long-term care use and supply in europe: projections for germany ...

LONG-TERM CARE USE AND SUPPLY IN EUROPE | 9
receive benefits. The number of people in need of care that were deemed ineligible to receive LTCI
funds included 3 million in private households in 2002 and 45,000 people in institutions in 2005
(Schulz, 2011). The prevalence of institutionalisation is thus likely understated.
Benefits are made available to all insured persons irrespective of age, income or wealth. Benefit levels
are based on need, where the “need of long-term care” legally refers to those who, owing to a physical,
psychological or mental disease or handicap, require significant help to carry out the daily and recurring
activities of everyday living over a prolonged period of time (for at least six months). Eligibility is based
on whether individuals need help carrying out at least two basic activities of daily living and one
additional instrumental activity of daily living (IADL). Dependency levels are based on how often
assistance is needed and how long it takes a non-professional caregiver to help the dependent person 4 ,
as follows:
• Care level I: People who need assistance with personal hygiene, feeding or mobility for at least
two activities at least once per day and who additionally need household help for at least 90
minutes per day (45 minutes of which is accounted for by basic care) several times per week.
• Care level II: People who need assistance with at least two basic ADL at least three times per day
at various times of the day and who additionally need help in IADL (two hours of which is
accounted for by basic care) several times per week.
• Care level III: People who need assistance with at least two ADL around the clock and who
additionally need help in IADL for at least five hours per day (four hours of which is accounted
for by basic care) several times per week.
• Hardship cases: People who exceed the requirements of care level III by needing assistance with
ADL for at least seven hours a day, at least two of which are during the night or whose basic care
may only be met by several people working at the same time 5 .
Thus, we much keep in mind in the following section that functional impairment is defined differently
for the German, Dutch and Spanish cases. Nonetheless, Table 2.3 demonstrates that the prevalence of
institutionalisation among persons receiving LTCI benefits increases with the severity of disability and
age (age being correlated with both health status and marital status). More interestingly, prevalence rates
are higher for women except for care level I before age 75 and for care level II before age 70. In other
words, prevalence rates increase more quickly with age for women than for men. This result can be
partly explained by differences in marital status between men and women at old ages, with women being
more likely to live alone.
4 The Medical Review Boards of the Statutory Health Insurance Funds perform the assessment to determine
whether an individual is entitled to benefits. Individuals are assessed for limitations in activities of daily living,
such as bathing and dressing, and instrumental activities of daily living, such as shopping and cooking, as well as
hours of care needed per day. These assessments have focused largely on physical needs for personal care,
nutrition and mobility rather than on needs for supervision or cueing, which persons with dementia or learning
disabilities often need. The new LTCI reform changed this situation in 2008. People whose competence in coping
with everyday life is considerably impaired are now assessed on the basis of a special criteria catalogue. If
applicants fulfil the criteria, they are eligible to receive additional benefits. Also, people who do not fulfil the
criteria for care level I are now entitled to receive benefits (MDS, 2008).
5 Because few individuals in our data were categorized as being hardship cases, we have not reported prevalence
rates of institutionalization for this category of care level in Table 2.3.