Within the German social security system, the yearly per capita health and long-term care expenses on institutionalized dementia patients amount to ca. €21,400, of which almost three quarters is attributable to professional long-term care. The overall spending on community-living dementia patients is ca. €9,800 – less than half as much – and at ca. €4,200, the corresponding long-term care expenses are substantially lower.
A comprehensive comparison of both settings according to ADL dependency reveals a trend of rising costs of care with greater physical impairment. Comparing mildly dependent patients with severely dependent ones, the increase – including, again, SHI and LTCI – is ca. €9,400 (+104%) in the community and ca. €5,900 (+35%) in nursing homes. In both patient groups, the long-term care expenses rise more than the health care expenses: SHI spending on nursing home residents increases by ca. €1,300 (+28%) but LTCI spending by ca. €4,600 (+ca.38%). The corresponding figures for community-living individuals are ca. €1,300 (+22%) in SHI and ca. €7,800 (+245%) in LTCI.
A rise in expenditures from care level to care level was by and large expected, even though it has to be considered as artificial regarding long-term care: LTCI tariffs are fixed by legal definition and, hence, different from SHI payments, partially detached from effective needs.
Focusing on the distinct SHI categories, the utilization of routine services increases at higher care levels, but more complex services (medical specialist, hospital, rehabilitation) are utilized less frequently. This might indicate that specialized, interactive – and therefore costly – treatment approaches that aim to restore the patients’ capabilities for independent living are perhaps not considered promising any longer when a certain degree of ADL dependency is reached.
Comparing the health care expenditures between both settings, it has to be kept in mind that SHI services include ‘home health care’, which accounts for short-term medical nursing and temporary household support in community-living individuals. These services are by definition not available for nursing home residents. To fairly judge the costs of health care service provision within the distinct settings, we thus contrasted SHI spending exclusive of expenditures on home health care. In doing so, we found no significant difference between both patient populations.
Despite the fact that overall health care expenses for community-living and institutionalized dementia patients are comparable, the underlying utilization patterns show some notable differences.
First, community-living dementia patients have more inpatient days than their institutionalized counterparts. Our result is similar to the findings of two US-based studies which reported more frequent hospital admissions in community-living elderly patients
[9, 25]. This suggests that some acute illnesses overburden informal family caregivers but can be brought under control by professional nursing staff in institutions, which renders hospitalization dispensable sometimes. A further contribution to extended inpatient days in community-living dementia patients might be the relieving effect on informal family caregivers.
Obviously, community-living dementia patients face an increased risk of inpatient treatment, and SHI should consider offering caregiver support programmes and case management approaches to prevent avoidable hospitalizations.
Second, contrary to previous studies
[8, 12], there is no evidence for worse access of nursing home residents to medical specialists. The contact frequency is comparable with most medical specialists and even significantly increased regarding internal specialists and neurologists. Nursing home residents might have more regular access to specialized medical care because some medical specialists visit their institutions according to a fixed schedule. Thus, it seems to be easier to get an appointment for all patients in need. As a consequence, institutionalized dementia patients might receive more systematic treatment of physical comorbidity and dementia-related symptoms.
To achieve a corresponding advantage for the community-living population, it would be advisable to develop recommendations on which medical specialists have to be visited regularly. Moreover, especially in rural areas, innovative remuneration schemes might be required to secure a sufficiently dense network of specialized care.
Third, a higher quota of community-living than of institutionalized dementia patients receives dementia-specific pharmacological treatment. A corresponding difference was also observed by Reese et al.
. Perhaps physicians feel more obliged to tap the full potential of pharmacological treatment in community-living individuals, whose families most likely feel overburdened by worsening dementia symptoms, than in institutionalized dementia patients, whose disease progression is witnessed by professional nursing staff with a larger personal distance.
Although dementia-specific drugs can achieve temporary symptomatic improvement and postpone the inevitable disease progression, only 12.8% of our study sample received cholinesterase inhibitors or memantine. The minor relevance of anti-dementia drug therapy was also stated within another recent German claims data analysis
To improve adequate pharmacological treatment, physicians need to be more aware of the beneficial aspects of anti-dementia drugs. To this end, they could be offered targeted vocational training.
To better judge the informative value of our findings, the strengths and weaknesses of claims data-based studies have to be considered.
First, claims data lack information on cognitive status
. Thus, we had no means of stratifying our analyses according to dementia severity itself. Given sufficient evidence that dementia progression increases the risk of institutionalization, it must be concluded that institutionalized patients are at a more advanced disease stage. If accepting a relation between cognitive and physical decline
, the care level strata can serve as a rough proxy for disease severity and at least partially reflect how worsening symptoms of dementia affect health and long-term care expenditures in both settings.
Second, the documented diagnoses cannot be verified via medical examinations; thus, their accuracy is not absolutely guaranteed
[28–31]. To avoid including false-positive cases, we required multiple dementia quarters. To incur multiple dementia quarters, an individual needs regular contact with the health care system. This implies the selection of dementia patients, who in principle have a higher morbidity burden than the entire population of insurants with dementia. Hence, our estimates most probably represent a ceiling amount for per capita expenses for dementia patients within the German social security system.
Third, claims data barely provide information on educational level, economic situation and family status, but these factors influence the intensity of demand for professional long-term care. We assume that the denser the informal care network, the lower the need for professional support. The LTCI component ‘allowance for nursing care’ allows the identification of whether informal care is available, but does not assess the informal care hours exactly. Among the community-living individuals in our sample, ‘allowance for nursing care’ accounts for approximately 50% of LTCI spending, and almost every insurant receives corresponding payments. Obviously, informal care plays a crucial role for community-living dementia patients and professional care has a barely supplementary character. In contrast, care provision is almost totally professional in nursing homes. The dimensions of confounding resulting from a different degree of professionalization remain unclear.
On the other hand, claims data-based patient samples seem to be better suited to describing routine care than study samples recruited from neurological wards and memory clinics
[10, 12] because the patient clientele is less selective. Moreover, claims data provide comparatively reliable figures because, contrary to survey-based estimates, recall bias, cost unit definition and extrapolation rules are dispensable. Third, claims data-based estimates are less influenced by single outliers because of their large sample sizes.
Despite its limitations, to our knowledge, our analysis is one of the most comprehensive comparisons between community-living and institutionalized dementia patients from a payer perspective yet undertaken. It addresses the different case mix in nursing homes and the community by care level-stratified analyses adjusting for age, gender, morbidity and mortality to ensure the best possible comparability between settings. Moreover, it presents costs of care on a disaggregated level and itemizes the distinct health care services. This allows easy tracing of which components first and foremost trigger SHI spending. As comprehensive care strategies have to consider the health and long-term care needs of dementia patients, the chosen perspective includes both the SHI and the LTCI, although they are basically independent insurance branches. In doing so, our study revealed that community-based care for dementia patients is the cost-saving option for the German social security system because of significantly lower long-term care expenditures.
However, it has to be clearly stressed that the presented payer-based view is not necessarily in accordance with the societal perspective. Here, production losses and expenditures on behalf of the patients and their families would also be accounted for. For example, food and lodging in nursing homes have to be financed privately. In 2007, nursing home fees averaged €1,900 per month for care level 1, €2,300 for care level 2 and €2,800 for care level 3
. Thus, only around 50% of monthly expenditures are covered by LTCI tariffs. This comes close to the results of a Belgian study, in which around 55% of expenditures for institutionalized dementia patients were borne by their families
. A fair comparison should thus consider food and lodging in community-living individuals. This approach was followed by Kuo et al. and yielded 2.5 times higher spending in the community
Moreover, community-based care is associated with substantial costs of informal care
[10, 12, 32], which most probably overcompensate for savings on professional long-term care services. Altogether, the economic advantage of community-based dementia care cannot be judged unambiguously from a societal perspective.
In addition, pure financial figures abstract away from quality of service delivery, caregiver-related issues and patient preferences. Future research combining primary and secondary data could account for these manifold aspects of dementia care. This would allow a more comprehensive judgement on the preferability of both settings and help to understand why – despite shared clinical and demographic characteristics – some dementia patients are cared for in the community and others in nursing homes.