ContentslistsavailableatScienceDirect
Health
Policy
jo u rn al h om ep a g e :w w w . e l s e v i e r . c o m / l o c a t e / h e a l t h p o l
Mapping
variability
in
allocation
of
Long-Term
Care
funds
across
payer
agencies
in
OECD
countries
夽
Ruth
Waitzberg
a,b,c,∗,
Andrea
E.
Schmidt
d,
Miriam
Blümel
c,
Anne
Penneau
e,f,
Antonis
Farmakas
g,
Åsa
Ljungvall
h,
Francesco
Barbabella
i,
Gonc¸
alo
Figueiredo
Augusto
j,
Gregory
P.
Marchildon
k,
Ingrid
Sperre
Saunes
l,
Dorja
Voˇcanec
m,
Iva
Miloˇs
m,
Joan
Carles
Contel
n,
Liubove
Murauskiene
o,
Madelon
Kroneman
p,
Marzena
Tambor
q,
Pavel
Hrobo ˇ
n
r,
Raphael
Wittenberg
s,
Sara
Allin
l,
Zeynep
Or
e,faTheSmoklerCenterforHealthPolicyResearch,Myers-JDC-BrookdaleInstitute,JDCHill,P.O.B.3886,Jerusalem91037,Israel
bDepartmentofHealthSystemsManagement,SchoolofPublicHealth,FacultyofHealthSciences,Ben-GurionUniversityoftheNegev,Beer-Sheva,Israel cDepartmentofHealthCareManagement,FacultyofEconomics&Management,TechnicalUniversityBerlin,Germany
dAustrianPublicHealthInstitute,DepartmentofHealthEconomics&HealthSystemAnalysis,1010Vienna,Austria eInstitutderechercheetdocumentationenéconomiedelasanté(IRDES),France
fLaboratoired’ÉconomiedeDauphine(LEDa),France gUniversityofNicosiaCyprus,Cyprus
hSwedishAgencyforHealthandCareServicesAnalysis,Stockholm,Sweden
iCentreforSocio-EconomicResearchonAgeing,NationalInstituteofHealthandScienceonAgeing(IRCCSINRCA),Ancona,Italy
jGlobalHealthandTropicalMedicine(GHTM),InstitutodeHigieneeMedicinaTropical–UniversidadeNOVAdeLisboa(IHMT-UNL),1349-008,Lisbon,
Portugal
kInstituteofHealthPolicy,Management&Evaluation,UniversityofToronto,Toronto,OntarioM5T3M6,Canada lDepartmentofHealthServicesResearch,NorwegianInstituteofPublicHealth,Norway
mAndrijaStamparSchoolofPublicHealth,SchoolofMedicine,UniversityofZagreb,Zagreb,Croatia nChronicCareProgram,DepartmentofHealth,Barcelona,Spain
oPublicHealthDepartment,InstituteofHealthSciences,FacultyofMedicine,VilniusUniversity,LT-03101,Vilnius,Lithuania pNivel(NetherlandsInstituteofHealthServicesResearch),3513CRUtrecht,theNetherlands
qDepartmentofHealthEconomicsandSocialSecurity,InstituteofPublicHealth,FacultyofHealthSciences,JagiellonianUniversityCollegiumMedicum,
31-531Krakow,Poland
rAdvanceHealthcareManagementInstituteandCharlesUniversityinPrague,CzechRepublic
sCarePolicyandEvaluationCentre,LondonSchoolofEconomicsandPoliticalScience,LondonWC2A2AE,UnitedKingdom
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received30October2019
Receivedinrevisedform21February2020 Accepted22February2020 Keywords: Long-termcare Equity Fundsallocation Payeragencies Allocationformula
a
b
s
t
r
a
c
t
Introduction:Long-termcare(LTC)isorganizedinafragmentedmanner.Payeragencies(PA)receive
LTCfundsfromtheagencycollectingfunds,andcommissionservices.Yet,distributionalequity(DE)
acrossPAs,apreconditiontogeographicalequityofaccesstoLTC,hasreceivedlimitedattention.We
conceptualizethatLTCsystemspromoteDEwhentheyaredesignedtoseteligibilitycriterianationally
(vs.locally);andtodistributefundsamongPAsbasedonneeds-formula(vs.past-budgetsorgovernment
decisions).
Objectives:Thiscross-countrystudyhighlightstowhatextentdifferentLTCsystemsaredesignedto
promoteDEacrossPAs,andtheparametersusedinallocationformulae.
Methods:Qualitativedatawerecollectedthroughaquestionnairefilledbyexpertsfrom17OECD
coun-tries.
夽 OpenAccessforthisarticleismadepossiblebyacollaborationbetweenHealthPolicyandTheEuropeanObservatoryonHealthSystemsandPolicies. ∗ Correspondingauthorat:TheSmoklerCenterforHealthPolicyResearch,Myers-JDC-BrookdaleInstitute,JDCHill,P.O.B.3886,Jerusalem91037,Israel.
E-mailaddresses:[email protected](R.Waitzberg),[email protected](A.E.Schmidt),[email protected](M.Blümel),
[email protected](A.Penneau),[email protected](A.Farmakas),[email protected](Å.Ljungvall),[email protected](F.Barbabella),
fi[email protected](G.F.Augusto),[email protected](G.P.Marchildon),[email protected](I.S.Saunes),[email protected](D.Voˇcanec), [email protected](I.Miloˇs),[email protected](J.C.Contel),[email protected](L.Murauskiene),[email protected]
(M.Kroneman),[email protected](M.Tambor),[email protected](P.Hrobo ˇn),[email protected](R.Wittenberg),[email protected](S.Allin), [email protected](Z.Or).
https://doi.org/10.1016/j.healthpol.2020.02.013
0168-8510/©2020TheAuthors.PublishedbyElsevierB.V.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4. 0/).
492 R.Waitzbergetal./HealthPolicy124(2020)491–500
Results:11outof25LTCsystemsanalyzed,fullymeetDEaswedefined.5systemswhichgivehigh
autonomytoPAshavedesignswithlowlevelsofDE;whileninesystemspartiallypromoteDE.Allocation
formulaevaryintheircomplexityassomesystemsusesimpledemographicparameterswhileothers
applysocio-economicstatus,disability,andLTCcostvariations.
Discussionandconclusions:AminorityofLTCsystemsfullymeetDE,whichisonlyoneofthecriteriain
allocationofLTCresources.Somesystemspreferlocalpriority-settingandgovernanceoverDE.Countries
thatvalueDEshouldharmonizetheeligibilitycriteriaatthenationallevelandallocatefundsaccording
toneedsacrossregions.
©2020TheAuthors.PublishedbyElsevierB.V.ThisisanopenaccessarticleundertheCCBY-NC-ND
license(http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction
LongTermCare(LTC)isasetofservicesaimedtoreduceor man-agethedeterioration in healthstatus inpatientswitha degree oflong-termdependency,ortoalleviatepainand suffering[1]. Itincludes personalcare, i.e.help withactivitiesofdaily living (ADL)suchaseating,bathing,washing;socialcare,i.e.assistance servicesthatenableapersontoliveindependentlyhelpingwith instrumental activities of daily living (IADL) such as shopping, laundry,cooking;cashallowancestobuytheaforementioned ser-vices,i.e.monetarybenefitsforpeoplewithneedsforADLand/or IADL;andmedicalornursingLTC,e.g.wounddressing, adminis-teringmedication, healthcounselling, palliativecare,painrelief andmedicaldiagnosiswithrelationtoalong-termcondition[2]. AsneedforLTCcontinuestogrow,itwillrepresentincreasingly significantexpensesforhealth and social caresystems inmost high-incomecountries,aswellasfortheolderpeopleandtheir families[3].Therefore,accesstoLTC,particularlypublicly-funded LTC,isanimportantpublicpolicytopicbeingdealtwith policymak-ersinmanyhigh-incomecountries.Recentstudieshaveanalyzed issuesofequityinaccesstoanduseofLTCofdifferentpopulations amongandwithinEuropeancountries[4–8].Fromapublicpolicy perspective,thequestion ofallocation of authority in decision-makinginhealthandsocialcareisnottrivial,andpopsupalsoin debatesaroundcentralizationversusdecentralizationofauthority overlaws,moneyandresources[9].Theliteraturerelatedtothe publicfundingofLTCatthesystemleveldealsmainlywith col-lectionoffunds.For example,studiesanalyzethevarioustypes oftaxationorinsurance,theiradvantagesanddisadvantages,the amountandshareofpublicfunding,ineachcountry[10,11].Only afewstudiesfocusontheallocationofpublicfundstoLTCpayer agencies (PAs)[12,13]. Usually, multiplePAsreceive publicLTC fundsfromanationalorlocalcollectoroffunds,andcommissionor purchaseLTCservicesfromprovidersonbehalfofrecipients[14]. Alternatively,PAsprovidecashbenefitstorecipients(seeFig.1).
Fig.1. RepresentationofLTCpubliclyfundedsystemsandthepayeragency. Source:adaptedbyauthorsbasedon[14].
Incountrieswithmultiplepayers,PAscanbelocalgovernmentsor health/LTCinsuranceplans,whileincountrieswithasinglepayer, thePAcanbethecentralgovernmentitselforanotheragencysuch asthenationalinsuranceinstitute. In singlepayersystems,the agencythatcollectsfunds,usuallythecentralgovernment,isalso thePA,asitcommissionsservicesfromprovidersortransferscash benefitstorecipientsdirectly.PAs,thus,haveanimportantrole incommissioningtheLTCservicesandensuringtheirsupplyfor thoseinneed,accordingtoeligibility,inanequalandefficientway [15].Wearguethat thewayresourcesareallocatedamongPAs andthelevelofgovernmentthatsetseligibilitycriteriaisa pre-conditionfor equityinaccesstoLTC.Our paperanalyzesissues ofequityinresourceallocationfromapublicpolicyperspective, andfocusesonthePA,ratherthantheindividual,asunitof analy-sis.
Analyzing “equity” in public policy involves understanding “whogetswhatandbywhatrules”.Severalnormsorcriteriacanbe appliedtoallocatepublicresourcesorservicesamongindividuals, populations,regionsorPAs.AccordingtoBlanchard[16]thereare seventypesof‘fairness’normsbywhichpublicresourcesor ser-vicescanbeallocated:(1)strictequality,everybodygetsthesame shareofservices;(2)need,sharesaredistributedinproportionto individuals’needs;(3)effortormoneyexpended,wheresharesare distributedaccordingtotheeffortsormoneypeopleinvestedfor thepublicservice;(4)results,i.e.sharesofservicesaredistributed inproportiontotheresultsexpectedforeachindividual;(5) ascrip-tion,sharesareallocatedaccordingtopredefinedcharacteristicsof individualssuchasage,gender,socioeconomicstatus;(6) proce-dure,sharesareallocatedaccordingtoacertainproceduresuchas ‘firstcome,firstserve’,orlottery;and(7)localdemandor prefer-ence[16].Thesenormsmayvaryamongcountriesdependingon theircultureortradition.WeadoptDaniel’s[17]definitionof dis-tributionalequityasthe“mostdesirabledistributionofgoodsand servicesinaneconomy”,choosingthenormof‘need’asthemost desirablewaytodistributeLTCresourcesamongPA.Ifresourcesare distributedaccordingtoothercriteria,non-needs-relatedfactors suchassocio-economicordemographiccriteriamaygain impor-tance:forinstance,thegapsbetweenrichandpoor,oryoungand oldregionsmaywidensincerichoryoungareasareina better positiontocollectfunds.Yet,regionswithamoreadvantageous socio-economicstructure(e.g.lowershareoflow-incomegroups, younger)alsotendtohavealowerneedforlong-termcarethan otherregions.Poolingresourcesandredistributingthem accord-ingto‘need’maypotentiallyimproveallocationofresources,and promoteequityamongregions.Therefore,weusetheterm ‘dis-tributionalequity’referringtoLTCsystemdesignsthatdistribute resourcesamongregionsorPAbasedonneedandpromoteequity amongresidentsoftheseregions/PAs.While,weacknowledgethat othernormsmaybealsousedfor allocatingresources,we pro-poseinthispaperaconceptualframeworkof‘distributionalequity’ basedonneed foranalyzing LTCsystemsacrosscountries(Box 1).
Box1:Termsdictionary
Long-term care (LTC): setof servicesaimed to reduceor managethedeteriorationinhealthstatusof patientswitha degreeoflong-termdependency,ortoalleviatepainand suffer-ing[1].Itincludespersonalcare,socialcare,cashallowances, andmedicalornursingLTC[2].Inthisworkweexcluded med-icalornursingLTCfromouranalysis.
Payer agency(PA):agencythatreceivespublicLTCfunds fromanationalorlocalcollectoroffunds,andcommissionsor purchasesLTCservicesfromprovidersonbehalfofrecipients. Eligibilitycriteria:criteriabywhichentitlementto publicly-fundedLTCcare,andtherespectivesizeofthe(cash)benefit, typeandamountof(inkind)care,andassuchalsothebasket ofservicesitself,aredetermined.Examplesofcriteriaareage, dependencylevel,cognitiveimpairmentlevel,functional dis-ability.Thesecriterialeadtorules,toolsoralgorithmsusedto assessindividuals’eligibilitytoLTC.
Horizontalequity:equaltreatmentofpeoplewhohave sim-ilar‘needs’forcareandsupport,i.e.equalaccesstocarein termsofcarepackagesforindividualswiththesameneed. Distributional equity(DE): payer equity,which meansin manycountries geographicalhorizontal equity of accessto careservices.WedefineaLTCsystemaspromotingDEif:(1) therearenationaleligibilitycriteria(notdifferentcriteriain dif-ferentregions)and(2)resourcesareallocatedtoPAsbased onneed-formula(alternativelyifthereisasinglepayersystem whereitisthesameagencythatcollectsthefundsisthePA)
2. Conceptualizingdistributionalequityinthecontextof LTC
PAsneedtoreceivetherespectivefundstocommissionLTC ser-vices(yellowarrowinFig.1).Wearguethatdistributionalequity (DE)ofLTCfunding,apreconditiontogeographicalequityofaccess (of individuals) to LTC,is stronger when two following condi-tionsaremetinthenationalLTCsystemdesign.First,whenthere isa common/standardized eligibilitycriteria, determinedatthe nationallevelratherthanbeingsetataregionallevelwith vari-ances,ornotbeingdefinedatall.Eligibilitycriteriadefinestherules ofentitlementtopublicly-fundedcare,andtherespectivesizeof the(cash)benefit,typeandamountofcare,andservices.Wealso arguethatthereshouldbeconsistentrules toidentify individu-alsin needofLTC,andthus ensurehorizontalequity,definedas equaltreatmentforequalneed.ThesecondconditionofDEisthat fundsaredistributedina‘fair’manner,itmeans,usingobjectiveand transparentcriteriathatreflectLTCneeds:theyareredistributed toPAsaccordingtotheneedsofthepopulationtheyservethrough aneeds-formula.Distributionoffundsaccordingtoa(predicted) needs-formulaalonedoesnotpromoteDE,ifeachregion/PA com-missionsadifferentsetofservices,ordoessoaccordingtodifferent eligibilitycriteria.Therefore,accordingtoourconceptual frame-workboth conditions shouldbemetconcomitantlyin orderto promoteDE(Fig.2).
Inourconceptualframework,DEiscomposedbytwoelements ofLTCsystemdesign.Thefirstrelatestoeligibilitycriteriatoaccess topublic-fundedLTC,which differsfromindividual assessment (verticalaxisinFig.2).Eligibilitycriteriaplayanimportantrole intheanalysisofdistributionalequity,becausetheyrepresentthe ‘gateway’orcommonprinciplesforaccessingpubliclyfundedLTC [18].Needforcare,i.e,ifanindividualhasdifficultieswithpersonal ordomesticcareandwouldbenefitfromassistance,isnot neces-sarilythesameas“needforpublicly-paidcare”,anditiseligibility criteriathatdeterminestheamountsandtypesofpublicly-funded formal care that the individualin need willreceive, while the remainingneedisusuallycomplementedbyunpaidor privately-paidcare[18,19].Weassumethattoassurehorizontalequity,PAs
shouldcommissionthesametypesofcareaccordingtoneeds,i.e. sameeligibilitycriteriaacrossPAs.Thisoccurswheneligibility cri-teriaaresetatthenationallevel,orinsystemswithasinglepayer (topofverticalaxisinFig.2).Wheneligibilitycriteriaaresetat thelocallevelorbyPAs(bottomofverticalaxis),theremightbe unwarrantedvariationsinthetypesandamountsofcare commis-sionedonbehalfofindividualswiththesameneedacrossregions or PAs,thushamperingDE. Harmonizedcommissioningof ser-vicesdoesnotnecessarilymeancommissioningenoughquantities oradequatetypesofservices.Eligibilitycanbegenerousortight regardlessthelevelthatsetsit.
ThesecondelementofLTCsystemdesignthatcontributesto dis-tributionalequityisthelevelofconcentrationandpoolingofLTC funds,andthewayfundsareallocatedtoPAs(horizontalaxisin Fig.2).Weconceptualizethatdistributionalequityislargerwhen LTCfundsarepooledbycentralgovernmentoragencyand real-locatedamongPAsacrossregions accordingtoaneedsformula (rightsideofhorizontalaxis)orinasinglepayersystem,wherethe agencythatcollectsandpoolsfundsisalsothePA.Therationale isthatpoolingandredistributionoffundsenablescross-subsidy betweenpoorandrich,oldandyoung,orunhealthyandhealthy individualsorareas,whichinturn,promotesafairerdistribution offunds[14].Relativeneedsformula toallocatecentral govern-mentfundsstrengthenthelinkbetweenprovisionandneed[20]. Distributionoffundsaccordingtoaneedformulaisalsoa mecha-nismtoensurelocalgovernmentsthemeanstosupplyuniformcare [21].Themore ¨objective ¨andneeds-basedthedistributionoffunds, thefaireritis.WearguethatcountrieswithLTCallocation formu-lasbasedonneedsorrisks,haveafairerwayofdistributingLTC fundsthancountrieswhere,forexample,pastbudgetisinplace, orwherelocalauthoritiescollectthefundsthemselvesbutdonot poolandredistribute(leftsideofhorizontalaxis).Usingprior uti-lizationandexpendituretoallocatefundsamongPAsissomewhat arbitraryandmayperpetuateinefficienciesandinequities[20,21]. InsystemswithcompetingPAs,pastbudgetsalsocreateincentives forriskselectionagainstsomeeasilyidentifiablesubgroups[12]. Innon-competitivesystems,anunequaldistributionoffundsmay leadtodelaysorunwantedrationingofcare,orunequalincreases inlocaltaxesandusercharges,thushamperingequityinaccess tocare[20].Weemphasizethatafairallocationoffundsdoesnot meanthatLTCsystemsallocateenoughamountsoffunds.Fair allo-cationisnotdirectlyrelatedtothegenerosityofthefunds,andthere mightbeshortagesoffundseveninafairallocationsystem.
DEpromoteshorizontalequity,withharmonizednational eli-gibilitycriteriaforagivenlevelofneedandverticalequity,where moneyfollowsneed,andareallocatedbasedonanobjective needs-formula.Itisanecessarypreconditionforequityofaccessatthe populationlevel,althoughnotsufficientalone.WithoutDE,two peoplewiththesamelevelofneed,mightbeeligibletodifferent typesorquantitiesofcareacrosspayers,or thesepayersmight haveadifferentabilitytopurchasethecareneeded.Butitisalso importanttoreducebarriersonthedemandside,suchaslackof information,administrativehurdle,complexityofclaiming.Onthe supplyside,variationsinthequalityofcareprovidedacrossPAs mayexist[22,23].
Summarizing,aLTCsystemisdefinedtopromoteDEif: i)Therearenationaleligibility criteria(notdifferentcriteriain
differentPAs/regions)AND
ii)ResourcesarepooledandreallocatedtoPAsaccordingtoa need-basedformula(alternativelyifthereis asinglepayersystem whereitisthesameagencythatcollectsthefundsandisPA) Fromtheconceptualframeworkaboveweidentifythree mod-elsof ¨LTCequitydesign¨:(1)designsthatmeetDE(singlepayeror need-basedallocationofresourcesandeligibilitycriteriauniform
494 R.Waitzbergetal./HealthPolicy124(2020)491–500
Fig.2.Conceptualframeworkofthedimensionsofdistributionalequity.
acrosscountry);(2)systemsthatpartiallymeetDE,i.e.mixed dis-tribution(systemswhereeitherallocationisnotbasedonneeds formulaoreligibilitycriteriaisnotsetatthenationallevel);and (3)systemsthatdonotmeetDE(neitherallocationisbasedonneed noreligibilityisunified).
3. Objectives
OurstudyaimstohighlighttowhatextentdifferentLTC sys-temsaredesignedtopromoteDEamongPAs,across25countries usingtheconceptualframeworkpresentedabove.Wecontribute totheliteratureonLTCequityinthreemainways.First,wepresent acomprehensivecross-countrycomparisonofLTCsystemdesigns. Second,wecomparetowhatextentLTCsystems’designpromote DEacrossPAs:weanalyzewhatlevelofgovernmentsetseligibility criteriaandhowcountriesallocatefundstoPAs,focusingonthe dis-tributionformulae.Third,wedescribeandunpacktheparameters usedbythedifferentcountriesintheirneeds-allocationformulae. Itisimportanttonotethatweanalyzethecountries’LTCsystem design,notthegenerosityoffundsor thecontents, amountsor typesofcare,orhowimplementationisdoneinpractice.
4. Methods
Thedataandinformationpresentedinthispaperarecollected bytheauthorswhoareexpertsfromtheEuropeanObservatory’s HealthSystemsandPolicyMonitor(HSPM)network(https://www. hspm.org/hspmmembers.aspx) or are experts on LTC beyond HSPM.Inordertocollectdetailedqualitativedataina compara-blemanner,RWandAESdevelopedaquestionnairebasedonthe conceptualframework(seesupplementaryonlinematerial).
The questionnaire included all settings of LTC(home, insti-tutions and day care centers) and different types of services formedical,personalcare,socialcare,and cashallowances.We decidedtoexcludemedicalornursingLTCbecauseinmost coun-triesthatparticipatedinthestudytheseservicesarepartofthe healthcaresystemforwhicheligibilityrulesandissuesaredifferent comparedwithLTC/social systems.Alsothere isa broad litera-tureonthistopicinhealthcare(poolingandallocationoffunds, andbasketofservicesandeligibilitycriteria),thuswepreferred tofocusonnon-medicalLTCinthecurrentarticle.SincemostLTC fundsarededicatedtoolderpeople,wedonotexaminespecificLTC conditionsfordisabledyoungpeopleorchildren.Finally,aswe ana-lyzeLTCsystemdesigns,welimitedourstudytopubliclyfunded servicesorinformalcarethatisreimbursedbythegovernments.
Theexperts(co-authors)filledthequestionnairesentbyemail betweenNovember2018andApril2019,andhelpedtoanalyzethe data.AnalysisofthedataaimedtodescribeLTCsystems,not coun-tries,asonecountrymayhavemorethanonesystemdepending onwherethecareisprovidedandtypeofcare(e.g.institutionalvs.
communitycare),ortypeofbenefit(inkindvs.cash).LTC-systems arenotedusingthecriteriadefinedinourconceptualframework inordertoconsolidatemodelsofLTCregardingthelevelofDE. Finally,wesummarizedandanalyzedthecomponentsofallocation formulaeofthevarioussystems.Alltheresultswerereviewedand crosscheckedbytheauthorsinordertoenhancetrustworthiness.
5. Results
5.1. LTCsystemsdesignandtheextenttowhichtheypromote distributionalequity
Table1presentsthesummaryofthedataprovidedby country-expertsaboutthecomponentsandconditionsofLTCsystemsthat composeDE. Regardingeligibility, in15 out ofthe25 LTC sys-temsanalyzedseteligibilitycriteriaatthenationallevel.InSpain, Canada,theNetherlands,Poland(forcommunitycare),andAustria andItaly(inkindbenefits),LTCsystemsaredecentralized,andlocal governments(healthinsurers/plansfortheNetherlands)arefree todecideontheeligibility,i.e.thetypesandamountsofcarethey payfor.Norway,Sweden,France,PortugalandEnglandsetbasic eligibilitycriteriaatthenationallevelbutlocalgovernmentsor authoritiesfurtheradjustandredefineit.
Regardingallocationoffunds,inmostcountries,theagencythat collectsthefundsforLTCisthecentralgovernmentora combina-tionofthecentralwithsubnational(regionalorlocal)governments. Fromoursample, in onlyin two systemswerethemajority of fundscollectedsub-nationally:CanadaandGermany.InGermany, individualsareassignedanLTCplanassociatedwiththespecific healthplanofthatindividual.GermanLTCplanscollectfunds sep-aratelyfromhealthplans,butdonotcompeteonmembers,funds orservices.FundsfromLTCplansinGermanyarepooledand redis-tributedretrospectivelyaccordingtodefactoexpenses.InCanada, roughly77%ofthefundsarecollectedbythePA(provincesand ter-ritories)butthesearenotpoolednationally.Theother23%come fromfederaltransferstotheprovincesandterritoriestofundtheir healthcaresystems.Thesefundsarenot earmarkedandarenot pooledorredistributedacrossprovincesandterritories.InCanada, theuniversalhealthcoveragesystemdoesnotincludeLTCservices, whichareadministeredandlegislatedsolelyattheprovincialand territoriallevels.Therefore,thereisnomechanismforensuring dis-tributionalequityacrossthecountryintheLTCsectorasthereis withhospitalsandphysicianservicesundertheCanadaHealthAct. ThreeoutofeighteenLTCsystemswithmultiplepayersdonotpool andredistributefundsnationally(Canada,theNetherlands (com-munity,IADL/daycare)andGermany,thathasretrospectiverisk equalization).
Incontrastwiththestarkdominanceofcountrieswherea cen-tralcollectoroffundsispresent,inmostsystemstherearemultiple payers.Onlyinsevenoutofthe25systemsthereisasinglepayer
R. Waitzberg et al. / Health Policy 124 (2020) 491–500 495
ComponentsofLTCsystemsthatcomposedesignmodels,bycountry.
Country Whatagencysets
eligibilitycriteriafor theLTCservices?
Whatagencycollects thefunds?
WhatisthePA? Arefundspooledand
redistributed?
Howarethey redistributed?
Sources
Austria(cash) Centralgovernment Centralgovernment Centralgovernment N/A [24–27]
Austria(inkind) Localgovernments Centralgovernment Localgovernments yes Allocationformula
Canada Regionalgovernments
(provinces) Regionalgovernments about77%,federal transfersabout23% Regionalgovernments (provincesand delegatedhealth authorities) no [28–33]
Croatia(institutional) Centralgovernment CentralandLocal governments
Centralgovernment N/A [34–40]
Croatia(community) Centralgovernment Centralgovernment Centralgovernment N/A
Cyprus Centralgovernment Centralgovernment Centralgovernment N/A [41,42]
CzechRepublic(cash) Centralgovernment Centralgovernment Centralgovernment N/A [43,44]
CzechRepublic(inkind) Centralgovernment Centralgovernment (85%)andhealthplans (15%)
Localgovernments yes Pastbudget
France(community) Centralgovernment Central(40%)andLocal governments(60%)
localgovernment yes(40%) Allocationformula [45–47] France(institutional) Centralgovernment CentralandLocal
governments
localgovernment yes(40%) Allocationformula
Germany Centralgovernment LTCplans,
administeredbythe healthplans
LTCplans yes expenses(equalization
fund)
[48,49]
Italy(inkind) Localgovernments CentralandLocal governments
Localgovernments partially Governmentdecisions andlocalauthorities collectedfunds
[50–55]
Italy(cash) Centralgovernment Centralgovernment Centralgovernment N/A
Israel Centralgovernment Centralgovernment Centralgovernment N/A [56,57]
Lithuania Centralgovernment Centralgovernment CentralandLocal governments
yes Pastbudgetand
formula
[58–66] theNetherlands(institutional) Centralgovernment Centralgovernment Healthplans(care
offices)
yes Allocationformula [67–70] theNetherlands(community,ADL) Districtnurses Healthplansand
Centralgovernments
Healthplans yes Allocationformula
theNetherlands(community,IADL/daycare) Localgovernments Centralgovernment Localgovernments no
Norway Localgovernments Centralandlocal
government
CentralandLocal governments
yes Allocationformula [71–74] Poland(institutional) Centralgovernment Centralandlocal
governments
Localgovernments Paritally pastbudetand governmentdecision
[7576–80] Poland(community) Localgovernments Centralandlocal
governments
Localgovernments Partially pastbudgetand governmentdecision
Portugal Centralgovernment Centralgovernment Localgovernments yes Allocationformula [81–84]
Spain Localgovernments CentralandLocal
governments
Localgovernments yes Automaticupdates [85–88]
Sweden Localgovernments CentralandLocal
governments
Localgovernments yes Allocationformula [89,103,104]
UK(England) CentralandLocal
governments
Centralandlocal governments
496 R.Waitzbergetal./HealthPolicy124(2020)491–500
Fig.3.DistributionofLTCsystemsaccordingtothemodelsofsystemdesign.
wherethecentralgovernmentisalsothePA(AustriatheCzech RepublicandItalyforcashbenefits,Cyprus,Croatiainstitutional andcommunitycare,andIsrael).Fromtheremainingeighteen sys-tems,tendistributefundsaccordingtoaspecificLTCneeds-based formulaand theothereight do sobasedonpast budgets, gov-ernmentdecisionsorageneralpublic-servicesneedsformula.For example,IntheNetherlands(community,IADL/daycare)fundsare collectedatthenationalleveltogetherwithfundsforother ser-vicessuchaseducation,andaredistributedoverthemunicipalities accordingtoanallocationformulathatincludes,amongother crite-ria,expectedneedforLTC.However,sincefundsarenotearmarked, oncefundsareallocated,municipalitiescanspendthebudgetas theylike(althoughtheyhaveastatutorytasktoprovideiADLcare). Somemunicipalitiesoverspendtheallocatedbudget,whereas oth-ersunderspend,thusleadingtovariationsinthebudgetavailable relativetotheexistingneeds.Fig.3presentsthecountriesinour sampledistributedamongtheLTCmodels.
Thedetailedmodelsareasfollows:
ISystemsthatmeetDE
1Eligibility set nationally, Funds collected nationally,single payer:Austria(cashbenefits),Croatia(institutionaland com-munity),Cyprus,CzechRepublic(cashbenefits),Israel,Italy (cashbenefits)
2Eligibilitysetnationally,Fundspooled,andredistributedto multiplepayersbasedonneeds-formula:Germany,Lithuania, theNetherlands(institutionalcare),Portugal
IISystemsthatpartiallymeetDE
1Eligibilitysetnationally,Fundscollectedlocally,notpooled (noredistribution):Italy(cashbenefits),France(40%pooled andredistributedbasedonneedformula,therestislocally collected),Poland(institutionalcare)
2Eligibilitysetnationally,Fundscollectedcentrally,and redis-tributed based on past budget: Czech Republic (in kind benefits)
3Eligibilitysetlocally,Fundspooled,andredistributedto multi-plepayersbasedonneeds-formula:Austria(inkindbenefits), England, the Netherlands (IADL, day care, ADL), Norway, Sweden
IIISystemsthatdonotmeetDE
1Eligibilitysetlocally, Fundspooledandredistributedbased onpastbudgetsorgovernmentdecision:Poland(careinthe community)
2Eligibility set locally, Funds collected locally, not pooled (no redistribution): Canada, Italy (in kind benefits), The Netherlands(communityIADLcare),Spain
5.2. Allocationneeds-formulasandparameters
Roughly half of the systems with multiple payers allocate resourcesamongpayersbasedonaLTCneeds-formula(France– 40%,Lithuania,Portugal,Norway,Sweden,Germany,England,the NetherlandsforinstitutionalcareandcommunityADLcare,Austria forinkindbenefits;CzechRepublicdoesthatfor15%ofitsbudget) (seeTable2).SwedenandNorwayapplydemographicparameters suchasmaritalstatus,inordertoreflectexistenceofalternative informalcare.Theyalsoconsiderspokenlanguageandresidence insparselypopulatedareas,in ordertoreflect specialcaregiver needs. A few countriesdeveloped formulas that takeinto con-siderationfurtherriskadjusterssuchasdisabilityordependency levelorchronicdiseases(theNetherlands,England)and/or previ-ousyears’expenditures(Austria,France,Norway).Francefurther considersocioeconomicparameterssuchasnumberofallowance claimantsandincomeofelderlyintheregionunderresponsibility ofthelocalauthority.InEngland,theneeds-basedallocation for-mulaetakeaccountofdifferencesbetweenareasinwagerates,in ordertorecognisedifferencesinthecostsofcaredrivenbyfactors outsidethecontrolofpayers(localauthorities)andproviders.In Germany,althoughfundsarepooledfromLTCfunds,reallocation occursonlyretrospectivelyaccordingtodefactoexpenditures.For thedetailedformulasofeachcountryseeonlinesupplementary material.
6. Discussion
InthispaperweproposeaconceptualframeworkwhereDE pro-motesbothhorizontalequity,withharmonizednationaleligibility criteria;andverticalequity,asfundsareallocatedbasedon objec-tiveneeds-formulas.WearguethatDEisanecessaryprecondition forequityofaccessatthepopulationlevel,althoughnotsufficient alone,asinimplementationtherecouldbegapsorinconsistencies [7,8].Weanalyzedfeaturesof25LTCsystemsdesignin17countries tounderstandtowhatextenttheypromoteDEofresourcesfrom asystemdesignperspective.Accordingtoourconceptual frame-work,11systemsarecharacterizedbyadesignthatmeetDE,i.e. eligibilityissetatthenationallevelandallocationoffundsamong PAsisbasedonaneeds-formula,orthereisasinglepayer.Infive systems,thedesigndoesnotpromoteDEacrossPA,theseare usu-allyfederalordecentralizedsystems,whichgiveautonomytoPAs. Finally,inanotherninesystemsthesystempartiallypromotesDE. UsuallyinstitutionalcaredesignsmeetmoreDEthancommunity care.Inkindbenefitsareusuallydesigned partiallymeetingDE, whilecashbenefitsusuallymeetDE.Wefoundthatinroughlyhalf oftheLTCsystemswithmultiplepayers,fundsareallocated
accord-Table2
Parametersusedfordistributingpooledfundsbycountry*. Demographic(age,gender, maritalstatus,household composition)
Socio-economic(income, education,allowance claimants)
Health/disabilitycondition (numberofADLlimitations, chronicconditions,levelof helpneeded)
LTCcosts(previousyear,and expected)
Austria(inkind) x
CzechRepublic(15%) x x
France x x x
Germany x
Lithuania x
theNetherlands(institutional) x
theNetherlands(community) x x x
Norway x x x
Sweden x
UK(England) x x x x
(*)Note:datafromPortugalwasnotavailable.
ingtoaneeds-formulaandtheotherhalfiseithernotpooled,or pooledandredistributedaccordingtopastbudgetsorgovernment decisions.Someoftheallocationformulaeweresimple,andmight missfactorsthatinfluencetheriskofneedingLTC.Forexample, exceptSweden,LTCsystemsdonotadjusttheirformulaefor ethnic-ity,orfortypeofimpairmentsuchascognitive,physicalfunctions, neurologicaldiseases.Whileforhealthcarethereisavastliterature onriskadjustmentallocationformulasandmechanisms[91,92,20], forLTC,literatureisscarce[93].ThecomplexityofLTCsystemsand thedifficultyofpredictionoffuturecostsofLTCmightcreate bar-riersforafairdistributionoffundsbasedonneed.Alternatively, allocationofresourcestopayersisapartofLTCsystemdesigns thathasnotreceivedenoughattentionyetoritisbelievedthatthe riskofneedingLTCismorehomogeneouslydistributedcompared toacutecare.Whatissureisthatriskadjustmentformanysettings ofLTCisstillimmature[94].
DEinLTChas,forsometime,beenofconcerntopolicy-makers and researchers alike, especially aspublic resources are scarce and demandfor LTCis boundtoincrease [95]. Regional differ-ences,sometimescoinedastheproblemof‘postcodelottery’[96], ariseinLTCasthisfieldofpublicpolicyhasemergedfromsocial care,inmostcountriesisundertheresponsibilityoflocal govern-ments[97].Regionaldifferences canpointtolimitedhorizontal equityinaccess.Toourknowledge,fewcomprehensive empiri-calanalysesexisthithertoonhowLTCresourceallocationdesign divergesregionally,andhowsuchdifferencesmightbetiedtothe mechanismsunderlyingLTCfundallocationandharmonizationof eligibilitycriteriaacrosscountries.FernandezandForder[98] iden-tifiedregionalvariancesinsocialcarepercapitaexpenditureacross Englishlocalauthorities.Theymentionthatpartofthisvariation maybeduetodifferentregionalsupply conditionssuchas dif-ferentqualityorcostsofprovidersordifferentcapacitytoraise localrevenue duetovariationsin thepopulationwealthinthe differentregions.Inarecentstudy,GoriandMorciano[99] com-parehowcash-for-carebenefitsvaryincoverage,policymixand generosityin6Europeancountriesovertime,buttheirstudydoes notrelatetoin-kindbenefitsnortoabroadrangeofOECD coun-tries.TwodifferentrecenttrendsinLTCsystemdesignsmayaffect theroleofPAsandtheneedofallocationmechanismsinopposite directions.Thefirst,isthatorganizationandregulationofcareis increasinglybeingdecentralizedandpassedontolocalauthorities, basedontheassumptionthat,iftheprovisionofcareisorganized closetotherecipient,thiswillleadtomoreappropriatecare solu-tions[10,13,100,101].Inthiscase,Pas’rolemayincrease,andso maytheneedofanaccurateandtransparentneeds-formula.The secondtrendistheshiftfromin-kindtocashbenefitsinorderto promoteflexibilityforrecipientsinthewayandtypeofcareof theirpreference[99,101].ThetendencyistoskipPAsandtransfer fundsdirectlyfromcentralgovernmentstotherecipientsthrough
personalbudgets.ExamplesareAustria,Italy,theCzechRepublic. Ifthistrendcontinues,allocationofresourcesislikelytochange, andtheroleofthePAmightdecrease.
InthisworkweassumedthatDEisamainobjectiveofresource allocationforLTCandthatthenormtodistributeresourcesshould be‘need’.However,DEmightnotalwaysbetheobjectiveofaLTC system,assomesystemsregardmorelocalutilities,i.e.theextent towhichlocalitiesvalueandprioritizeLTC,andpreferproviding localauthoritieswithautonomyandflexibilitytosetoradapt eli-gibilitycriteriaandhowtospendtheirmoney.Aswedescribedin theintroduction,therecanbevariousnormsthroughwhichpublic policyresourcescanbedistributed[16].Inthesesystems,thenorm chosentodistributeresourcesmightbe‘preference’.Forexample, inalocalitypeoplemightvaluemoreeducationthanLTC,orwithin LTC,preferinformalcare,orpreferinstitutionalcareorhaveother alternatives,thaninanotherlocality.Thereisatensionbetween DEandlocalpreferencesandutility,andsystemsthatchooselocal utilitydonotallocatefundsbasedonaformulanecessarily,but considerlocalpreferencesandpriorities[97].Weidentifya trade-offbetweenlocalutilityandDE:whilelocalutilityfavorschoice, prioritysettingandcostconsciousnessatthelocallevel,it may leadtoregionalvariationinaccessandqualityofLTCservicesdue tovariationinlocalincomeandpriorities.Similarly,DEmayreduce regionalvariationattheexpenseoflocalpriority-settingandcost control[102].
6.1. Limitations
LTCsystemsarecomplexand,inourattempttoclassifyeach countryintoamodel,wecouldnotanalyzeeveryLTCcomponent ortypeofcareindetail.Inotherinstances,countries’systemsmay notfitthecategoriesweuseintheirentirety.Forexample,the dif-ferentnuancesofservicesforADLandIADL,ortheextenttowhich eligibilitycriteriaisobjectiveorcanvarybyevaluationagent. How-ever,theadvantagesofobservingvariouscountries’experiencesin across-countrycomparisonoutweighthedisadvantagesoflosing eachcountry’sdetails.Anotherlimitationofthisstudyisthatdata wascollectedbasedonresearchers’knowledge,policydocuments andliterature.However,sometimesdetaileddataisnotavailable, forexample,theexactdistributionneed-formulas.Theabsenceof documentationonneeds-basedformulais,inandofitself,valuable informationontheimportanceofequityinthesystem,whichhas beenoverlookedbypolicymakers.Publicpolicyisnotalways trans-parentordoneinamethodicalmanner,andthisworksattempts tounpackpartoftheLTCpolicy-making,whichisoneofthemost relevantnowadays.Finally,thisworkanalysesLTCsystemsdesign, therefore,itcannottellifimplementationofthesystemisindeed homogeneousorifitsucceedsinensuringequalcommissioningof
498 R.Waitzbergetal./HealthPolicy124(2020)491–500 careacrosspayersinpractice.However,analyzingitwasbeyond
thescopeofthiswork. 7. Conclusions
TwothirdsofLTCsystemsseteligibilitycriteriaatthenational level,andonethirdpreferlocalgovernmentstodetermine eligibil-ityaccordingtotheirowndiscretion.MostLTCsystemsdelegate commissioningof LTCtolocalPAs,butonly halfallocatefunds amongthem accordingtoa needs-formula. Allocationformulas usedareoftensimpleand deservefurtherattentioninorderto promoteDE.Policymakersshouldpayattentiontotheextentto whichallocationformulasreflectexpectedcarerisksandneedsand distributefundsinafairmanner,especiallyasmorecountriesare consideringmovingtowardsasystemofLTCsocialinsurance.
DistributionalequityisoneoftheobjectivesoftheLTCsystems. LTCsystemsmeetingdistributionalequityarenotforciblythose betterperforming,sincelocaldecisionmakinghasitsadvantages. ThispaperproposesonewayofclassifyingLTCsystemsbasedon needforprovokingreflectionandfurtherresearchontheequityof LTCsystems.Inparticular,futureworkisneededinorderto ana-lyzethelinkbetweenLTCsystemdesignandoutcomesintermsof access,qualityandDE.
DeclarationofCompetingInterest
Theauthorscertify that theyhaveconflictof interests,they haveNOaffiliationswithorinvolvementinanyorganizationor entitywithanyfinancialinterest(suchashonoraria;educational grants;participationinspeakers’bureaus;membership, employ-ment, consultancies,stock ownership, or other equity interest; andexperttestimonyorpatent-licensingarrangements),or non-financialinterest(suchaspersonalorprofessionalrelationships, affiliations,knowledgeorbeliefs)inthesubjectmatterormaterials discussedinthismanuscript.
Acknowledgements
WethankShirlyResniskyfortheconstructivecomments.We thanktheIsraeliNationalInsuranceInstituteforpartiallyfunding thisproject,andRicercaCorrentefundingfromtheItalianMinistry ofHealthtoIRCCSINRCA.
AppendixA. Supplementarydata
Supplementarymaterialrelatedtothisarticlecanbefound,in theonlineversion,atdoi:https://doi.org/10.1016/j.healthpol.2020. 02.013.
References
[1]OECD, Available at Accounting and mappingof long-term care expen-diture under SHA 2011; 2018https://www.oecd.org/els/health-systems/ AccountingMappingofLTC.pdf.
[2]GoriC,FernandezJL,WittenbergR.In:Long-termcarereformsinOECD coun-tries.PolicyPress;2016.
[3]EuropeanUnion,AvailableatThe2018ageingreport:economicand bud-getaryprojectionsfortheEUmemberstates(2016-2070);2018https://ec. europa.eu/info/sites/info/files/economy-finance/ip079en.pdf.
[4]Rodrigues R, Ilinca S, Schmidt AE. Income-rich and wealth-poor? The impactofmeasuresofsocio-economicstatusintheanalysisofthe dis-tribution oflong-term careuseamong olderpeople. HealthEconomics 2018;27(3):637–46.
[5]BakxP,DeMeijerC,SchutF,VanDoorslaerE.Goingformalorinformal,who cares?Theinfluenceofpubliclong-termcareinsurance.HealthEconomics 2015;24(6):631–43.
[6]García-GómezP,Hernández-QuevedoC,Jiménez-RubioD,Oliva-MorenoJ. Inequityinlong-termcareuseandunmetneed:twosidesofthesamecoin. JournalofHealthEconomics2015;39:147–58.
[7]TenandM,BakxP,vanDoorslaerE,Paperpreparedforthe2018Netspar International Pension Workshop (Leiden). Available at: https://pdfs. semanticscholar.org/8814/a4058130081d21d841c7b7248c5f3cec4a96.pdf (Accessed13.1.19)Long–termcareuseintheNetherlands:equaltreatment forequalneeds?Anassessmentusingadministrativedata;2018.
[8]LopesH,MateusC,Hernández-QuevedoC.Tenyearsafterthecreationofthe Portuguesenationalnetworkforlong-termcarein2006:achievementsand challenges.HealthPolicy2018;122(3):210–6.
[9]Costa-FontJ,GreerS,editors.FederalismanddecentralizationinEuropean healthandsocialcare.Springer;2016.
[10]ColomboF,etal.Helpwanted?:Providingandpayingforlong-termcare. Paris:OECDPublishing;2011,http://dx.doi.org/10.1787/9789264097759-en. [11]MuirT,OECDHealthWorkingPapers,No.93Measuringsocialprotection forlong-termcare.Paris:OECDPublishing;2017,http://dx.doi.org/10.1787/ a411500a-en.
[12]BakxP,SchutE,VanDoorslaerE,TinbergenInstituteDiscussionPaper 13-017/VCanriskadjustmentpreventriskselectioninacompetitivelong-term careinsurancemarket?;2013.
[13]DartonR,ForderJ,NettenA,BebbingtonA,HolderJ,TowersAM.Slicingupthe pie:allocationofcentralgovernmentfundingofcareofolderpeople.Social Policy&Administration2010;44(5):529–53.
[14]BusseR,SchreyöggJ,StargardtT.ManagementimGesundheitswesen–das Lehrbuchfurstudiumundpraxis.Berlin:SpringerVerlag;2017.
[15]ThomsonS,FoubisterT,MossialosE.FinancinghealthcareintheEuropean Union:challengesandpolicyresponses.WorldHealthOrganization;2009. [16]BlanchardW.Evaluatingsocialequity:whatdoesfairnessmeanandcanwe
measureit?PolicyStudiesJournal1986;15(1):29.
[17]DanielTE.Arevisedconceptofdistributionalequity.JournalofEconomic Theory1975;11(1):94–109.
[18]EleftheriadesC,WittenbergR.Acriticalreviewofinternationalpracticeon assessmentandeligibilityinadultsocialcare:lessonsforEngland;2013 https://www.chseo.org.uk/downloads/report5-adultsocialcare.pdf. [19]WittenbergR,PickardL,Comas-HerreraA,DaviesBP,DartonR.Demand
forlong-termcare:projectionsoflong-termcarefinanceforelderlypeople. PSSRU;1998https://www.pssru.ac.uk/pub/ltcrep98.pdf.
[20]Smith PC,Rice N, Carr-HillR. Capitation fundingin the public sector. Journal of the Royal Statistical Society: Series a (Statistics in Society) 2001;164(2):217–57.
[21]RiceN,SmithPC.Capitationandriskadjustmentinhealthcarefinancing:an internationalprogressreport.TheMilbankQuarterly2001;79(1):81–113. [22]IlincaS,RodriguesR,SchmidtAE.Fairnessandeligibilitytolong-termcare:
ananalysisofthefactorsdrivinginequalityandinequityintheuseofhome careforolderEuropeans.InternationalJournalofEnvironmentalResearch andPublicHealth2017;14(10):1224.
[23]FernándezJL,KendallJ,DaveyV,KnappM.DirectpaymentsinEngland: factors linked to variations in localprovision. Journal of Social Policy 2007;36(1):97–121.
[24]Federal Long-Term Care Fund Law. Pflegefondsgesetz – PFG. https:// www.ris.bka.gv.at/GeltendeFassung.wxe?Abfrage=Bundesnormen &Gesetzesnummer=20007381.
[25]Federal Long-Term Care Fund Law §2. Pflegefondsgesetz – PFG. https://www.ris.bka.gv.at/GeltendeFassung.wxe?Abfrage=Bundesnormen &Gesetzesnummer=20007381.
[26]Art.15aB-VG,BGBl.866/1993Agreementbetweenfederallevelandlocal governments.Vereinbarungzwischendem BundunddenLändern über gemeinsameMaßnahmen für pflegebedürftigePersonen (1993).https:// www.ris.bka.gv.at/Dokumente/BgblPdf/19938660/19938660.pdf. [27]BGBI.NR.110/1993FederalLawonLong-term CareCashBenefit.
Bun-despflegegeldgesetz – BPGG (1993). https://www.ris.bka.gv.at/Geltende Fassung.wxe?Abfrage=Bundesnormen&Gesetzesnummer=10008859. [28]CanadaHealthAct(R.S.C.,1985,c.C-6).https://laws-lois.justice.gc.ca/eng/
acts/c-6/page-1.html.
[29]Canadian Institutefor HealthInformation:National HealthExpenditure Trends,1975–2019.
[30]CanadianInstituteforHealthInformation(2018):SelectingPan-Canadian IndicatorsforAccesstoMentalHealthandAddictionServices,andtoHome andCommunityCare. https://www.cihi.ca/sites/default/files/document/shp-interim-progress-rep-en.pdf.
[31]HomeCareandCommunityServicesAct,1994.c.26,LastAmendment:2019, c.7,Sched.17,s.89.https://www.ontario.ca/laws/statute/94l26.
[32]LocalHealthSystemIntegrationAct,2006,S.O.2006,c.4.LastAmendment: 2019,c.7,Sched.53,s.7.https://www.ontario.ca/laws/statute/06l04. [33]Long-TermCareHomesAct,2007,S.O.2007,c.8.LastAmendment:2019,c.
5,Sched.3,s.12.https://www.ontario.ca/laws/statute/07l08.
[34]Compulsory Health Insurance Act (2009). https://www.zakon.hr/z/192/ Zakon-o-obveznom-zdravstvenom-osiguranju.
[35]Regulationsonconditionsandmannerofexcercisingcompulsoryhealth insurancerighttohomehealthcare(2010).https://narodne-novine.nn.hr/ clanci/sluzbeni/201007882474.html.
[36]Regulationsonconditionsandmannerof exercisingcompulsoryhealth insurancerighttohospitaltreatmentbymedicalrehabilitationand phys-icaltherapy at home;2009 http://www.hzzo-net.hr/dload/pravilnici/03 procisceni.pdf.
[37]Regulationsonthemeasuresfortheclassificationofhomesfortheelderlyand disabledpersons;2000https://narodne-novine.nn.hr/clanci/sluzbeni/2000 121212302.html.
[38]SocialWelfareAct(2019a). https://www.zakon.hr/z/222/Zakon-o-socijalnoj-skrbi.
[39]Social Welfare Act (2019b). https://mdomsp.gov.hr/userdocsimages/
arhiva/files/67367/KATALOG%20PRAVA%20I%20USLUGA%20-%20ODRASLE%20OSOBE.pdf.
[40]VoluntaryHealthInsuranceAct(2010). https://www.zakon.hr/z/792/Zakon-o-dobrovoljnom-zdravstvenom-osiguranju.
[41](I)/Law2014(2014).http://www.cylaw.org/nomoi/arith/20141109.pdf. [42]Law69/2018(2018).http://www.cylaw.org/KDP/data/2018169.pdf. [43]Mandatory health insurance law 48/1997 (1997). https://www.mzcr.
cz/.../zakon...zakon.../1997-sb-o-verejnem-zdravotni1425524391. [44]Socialserviceslaw108/2006(2006).https://www.mpsv.cz/files/.../Zakono
socialnichsluzbach-stavk1.10.2017.pdf; https://www.zakonyprolidi.cz/cs/1997-48.
[45]CNSA (24.01.2020): Concours allocation personnalisée d’autonomie. https://www.cnsa.fr/budget-et-financement/concours-aux-departements/ concours-allocation-personnalisee-dautonomiehttps://www.cnsa.fr/ budget-et-financement/concours-aux-departements/concours-allocation-personnalisee-dautonomie,LastChecked:24.01.2020.
[46]Ministry ofHealth (2016): Allocation personnalisée d’autonomie (APA) à domicile. https://solidarites-sante.gouv.fr/affaires-sociales/personnes-agees/droits-et-aides/apa-allocation-personnalisee-d-autonomie/article/ allocation-personnalisee-d-autonomie-apa-a-domicile.
[47]MinistryofHealth(2019):Emploiàdomicile.https://www.impots.gouv.fr/ portail/particulier/emploi-domicile,LastUpdate:24.01.2020,LastChecked: 24.01.2020.
[48]11thSocialCodeBook(SGBXI).SozialePflegeversicherung(2019).https:// www.sozialgesetzbuch-sgb.de/sgbxi/1.html,LastUpdate:09.08.2019. [49]5thSocialCodeBook(SGBV).GesetzlicheKrankenversicherung(2019).
https://www.sozialgesetzbuch-sgb.de/sgbv/1.html,LastUpdate:09.08.2019. [50]GazzettaUfficialeNo.129of6June2001(Hg.)(2001):DPCM14February 2001Coordination ofhealth and socialcare services. Attodi indirizzo ecoordinamentoinmateriadiprestazionisocio-sanitarie.https://www. gazzettaufficiale.it/eli/id/2001/06/06/001A6080/sg.
[51]GazzettaUfficialeNo.165of16July1999(Hg.)(1999):D.lgs.229/199 Ratio-nalisationofNHS.Norme perlarazionalizzazionedelServiziosanitario nazionale,anormadell’articolo1dellalegge30novembre1998,n.419. https://www.gazzettaufficiale.it/eli/id/1999/07/16/099G0301/sg.
[52]GazzettaUfficialeNo.265of11November2000(Hg.)(2000):Law328/2000 Frameworklawonsocialservices.Leggequadroperlarealizzazionedel sis-temaintegratodiinterventieservizisociali.https://www.gazzettaufficiale. it/eli/id/2000/11/13/000G0369/sg.
[53]GazzettaUfficialeNo.278of26November1988(Hg.)(1988):Law509/1988 Cashallowanceforpeoplewithdisability.Normeperlarevisionedelle cat-egoriedelleminorazioniemalattieinvalidanti,nonche’deibeneficiprevisti dallalegislazionevigenteperlemedesimecategorie,aisensidell’articolo2, comma1,dellalegge26luglio1988,n.291.https://www.gazzettaufficiale.it/ eli/id/1988/11/26/088G0584/sg.
[54]GazzettaUfficialeNo.44of14Feb.1980(Hg.)(1980):Law18/1980Cash allowanceforpeoplewithdisability.Indennita’diaccompagnamentoagli invalidicivilitotalmenteinabili.https://www.gazzettaufficiale.it/eli/id/1980/ 02/14/080U0018/sg.
[55]GazzettaUfficialeNo.65of18March2017(Hg.)(2017):DPCMof12January 2017Definitionandupdateofessentiallevelsofassistance.Definizione eaggiornamentodeilivelliessenzialidi assistenza,dicuiall’articolo1, comma7,deldecretolegislativo30dicembre1992,n.502.https://www. gazzettaufficiale.it/eli/id/2017/03/18/17A02015/sg.
[56]Nationalhealthinsurancelaw(NHIL)from1995(1995).https://www.health. gov.il/LegislationLibrary/Bituah01.pdf.
[57]NationalInsuranceInstitutewebpage(Hg.)(1988):ElderlyNursingLawfrom 1988.https://www.btl.gov.il/benefits/LongTermCare/Pages/default.aspx. [58]DirectoroftheNationalHealthInsuranceFund(2011):Ordinanceonthe
ApprovaloftheRulesofPlanningandAllocationoftheCompulsoryHealth InsuranceFundVLKdirektoriaus2011-11-28˛isakymasNr.1K-260“D ˙el Pri-valomojosveikatosdraudimofondobiudˇzetol ˙eˇs ˛uPlanavimoirpaskirstymo tvarkosapraˇsopatvirtinimwww.vlk.lt.
[59]GovernmentResolutiononMethodologyforPlanningSocialServices. Lietu-vosRespublikosVyriausyb ˙eNutarimasD ˙elsocialini ˛upaslaug ˛uplanavimo metodikospatvirtinimo;2006https://e-seimas.lrs.lt/portal/legalAct/lt/TAD/ TAIS.286889/rjdZEjEeZQ.
[60]Health Insurance Law. LIETUVOS RESPUBLIKOS SVEIKATOS DRAUDIMO STATYMAS; 1996 https://www.e-tar.lt/portal/lt/legalAct/TAR. 94F6B680E8B8/jylPSqHbsV.
[61]MinisterofHealth.OrdinanceontheApprovaloftheProcedureforthe AllocationofCompulsoryHealthInsuranceFundBudgetFundto Territo-rialPatientFundsaccordingtothenumberofresidents.Sveikatosapsaugos ministro˛isakymas“D ˙elPrivalomojosveikatosdraudimofondobiudˇzetol ˙eˇs ˛u paskirstymoteritorin ˙emsligoni ˛ukasomspagalgyventoj ˛uskaiˇci ˛utvarkos apraˇsopatvirtinimo;2004https://e-seimas.lrs.lt/portal/legalAct/lt/TAD/TAIS. 245538/WFPqPpAQeW.
[62]MinisterofSocialSecurityandLabour,LIETUVOSRESPUBLIKOSSOCIALIN ˙ES APSAUGOS IR DARBOMINISTRO SAKYMAS Nr.A1-93 “D ˙EL SOCIALINIU˛ PASLAUGU˛KATALOGOPATVIRTINIMO“Governmentresolutionon method-ologyforplanningsocialservices;2006https://www.e-tar.lt/portal/legalAct. html?documentId=TAR.5C7ED7A6B1EA.
[63]MinisterofSocialSecurityandLabourandMinisterofHealth,LIETUVOS RESPUBLIKOS SOCIALIN ˙ES APSAUGOS IR DARBO MINISTRO IR LIETU-VOSRESPUBLIKOSSVEIKATOS APSAUGOSMINISTROSAK YMASD ˙EL SPECIALIUJ˛U˛ NUOLATIN ˙ES SLAUGOS, NUOLATIN ˙ES PRIEˇZI ¯UROS (PAGAL-BOS),LENGVOJOAUTOMOBILIOSIGIJIMOIR JOTECHNINIOPRITAIKYMO IˇSLAIDU˛ KOMPENSACIJOS IR TRANSPORTO IˇSLAIDU˛ KOMPENSACIJOS POREIKIU˛NUSTATYMOKRITERIJU˛S ˛ARAˇSO,TVARKOSAPRAˇSOIRPAˇZYMU˛ FORMU˛ PATVIRTINIMO Ordinance on the Approval of the Rules of ReimbursementofExpenditureduetospecial needsofnursing, careor transportation; 2005 http://www.negalia.lt/wp-content/uploads/2015/ 06/D%C4%96L-SPECIALI%C5%B2J%C5%B2-NUOLATIN%C4%96S-SLAUGOS-NUOLATIN%C4%96S-PRIE%C5%BDI%C5%AAROS.pdf.
[64]Nationalhealthinsurancelaw(NHIL)from1995(1995).https://www.health. gov.il/LegislationLibrary/Bituah01.pdf.
[65]NationalInsuranceInstitutewebpage(Hg.).Elderlynursinglawfrom1988; 1988https://www.btl.gov.il/benefits/LongTermCare/Pages/default.aspx. [66]SocialServicesLaw.LIETUVOSRESPUBLIKOSSOCIALINIU˛PASLAUGU˛
STATY-MAS; 2006 https://www.e-tar.lt/portal/lt/legalAct/TAR.91609F53E29E/ IIGosZrdtZ.
[67]HealthInsuranceAct(Zvw).Zorgverzekeringswet(2006).https://wetten. overheid.nl/BWBR0018450/2020-01-01.
[68]Long-TermCareAct(Wlz).Wetlandurigezorg;2015https://wetten.overheid. nl/BWBR0035917/2020-01-01.
[69]NederlandseZorgautoriteit.BudgetaryframeworkLong-termCareAct2019 2019-BR/REG-19125b. BudgettairkaderWlz 2019-BR/REG-19125b;2019 https://puc.overheid.nl/nza/doc/PUC26095922/3/).
[70]SocialSupportAct(Wmo2015).Wetmaatschappelijkeondersteuning2015; 2015https://wetten.overheid.nl/BWBR0035362/2015-01-01.
[71]ACT1997-02-28-19. TheNationalInsuranceAct(Folketrygdloven- ftrl) /eli/lov/1997/02/28/0//2018-01-01/nor.
[72]ACT1999-03-26-14.TheTaxationonWealthandIncomeAct(Skatteloven -sktl)/eli/lov/1999/03/26/14/nor.
[73]ACT1999-07-02-63.ThePatients’RightsAct(Pasient-og brukerrettighet-sloven-pbrl);1999,/eli/lov/1999/07/02/63/nor.
[74]ACT2011-06-24-30.TheHealthandCareServicesAct(Helse-og omsorgst-jenesteloven-hol);2011,/eli/lov/2011/06/24/30/nor.
[75]Actof12March2004onsocialassistance;2014http://prawo.sejm.gov.pl/ isap.nsf/DocDetails.xsp?id=WDU20040640593.
[76]Actof12March2004onsocialassistance&Regulationof23August2012 onsocialassistancehomesMinisterorLaborandSocialPolicy2012;http:// prawo.sejm.gov.pl/isap.nsf/DocDetails.xsp?id=WDU20040640593. [77]Actof27August2004onhealthservicesfinancedfrompublicfunds;2004
http://prawo.sejm.gov.pl/isap.nsf/DocDetails.xsp?id=WDU20042102135. [78]ActofNovember13,2003onrevenuesoflocalgovernmentunits;2003http://
prawo.sejm.gov.pl/isap.nsf/DocDetails.xsp?id=WDU20032031966. [79]RegulationoftheMinisterofHealthof17November2009onthedetailed
pro-cedureandcriteriaforthedistributionoffundsbetweentheheadofficeand voivodshipbranchesoftheNationalHealthFundforthefinancingofhealth careservicesforinsuredpersons(2009).http://prawo.sejm.gov.pl/isap.nsf/ DocDetails.xsp?id=WDU20091931495.
[80]RegulationoftheMinisterofHealthof22November2013onguaranteed nursingandcareserviceswithinthescopeoflong-termcare(2013).http:// prawo.sejm.gov.pl/isap.nsf/DocDetails.xsp?id=WDU20130001480. [81]DiáriodaRepública[GovernmentGazette],No.109,SerieI-A,6June2006
(Hg.)(2006):Decree-LawNo.101/2006,of6June2006.CreatesdeNational NetworkforIntegratedLong-TermCare.https://dre.pt/pesquisa/-/search/ 353934/details/maximized.
[82]DiáriodaRepública[GovernmentGazette],No.174,SerieI,10September 2014(Hg.)(2014):OrdinanceNo.174/2014,of10September.Definesthe conditionsforimplementationandfunctioningofhospitalizationand ambu-latoryunitsandofhospitaldischargeteamsandlong-termcareteamsinthe scopeoftheNationalNetworkforIntegratedLong-TermCare.http://www. acss.min-saude.pt/wp-content/uploads/2016/07/Port1742014.pdf. [83]DiáriodaRepública[GovernmentGazette],No.221,SerieI,16November
2017(Hg.).OrdinanceNo.353/2017,of16November.Updatesthepricesto bechargedbyunitsoftheNationalNetworkforIntegratedLong-TermCare; 2017https://dre.pt/application/conteudo/114214655.
[84]GovernmentofPortugal-MinistryofLabour.Solidarityandsocialsecurity and ministryof health:developmentplan forthe nationalnetworkof integrated long-term care, 2016–2019; 2020 https://www.sns.gov.pt/ wp-content/uploads/2016/02/Plano-de-desenvolvimento-da-RNCCI-2016-2019-Ofi%CC%81cial-Anexo-III.pdf.
[85]Department of Health (Catalonia). Act 84/1985, March 21. Services provided by Primary care Teams; 1985 https:// portaljuridic.gencat.cat/ca/pjurocults/pjurresultatsfitxa/
?action=fitxa&mode=single&documentId=240562&language=caES. [86]Department of Health (Catalonia), http://salutweb.gencat.cat/ca/ambits
actuacio/liniesdactuacio/estrategiessalut/sociosanitari/pladirector/index. html#googtrans(ca|en)Act39/2006,March14.LongTermCaredevelopment withspecificbeds:longterm,convalescence;2006.
[87]MinistryPresidency.Spain.Law39/2006,December14.CommonSpanish instrumentofAssessment;2006https://www.boe.es/eli/es/rd/2011/02/11/ 174.
[88]MinistryPresidency.Spain.Law39/2006,December2014.DependencyLaw coveringtheseservicesmildandseveredependentpeople;2006https:// www.boe.es/eli/es/l/2006/12/14/39/con.
500 R.Waitzbergetal./HealthPolicy124(2020)491–500 [89]Kommunalekonomiskutjämning.SCB–statisticsSweden;2018.
[90]CareAct2014.Eligibility:chapter6;directpayments:chapter12.UK: Depart-ment ofHealthandSocialCare;2014.https://www.gov.uk/government/ publications/care-act-statutory-guidance/care-and-support-statutory-guidance#Chapter6; https://www.gov.uk/government/publications/care-act-statutory-guidance/care-and-support-statutory-guidance#Chapter6. [91]McGuireTG,VanKleefRC,editors.Riskadjustment,risksharingandpremium
regulationinhealthinsurancemarkets:theoryandpractice.AcademicPress; 2018.
[92]VandeVenWP.Riskadjustmentandriskequalization:whatneedstobe done?HealthEconomics,PolicyandLaw2011;6(01):147–56.
[93]BakxP,ChernichovskyD,PaolucciF,SchokkaertE,TrottmannM,Wasem J,etal.Demand-sidestrategiestodealwithmoralhazardinpublic insur-ance for long-term care. Journal of HealthServices Research & Policy 2015;20(3):170–6.
[94]BerlowitzD,IntratorO,2013RiskadjustmentforLong-termcare.In:Iezzoni LI,editor.Riskadjustmentformeasuringhealthcareoutcomes,4thedition Chicago,IL:HealthAdministrationPress;2013.
[95]AlbertiniM,PavoliniE.Unequalinequalities:thestratificationoftheuseof formalcareamongolderEuropeans.JournalsofGerontologySeriesB: Psy-chologicalSciencesandSocialSciences2015;72(3):510–21.
[96]Graley CE, May KF, McCoy DC. Postcode lotteries inpublic health-the NHSHealthChecksprogrammeinNorthWestLondon.BMCPublicHealth 2011;11(1):738.
[97]Britannica,Availableathttps://www.britannica.com/science/old-ageAccess Date:October25,2019Oldage,atEncyclopaediaBritannica;2018. [98]FernandezJL,ForderJ.Local variabilityinlong-termcareservices:local
autonomy,exogenousinfluencesandpolicyspillovers.HealthEconomics 2015;42(1):146–57.
[99]GoriC,MorcianoM.Cash-for-carepaymentsinEurope:changesinresource allocation.SocialPolicy&Administration2019;2019:1–14,http://dx.doi.org/ 10.1111/spol.12498.
[100] Verbeek-OudijkD,WoittiezI,EgginkE,PutmanL.WhocaresinEurope?Geron 2015;17(1):62–5.
[101] RodriguesR,GlendinningC.Choice,competitionandcare–developmentsin Englishsocialcareandtheimpactsonprovidersandolderusersofhomecare services.SocialPolicy&Administration2015;49(5):649–64.
[102] Iversen T. Challenges in Long-term care financing and provision. In: Presented at the 13th Social Survey - 08.10.2019. 2019. Available at: http://www.hauptverband.at/cdscontent/load?contentid=10008. 724262&version=1570718908.
[103] Swedish Ministry of Social Affairs. Social Services Act from 2001: https://www.riksdagen.se/sv/dokument-lagar/dokument/svensk-forfattningssamling/socialtjanstlag-2001453sfs-2001-453.
[104] OECD(2013),OECDReviewsofHealthCareQuality:Sweden2013,OECD ReviewsofHealthCareQuality,OECDPublishing,Paris,https://doi.org/10. 1787/9789264204799-en,availableat: https://read.oecd-ilibrary.org/social- issues-migration-health/oecd-reviews-of-health-care-quality-sweden-20139789264204799-en#page127.
