1. Yuki Murakami
(OESO)
De meerwaarde van ouderenzorg in België:
een profielschets in Europees perspectief

2. LONG-TERM CARE FOR
OLDER PEOPLE
Conference Voka Health Community
30th September, 2013
Yuki MURAKAMI
OECD
ECONOMIC VALUE AND EFFICIENCY

3. • Disability numbers mainly predicted by demographic
ageing, not risk factors
• How LTC is organised in OECD?
• How will this impact on choice of care settings, unit labour
cost and hence expenditure?
• What options are there to gain efficiency?
Topics of discussions

4. Steep rise in the share of over 80 years old
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
1960 1970 1980 1990 2000 2010 2020 2030 2040 2050
EU-27 Japan OECD Key Emerging Countries1 World
1. Emerging economies include Brazil, China, India, Indonesia and South Africa.
Source: OECD Historical Population Data and Projections Database, 2013.

5. Pop over 80 years + in Belgium will be
double by 2050
Source: OECD Historical Population Data and Projections Database, 2013.
0 5 10 15 20
Turkey
South Africa
India
Indonesia
Mexico
Israel
Russian Fed.
Brazil
Estonia
Chile
Hungary
China
United States
Australia
Ireland
Slovak Rep.
Luxembourg
Iceland
Norway
Denmark
Poland
Belgium
Sweden
Canada
OECD33
United Kingdom
Czech Rep.
Greece
New Zealand
Slovenia
Portugal
France
Finland
Netherlands
Austria
Switzerland
Italy
Korea
Germany
Spain
Japan
%
2010 2050

6. Old-age dependency ratio is increasing
0%
5%
10%
15%
20%
25%
30%
OECD EU (27) world
Source: OECD Labour Force and Demographic Database, 2010. World population projection estimates based on UN World Population
Prospects, 1950-2050 (2006 Revision)

7. Limitations of daily activities increase
with age
Limitations in daily activities, population 65-74 and 75 years and over, 2011
Norway
Sweden
Denmark
Iceland
Luxembourg
Switzerland
Ireland
United Kingdom
Czech Rep.
France
Belgium
Netherlands
Spain
Greece
OECD (25)
Finland
Austria
Poland
Italy
Turkey
Germany
Hungary
Portugal
Slovenia
Estonia
Slovak Rep.
Source: Eurostat Database 2013.
0 20 40 60 80
Limited to some extent Limited strongly
% of population aged 75 years and over
020406080
Limited to some extent Limited strongly
% of population aged 65-74 years

8. What do these demographic trends mean?
• Not uniform sign of disability compression
• Multiple co-morbidities
• Preference for home and independent living
• Demand for responsive, patient-centred services
• Diverse user groups with different needs (e.g., Alzheimer;
young disabled)
Demand
for more
and
better
formal
care
Pressure
on LTC
workforce
and
financing
• LTC workers will account for a larger share of a
shrinking workforce
• Pressure on financing of the welfare state
especially if levies on labour income
• Economic and financial crisis

9. 0
4
8
12
16
20
24
28
32
36
Social
protection
Health Education Economic
affairs
General
public
services
(excluding
interest)
Interest* Public order
and safety
Defence Recreation;
culture and
religion
Housing and
community
amenities
Environment
protection
2007
2010
Source: OECD Fiscal Consolidation Survey 2012.
Health and LTC: the 2nd largest area of
government spending
Structure of general government expenditures, 2007 & 2010 (% of total expenditures)

10. Source: OECD calculations and 2009 Ageing Report, European Union,
LTC expenditure is projected to at least
double by 2050
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
8.0%
9.0%
10.0%
United States Germany EU-OECD Belgium Japan Norway Netherlands
Public LTC Expenditure as a Share of GDP
2007 2050 (Low) 2050 (High)

11. Belgium’s public LTC spending higher than
OECD average
Note: The OECD average only includes the 11 countries that report health and social LTC.
Source: OECD Health Statistics 2013
0.0
3.7
3.6
2.4
2.4
2.1
2.0
1.8
1.8
1.7
1.6
1.5
1.4
1.3
1.2
1.2
1.0
1.0
0.7
0.6
0.6
0.5
0.4
0.3
0.2
0.2
0.2
0
1
2
3
4
Total Social LTC% of GDP

12. -1.1%
-1.1%
2.2%
2.4%
2.6%
3.1%
3.1%
3.1%
3.8%
3.8%
4.5%
4.6%
4.7%
4.8%
4.8%
5.1%
5.4%
5.5%
6.8%
6.9%
9.1%
12.5%
14.4%
43.9%
-10% 0% 10% 20% 30% 40% 50%
Hungary
Iceland
Sweden
Germany
Denmark
Netherlands
Canada
United States
Finland
Slovenia
Switzerland
Austria
France
Spain
OECD22
New Zealand
Poland
Norway
Belgium
Czech Republic
Estonia
Japan
Portugal
Korea
A
Average annual growth rate
8.7
4.0
4.0
2.6
4.7
-4.0
4.9
3.9
4.1
8.1
11.6
6.0
1.7
1.7
3.2
3.1
-1.6
8.2
3.5
4.3
16.6
8.0
7.6
7.3
6.9
6.5
6.4
6.4
5.0
4.8
4.5
3.7
3.1
3.1
2.5
2.2
1.9
1.8
1.3
1.0
-10 0 10 20
Korea
Estonia
Spain
Switzerland
Japan
France
Finland
Norway
New Zealand
OECD19
Belgium
Poland
Austria
Germany
Sweden
Canada
Denmark
Hungary
Czech Republic
Netherlands
Slovenia
Average annual growth rate (%)
Institution LTC Home LTC
Annual growth rate in LTC public
expenditure 2005-11
Annual growth rate of public LTC institution
and home care expenditure 2005-2011
Source: OECD Health Statistics 2013,
LTC spending growing more in home care

13. OECD countries at different stages of
developing of formal LTC workforce supply
1. In New Zealand, Sweden, Spain and the Slovak Republic, it is not possible to distinguish LTC workers in institutions and at home.
Source: OECD Health Statistics 2013
12.2
6.5
9.6
6.5
0.7
6.4
5.7
4.5
3.6
0.6
1.5
3.9 4.4 4.3
2.7
1.5
0.9
3.0 2.8 2.5
1.6 1.4 1.6 1.6 1.1
5.6
2.3
4.4
9.3
2.9
2.5
2.8
3.2
5.9 4
1.4
1.3
1.7
2.2 0.8 1.0
0
2
4
6
8
10
12
14
Home Institutions% of population aged 65 years and over Institutions + Home

14. Greater staffing challenges in home care?
2.0
4.7 4.7 5.2
8.0
12.9 14.5
19.6
33.1
39.2
2.0 3.4
1.3 2.2 1.3 1.2 2.3 2.4 1.8
9.2
2.2
0
5
10
15
20
25
30
35
40
Users per FTE home care Users per FTE institutional care
Higher ratio of LTC users per Full-Time Equivalent (FTE)
worker in home care than in institutions
Source: OECD (2011), Help Wanted? Providing and Paying for Long-Term Care, based on OECD Health Data 2010

15. Employment opportunities in LTC?
50
100
150
200
250
2000 2002 2004 2006 2008 2010
Japan
Long-term care Total employment
Index (2000=100)
90
100
110
120
130
140
150
2001 2003 2005 2007 2009 2011
Germany
Long-term care Total employment
Index (2001=100)
90
100
110
120
130
2000 2002 2004 2006 2008 2010
Denmark
Long-term care Total employment
Index (2000=100)
90
100
110
120
130
2003 2005 2007 2009 2011
Norway
Long-term care Total employment
Index (2003=100)
Source: OECD Health Statistics 2013
Trends in long-term care employment and total employment, selected OECD
countries, 2000-11 (or nearest year)

16. Services related to activities of daily living
(help with feeding, bathing, mobility)
Universal coverage within
a single programme:
– Tax-funded Nordic
system;
– Social LTC insurance in
Jap, Kor, NL, Lux, Ger);
– as part of health system in
Belgium
MMeans-tested systems
– (England social-care
system; US: Medicaid)
Mixed schemes:
– Parallel universal benefits
(Scotland, Italy)
– Progressive universal
benefits (Israel, France,
Austria, Australia)
– Mix universal & means-
tested (NK, Canada, Greece)

17.  Basing funding on a wider basis as employee contributions
(Japan, Belgium, Luxembourg, Netherlands);
 Better distribute the force between generations (the retired
pay an LTC insurance premium in Germany and Japan);
 Introduce elements of pre-financing: the creation of a
financial reserve (eg, private insurance, Luxembourg);
 Private insurance with automatic enrollment (Singapore).
Financing Long-term care

18. Long-term care insurance model in
Japan
• Universal care insurance
• Who benefits? Elderly dependents over 65 years of age or over
40 years with a disease related to aging (eg, Alzheimer's)
• Financing: 25% income tax and 25% local taxes, 50%
dependence insurance contribution paid by people over 40
years
• Local variation in individual contributions, because the costs
of services vary between locations.
• Individual participation in labor costs being modest increase
• Control over payments to providers can keep costs even
though Japan has a institutionalization rate high

19. Accommodation costs and restore
facility
Funding through
participation related
to individual
resources
(Australia, Nordic
countries, Ireland)
Funding through
social
assistance, reserved
for the poorest
(Belgium, Germany, It
aly)

20. In all countries, a portion of the cost is
borne by individuals
• Maximum public contribution capped (eg, Germany, Austria (1),
Italy), the public contribution may depend on resources (APA
France, Austria (2), Australia);
• "Stay-in-charge" leveled according to individual resources (EUR
180 per month in Sweden, 1 800 EUR Netherlands);
• Co-payment based on the cost of services (Japan 10% Korea, 20%
in institutions, 15% at home).

21. Help users to mobilize their resources to
pay part of the costs
 Buying bonds or shares of accommodation and other devices
interest-free loan (Australia) structures;
 Public measures to defer payment of the stay in the institution
(Ireland, United States, England)
 Private products (reverse mortgage, associants devices and life
insurance care insurance)

22. • Policy on expenses related to the level of
income and / or severity of dependence
• Define the level of dependency trigger
coverage as resources (Korea);
Direct care benefits to those who need it
most

23. • Enlargement towards universal coverage (Korea, Spain, Czech Republic);
• ... But better targeted support to the most significant risks (Austria, Czech Republic, Sweden, the
Netherlands);
• Innovative solutions:
– Public-private partnerships (United States - Medicaid, under discussion in England);
– Voluntary insurance + automatic subscription (Singapore).
• Reforms based on user choice:
– Cash benefits (United States and several European countries);
– "Vouchers" / check (Nordic countries).
Four directions of reforms

24. Irrespective of financing model, moving towards universal LTC
benefits is desirable on access and affordability grounds…

25. … the cost associated with high-care need can account for more
than 60% of seniors’ disposable income, including for those
from relative high income deciles
Low care needs High care needs
Share of adjusted disposable income for individuals 65 years and over in different
income deciles, mid-2000s
Source: OECD Secretariat calculation based on the OECD Income Distribution and Poverty Database (www.oecd.org/els/social/inequality).

26. Quo vadis, long-term care?
The only way to square the circle of higher demand, higher
use, higher expectations and higher cost is by improving value for
money. Three avenues to explore:
– Allocative efficiency: optimising care settings, care coordination across
pathways
– Behavioural efficiency: incentives for providers (e.g., payment;
competition) and users (e.g., prevention)
– Technical efficiency: assessing cost & benefits of technology to help
managing work processes, reduce errors, improve productivity

27. • OECD (2013), A Good Time in Old Age? Measuring
and Ensuring Quality of Long-Term Care
• OECD (2011), Help Wanted? Providing and Paying
for Long-Term Care, Paris
• OECD (2010), Value for Money in Health Spending
• www.oecd.org/health/longtermcare
Yuki Murakami: yuki.murakami@oecd.org
Thank you!!