriate set of services is delivered to meet the needs of both the individual
and the family.
Support of informal caregivers achieves two objectives including allowing
the individual in need to stay at home and decreasing stress on the caregiver
and the family. Involving the family in the care plan and recognizing their role
and contribution towards the client's care may help to enhance the care provided
25
in the home. Some safeguards, however, must accompany direct cash
payments to informal caregivers to ensure that care is actually being provided.
These countries encourage people to remain in their own homes and
communities and live with dignity for as long as possible. Eligibility criteria
based on need, expanded funding for home and community based services, and
support of informal caregivers move countries towards that end. However,
dramatically increasing costs and strained national budgets hinder many such
efforts. Governments face a myriad of competing demands for public resources
and can no longer afford to continue to pay for programs without controlling
costs.
Containing Costs
Prior to modification efforts, government spending for LTC in Canada,
Germany, Israel, Japan, the Netherlands, and the United Kingdom was financed
primarily through welfare programs. In addition to dramatic increases in public
costs, individuals were required to impoverish themselves to qualify for public
coverage of institutional care. As a result, countries faced pressure to expand
coverage for institutional and home and community based services while limiting
the growth of public spending. Countries began to consolidate administrative
and funding responsibility to allow for more efficient targeting of public
resources. Some countries also established global or capped budgets to control
26
public costs (GAO, 1994). Due to operating within fixed budgets and seeking to
contain overall LTC costs, countries increased cost sharing and implemented
rate setting, fee negotiation, and control of supply.
Changing the Administrative Structure
To create more efficient and accessible LTC delivery systems, Canada,
Germany, Israel, the Netherlands, Sweden, and the United Kingdom are
transferring greater responsibility for the administration and delivery of LTC to
local authorities. Local level agencies understand the dynamics and the needs
of the people in their communities. Consolidation of administrative responsibility
and funding streams for long-term care at all levels of government coupled with
increasing the role of local governments through decentralization, is expected to
reduce the number of entry points to care, improve consumer access to services,
and allow more efficient targeting of scarce public resources (GAO, 1994).
Sweden. According to the GAO (1994), the elderly and disabled have
traditionally received a wide array of public benefits. In an effort to control public
costs and promote efficiency in the delivery of LTC, Sweden has further
decentralized the provision of care. In 1992, Sweden transferred public funds
from county councils to local municipalities. Local municipalities will have
responsibility for targeting public resources and administering LTC. The intent
of this effort is to expand home and community based services and to promote
greater efficiency in the delivery of care.
27
Israel. Although eligibility is determined at the national level for Israel’s
LTCI program, service delivery is coordinated and administered by local
agencies. Local committees determine which agencies will provide the needed
services. These committees are staffed by a local community senior social
worker, a nurse from one of the health funds, and a claims officer from the
National Insurance Institute which is responsible for overseeing LTCI at the
national level. All private and non-profit agencies must be certified by and
contracted with the central government. Case management teams have the
responsibility of determining care plans, arranging services, and periodically
reassessing care needs. The family is considered a key component of long-term
care, and the care team assumes that the family will work with them to determine
the best care plan for the elder relative.
Canada. Since the 1970s, Canadian provinces have undertaken a
number of incremental policy changes to change LTC financing and delivery
(GAO, 1994). Although the timing and characteristics of these changes have
varied, most provinces have developed universally insured benefits for
institutional care and home and community care. More recently, in response to
declining federal support of provincial long-term care programs, many provinces
have taken steps to maintain service provision while containing overall costs.
The GAO (1994) reports that Ontario is currently consolidating its health and
social service components for LTC under one newly created division at the
provincial level. The new division will report to the Ministry of Health and
28
Ministry of Social Services, which previously had funded and administered long
term care services separately. With a history of comprehensive and coordinated
LTC, British Columbia continues to support a single division within the Ministry
of Health with federal grant money. The Ministry of Health in turn funds and
administers most services at the provincial level.
Targeting Public Resources
Enhanced access to services which are administered by local authorities
provides the avenue for increases in the number of services offered in the home
and community. In particular, local authorities have better and quicker access to
individuals living in their communities, and thus are better able to identify needs
and provide home and community services appropriate to those needs.
Monitoring the needs of their populations, local authorities can more effectively
track the progress or decline of their clients than the central government to
determine the most appropriate type of care required.
The United Kingdom. Local governments have become the authorities to
purchase home and community based care for people in their districts. The local
governments receive money for community care from the central government as
a capped grant. To contain costs, the local governments implemented
approaches including designating case managers, using care teams during
assessments, coordinating individual care packages with various agencies, and
providing services if money is available. Concern about variation in plans
29
between localities exists because people may not receive uniform benefits
across the country (GAO, 1994).
The Netherlands. The central government of the Netherlands wants to
reduce the number of older persons in nursing homes and homes for the elderly
to reduce costs and promote an independent lifestyle (Tilly & Stucki, 1991). To
that end, the provinces and municipalities are being given more responsibility for
planning for older persons needs. Traditionally very service oriented towards
older persons, the central government is offering subsidies to stimulate home
care. The central government is also encouraging coordination and cooperation
through networks of facilities that can give complementary care. In addition,
sen/ice centers recently have been established in neighborhoods to provide
information and coordination points for home care services, home nursing, and
social security inquiries (Tilly & Stucki, 1991).
Targeting public resources through case management and giving control
to local communities to identify those individuals most in need of services may
allow countries to serve more people at relatively lower costs. Identifying and
coordinating care needs and developing an appropriate care plan may reduce
pubic and private costs for care and stress on the client. Working within fixed
budgets, local authorities must approach service delivery with innovative
methods to provide the most appropriate care from all agencies that otter long
term care services to the person in need.
30
Implementing Global Budgeting or Budget Caps
Global budgeting is a possible mechanism for containing the growth of
health and long-term care costs. A global budgeting strategy encourages the
efficient use of resources by capping the total amount of the national budget
allocated to health and long-term care. Therefore, local authorities may
implement a wide range of methods to keep costs within the budget, including
changing physician behavior, setting uniform reimbursement rates, and limiting
the amount and type of services provided. Global or capped budgets tend to be
set annually on a prospective basis.
The United Kingdom. Implemented in 1993, the United Kingdom's
Community Care Act replaced national welfare-based financing for institutional
LTC with a locally administered system of LTC benefits operating within capped
budgets (GAO, 1994). Using a managed care approach to financing and
delivering services, local case mangers determine eligibility for services based
on functional ability criteria. The expectation is that case managers will provide
an objective analysis of an individual's needs that will result in the provision of
services most appropriate to those needs. Thus, the care provided will be more
cost effective and efficient.
The Netherlands. In the Netherlands, an increase in the number of
people over the age of 65 has been estimated at one and one-half percent per
year resulting in a similar projection in LTC service use (GAO, 1993). As a
3 1
result, the government is focusing on increasing the flexibility and improving the
effectiveness of care. A new health system has been proposed that will include
both acute and long-term care in the basic health insurance package provided to
all citizens. Oversight of health care supply and demand will be shifted from the
central government to sick funds administered by semi-public organizations
which will be responsible for negotiating with clients and treatment providers.
The new program will be financed by deductions from an individual’s income,
collected by the Dutch IRS and directed to a central treasury fund. The health
insurance companies will then receive a capped pool of funds from the central
treasury fund to finance the basic health insurance package. Individuals will be
able to purchase a supplemental policy covering the costs of services like dental
care and physical therapy for additional premium. Rather than administering the
delivery of health care, the central government's primary role will be collecting
funds to distribute to the sick funds, maintaining oversight, and quality control.
Particular attention will be paid to potential discrimination including fewer
services and longer waits for services by the insurers and providers against the
elderly because of associated high costs of providing them both acute and long
term care.
Working within fixed budgets requires the use of methods like care
coordination, to decrease costs. It remains to be seen if local levels of
government can most effectively and efficiently provide or purchase services for
individuals in their community. Nonetheless, people operating local agencies
32
are likely to be people that are familiar with community resources and know the
people in need.
A major difficulty with exploring how other countries finance and deliver
long-term care rests in the reality that long-term care is not really a system.
Disparate funding streams and administrative responsibilities characterize the
provision of LTC in all of the countries examined. In addition, the elements of
long-term care are not mutually exclusive and therefore, they are difficult to
isolate in discussion. Nonetheless, in any country, before implementing
modifications, each segment of long-term care must be analyzed and determined
to be the best option for optimalizing funding and providing quality services.
This thesis has presented several options for achieving this goal. The
parameters of the long-term care puzzle including increasing demand for
services and associated costs is complete. Now, policy makers in the United
States must finish the puzzle.
Conclusion
In the final analysis, the goals of long-term care system modifications are
to broaden access to an appropriate set of services while controlling costs and
utilizing caregiver support provided by family and friends. Unfortunately, most
countries are far from reaching these goals because the demand for and cost of
long-term care will continue to increase. Policy makers in the United States at
33
the federal and state levels must face the reality that they will have to find more
creative ways to finance the delivery of care. Furthermore, demographic
changes in the United States are increasing the demand on informal caregivers'
time and resources. The changing definition of "traditional households” is
supported by the reality that the number of single parent families, two parent
working families, and families that are supporting younger and older generations
in their households are increasing.
Other countries have assisted their respective populations with funding
for and delivery of long-term care services. Germany and the Netherlands
realize that as people age, they will be more likely to use medical services for
acuta conditions and experience a greater number of chronic conditions than
younger people. This is costly. To that end, these countries are structuring their
acute and long-term care delivery systems to provide a continuum of services
and ultimately decrease the public and private costs of financing LTC.
Sweden and the United Kingdom transferred administrative and delivery
control to local authorities. However, the central government restricted their
ability to raise revenues to provide services suggesting that local authorities
have to achieve more with less in the future. Israel and Japan have developed
home and community based programs to reduce institutionalization and build
upon the family's existing commitment to caring for the individual in need.
Furthermore, assessing the individual’s social support network in addition to
34
functional ability will support a more comprehensive approach to providing LTC
services.
For policy makers in the United States and the countries examined in this
thesis, the debate about long-term care changes revolves around finance,
service, and access issues. Germany and Israel implemented new general taxes
to finance their modificatons. The Netherlands is decreasing its role in health
care by transferring control to private insurers and adopting a role in which the
central government collects taxes and redistributes the funds to the insurers.
Each of these countries is modifiying its approach to financing and delivering
long-term care to control and/or decrease costs and provide care for people that
need it.
The ultimate determination of how the United States chooses to address
the needs for chronic care rests with the policy makers. A variety of structures
for financing and delivering long-term care have been presented in this thesis.
Although the United States is not likely to design programs in the exact image of
other countries, informed decisions can be made to design programs that
incorporate elements of each of these programs while best meeting the need for
LTC in the United States.
35
Bibliography
Administration on Aging, Department of Health and Human Services. (1994).
Sfafe and can revise allotments for 1994, Title III (Table). Washington,
DC: Author.
Administration on Aging, Department of Health and Human Services. (1994).
State and can revise allotments for 1994, Title VII (Table). Washington,
DC: Author.
Ben-Zvi, B. (1990). The contribution of long-term care insurance law to the
welfare of the severely dependent elderly. Journal of Welfare and Social
Security Studies, 2, 100-116.
Brodsky, J. & Sobol, E. (1992). Coordinated care teams: improving health and
social care for older Israelis. Ageing International, 14(3), 10-14.
Cohen, S. (1986). The long-term care insurance law: Background, principles and
organization toward implementation. Journal of Welfare and Social
Security Studies, 4-22.
Committee on Ways and Means, U.S. House of Representatives. (1994). Green
book: Background material and data on programs within the jurisdiction of
the committee on ways and means (WMCP Publication No. 103-27).
Washington, DC: U.S. Government Printing Office.
Congressional Research Service. (1993). Medicaid source book: Background
data and analysis (Committee Print Publication No. 103-A). Washington,
DC: U.S. Government Printing Office.
Davies, B . (1992). Resources, needs and outcomes in community services: Why
academic caution is useful. In K. Morgan (Ed.), Gerontology: Responding
to an ageing society (pp. 215-248). London: J. Kingsley Publishers, in
association with The British Society of Gerontology.
Dentzer, S. (1991, September 30). The graying of Japan. U.S. News and World
Report, 3, 65-73.
Doty, P. (1990). Dispelling some myths. Generations, 14(2), 10-14.
Doty, P. (1993). International long-term care reform: A demographic, economic
and policy overview. Journal of Cross Cultural Gerontology, 8(4), 447-
461.
36
Employee Benefits Research Institute. (1989, May). Canada's health care
system: Lessons for the United States (Issue Brief No. 90). Washington,
DC: Author.
Employee Benefits Research Institute. (1989, July). Japan copes with its
* honorable elders": Retirement and health benefits systems in Japan
(Issue Brief No. 92). Washington, DC: Author.
Gelfand, D. (1988). Directions and trends in aging services: A Gemnan-American
comparison. International Aging and Human Development, 27(1), 57-68.
Hardwick, S.E., Pack, P.J., Donohoe, E.A., & Ateksa, K.J. (1994). Across the
states: Profiles of long-term care systems. Washington, DC: American
Association of Retired Persons.
Henke, K.D. (1989). Health care cost containment in the Federal Republic of
Germany. In T. Schwab (Ed.), Caring for an Aging World (pp. 96-101).
New York: McGraw Hill.
Hokenstad, M.C. & Johnansson, L. (1990). Swedish policy initiatives to support
family caregiving for the elderly. Ageing International, 16(1), 33-35.
Hurst, J.W. (1991). Reform of health care in Germany. Health Care Financing
Review, 12(3), 73-86.
Hurst, J. & Organisation for Economic Co-Operation and Development. (1992).
The reform of health care, a comparative analysis of seven OECD
countries (Health Policy Studies, No. 2). Paris: OECD.
Jackson, B. (1992, October). Family caregiving: Still going strong? Paper
presented at the U.S. Department of Health and Human Services and the
Office of Assistant Secretary for Planning and Evaluation's meeting of
The Changing Face of Informal Caregiving, Berkeley Springs, WV.
Johansson, L. (1991). Informal care of dependent elderly at home-Some
Swedish experiences. Ageing and Society, 2, 41-58.
Johnson, M. (1969). Long-term care for the elderly in England. In T. Schwab
(Ed.), Caring for an Aging World (pp. 162-189). New York: McGraw-Hill.
Kane, R. & Kane, R. (1985). Will and a way: What the United States can learn
from Canada about caring for the elderly. New York: Columbia University
Press.
37
Kane, R. & Kane, R. (1985). The feasibility of universal long-term care benefits:
Ideas from Canada. New England Journal of Medicine, 312(21), 1357-
1364.
Kane, R. & Kane, R. (1989). Long-term care for the elderly in Canada. In T.
Schwab (Ed.), Caring for an aging world (pp. 246-264). New York:
McGraw-Hill.
Lawrence, T. L. (1985). Health care facilities for the elderly in Japan.
International Journal of Health Services, 15(4), 677-697.
Lindgren, B. (1989). The Swedish health care system. Health Care Financing
Review Annual Supplement, 66-71.
Maeda, N. (1989). Long-term care for the elderly in Japan. In T. Schwab (Ed.),
Caring for an aging world (pp. 646-264). New York: McGraw-Hill.
Maeda, N. & Takahashi, S. (1992). Case management in rural Japan. Ageing
International, 14(3), 5-9.
Martin, L. (1991, February 1). Population aging policies in East Asia and the
United States. Science, 251, 527-531.
Miller, R.H. (1993). Containing use and expenditures in publicly insured long
term care programs. Health Care Financing Review, 14(4), 181-207.
Morginstin, B. & Shamai, N. (1990). Issues in planning long-term care insurance
in Israel's social security system. Journal of Welfare and Social Security
Studies, 2, 31-48.
The Netherlands Ministry of Welfare, Health and Cultural Affairs. (1989). Health
insurance in the Netherlands. Rijswijk, The Netherlands: Author.
Norberg, A. & Asplund, K. (1989). Family caregiving for the elderly in Sweden.
Recent Advances in Nursing, 23, 13-22.
Office of Management and Budget. (1995). Budget of the United States
Govemment-Appendix. Washington, DC: U.S. Government Printing
Office.
Potter, C. & Porter, J. (1989). American perceptions of the British national health
service: Five myths. Journal of Health Politics, Policy, and Law, 14(2),
341-365.
38
Reference Services. (1990). National health service and community care
reforms: Legislative proposals (Central Office of information Publication
No. 339/90). London: Author.
Schneider, M. (1991). Health care cost containment in the Federal Republic of
Germany. Health Care Financing Review, 12(3), 87-101.
Spooner, D.P. (1986). A British perspective on hospice: The development,
planning, and inception of a program. The American Journal of Hospice
Care, 24-40.
Stone, R. & Keigher, S. (1994). Toward an equitable and universal caregiver
policy: The potential of financial supports for family caregivers. Journal of
Aging and Social Policy, 6(1/2), 513-526.
The Swedish Institute. (1989a). Facts sheets on Sweden: The care of the elderly
in Sweden (The Swedish Information Service Publication No. FS 8 h
Ohfe). Stockholm: Author.
The Swedish Institute. (1989b). Facts sheets on Sweden: Health and medical
care in Sweden (The Swedish Information Service Publication No. FS 76
p Vpb). Stockholm: Author.
Tilly, J. and Stucki, B. (1991). International perspectives on long-term care
reform in the United States. Washington, DC: American Association of
Retired Persons.
U.S. Bureau of the Census. (1994). Federal expenditures by state for fiscal year
1993. Washington, DC: U.S. Government Printing Office.
U.S. General Accounting Office. (1993, June). Health and long-term care in the
Netherlands survey (Working Paper). Washington, DC: Author.
U.S. General Accounting Office. (1993, June). Health and long-term care in
Japan survey (Working Paper). Washington, DC: Author.
U.S. General Accounting Office. (1993, June). Health and long-term care in
Israel Survey (Working Paper). Washington, DC: Author.
U.S. General Accounting Office. (1993). Five federally-based programs that
finance long-term care (Working Paper). Washington, DC: Author.
30
U.S. General Accounting Office.(1994, March). Lessons from other lands. Paper
presented at the meeting of the American Society on Aging, San
Francisco, CA.
U.S. General Accounting Office. (1994). Long-term care: Other countries tighten
budgets while seeking better access (GAO Publication No. HEHS-94-
154). Washington, DC: Author.
U.S. General Accounting Office. (1994). Long-term care: Diverse growing
population includes millions of Americans of all ages (GAO Publication
No. HEHS-95-26) Washington, DC: Author.
Vladeck, B. C., Miller, N. A., & Clauser S. B. (Summer 1993). The changing face
of long-term care. Health Care Financing Review, 14(4), 5-23.
Rivlin, A.M., Wiener, J. M., Hanley, R. J., & Spence, D.A. (1988). Caring for the
disabled elderly: Who will pay? Washington, DC. Brookings Institution.
Zappolo, A. A. & Sundstrom, G. (1989). Long-term care for the elderly in
Sweden. In T. Schwab (Ed.), Caring for an aging world (pp. 22-57). New
York: McGraw-Hill.
40
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Asset Metadata

Creator Thorstenson, Kirsten Heide (author)

Core Title Cross-cultural comparisons of long-term care practices: modifications to financing and delivery approaches in seven countries

School School of Gerontology

Degree Master of Public Administration

Degree Program Gerontology,Public Administration

Degree Conferral Date 1995-05

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag gerontology,OAI-PMH Harvest,political science, public administration,sociology, public and social welfare

Format masters theses (aat)

Language English

Contributor Digitized by ProQuest (provenance)

Advisor Wilber, Kathleen H. (committee chair), Peterson, David B. (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c18-5777

Unique identifier UC11356903

Identifier 1376525.pdf (filename),usctheses-c18-5777 (legacy record id)

Legacy Identifier 1376525-0.pdf

Dmrecord 5777

Document Type Thesis

Format masters theses (aat)

Rights Thorstenson, Kirsten Heide

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA