The Challenge of Sustaining Long-term Care in Aging Societies: Lessons From Japan and SpainComment on “Financing Long-term Care: Lessons From Japan”

This article compares the provision of long-term care (LTC) in Japan and Spain, two countries with similar demographic structures but which address the provision of LTCs in very different ways. Both countries provide universal LTC. However, Japan has developed a generous benefit package of formal services for dependents to alleviate the care burden on the family, but provides no cash benefits. In Spain, on the other hand, cash allowances are the norm rather than the exception in the practical implementation of LTC services. After discussing the necessary delineation of LTC in response to future sociodemographic challenges, we discuss LTC system characteristics and the recent cost containment reforms implemented in Japan and Spain. Finally, we consider the lessons that may be drawn from each country’s experience and the reforms that must be undertaken in order ensure the sustainability of LTC provision in other countries with incipient or more developed LTC systems. In addition, since Japan and Spain are both faced with challenging demographic projections, it is important for each country to learn from the other’s initiatives and reforms

Sociodemographic and health factors associated with the risk of financial catastrophe when informal care for patients with haematological neoplasms is replaced by formal care.

Background: Cancer is one of the diseases with the highest incidence and mortality in the world, and one that requires greater care (formal and informal). At present, the traditional informal caregiver is disappearing. The objective is to analyse the sociodemographic and health factors associated with the possible catastrophic financial effect on households of replacing informal care by formal care for patients with blood cancer, during the different stages of treatment in Spain. Methods: A total of 139 patients with haematological neoplasm who underwent stem cell transplantation completed a longitudinal questionnaire during each of three treatment phases. Of this population, 88.49% received informal care. The households were classified into those where the replacement of informal care with formal care would impose a financial burden exceeding 40% of equivalent household income, versus those who would not suffer this consequence. Three logistic regression models (one for each treatment phase) were estimated and the corresponding marginal effects determined. Results: The factors associated with a higher probability of financial catastrophe were married marital status, low education level, fair to very poor self-perceived health status, the diagnosis of leukaemia in the pre-transplant and first-year post-transplant phases and of multiple myeloma disease in the final post-transplant phase. Conclusions: These findings reveal the need to design social policies to meet the care needs of patients with blood cancer which at present are covered by informal care. Given the foreseeable elimination of this option, these families must be protected from the financial burden incurred from the use of privately-contracted assistance

Catastrophic financial effect of replacing informal care with formal care: a study based on haematological neoplasms

Informal care is a substantial source of support for people with cancer. However, various studies have predicted its disappear ance in the near future. The aim of this study is to analyse the catastrophic effect resulting from the substitution of informal care with formal care in patients with blood cancer throughout the different stages of treatment. A total of 139 haematological neoplasm patients who underwent stem cell transplantation in Spain, completed a longitudinal questionnaire according to the three phases of treatment between 2012 and 2013. The economic value of informal care was estimated using proxy good, opportunity cost, and contingent valuation methods. Catastrophic health expenditure measures with thresholds ranging from 5 to 100% were used to value the financial burden derived from substitution. A total of 88.5% of patients reported having received informal care. In 85.37%, 80.49%, and 33.33% of households, more than 40% of their monthly income would have to be devoted to the replacement with formal care, with monthly amounts of €2105.22, €1790.86, and €1221.94 added to the 40% in the short, medium, and long-term, respectively (proxy good method, value=9 €/h). Informal caregivers are a struc tural support for patients with blood cancer, assuming significant care time and societal costs. The substitution of informal care with formal care would be financially unaffordable by the families of people with blood cancer

Atención a la dependencia y cuidados sanitarios: obligados a entenderse

Los sistemas sanitarios y de cuidados de larga duración (CLD) conforman dos pilares esenciales del estado de bienestar en España. Si bien el sistema de CLD nació como independiente del sanitario, su carácter y objetivos implican su necesaria integración, o al menos, coordinación con el sistema sanitario. La estrategia de atención integrada al paciente podría permitir un ahorro de recursos, realizar una óptima asignación de estos, ahorrar tiempos de espera y mejorar la calidad de vida de las personas con dependencia. En este trabajo se contextualiza la situación actual y se propone un conjunto de políticas públicas para el avance del estado de bienestar. / Both, the health care system and the long-term care system (LTC) are important pillars of the Spanish welfare state. Although Spanish LTC system was born independent of the health care system, its own nature and objectives suppose a necessary integration, or at least, coordination between both. This strategy would save resources, allocate them optimally, reduce waiting times and improve the quality of life of people with long-term care needs. In this chapter the current situation is contextualized and a set of public policies are proposed to achieve progress in the welfare state

Impact of implementation of the Dependency Act on the Spanish economy: an analysis after the 2008 fnancial crisis

The aim of this paper is to assess the industry-wide impact of Long-Term Care (LTC) spending on the Spanish economy. LTC spending includes benefciaries’ copayment and the impact is quantifed in terms of output, employment and value added. To this purpose, we use an input–output model of the Spanish economy that allows us to further describe how the value added generated is distributed throughout the economy according to the existing beneft-mix (in kind services, cash beneft for informal care and cash beneft for personal assistance). Additionally, the model provides results on how the return on LTC spending would improve by using only in-kind services instead of the beneft mix currently in place. The 2012 Spanish Input–Output Table at current prices was extracted from the WIOD Database’s 2016 Release. Consumption data for dependent, employed, and unem ployed households were collected from the Spanish Household Budget Survey for 2012. The fndings reveal that the total annual costs are 7,205.43 million €, with total costs from in-kind services being almost 71% higher than total costs from cash benefts. Each mil lion euros invested in in-kind services and CBPA would create 41.91 jobs (68.41% direct, 9.16% indirect and 22.43% induced). However, each million euros spent on cash benefts would result in 16.88 jobs overall (53.02% direct, 24.53% indirect and 22.45% induced). The total number of jobs is 151,353 at the aggregate level, being 46,840 depending on cash-benefts and 104,513 on in-kind services

Financial Catastrophism Inherent with Out-of-Pocket Payments in Long Term Care for Households: A Latent Impoverishment

Background: Out-of-pocket (OOP) payments are configured as an important source of financing long-term care (LTC). However, very few studies have analyzed the risk of impoverishment and catastrophic effects of OOP in LTC. To estimate the contribution of users to the financing of LTC and to analyze the economic consequences for households in terms of impoverishment and catastrophism after financial crisis in Spain. Methods: The database that was used is the 2008 Spanish Disability and Dependency Survey, projected to 2012. We analyze the OOP payments effect associated to the impoverishment of households comparing volume and financial situation before and after OOP payment. At the same time, the extent to which OOP payment had led to catastrophism was analyzed using different thresholds. Results: The results show that contribution of dependent people to the financing of the services they receive exceeds by 50% the costs of these services. This expenditure entails an increase in the number of households that live below the poverty. In terms of catastrophism, more than 80% of households dedicate more than 10% of their income to dependency OOP payments. In annual terms, the catastrophe gap generated by devoting more than 10% of the household income to dependent care OOP payment reached €3955, 1 million (0.38% of GDP). Conclusion: This article informs about consequences of OOP in LCT and supplements previous research that focus on health. Our results should serve to develop strategic for protection against the financial risk resulting from facing the costs of a situation of dependence

Viabilidad Financiera de los Hogares en el Sistema de Atención a la Dependencia en España: Evidencia Regional

One of the most extensively analysed issues in recent decades has been financial catastrophe due to out-of pocket payments (OOP) made by households to access and use health systems. This paper has two main objectives. The first is to predict the rates of financial catastrophe and determine the importance of the chosen variables for predicting the rates of catastrophe for high, medium and low income levels in the different Spanish regions. To this end, a comparison will be made between two machine learning algorithms, one based on elastic-net regressions to estimate generalised linear models; and another based on random forest algorithms, which makes it possible to capture the possible non-linearities and interactions that may occur in the data. The results show that the random forest is more appropriate. Based on these results, the second objective is to establish a ranking of the different regions by income level for the different categories of financial catastrophic expenditure rates, using a discrete multi-criteria decision model (PROMETHEE method). Uno de los temas más analizados en las últimas décadas ha sido el catastrofismo financiero debido a los Pagos de Bolsillo (PDB) que realizan los hogares por el acceso y utilización de los sistemas de salud. En este trabajo se persiguen fundamentalmente dos objetivos. El primero, se centra en predecir la tasa de catastrofismo financiero y obtener la importancia de las variables para predecir la tasa de catastrofismo para un nivel de renta alto, medio o bajo de las diferentes Comunidades Autónomas. Para ello, se establecerá una comparativa entre dos algoritmos machine learning, uno basado en regresiones elastic-net para estimar modelos lineales generalizados; y, otro basado en algoritmos random forest, que permite captar las posibles no linealidades e interacciones que se pueden producir en los datos. Los resultados muestran que es más adecuado el random forest. A partir de estos resultados, el segundo objetivo, se centra en establecer un ordenamiento entre las diferentes Comunidades Autónomas según su nivel de renta para las diferentes categorías de las tasas de catastrofismo mediante la utilización de un modelo de decisión multicriterio discreto (método PROMETHEE)

The Classification of Profiles of Financial Catastrophe Caused by Out-Of-Pocket Payments: A Methodological Approach

The financial catastrophe resulting from the out-of-pocket payments necessary to access and use healthcare systems has been widely studied in the literature. The aim of this work is to predict the impact of the financial catastrophe a household will face as a result of out-of-pocket payments in long-term care in Spain. These predictions were made using machine learning techniques such as LASSO (Least Absolute Shrinkage and Selection Operator) penalized regression and elastic-net, as well as algorithms like k-nearest neighbors (KNN), MARS (Multivariate Adaptive Regression Splines), random forest, boosted trees and SVM (Support Vector Machine). The results reveal that all the classification methods performed well, with the complex models performing better than the simpler ones and showing no evidence of overfitting. Detecting and defining the profiles of individuals and families most likely to suffer from financial catastrophe is crucial in enabling the design of financial policies aimed at protecting vulnerable groups

Catastrophic Household Expenditure Associated with Out-of-Pocket Healthcare Payments in Spain

Background. The financial effect of households’ out-of-pocket payments (OOP) on access and use of health systems has been extensively studied in the literature, especially in emerging or developing countries. However, it has been the subject of little research in European countries, and is almost nonexistent after the financial crisis of 2008. The aim of the work is to analyze the incidence and intensity of financial catastrophism derived from Spanish households’ out-of-pocket payments associated with health care during the period 2008–2015. Methods. The Household Budget Survey was used and catastrophic measures were estimated, classifying the households into those above the threshold of catastrophe versus below. Three ordered logistic regression models and margins effects were estimated. Results. The results reveal that, in 2008, 4.42% of Spanish households dedicated more than 40% of their income to financing out-of-pocket payments in health, with an average annual gap of EUR 259.84 (DE: EUR 2431.55), which in overall terms amounts to EUR 3939.44 million (0.36% of GDP). Conclusion. The findings of this study reveal the existence of catastrophic households resulting from OOP payments associated with health care in Spain and the need to design financial protection policies against the financial risk derived from facing these types of costs

Shadow and extended shadow cost sharing associated to informal long-term care: the case of Spain

Background: A large part of the long-term care is provided by non-professional caregivers, generally without any monetary payment but a value economic of time invested. The economic relevance of informal caregivers has been recognized in Spain; however, public provision may still be scarce. The objective of this paper is to estimate the economic burden associated with informal long-term care that should assume the families through a new concept of cost sharing that consider opportunity costs of time provided by informal caregivers. Methods: The study sample includes all dependent adults in Spain. Socioeconomic information and the number of hours of informal care was collected through the Spanish Disability and Dependency Survey. The terms of shadow and extended shadow cost sharing were defined as the difference between the maximum potential amount of money that families could receive for the provision of informal care and the amount that actually they received and the value of informal care time with respect to the amount received, respectively. Results: 53.87% of dependent persons received an economic benefit associated to informal care. The average weekly hours of care were 71.59 (92.62 without time restrictions). Shadow cost sharing amounted to, on average, two thirds, whereas the State financed the remaining third. In terms of extended shadow cost sharing, the State financed between 3% and 10% of informal care provided by caregivers. Conclusions: This study reveals the deficient support received for the provision of informal care in Spain. More than 90% of informal care time is not covered by the economic benefits that families receive from the State