Long-awaited Long-term Care

The number of older persons and their life expectancy are on the rise in many countries worldwide. As they age, some people need assistance with daily living activities, something their family is not always capable of providing. This creates a demand for professional long-term care that integrates medical and social services. How Russia can benefit from other countries' experience of providing public long-term care is discussed in a report* presented by the HSE Centre for Social Policy Studies at the XXIII Yasin International Academic Conference on Economic and Social Development hosted by the HSE University.

Support for the elderly

A pilot scheme to create a system of long-term care (LTC) has been ongoing in Russian regions since 2018 as part of the 'Demography' National Project. Designed to meet the needs of older people and those with disabilities, LTC services can support a better quality of life and increase life expectancy. In view of population ageing, this is particularly relevant and makes good economic sense.

Professional long-term care improves health and psychological wellbeing and reduces the need for hospitalisation. Longer life expectancy is associated with an increase in a healthy life span.

Russia is still at the early stages of building a long-term care system and can benefit from the experience of countries with well-established LTC services. This new report prepared by HSE experts provides a detailed overview of LTC in a number of countries, covering a range of topics from needs assessment to LTC financing and administration to quality-of-care frameworks. Lessons learned by others can help Russia develop and improve its long-term care model.

Need for long-term care

Over the last few decades, five global trends linked to socio-demographic shifts and economic policies have shaped the need for long-term care.

According to the authors of the report, 'while the turbulence currently faced by the Russian economy may limit the availability of funding for LTC in the short term, this should not be considered an argument for winding down or freezing the country's long-term care system'. The challenges which LTC is designed to address — from demographic ageing to quality of life in old age — are definitely here to stay.

Demand for long-term care is determined by a number of factors, with the authors emphasising the following five.

The high cost of providing these services accounts for more than half of the unmet need for LTC in Romania, Bulgaria, Greece, Spain and Poland, leading to income-related inequality and a lower quality of life in old age.

Family members do not always have the means — or the skills — to provide LTC. Carers can become exhausted and burned-out, in addition to having to bear significant financial costs, which can also affect the elderly relative who resents being a burden on the family.

Limited coverage

Access to LTC in Russia is far below need. In 2017, according to Rosstat, social services were provided only to 3.4% of all seniors (persons beyond retirement age) in need of assistance with day-to-day activities. By 2019, the coverage had increased to 3.6% due to more services being provided in the countryside, but not in cities. In OECD countries, on average, 11% of people aged 65 and older are receiving long-term care.

The Russian public is conscious of the service gap: 40% of social service recipients are dissatisfied with their availability and accessibility. Families have to make up for the lack of institutional long-term care. Private providers are also available, but their services are not always of good quality.

In addition to this, studies have found a relatively early occurrence of problems with mobility and perception of information in Russian seniors, making professional LTC even more relevant.

Until recently, a lack of sample-based studies to estimate the demand for services was a major barrier to developing the country's LTC model. Today, data from EVKALIPT (Epidemiological Survey of Prevalence of Geriatric Syndromes and Age-related Diseases in Elderly Residents of Russian Regions) and from the first wave of a national survey conducted in Russia as part of the Survey of Health, Ageing and Retirement in Europe (SHARE) is expected to fill this gap.

Growth of the target group and increases in service costs

The current spending on long-term care averages 1.5%–1.6% of GDP in the EU and OECD countries. Rich countries today spend less on LTC than on healthcare and pensions, but the costs of long-term care continue to increase, along with the number of people in need of it.

According to current projections, people aged 80 and older — a major LTC target group — will exceed 10% of the entire population in middle- and high-income countries within the next 80 years. Spending on long-term care in OECD countries is estimated to double by 2060 in response to changes in age distribution. In Russia, given the current low LTC spending, the increase should be much higher to meet this anticipated need.

The ageing of society is a well-established trend, but a longer healthy lifespan can reduce the demand for LTC in old age. Approaches such as geriatric services and support for family-based and community-based care can also mitigate the burden on the system.

The first lesson to be learned from international experience is that providing LTC is imperative in the current demographic context. Trying to limit investment in LTC does not make good economic sense, because it may lead to higher overall spending on healthcare and on nursing homes.

Eligibility and funding

Sources of financing long-term care in OECD countries include general taxation, mandatory social security contributions, voluntary private insurance, and out-of-pocket payments. In developed countries, the public budget usually covers most LTC costs. More specifically, some LTE funding models are tax-based with private co-payments, while some others rely on social insurance schemes, co-payments, and partial public funding.

With the exception of Nordic countries, public financing covers LTC for low-income groups, while services for the middle class are paid from private sources. Insurance-based models provide a more reliable source of social service financing and can attract additional resources into the system.

Countries can control their LTC spending by setting eligibility criteria, mainly based on some kind of functional capacity assessment. As a cost-saving approach, only people with severe limitations may be eligible, or a range of care packages with different levels of public subsidies may be available depending on the need. In some countries, such as the Czech Republic and Israel, only high-need seniors are entitled to public LTC support, while in the UK, those not considered high-need are not eligible to publicly-provided services but can qualify for benefits.

Eligibility for care may be extended, for example, to include people with cognitive impairments, as in Germany, or restricted, as in Japan, for cost-saving reasons.

Service targeting

Certain countries, such as Iceland, Canada, the U.S. and Finland, use the interRAI tool to assess care needs based on indicators of physical, mental or other disability. Current trends in developed countries include expanding the range of conditions which make a person eligible for public LTC (e.g. by adding indicators for cognitive ability and social contacts), adopting national, rather than local, policies to ensure equal access countrywide, and standardisation and transparency of the assessment process.

The approach to care needs assessment in Russia is similar to international practices. Entry into the system is based both on personal application and on proactive identification of individuals in need of LTC, and involves a comprehensive assessment of self-sufficiency levels. However, there is no formal national standard on whether the availability of family help should be factored in and what care packages are available — policies vary from region to region.

Addressing challenges

Having assessed the need for LTC, countries then have to decide which part of the services will be covered by public subsidies or by social insurance. In universalist LTC regimes (the Nordic countries), care is provided free of charge to all those who need it. While such systems are expensive, everyone is covered. Other countries have adopted a means-testing approach and assess eligibility based on income and/or assets. In minimalist systems (Cyprus, the U.S., and incresingly England), only the poorest are entitled to publicly subsidised LTC. While such systems spend less on LTC per se , they bear the extra cost of means testing and fall far short of meeting actual demand, creating inequality of access to care.

Mixed systems are a compromise option combining both universal and means-tested LTC entitlements. Either they run parallel universal schemes, each providing LTC to a limited share of people in need (Italy, the Czech Republic, Scotland); or all eligible recipients receive a public benefit, but the amount is adjusted to their income (Austria, Australia, Ireland, France); or universal and means-tested services or benefits are provided within one programme (Greece, Canada, New Zealand, Switzerland, China).

The second lesson for Russia is that LTC expenditure can be controlled by establishing eligibility criteria for public funding and requiring certain amounts of co-financing for different groups based on their need and means.

When the public budget is tight, LTC benefits may be initially targeted to those with the highest need and lowest means. Over time, given the ageing population, coverage can be extended by creating a mixed system with a range of funding options.

Governance arrangements

Deinstitutionalisation, decentralisation and integration are the key trends in LTC provision worldwide. Research across countries suggests that most older people prefer home-based care and day care facilities to institutionalisation. In OECD countries, the proportion of people receiving LTC in residential facilities dropped from 33% to 28% between 2009 and 2019. Deinstitutionalisation is a trend in Russia as well, with day care centres, adult foster homes and assisted living facilities increasingly available.

Decentralisation means that many decision-making and management functions are transferred to provincial and municipal levels. This approach promotes better targeting of care and addressing the needs of the local community. However, there is also a downside, since decentralisation may lead to unequal access to services across provinces, as has been the case in, for example, China. This risk can be mitigated by adopting uniform service standards and making federal co-financing available to support provincial LTC schemes.

The third lesson for Russia is the need to strike a good balance between decentralised and centralised functions in LTC provision to ensure adequate care needs assessment as well as equal access to quality LTC.

Integration of long-term care means that it is delivered by a team of collaborating professionals and carers who interface with the healthcare system to ensure high quality of services.

Efforts have been ongoing in Russia to integrate health and social care services for the elderly by setting up multidisciplinary care teams and information-sharing arrangements.

Quality assurance

Over the last two decades, quality of care has come to be understood broadly as promoting the patient's overall quality of life by meeting their basic needs beyond physical health. While this approach is essential, it requires a more sophisticated system of quality assurance indicators, affords care recipients a more active role in service quality assessment, and requires more flexible standards of care.

LTC quality assurance is based on administrative approaches such as licensing and accreditation, quality of care standards and compliance monitoring, and provider rankings.

Successful LTC systems also use financial incentives and information-sharing tools to support good performance.

Outsourcing LTC services to private commercial and non-profit providers can improve care delivery by making it more targeted and flexible. Making privately provided services reimbursable by the state is an effective economic incentive. However, competition among providers is required for market-based quality assurance mechanisms to work. 'In Russia, offering economic incentives to private social service providers is unlikely to be an effective approach as long as only a limited number of private providers are prepared to accept the terms and conditions of public contracts and subsidies', according to the report's authors.

Research shows that consumer power in long-term care markets is low. People who need assistance with day-to-day living activities tend to stick to one provider, even if the service quality is lacking. Thus, despite potential advantages, outsourcing LTC comes with risks that can be mitigated by contractual arrangements, accreditation, licensing and other quality control measures.

Another lesson for Russia is that a good LTC system must prioritise service quality and protection of LTC recipients' rights. Creating a long-term care information system is a vital first step in this direction.

Short-term outlook

Creating a well-functioning a long-term care system can take decades. Such systems have been taking shape in the U.K., the Netherlands, France and Sweden over the last 30 to 40 years. On one hand, the long-time horizon with substantial lags between inputs and outcomes makes performance assessment a challenge. On the other hand, international experience suggests that such systems are never set in stone but evolve in response to challenges and changes in the operational context.

The final lesson for Russia concerns the importance of data collection and critical analysis to inform policy adjustments.

In the Russian context, this means that comprehensive data from the ongoing regional LTC pilot projects must be collected and processed to inform any changes needed in the programme design before it is rolled out to the entire country.
IQ
 

*The report 'Creating a Long-term Care System: Lessons That Russia Can Learn from International Experience' was prepared as part of the 'Demography and Active Aging' area of research of the Human Capital Multidisciplinary Research Centre. Authors: Elena Selezneva, Senior Research Fellow, HSE Centre for Comprehensive Social Policy Studies; Oksana Sinyavskaya, Deputy Director, HSE Institute for Social Policy, Director, Centre for Comprehensive Social Policy Studies; Evgeny Yakushev, Leading Expert, HSE Centre for Comprehensive Social Policy Studies; Elizaveta Gorvat, Research Assistant, HSE Centre for Comprehensive Social Policy Studies; Natalya Grischenko, Junior Research Fellow, HSE Centre for Comprehensive Social Policy Studies; Darya Kareva, Junior Research Fellow, HSE Centre for Comprehensive Social Policy Studies.

Author: Olga Sobolevskaya, May 17, 2022