XXXIII Economic Analysis Symposium Unmet needs of dependent people in Spain Cristina Vilaplana Prieto (UCAM, FEDEA) Sergi Jiménez-Martín (UPF, FEDEA) Zaragoza, December 2008

XXXIII Economic Analysis Symposium Motivation  26.5% of +65 people (82.2% for +80 years) are limited in DAL (Living Conditions of Older Population, 2004):  46.1% bone problems; 41% high blood pressure; 29.3% cardiovascular disease; 13.2% respiratory disorders; 13.2% mental illnesses (National Health Survey, 2003).  53% disability for moving outside home; 56% using public transport; 40% go shopping; 31% maintaing body positions (Disabilities, Deficiencies, Health Status Survey, 1999) Disabilities may be alleviated with the use of technical aids (7.86% for years; 19.58% for +80 years), but there exist many barriers to independence (DDHS, 1999)  Elder people prefer to live integrated in the community as long as possible (77%; Elders Living Conditions, 2006)

XXXIII Economic Analysis Symposium Motivation  Research has started to explore the causes and consequences of unmet needs (Allen, 1994; Tennstedt et al., 1994; Desai et al., 2001; Sands et al., 2006 ).  Consequences of unmet needs (UN):  Morbidity rate More severe disabilities Dowfalls  Use of emergency departments  Physician visits Longer stays at hospital More institutionalization  Health expenditure (Allen and Moor, 1997) (Komisar et al., 2005; ) (Long et al., 2005) Limitations of these studies: Do not separate between users/non-users, do not consider informal network characteristics, primary’s caregiver perspective is ignored

XXXIII Economic Analysis Symposium Motivation  Reliability of dependent’s self-reports about unmet needs or those provided by the primary caregiver (Williams et al., 1997 ; Albert et al., 2004 )  Literature about unmet needs in Spain: quite scarce

XXXIII Economic Analysis Symposium Objectives  To which extend, personal social services for dependent people (Home Care and Day Centres) are able to satisfy dependent’s needs?  Could it be possible to increase Home Care attention at a reasonable cost and taking into account the provision of other personal services?  Which factors are associated to the emergence of personal unmet needs?

XXXIII Economic Analysis Symposium Data  Informal Support Survey (IMSERSO; 2004)  Personal interviews to informal caregivers of +65 years dependent people, who may co-reside or not with the dependent individual. (N=1.504)  Ceuta, Melilla and La Rioja were not included  Conclusions cannot be extrapolated to the fraction of institutionalized dependent people or those who only receive formal care.  Innovative approach to determine the degree of dependency Apply the Ranking Scale mentioned in the Law of Dependency

XXXIII Economic Analysis Symposium Degree of dependency (I)  Ranking Scale (Delegated Legislation 504/2007, 20 th April):  Three degrees of autonomy:  Moderate dependency: individual needs help for doing daily living activities (DAL) once a day.  Severe dependency: individual needs help for doing DAL’s two or three times a day.  Great dependency: individual needs help for doing DAL’s several times per day and requires permanent supervision

XXXIII Economic Analysis Symposium Degree of dependency (II)  Two levels of dependency inside each degree:  Level 1: individual can perform the activity without the direct support of a third person  Level 2: individual requires specific support  Suppervision  Partial physical attention  Maximum physical attention  Special attention (behaviour disorders)

XXXIII Economic Analysis Symposium Degree of dependency (III)  47 tasks grouped in 10 activities:

XXXIII Economic Analysis Symposium Degree of dependency (IV)  Results consistent with forecasts from DDHSS for 2005: 15.39% (great), 27.52% (severe), 34.96% (moderate)

XXXIII Economic Analysis Symposium Descriptive statistics (I) Informal care entails around 90% of total care Strange behaviour of the nº of public caregiving hours for severe dependent people  unmet needs problem??

XXXIII Economic Analysis Symposium Descriptive statistics (II) Definition of unmet needs  “ Need” is the “ability to benefit from social services” (Stevens and Gabay, 1991; Stevens and Raftery, 1994).  Unmet Need: Situation when a dependent individual (or the caregiver) has applied for any type of personal or technical aid, but has not received it. (Allen and Mor, 1997); Alonso et al, 2007)

XXXIII Economic Analysis Symposium Probability of suffering unmet needs Dependent characteristic s Social services for dep. people Pr[UN] Possible endogeneity of the caregiving hours” variable Solution: Instrumental variables approach  Tobit for private and public formal caregiving hours:  Dependent’s characteristics (age, sex, marital status, level of education)  Caregiver’s characteristics (age, sex, marital status, level of education, relation with economic activity, number of children, number of hours and years of caregiving, preparation and belonging to associations).  Health variables (level of disability and certain pathologies)  Environmental variables (size of municipality, dependent’s income, living alone and number of informal caregivers)  Long-term care regional policy (Home care coverage index, ratio Home Care/Day Centre and cost Home Care per hour)

XXXIII Economic Analysis Symposium Probability of suffering unmet needs Excluded variables:  Marital status (dependent & caregiver)  Number of children  Relation with economic activity (caregiver)  Predicted hours of care :  Classified in high, medium and low  Similar approach for Mix of formal and informal care High: Above the top 25th percentile Medium: Between 26th-74th percentil Low:Below the bottom 25th percentile

XXXIII Economic Analysis Symposium Results: Home Care

XXXIII Economic Analysis Symposium Results: Day Centres/Resid. Homes

XXXIII Economic Analysis Symposium Results: Technical aids/Telecare

XXXIII Economic Analysis Symposium Predicted effect of different policies on Home Care hours Question: Which combination of social policies is more effective for increasing the number of Home Care hours? Variables considered:

XXXIII Economic Analysis Symposium Predicted effect of different policies on Home Care hours  Estimate the model for the nº of public caregiving hours  Compute predictions for combinations of policy variables.

XXXIII Economic Analysis Symposium Predicted effect of different policies on Home Care hours  Estimate the model for the nº of public caregiving hours  Compute predictions for combinations of policy variables. Why this combination is not better? Could be connected with the relation price, nº of caregiving hours and time devoted to personal tasks

XXXIII Economic Analysis Symposium Predicted effect of different policies on Home Care hours  More expensive Home Care  higher fraction devoted to personal care  more hours per month for personal care  Cataluña best approximates the preferred simulation  (Home Care CI: 3.87; Ratio Home Care/Day Centre: 7.81; 10.24€/hour; 76% of time devoted to personal care)  Spending more on long term care is effective  Policies should tend towards an homogeneization of the distribution of formal caregiving hours between personal care and houseworking

XXXIII Economic Analysis Symposium Conclusions  Findings underscore that Regions need to accelerate efforts toward greater provision of Home Care and Day Centres  Importance of recognizing the limits of informal caregivers  Two types of substitution effects  Lack of Day Centres  IC hours or  private employees   Coverage index Home Care  Pr[UN for Day Centre]  Future research:  We cannot completely control for unobserved factors that could be correlated with regional variables  exploit within-region variation in policies  requires longitudinal database (not available until now)  Comparison of situations in two moments does a reduction in UN (even if not eliminated) improves dependent’s quality of life?  Are some UN of more concern than others?  Findings underscore that Regions need to accelerate efforts toward greater provision of Home Care and Day Centres  Importance of recognizing the limits of informal caregivers: mental patients, great dependents  Two types of substitution effects:  Lack of Day Centres, Home Care  IC and/or  private employees   Coverage index Home Care  Pr[UN for Day Centre]