Long-term care in the Netherlands: the
determinants of using personal care
and nursing care
This thesis investigates the determinants of the use of the AWBZ outpatient functions personal care and nursing care in the Netherlands in 2012. Furthermore, it examines which variables influence the costs of personal care and nursing care, conditional upon use. For the execution of this study, a dataset consisting of the total elderly population of the Netherlands is used.
Main conclusion is that a higher age and being female are important determinants for both the probability to use and for the costs of using personal care and nursing care. Furthermore, having a lower socioeconomic status and living in a rural area increases the probability of usage. In addition, suffering from mental diseases, epilepsy, conditions on the brains or spinal cord and muscle disorders increase the probability and the costs of using personal care and nursing care. Having a chronic disease in general strongly influences the probability and the costs of usage. Lastly, a strong correlation between the use of the AWBZ outpatient functions and other, more cure-related, health care services emerges. Especially the costs of using the general practitioner and the costs of medicine use increase the probability and the costs of personal care and nursing care.
Preface
Writing this thesis has been a process of struggling, thinking, and changing the whole thing around yet again. Finding a topic is quite difficult as an Economics student, since the range of topics is as broad as possible. However, once I found a topic things became clearer and I was able to really get started. Even though some difficulties passed along the way (waiting for the dataset), the result is something to be proud of.
Management summary
Institutional reviewThe Dutch health insurance system consists of two main national insurances, the Exceptional Medical Expenses Act (AWBZ, in Dutch: Algemene Wet Bijzondere Ziektekosten) and the Health Insurance Act (Zvw, in Dutch: Zorgverzekeringswet). In addition, the Social Support Act (Wmo, in Dutch: Wet Maatschappelijke Ondersteuning) complements the health insurance system on the field of wellbeing. This system of national insurances is about the change. The (proposed) policy reforms concern the transition of the outpatient functions of the AWBZ (personal care, nursing care, assistance and treatment) to the Zvw (executed by the health insurance companies) and the Wmo (executed by the municipalities). Personal care (for 95%), nursing care and treatment will shift to the Zvw while assistance and 5% of personal care will be transferred to the Wmo. This transition is necessary to retain a sustainable and affordable long-term health care system in the Netherlands.
By shifting the outpatient functions to the health insurance companies and municipalities, the execution should become more efficient. In the Zvw, this is done by combining the outpatient functions with the primary care functions (e.g. general practitioner, dentist, physiotherapist, psychologist etc.). Main purpose is to keep health care affordable and of good quality, but implicitly the primary care practitioners will function as gatekeepers. This is to prevent patients to make unnecessarily use of secondary and inpatient care, which is very expensive. Furthermore, in the new system the patients are expected to become more self-reliant and live long at home. As a consequence, informal care will become more important.
Literature review
There are several articles available in the literature that performs a similar kind of research as is executed in this thesis. Many different explanatory variables for the use of personal care, nursing care, inpatient care and homecare can be found. The most important variables are age, gender, socioeconomic status (where education and/or income are used as proxies), several chronic conditions or diseases, availability of informal care (or proxies for informal care) or private care and having disabilities.
Data
Data from Vektis C.V. where used to perform the analysis. The dataset available contains the complete elderly population (over age 65) in the Netherlands in the year 2012. Of these elderly the following variables are known: gender, age, ZIP-code, socioeconomic status, urbanization area, chronic groups of the Wtcg and the costs of several types of health care (e.g. outpatient functions, GP, hospital care etc.). The combination of data from the Zvw and the AWBZ makes this research valuable and unique; it was not possible to combine these data before 2012.
Model
To estimate the results, a two-part model is executed. First, a probit model was formed to estimate the binary outcome of using versus not using personal care and/or nursing care. Second, an OLS regression model was implemented to estimate the costs conditional upon use (as a proxy for the extent of use). For both parts, three different models are carried out to be able to make a distinction between personal care, nursing care and homecare (combination of personal care and nursing care) as the dependent variables.
Conclusions
Furthermore, having a lower socioeconomic status and living in a rural area increases the probability of usage. The effect of socioeconomic status (SES) can be explained by the fact that people with a higher SES have a different lifestyle and might substitute outpatient care for private care.
In addition, suffering from mental diseases, epilepsy, conditions on the brains or spinal cord and muscle disorders increase the probability and the costs of using personal care and nursing care. Elderly people with Parkinson’s disease are more like to use and to have higher costs for personal care. Nursing care is more likely to be used by diabetes patients. Having skin conditions increases the probability of using personal care and nursing care, this relates immediately to wound care. Having a chronic disease in general strongly influences the probability and the costs of usage.
Lastly, a strong correlation between the use of the AWBZ outpatient functions and other, more cure-related, health care services emerges. Especially the costs of using the general practitioner and the costs of medicine use increase the probability of using and the costs of personal care and nursing care.
Policy implications
The results of this thesis might in particular be interesting for the discussion and policy making around the provider payment models. These models determine the payment system of health care providers. The payment model for homecare is currently under discussion and needs to be finalized in 2014.
The results of this thesis show that important determinants for the use of homecare can be revealed. This emphasizes that segmenting based on population characteristics is possible and can be used as a part of the provider payment modes. Therefore, the results revealed in this thesis might be useful in the debate regarding a new payment model for homecare in the Zvw.
Furthermore, health insurance companies need to purchase homecare in advance for 2015 due to the shift out of the AWBZ. This purchasing is done in advance in 2014 already and it is hard to determine how much homecare to contract.
By using the determinants revealed in this thesis, health insurance companies may gain more knowledge on the health care needed in an area. To can help health insurance companies to make better purchasing arrangements and better predictions of the amount of health care needed.
The proposed transition of personal care to the Zvw is still under discussion, this thesis reveals that this shift is a natural one. Due to the large similarities between personal care and the health care services already under the Zvw, this transition can lead to several qualitative and financial improvements.
1. Table of content
1. Table of content ...
2. Introduction ... 1
3. Current institutional setting ... 2
3. 1The current Dutch health care system ... 2
3.1.1 AWBZ ... 2
3.1.2 Zvw ... 4
3.1.3 Wmo ... 6
3.2 Sustainability of the Dutch health care system ... 6
3.3 (Proposed) reforms in the Dutch health care system ... 7
4. International comparison ... 10 4.1 United States ... 10 4.2 Germany ... 10 4.3 Sweden ... 11 4.4 Comparison ... 11 5. Literature review ... 12
5.1 Literature with a similar dependent variable ... 12
5.2 Literature with a different dependent variable ... 12
6. Variables and hypotheses ... 14
6.1 Dependent variable ... 14 6.1.1 Nursing care ... 14 6.1.2 Personal care ... 14 6.1.3 Homecare ... 14 6.2 Independent variables ... 15 6.2.1 Personal characteristics ... 15
6.2.2 Diseases and/or conditions ... 16
6.2.3 Disabilities and/or restrictions ... 17
6.2.4 Health care usage ... 18
7. Data ... 19
7.1 Zvw data ... 19
7.2 AWBZ data ... 19
7.3 Thesis dataset ... 19
7.4 Completeness dataset ... 19
8. Research methodology and statistical design ... 21
8.1 Methodology in other research ... 21
9. Descriptive statistics ... 23 9.1 Dependent variables ... 23 9.1.1 Nursing care ... 23 9.1.2 Personal care ... 23 9.1.3 Homecare ... 23 9.2 Independent variables ... 23 9.2.1 Personal characteristics... 23
9.2.2 Diseases and/or conditions ... 25
9.2.3 Disabilities and/or restrictions ... 26
9.2.4 Health care usage ... 26
10. Empirical findings ... 27
10.2 Part 1 of the model: probit results... 27
10.1.1 Personal characteristics ... 27
10.1.2 Diseases and/or conditions ... 28
10.1.3 Disabilities and/or restrictions ... 28
10.1.4 Health care usage ... 28
10.2 Part 2 of the model: OLS results ... 31
10.2.1 Personal characteristics ... 31
10.2.2 Diseases and/or conditions ... 31
10.2.3 Disabilities and/or restrictions ... 32
10.2.4 Health care usage ... 32
11. Conclusion ... 34
12. Discussion and policy implications ... 37
12.1 Limitations ... 37
12.2 Policy implications ... 37
12.3 Further research ... 38
13. References ... 39
14. Appendix ... 44
14.1 Glossary of definitions and list of abbreviations ... 45
14.2 Inpatient ZZP’s VV ... 47
14.3 Details of research ... 48
2. Introduction
In 2060, the Netherlands will have the most expensive long-term care system in the world if no changes are made (European Commission and the Economic Policy Committee, 2009). Therefore, it is essential to improve the understanding of factors that determine long-term care use and expenditures (De Meijer et al., 2011). Uncovering the important factors will contribute to more accurate projections of the need for such health care and the development of appropriate policies. Since the most rapid growth in elderly cohorts is still to come, now is the right time to gain knowledge on this topic (De Meijer et al., 2011).
The enabling variables, such as income and household composition, personal characteristics of patients and health care usage are specifically interesting to uncover. Personal characteristics (e.g. age, gender) are useful since they do not change at short notice which makes them helpful for making predictions. Enabling variables (e.g. income and informal care) can be influenced by policy makers and are therefore interesting for research (Timmermans et al, 1997). Last, it is meaningful to gain more knowledge on the relationships between the use of different types of health care.
Focusing on the long-term care types, nursing care and personal care are particularly interesting. These parts of the AWBZ (Exceptional Medical Expenses Act) will become a component of the Zvw (Health Insurance Act) in 2015. In this research, factors that influence the use of nursing care and personal care will be revealed. The insights provided here might be helpful by uncovering possibilities for fitting in the new parts into the Zvw. For example, to embed the new parts into the existing parts of the Zvw it is important to know whether relationships exist between personal care, nursing care and types of health care already part of the Zvw. Particularly, the results of this research might be important for creating provider payment models for the current and new parts of the Zvw. Furthermore, insights for the sustainability of the Dutch health care system can be given, especially concerning qualitative sustainability for the future.
The main topic of aim of this thesis is to uncover the predictors for the use and the level of use (by using the costs) of personal care and/or nursing care. Even though similar research has been conducted in the past (i.e. Timmermans et al., 1997 and Van den Berg Jeths et al., 2004) the data available for this thesis will contribute strongly to the existing body of knowledge on the use and the costs of personal care and nursing care. The combination of data concerning both Zvw and AWBZ is unique and has never been used for this purpose before. Furthermore, the data used for this research are more reliable than data used in other research. In the literature, very often authors make use of surveys which are subject to measurement errors.
Relationships between different types of health care (e.g. the relationship between the use of the general practitioner in the Zvw and nursing care in the AWBZ) can now be uncovered. Furthermore, the links between age, gender, socioeconomic status, urbanization and several diseases on the one hand and the use and level of use (proxy is the costs) of personal care and/or nursing care on the other hand will be examined. Unfortunately, the data only provides information for the year 2012 in the Netherlands.
3. Current institutional setting
3.1 The current Dutch health care systemThe Dutch health insurance system comprises two main national insurances, the Exceptional Medical Expenses Act (AWBZ, in Dutch: Algemene Wet Bijzondere Ziektekosten) and the Health Insurance Act (Zvw, in Dutch: Zorgverzekeringswet). This format is often classified as respectively care and cure. In addition to these Acts the Social Support Act (Wmo, in Dutch: Wet Maatschappelijke Ondersteuning) complements the health insurance system on the field of wellbeing.
Figure 1 gives an overview of the current health care system in the Netherlands. The AWBZ consists of three functions;
outpatient care, inpatient care and short-term stay. Outpatient care and inpatient care consist of the functions; nursing care, personal care, treatment and assistance. For the Zvw, primary care is the generic term for GPs, dentists, physiotherapists and pharmacies. Secondary care is comprised of mental health care and hospital care. For the Wmo, only the functions that are closely related to health care are displayed in figure 1. 3.1.1 The AWBZ
The AWBZ was implemented in 1968, insures 15 functions (e.g. staying in a nursing care home) and is carried out by Care Offices (Zorgkantoren). The largest health insurer in a certain region is concessionaire and thereby obliged to carry out the Care Office duties. No profit or costs are made by the insurer; all costs are paid by the AWBZ fund, which is administrated by the government. This system based on regional care offices has been heavily criticized, since the incentives for efficiency are low and transparency is a problem (Mot, 2010). The care offices are responsible for contracting several care providing instances. In this process, arrangements are made about the types of care, the prices and amount of time per treatment.
Funding for the AWBZ is received through income contribution by the use of payroll taxes, a contribution from the government (funded by taxes) and co-payments from health care users. The details of this system that are relevant for this thesis will be explained in the paragraphs below.
Income contribution through payroll taxes
In the Netherlands, every citizen is obliged to pay tax on its wage. The AWBZ, state pension and the General Surviving Relations ’Benefits Act are part of this payroll tax. The premium for the AWBZ was 12,15% in 2012 for everyone and has a maximum income base.
This premium reared from income tax made up about 70% of the total income in the general AWBZ fund in 2012 (see figure 2). In the year 2012, there was a negative balance of minus €4,5 billion. This negative balance is financed by the
government. BIKK (Contribution in the costs of reductions, in Dutch: Bijdrage in de Kosten van Kortingen) is explained below. AWBZ •Outpatient care •Nursing •Personal care •Treatment •Assistance •Inpatient care
•same functions as outpatient •Short-term stay Zvw •Primary care •Secondary care Wmo •Housekeeping
•Adaptations in or around home •Addiction treatment
•Support volunteering and informal care
Figure 1. The current Dutch health care system.
AWBZ premiums BIKK
Co-payment
Every adult user of AWBZ care pays a co-payment to the AWBZ fund (through the CAK, Centraal Administratie Kantoor). The quantity of this contribution dependents on the income, capital, household composition and type of indication (see below). In 2012, the co-payments formed 7.2% (€1.8 billion) of the income of the general AWBZ fund.
Government contribution
The government pays a contribution to the general AWBZ fund due to a system change in the Income Tax Act in 2001. This system change resulted in a decrease in revenues for the national insurances. The government pays a yearly contribution to compensate the national insurances for this loss in revenue. This contribution is approximately €5 billion and is called BIKK (Contribution in the costs of reductions, in Dutch: Bijdrage in de Kosten van Kortingen). In addition, the government is the one that pays for possible deficits.
Personal budget versus care in kind
A personal budget (pgb, in Dutch: persoonsgebonden budget) gives someone the opportunity to decide which care providers to use. The money for the personal budget is collected from the Care Offices and can be used according to the individuals’ preferences. The respective care provider will send the bill for provided care to the patient who will pay this bill with its personal budget. Money that is not spend must be returned to the Care Office. Exceeding the budget is for own expenses. A personal budget must be applied for at the CIZ (Centre for Indication Assessment Care, in Dutch: Centrum Indicatiestelling Zorg), that deals with all indications for AWBZ care. The total expenditures for pgb were 2.7 million in 2012. These expenditures were made for about 135.000 people (Binnenlands Bestuur, 2013).
The opposite of the personal budget is care in kind. Within this type of format the patient uses a type of health care while the bill is directly paid by the Care Office. In this situation, the patient does not have the full freedom to choose its care provider, but can only choose from the providers contracted by the Care Office. The Care Offices buys the health care services in advance yearly. Care in kind is the most common form of financing in the Netherlands.
Outpatient and inpatient care
The AWBZ care can be roughly divided in two parts: inpatient and outpatient care. There is also a relatively small third component, short-term stay, for which about 18.000 people had an indication. Short-term stay serves mainly to relieve informal care givers, for residential training or in crisis situations.
Outpatient care is given at home or at a professionals’ practice on the patients’ request and is not continuous. Outpatient care can be divided into four parts: nursing care, personal care, treatment and assistance. Nursing care is defined as medical help at home, like wound care and injections. Personal care is help in daily activities such as showering, taking medication and getting dressed. Treatment is meant to restore or improve a condition or to improve skills or behaviour. Finally, assistance aims to support the daily routine and encourage participation in society.
Very often, patients use a combination of the outpatient functions. The total expenditures for elderly (excluding copayments and pgb users) in 2012 were €352 million for nursing care (138.953 people), €1.96 billion for personal care (309.379 people), €11.6 million for treatment (2.432 people) and €465 million for assistance (94.161 people) (source:dataset provided by Vektis).
In January 2012, almost 780.000 people had an indication for AWBZ-care. This indication needs to be requested from the CIZ. Not every person that received an indication uses it. Especially people with an inpatient indication may want to stay at home and use only the outpatient functions. About 45% of these 780.000 people has an indication for inpatient care and the other 55% for outpatient care (see above for the distinction between the outpatient functions).
AWBZ expenditures and revenues
The total expenditures on AWBZ (both inpatient and outpatient) were €27,9 billion in 2012 (Rijksjaarverslag VWS, 2012). When comparing this total to the expenditures mentioned above for the separate outpatient functions, it is clear that inpatient care is more expensive than outpatient care. Only 11% of the total AWBZ costs are made for outpatient functions.
Figure 3 displays the total hours of healthcare per outpatient function. From this diagram it can be seen that personal care is by far the largest function, while treatment is the smallest outpatient function.
Total AWBZ revenues were €12.431 million for inpatient care and €3.769 million for outpatient care in 2012. Strikingly, the gap between expenditures and revenues is largest for inpatient care. This difference amounts to €5.857 million while the difference for outpatient care is only €70.000,- (Marktscan extramurale AWBZ, 2012a and Marktscan intramurale AWBZ, 2012b).
Figure 4 displays the income and expenditures of the AWBZ from 1968 till 2012. The expenditures on AWBZ have grown from €275 million to €25.1 billion, which is 8,6% annual growth. Strikingly, the
first years after implementation were quite balanced. From 1999 onwards the differences between income and expenditures are further apart.
3.1.2 The Zvw
The Health Insurance Act (Zvw) was established in 2006 (before there was the Sickness Fund (Ziekenfonds), established in 1941) and states that every Dutch citizen is mandatorily insured for basic health insurance. This basic package insures treatments and hospitalization (up to 365 days) among other things. Such a basic package costs about €1200,- per person in 2013, children under the age of 18 are free of charge. The exact amount of health insurance premium depends on the health insurance company, income (lower incomes
Figure 3. Hours of care per outpatient function, 2011. Source: Marktscan extramurale AWBZ, Nza.
61% 11% 25% 3% Personal care Nursing Assistance Treatment
receive government compensation) and collective discounts through employers.
In addition to the basic insurance, one can (voluntarily) opt for supplementary insurance. Approximately 90% of the Dutch population has such a supplementary insurance(Kuijper, 2012). This supplementary insurance can cover a variety of health care services such as the dentist, physiotherapist and health care services abroad. Every health insurance company has an acceptance obligation for the basic health insurance, while medical selection for the supplementary insurance is allowed. In the Zvw, the health insurance companies are responsible for making arrangements concerning the types of health care provided, prices and time per treatment with care providers.
Primary versus secondary care
The Zvw can be divided in primary care and secondary care. Primary care consists of primary care professionals such as general practitioners, dentists, physiotherapists, social workers or psychologists. For this type of care, no referral is necessary. Its aim is to provide good primary care to as many people as possible and it is partly meant to prevent people to appeal for more expensive types of care (gatekeeper).
Secondary care consists of somatic health care (mostly for physical problems) such as hospitalization and inpatient mental health care. This type of care is in theory only available by referral from a primary care professional.
Earnings
The health insurance companies earn income by health insurance premiums, deductibles, co-payments and equalization contributions. The health insurance premiums applies to both basic and supplementary insurance, which is paid by clients themselves. In addition, there is an income dependent part (co-payment) via taxes for the Health Insurance Fund.
Deductibles are the part of the cost of the health insurance package directly billed to the individual. In 2012, deductibles were €220,-. The deductibles are mandatory and must be paid by everyone (provided that health care is used and has a deductible), they are meant to prevent people from using more health care than needed. The equalization contributions are paid by the Health Insurance Fund. This fund is financed by income related contribution and through government funding and is therefore financed by the tax payers. The main goal of this fund is to compensate health insurance companies when their insured population needs relatively more health care than average. Since health insurance companies have an acceptance obligation, this fund functions as a risk equalizer (BS&F, 2013). This type of compensation is called an ex-ante risk equalization mechanism, since the health insurers are compensated in advance.
Expenditures
Figure 5 displays a compact overview of the Zvw expenditures in 2012. This figure only concerns the basic insurance package of the Zvw. The largest expenditures relate to medical specialist care, followed by medicines and medical devices and primary care. It is interesting to see that primary care, which is used by the majority of people, has lower total costs than medical specialist care, which is only available after referral from a primary care specialist. The total Zvw costs for the basic insurance package were almost €37 billion in 2012.
In- kind policy and reimbursement policy
An in-kind policy implies that clients can only receive health care services from care providers that are contracted by their health insurer. The resulting bill will be paid immediately by their health insurance company. A reimbursement policy means that someone can visit the health care provider of their personal
preference. The bill must be paid in advance by the client and can subsequently be reimbursed at the health insurance company.
The majority of the Dutch population has an in-kind policy. About a quarter has a combination of both policies and a small proportion has a reimbursement policy.
3.1.3 The Wmo
The Social Support Act (Wmo) is not part of the health insurance system. This act corresponds more closely to wellbeing, to which the Zvw and AWBZ contribute as well. The Wmo was implemented in 2007, as the successor of several other wellbeing-related Acts and covers a variety of functions that are executed by the municipality. Housing adaptations, transport facilities, wheelchairs and home care for the disabled, anti- domestic violence initiatives, care for the homeless and woman’s shelters are some examples of the functions carried out by municipalities. Some functions of the Wmo are closely linked to the Zvw and the AWBZ. In 2012, Wmo expenditures were about €250 per citizen on average (SGBO, 2012).
Co-payments in the Wmo are common. Municipalities may establish the amount of co-payment themselves, framed by the maximum prices set by the government. Most municipalities use these maximum prices to benefit from this regulation. The use of personal budgets (pgb) is possible in the Wmo as well.
Informal care
It is estimated that there are about 1 million informal caregivers in the Netherlands (Steunpunt Mantelzorg, 2012). This number is quite insecure, since it is hard to measure this feature. In other European countries, especially in Southern- Europe, informal care is more important and more common. In the Netherlands the state bears responsibility for the elderly and others who are in need of long-term care. Therefore, there is no obligation for family members and others to provide informal care. This contrasts with taking care of children, which is largely the responsibility of parents (Mot, 2010). There is some form of compensation for informal care givers which can be requested through the Wmo.
Mot (2010) argues that informal care could potentially play a larger role in the Netherlands. This is because a relatively large share of women work part-time and elderly partners tend to grow old together. Compared to other countries, the potential availability of informal care in the Netherlands is therefore large.
3.2 Sustainability of the Dutch health care system
Figure 6 displays the balance between income and expenditures of the AWBZ from 1968 till 2012. From 1999 onwards there are larger differences between expenditures and income then before 1999. After 2009 the deficits are particularly large.
It is not just the AWBZ that causes high expenditures and an
unsustainable health care system, it is the sum of all the costs in the health system. An average Dutch family nowadays pays over €11.000 per year only for health care, which is about a quarter of their income. If the health care sector will keep growing in the same pace as the past 10 years, the same average family will have to pay half of its income on healthcare in 2040 (De Jong and Van der Horst, 2013).
Even though the health care costs are high when combined, the long-term care (LTC) costs are more disproportionate when compared to other countries. The costs for medical care and other curative health care are around OESO average, but LTC costs are consisdered extremely high (Mot, 2013). According to Mot (2010), the most important problems of the current Dutch LTC system are the sustainability, the lack of efficiency incentives, finding sufficient workers for the expected future increase in demand and the quality of health care.
Figure 7 displays the public expenditure on long-term care as a percentage of GDP (Gross Domestic Product) for the 27 member states of the European Union (EU). The abbreviation NL signifies the Netherlands. The United States is not included, but if it would be it would take the leading position (Fogel, 2008). However, when focusing on 2060, the Netherlands might
have the most expensive LTC system in the world. When compared to other European countries the Dutch healthcare system is very expensive. The Dutch citizens are relatively healthy and have a high life expectancy, but the amount of money spend on LTC is high (Dijkstra and Ter Brugge, 2013). It is clear from this graph that the situation in the Netherlands is not sustainable. The long-term care expenditure as a percentage of GDP will more than double from now till 2060 when using a pure demographical scenario. This is partly due to ageing and to higher life expectancy.
When focusing on elderly, out of the total AWBZ expenditure in 2009 (inpatient and outpatient), around 95% is perceived by elderly over 64 years old (Van Asselt et al., 2012).
Qualitative sustainability
Above, only financial sustainability is mentioned. However, it is important as well to look at qualitative sustainability. The quality and efficiency of the health care system need to be ensured for the future.
It is necessary to take into account that the needs of patients change. Not only because patients ask for different types of care, but also because patients have more knowledge than in the past. Furthermore, the growth in some types of diseases (such as diabetes) becomes more frequent. These changes need to be embraced and taken into account for the future.
The SER (2008) mention in their advice that not only financial difficulties influence the sustainability of the Dutch health care system. They find that the quality of the health care is not optimal everywhere or in some sectors and that there is a lack of coherence between cure and care. These deficiencies are taken into account in their advice to reform the AWBZ to secure efficiency and health care quality.
3.3 (Proposed) reforms in the Dutch health care system
The Dutch health care system is in transition nowadays, as the government is planning and currently implementing large changes. The main reasons for this policy change are the financial sustainability of the Dutch health care system and to safeguard health care quality.
Several changes have already been implemented, while other changes are still under construction without any final decisions being made. For inpatient care, this thesis will solely focus on ZZP VV, since these relate closely to elderly care. The policy assumptions and the changes will be discussed, not only for inpatient and outpatient care, but for pgb and supporting devices as well. Other changes, such as the changes in the disabled sector, will not be discussed here.
Policy assumptions
The reasoning behind the shift of parts of the AWBZ is that combining outpatient care and primary care will deter people from using too much (expensive) hospital or inpatient care. These policy shifts correspond to the finding that especially the long-term care is unsustainable in the Netherlands (Mot, 2013). The long-term care functions can currently be found in the AWBZ and in parts of the Wmo.
In a research commissioned by Zorgverzekeraars Nederland, Pomp (2012) found that a complete shift of the elderly care (inpatient and outpatient) to the Zvw can lead to savings of €500 million per year. This amounts to about 5% of the total costs on elderly care. The precondition is that health insurance companies are fully responsible and bear all of the risks.
By increasing peoples’ self-reliance and focusing on what people still can do instead of what they cannot, the Dutch health care system should become more sustainable. Informal care and community nursing care will become a bigger part of long-term health care. Only for the patients who cannot longer take care of themselves and have no other care options, the AWBZ will remain available in the form of the WLZ (see below). Outpatient
As from January 1st 2015, all the functions of the outpatient care of the AWBZ will move towards the Zvw and to the Wmo. This idea was already proposed by the SER (2008) and supported by several other parties (e.g. Schut and Van de Ven, 2010).
In this transition, the outpatient functions nursing care, personal care (for 95%) and treatment will be shifted towards the Zvw. The combination of the functions nursing care and personal care will be called homecare in this thesis. The remaining outpatient function called assistance and a small part of personal care (related to assistance of disabled) will be shifted towards the Wmo due to the similarities between these activities. The short-term stay will most likely move to the Wmo as well.
Inpatient
An overview of the ZZP’s of VV relevant for this thesis can be found in figure A.1 in the appendix. As of January 1st 2013, no new indications were issued for ZZP1 and ZZP 2 of VV. On the same date, ZZP VV 9a (geriatric rehabilitation) was transferred from AWBZ to Zvw. As from January 1st 2014, ZZP VV 3 will no longer be indicated for new cases. As from January 1st 2016, ZZP VV 4 will no longer be indicated. For all the ZZP’s mentioned above (except ZZP9a) holds that this will not have consequences for the people who already have an indication.
In 2012, there were 27.800 people with an indication ZZP VV 1 and 2 who stayed in an institution. For ZZP VV 3 there were 18.900 people who stayed in an institution in 2012 (Veldhuijzen van Zanten -Hyllner, 2012). On January 1st 2012, 31.095 people had an indication for ZZP VV 4. The people who are no longer eligible for these ZZP categories need to find other sources of care, either through informal, private or outpatient care.
WLZ
The remaining functions in the AWBZ (only inpatient) will receive a new name. These functions will continue under the new name of Long Term Care Act (WLZ, in Dutch: wet langdurige zorg). At first, the local Care Offices will execute the WLZ. The WLZ might be transferred to the Zvw in the future.
Supporting devices
Pgb
In 2012, only patients with an inpatient indication could apply for a pgb (see above for an explanation). For people with a more severe outpatient indication, there was a substitute for pgb called compensation personal care (VPZ, in Dutch: vergoedingsregeling persoonlijke verzorging). Since 2013, the inpatient and outpatient regulations were combined and the VPZ disappeared. Now all patients with an AWBZ indication can apply for a pgb. Nothing changed for patients in the Wmo.
The use of pgb will most likely remain possible in the WLZ. Whether this will be possible for users of personal care or nursing care in the Zvw is still unclear.
Proposed reforms
As mentioned above, not all of the reforms are in place yet. On some topics, decisions still have to be made and therefore there are still many uncertainties. Due to the short preparation period from now till 2015, it is possible that some measures will not be implemented directly but will have a transition period.
Decisions still need to be made on topics like the provider payment models, pgb and indication assessments in healthcare. The policy reforms in this thesis are up-to-date at the time of writing (December 2013), but new decision making might have a large impact.
Overview
See figure 8 for an overview of the system after the transition. In the AWBZ, most functions of the inpatient care will remain and this will be named the WLZ. The housekeeping/ house care part of the Wmo will eventually disappear. This function needs to be replaced by informal and private care.
The transition means that primary care and outpatient care will be combined and executed by the health insurance companies. Hospital care will remain under the Zvw and all previous Wmo functions will remain unchanged.
It is interesting to compare figure 1 and figure 8 to see the effect of the changes in the Dutch health care system. Particularly to find that the future WLZ component will drastically slim.
Figure 9 displays the breakdown in expenditures for the long-term care system. The shift from AWBZ to Wmo and Zvw is very clear. A small portion of the long-term care (4%) will be transferred to a new Youth Act (in Dutch: Jeugdwet), which will be executed by the municipalities. No further explanation of this law will be provided here, since the focus is on the elderly population. For the interested reader, more information can be found on the website of the Association of Dutch Municipalities (in Dutch: Vereniging van Nederlandse Gemeenten, VNG).
Obviously, the overview displayed in figure 13 is preliminary and subject to change.
WLZ •Inpatient care
•same functions as outpatient
Zvw •Primary
•nursing •personal care •outpatient treatment •original primary functions •Secondary
Wmo
•Adaptations in or around home •Addiction treatment
•Support volunteering and informal care
•Assistance •Short-term stay
Figure 8. Overview of the changes in the Dutch health care system.
Figure 9. Shift in the breakdown of expenditures. Source: Van Rijn, 2013.
4. International comparison of health care systems
Three general types of health care systems can be distinguished in the Western countries; private insurance systems, public(-regulated) insurance systems and national health services. These health care systems vary according to types of actors and in organisational relationships (Van Essen, 2009). An example of a country with a private insurance system of health care is the United States, where the government has little input in the regulation of health care. In the Netherlands, Germany and Belgium health care is organized by employing public insurance systems. In these systems, the state tends to function as a regulator. In the United Kingdom and in the Scandinavian countries health care is organized in national health services. National health services are financed by taxes paid by the community and are heavily regulated by the state.
In this chapter I will focus on three countries with different health care systems: the Unites States, Germany and Sweden. There are strong similarities between the Dutch and the German system, therefore finding out more about the German system is interesting. The United States has one of the most expensive healthcare systems in the world, but is currently subject to change which makes it interesting to research. Sweden is a country in which the government has an active role in healthcare. However, Sweden’s total expenditures are equally high as in the Netherlands. For these countries I will provide a short explanation of their systems, the costs of these systems and the health status of their citizens when compared to other countries. Finally, these countries are compared to the Netherlands. It is important to note is that the differences between the systems are substantial, which makes comparing the systems difficult.
4.1 United States
The health insurance system in the US consists of both private insurance and public insurance. Private insurance is mainly available through employers, while public insurance programs like Medicaid (for families and individuals with a low income) and Medicare (for elderly and disabled people) are financed by the government. Since it is not compulsory to have health insurance, over 15% of the American citizens are not insured (Pear, 2013).
In 2010, president Obama signed a contract for a new health care system which will be executed under the ‘Patient Protection and Affordable Care Act (PPACA, informally known as Obamacare). This Act is currently being implemented, starting from 2010 till 2020, with the centre of gravity around 2014. Since the 1st of October 2013, American citizens can apply online for health insurance. Having health insurance will gradually become mandatory for everyone and health insurance companies will have an acceptance obligation. The current mix of public and private health care causes the US to have the most expensive health insurance system in the world. Both expenditures on health as a percentage of GDP and the per capita spending on health are highest (OECD, 2013). Despite these high costs, the health status of the US citizens is below the OECD average (based on life expectancy and infant mortality, which are widely used proxies).
Homecare is either paid by Medicare, the patient’s insurance company (which mostly does not cover homecare) or by the patient itself. However, Medicare expenses primarily focus on inpatient costs. In 2007, over 1 million people aged 65 and older received home health care on a daily basis (Jones et al., 2012). Informal care is common in the United States, with approximately one-fifth of the population providing informal care (American Psychological Association, 2013).
4.2 Germany
The German health insurance system relies on both private and public insurance, like the US system. However, every German citizen is obligated to have health insurance. A part of the population is eligible for the government’s health insurance through the Sickness Funds and the other part of the population has to insure itself at a private health insurance company. This system is similar to the Dutch system before 2006. The German long-term care system makes the same distinction between a personal budget (pgb) and in-kind care (Schultz, 2010).
higher than the OECD average. In terms of health status Germany has a score above the OECD average. In Germany, working with a personal budget is a common practice. Besides this, homecare is stimulated (in particular informal care) and own responsibility is emphasized through higher co-payments. The entitlement for nursing care and homecare is not as easy as in the Netherlands. Therefore, the total expenditures in Germany are notably lower. An advice of Gradus and Van Asselt (2011) is to extend the use of personal budgets in the Netherlands in a similar fashion as the German system.
In 2007, there were 2.2 million people who received benefits from the social and private long-term care funds. About 23% used professional home care services, 31% stayed in an institution and 46% received informal care (Schultz, 2010). The total spending in this year amounted to €7.9 billion (World Health Organization, 2013). In 2007, around 11.3% of the elderly population received benefits for long-term care in Germany while an even larger group of around 12.7% needed help but did not receive any beneficiaries (Schultz, 2010).
4.3. Sweden
In Sweden, the health services are completely paid from tax resources by the Swedish government. Health care expenditures amount to 9.3% of GDP, compared to over 11% in the Netherlands (Peters, 2012). Every Swedish citizen is obliged to register at the Försäkringskassan, the national office for social insurance. In addition, people can apply for voluntary supplementary insurance at private companies. The Försäkringskassan pays almost all the costs, but everyone has deductibles.
Both health expenditure as a percentage of GDP and per capita expenditure on health care are a little bit higher than the OECD average. The life expectancy in Sweden is higher than the OECD average and child mortality is (next to Iceland) the lowest of all OECD countries in 2011. In terms of health status, Sweden is doing very well. Elderly people reside longer at their own home compared to the Netherlands. Therefore Sweden has an extensive home care sector where staff is educated to let people reside at home as long as possible. About 0.4% of the GDP is spent on home health care, this is comparable to the European average. In 2006, around 420.000 people received social home care and around 180.000 people received home nursing care (World Health Organization, 2013). Costs are borne by the municipalities, but elderly do have to pay deductibles for home care (Zweden Emigratie, 2013).
Informal care is not common in Sweden. It is only since 1997 that this type of care has received attention. The government recognizes the importance of informal care, especially given the ageing population (Fukushima, 2010).
4.4 Comparison
When comparing the countries covered above, the most striking difference is between private and public systems. In general, all of these countries have high health care expenditures, similar to the Netherlands. Sweden stands out positively when comparing health status. This is not the case for the US, where infant mortality and life expectancy are respectively higher and lower than the OECD average. In figure 10, LTC users as a share of the population are displayed for 2008. Sweden and the Netherlands are displayed at the top. Sweden has more home care use and a smaller portion of institutional care use when compared to the Netherlands. This might be because the Swedish focus is (as is the new aim in the Netherlands) on people living at home as long as possible. Important to notice is that inpatient care is generally much more expensive than outpatient care. Germany is slightly above the OECD average and the US is largely below this average. However, for the US only institutional care use is displayed which gives a biased image.
5. Literature review
This chapter will focus on the available literature on topics similar to this thesis. There is some literature available in which a similar kind of research is conducted in the Netherlands. This research does not always have the same dependent variable, but sometimes focusses on a related subject. The methodology used to execute the research differs as well. Figure 11 on the next page displays the overview of variables found in the literature and the variables available in the data (a complete overview can be found in figure A.21 in the appendix). The variables measured in this study will be discussed separately in chapter 6.
5.1 Literature with a similar dependent variable
This thesis focuses on the costs and use of personal care, nursing care and homecare (the combination of personal care and nursing care). This topic has been the subject of previous research. For example three reports written by Jonker et al. (2007), Van den Berg Jeths et al. (2004) and Timmermans and Woittiez (2004), all commissioned (partly) by the Social Assessment Agency (SCP, in Dutch: Sociaal Planbureau). They make a distinction between four groups of determinants of the need for a care product. These groups are: health characteristics (physical limitations, cognitive limitations, psychological conditions or chronic diseases), demographic characteristics (age, gender, household composition and degree of urbanization), socioeconomic characteristics (household income and education) and forms of support (informal care, private care, mobility devices, ADL devices, type of residence, general practitioner and other medical care). They find that age, gender, household composition, education and income are import determinants for the use of nursing care/ personal care. Besides this, they find significant results for several different types of diseases and disabilities, and for diseases in general. Other forms of health care use might play an important role as well, but this is not confirmed in this research.
Another research with the same dependent variable is conducted by Geerts et al. (2012). In their study, they make a distinction between predisposing (age, gender and education), enabling (income, household composition and children) and need variables (ADL (activities of daily life) and IADL limitations, cognitive functioning and chronic conditions) according to the Andersen model (Andersen, 1968). The authors of this research find that age, ADL measures, chronic conditions and proxies for informal care are significant determinants for the use of nursing care and personal care in the Netherlands.
5.2 Literature with a different dependent variable
Bakx et al. published two articles in order to explain public LTC expenditure (2013a) and LTC use (2013c). The first model tested used demographic and health care use data and aimed to find out whether risk adjustment can prevent risk selection in a competitive long-term health care insurance market. The second model aimed to make a distinction between informal and formal care for Germany and the Netherlands. These two articles found that age, gender, proxies for informal care, use of several other care services and having chronic diseases or disabilities are important determinants for the use of LTC.
De Meijer et al. (2011) argue that having disabilities is the best predictor of health care use. In their research they tried to indicate whether age and time to death (TTD) are good proxies for disability. They used both inpatient and outpatient care as dependent variables. Age, time to death, household composition, self-reported health status and obviously disability are the most important determinants found for inpatient and outpatient care use.
Van Campen and Van Gameren (2003) have a completely different dependent variable, namely the assignment of indications. In their study, they tried to find determinants that explain why indications are assigned to people who apply for it. Age, proxies for informal care, having (chronic) diseases and functional disability were important determinants found.
Van Campen et al. (2013) formed healthcare pathways in the Netherlands in their longitudinal study of 10 years. Informal care proxies, age, depression and co morbidity are identified as factors that influence health care use. - Age - Gender - - - Socioeconomic status - - - - Urbanization
Available
Nursing care, personal care
and homecare
Literature
- Prior LTC use - Hospital treatments - Informal care - Private care - Use of medicines - Disability general - Functional disability - Cognitive disability - Activities of daily life - Mobility- Home adaptations - Use of supporting devices - Diabetes - Stroke - Pulmonary problems - Depression - Cancer - Mental Illness
- Chronic diseases general - Self-reported health status - Dementia - Age - Gender - Time to death - Household composition - Socioeconomic status - Education - Income - Social Network - Urbanization
Dependent variable
Independent variables
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D
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D
isab
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/res
tricti
o
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s
H
ealth care
use
- Diabetes - Stroke - Pulmonary problems - Depression - Cancer - Mental Illness- Chronic diseases in general - All other chronic groups mentioned in the Wtcg - - - - - -
- Use of supporting devices
-
- Hospital treatments -
-
- Use of medicines - Primary care use - Use of supporting devices
6. Variables and hypotheses
This chapter provides more information about the possible explanatory variables for using nursing care and/ or personal care. First, a definition of the dependent variables is given. Second, general information on the independent variables is presented with the corresponding hypotheses.
6.1 Dependent variable
The dependent variables in this thesis are nursing care and/or personal care for elderly people (over 65 years old). These functions are still part of the AWBZ but will be transferred to the Zvw in 2015. A related function to nursing care is nursing under supervision of a medical specialist (MSVT, which is already part of the Zvw), this variable is not part of the dependent variable due to data limitations. The community nurse as part of the government financed project ‘Zichtbare schakel’ (visible link) is not included either, also due to data limitations. Finally, elderly using a pgb are not included either. The aim of the transfer of nursing care and personal care in 2015 is to include all elderly care in the Zvw, this way elderly people have to cope with less different authorities.
6.1.1 Nursing care
The outpatient function nursing care includes many different sub functions. Examples are the control of body functions, complicated wound and stoma care, and the dosing of complex medication. In addition, teaching these activities and guiding the proper implementation of the nursing care functions are included if the patient uses self-care (either formal or through informal caregivers). Only medical conditions, psychogeriatric disorders and physical disability grant access to this outpatient function. In 2012, about 175.000 people had an indication for nursing care, 80% was over the age of 65 (Vektis, 2013).
6.1.2 Personal care
Activities related to personal care are connected to some nursing care procedures. Personal care is meant to take over all or part of the activities in the personal care area and to assist to some extent. The most important aim is to provide support in daily life. Some personal care activities are related more to nursing care than others, such as wound care or help with chronic diseases.
Over 350.000 people had an indication for personal care in 2012. More than 85% of this group was over 65 years old (Vektis). There is a large group (almost 130.000 elderly) who have an indication for both personal care and nursing care. Important to note is that the personal care related to assistance (about 5 % of the AWBZ function), will be transferred to the Wmo instead of the Zvw in the future. Due to data limitations, no distinction can be made between these two different parts. This means that the dependent variable will include both the 5% Wmo and the 95% Zvw personal care. However, the part transferred to the Wmo consists mainly of relatively young, handicapped people. Therefore, the percentage of handicapped people over age 65 is relatively small and will comprise a very small portion in the dataset used.
6.1.3 Homecare
6.2 Independent variables
This paragraph provides more information about the independent variables. In principle, only the variables available in the dataset are explained in more detail. However, exceptions are made when the concerning variable has been empirically researched to be of great explanatory value.
6.2.1 Personal characteristics Age
Someone’s age is, not surprisingly, an important determinant for the use of health care. In almost all of the literature found (e.g. Timmermans et al., 1997 and Van Huis et al., 2013) age is identified as an indicator for using nursing care, home care, personal care, LTC or for institutionalization. The higher someone’s age, the more likely it is that one will make use of health care services.
In 2012, over 2,8 million people were over age 65 in the Netherlands, constituting is about 16% of the population. Almost 700.000 people were over 80 years old. According to the CBS, 26% of the population will be over 65 years old in 2060, this is approximately 4.7 million people. Of this group, about 2 million people will be above 80 years old in 2060.
Currently, the life expectation for men is 78.1 years old and for women 82 years old. Forecasts indicate that this will grow to an age of 87.1 for man and 89.9 for women (Van Duin and Stoeldraijer, 2012). The combination of an ageing population and the higher life expectancy is sometimes called the double ageing effect.
This leads to the following hypothesis:
H.1 A higher age will increase the probability of using and the costs of personal care and/or nursing care.
Gender
The variable gender gives mixed results in the literature; the relation between gender and health care use seems to differ among types of healthcare. Almost three-quarter of the health care demand comes from women (Jonker et al., 2007). However, women’s life expectancy is higher which might explain this finding to some extent. Next to this, women are more able to take care of an ill husband, while this is not necessarily the case the other way around. Upon closer inspection of the literature that mention gender as an explanatory variable, men generally use more inpatient care and personal care than women, and women more home care and nursing care than men (Van Huis et al., 2013).
This results in the following hypothesis:
H.2 Being a woman increases the probability of using and the total costs of personal care and/or nursing care.
Socioeconomic status (SES)
SES is named a few times as an indicator for health care use (Timmermans et al., 1997 and Van Campen and Van Gameren, 2003). Most research states that a higher socioeconomic status leads to lower health care costs (Sadiraj and Groot, 2006). This might be because people with a higher SES have a different lifestyle and because they choose more often for private health care. In figure 12 an overview is given of AWBZ costs in 2009 per SES (SES 1 is low and SES 3 is high). This indicates higher costs for people with a lower SES.
SES 1 SES 2 SES 3
AWBZ total 903 1.437 499
Inpatient 543 923 298
Outpatient 360 515 202
All in all, this leads to the following hypothesis:
H.3 People with a lower socioeconomic status have a higher chance of using and higher costs for personal care and/or nursing care.
Urbanization
This variable is named by several authors (e.g. Jonker et al.,2007; Andersen and Newman, 1973), but the results are quite contradicting. The percentage of health care users seems to be higher in urban areas (Jonker et al., 2007) while the chance of being an applicant for health care is higher in more rural areas (Jonker et al., 2007;Timmermans and Woittiez, 2004). Van Huis et al. (2013) state that people in urban areas make more use of nursing care services.
This results in the following hypothesis:
H.4 People in more urban areas have a higher chance of using and higher costs for the outpatient functions personal care and/or nursing care.
6.2.2 Diseases and/or conditions
In several articles (e.g. Van Gool et al., 2009), a distinction is made between diseases/ diagnosis and disabilities. Disabilities indicate the extent to which a person is hindered in daily living while diseases are diagnosable, for example diabetes, heart diseases and epilepsy. Often, people with diseases have several disabilities and vice versa, but this is not necessarily the case (Van Gool et al., 2009). This thesis acknowledges the distinction between diseases and disabilities; this paragraph discusses the influence of diseases or conditions on the use of health care the next paragraph will focus on disabilities.
In the literature, having one or more (chronic) diseases is named as an important variable in explaining the use of health care (e.g. Bakx et al., 2013a; Van den Berg Jeths et al., 2004). However, there are multiple diseases mentioned that have a significant influence by themselves. These are; diabetes, cancer (resolved by informal care as well), epilepsy, digestive system disorders, ailments caused by an accident, mental disorders, migraine, nerve system diseases, stroke, pulmonary problems, musculoskeletal disorders, cardio- vascular diseases, hip fractures and metabolic diseases (Luppa et al., 2009; Van Campen et al., 2013; Van Huis et al., 2013; Timmermans and Woittiez, 2004). Dementia is also commonly named in the literature, but remains difficult to measure (Vektis et al., 2012).
Differences arise in the influence these conditions and diseases have on the use of different types of health care. Diseases like cancer and diabetes have a bigger impact on nursing care, while mental disorders increase the probability of demanding day-care and inpatient care. When focussing on the target group of elderly people, we conclude that almost all of the diseases mentioned above are suffered from by the elderly. The diseases that are most common in the target group are cardio- vascular diseases, diabetes, arthritis and osteoporosis (Poos, 2012).
The following hypotheses can be derived from the literature mentioned above:
H.5 People who have a chronic disease have a higher chance on using and higher costs of personal care and/or nursing care.
H.6 Individual chronic groups as mentioned in figure 11 increase the probability of using and the costs of personal care and/or nursing care.
6.2.3 Disabilities and/ or restrictions
Having one or multiple disabilities or restrictions is the most important explanatory factor found for the use of health care services. There are several types of disabilities, such as cognitive disabilities, functional disabilities, physical disabilities, and psychosocial disabilities. Multiple types of restrictions may indicate the use of health care, for example restrictions in household tasks (HDL), restrictions in activities of daily life (ADL), personal care restrictions, and restrictions in mobility. Other indications may reveal the use of health care, such as home adaptations and the use of supporting devices. Disabilities and restrictions will be discussed only shortly below, because no data is available about these variables in the dataset used. Therefore, no hypothesis are formed. Disabilities
When consulting the literature, the determinant disability is named in almost all of the research on this topic (e.g. Timmermans et al., 1997; Bakx et al., 2013c). Physical disabilities logically explain the biggest part in health care use. Cognitive disabilities are common for dementia patients, but the relationship with health care use is unclear. Also, psychological limitations have a strong influence on health care use, especially when accompanying other disabilities (Van der Berg Jeths et al., 2004). Most types of disabilities are more common among people of age 65 and older.
Restrictions
The restrictions mentioned above are all measures of someone’s self-reliance. De Meijer et al. (2011) name mobility and ADL (all activities someone needs to perform during the day) as proxies for disability. Van der Berg Jeths et al. (2004) conclude that HDL is most important predictor for the use of nursing care and personal care, followed by mobility and ADL.
Other
Making use of home adaptations and using supporting devices are mentioned by some authors as predictors for the use of nursing care and personal care (Timmermans and Woittiez, 2004; Timmermans et al., 1997). Whether the use of supporting devices has a positive or negative influence on health care use remains unclear;
No. Description No. Description
0 Pain 17 Cancer
2 Endocrine disorders 18 Hiv/ aids
3 Mental disorders 19 Kidney disease
5 Diabetes 21 Metabolic diseases
6 Pulmonary problems 22 Liver disorders
8 Epilepsia 23 Immunological disorders
9 Crohn's / ulcerative colitis 25 Muscle disorders
10 Cardiovasculair diseases 26 Skin Conditions
11 Arthritis/ rheumatism 27 Other gastrointestinal disorders
12 Parkinson 28 Bone and joint disorders
14 Transplant 29 Not malignant blood diseases
15 Cystic fibrosis 30 Congenital anomalies
16 Conditions brains / spinal cord
several contradicting findings are presented. Some authors find that the people who use supporting devices and/or home adaptations will consequently use less health care, because they can take better care of themselves. Another finding is that once people start making use of supporting devices, they will become dependent on using health care and thus increase in their need for health care.
Due to data limitations, only a hypothesis for the use of supporting devices can be formed:
H.7 People who make use of supporting devices have a higher chance on using and have higher costs for personal care and/or nursing care.
6.2.4 Health care usage
In this paragraph, the focus will be on the use of health care. Of course, this means the use of other health care services than nursing care and personal care. Other health care services comprise formal health care services (hospital care, patient transportation, use of several primary care functions and use of medicines) and the use of informal care. For informal care, no information is available in the dataset used, so no hypothesis is formed. Informal care
According to several authors, the use or availability of informal care is an important indicator for the use of health care (Bakx et al. 2013c; Timmermans et al. 1997). When informal care is used, the use of other health care services decreases, especially for homecare services. Informal care is mainly a substitute for formal care for people with moderate disabilities. Once the disabilities become more severe, informal care is a less proper substitute (Timmermans et al., 1997).
The variable informal care is very often measured by proxies like having children, size of social network and household composition. This is because informal care is difficult to measure. A lot of people are either not officially registered as informal care providers or they do not think of themselves as informal care givers. Formal health care services
In several articles, the use of other health care services is named as an important variable in predicting someone’s outpatient care use (Timmermans and Woittiez, 2004; De Meijer et al., 2011). Besides that, previous use is found to be a good predictor as well. The prevalent thought is that those who made use of health care services in the past are more likely to make demands on the medical system in the future (Andersen and Newman, 1973). This thesis will only focus on the relationship between outpatient use and the use of other services, since no data on previous use is available.
Evashwick et al. (1984) found that people who visit a doctor regularly make more use of hospital care and the dentist. In addition, Timmermans and Woittiez (2004) found that the use of a medical specialist and hospital admissions are significant indicators of the use of other health care services. This finding is confirmed by Jonker et al. (2007), but does not hold for the function personal care.
For this thesis, there is data available on hospital care, GP, paramedical care (physiotherapist, dietitian etc.), patient transport, dental care, mental health care, medicine use and a category comprising other expenses. Only one hypothesis is formed for the usage of health care, since all types of health care are expected to have a similar effect:
