Long-term care the problem of sustainable financing (Ljubljana, November 2014) 1

Transcription

1 Long-term care the problem of sustainable financing (Ljubljana, November 2014) 1 Matěj Lipský Social Services Centre Tloskov Vojtěška Hervertová Ministry of Labour and Social Affairs 1. How would you define the role of the state in your country with regard to long-term care (LTC) needs? As main financer of LTC; As last resort safety net when no other support (from private providers, families) is available. The state is the main guarantor of funding for long-term care in both state and non-state institutions, and also through social benefits for families of relatives needing long-term care. Currently, comprehensive care is provided by health and social services in response to the needs of specific people, with a prerequisite for long-term care. The Czech Republic also carries out quality control of the registered services. If it is not possible to obtain support from family or the private non-profit sector; the state provides a sufficient amount of institutions established by cities, counties or directly by ministries. Has the role of the state evolved over recent years (passed or ongoing reforms)? The role of the state, as described in the answer to the previous question, has not changed much during the last years. However, the priorities in the provision of social services are changing. Within the project of transformation of social services the community way of realisation of social services is currently gradually developing. At the same time, the emphasis is put on maintaining the client's need for long-term care in his/her natural environment, i.e. within the family or in the place to which the client has established links (e.g. hometown, family, friends, work, etc.). 2. What are the public financing arrangements for long-term care in your country? Have there been any recent reforms related to the financing of long-term care or are there reforms under preparation? The system of long-term care in the Czech Republic is not considered as a specific sector of the social security system. Rather, services are provided within the medical and social sectors, and are not regulated by a unified legal arrangement administered by one central and/or regional institution. 1 Prepared for the Peer Review in Social Protection and Social Inclusion programme coordinated by ÖSB Consulting, the Institute for Employment Studies (IES) and Applica, and funded by the European Commission. ÖSB Consulting,

2 Thus the funding and provision of long-term care is separate into healthcare and social care elements. The healthcare elements are financed by the public health insurance system. The Act No. 372/2011 Coll. on medical services defines longterm inpatient care as care that is "provided to patients whose health condition cannot be significantly improved by medical care and because of the absence of systematic nursing care is getting worse". Provision of healthcare services at home is done by home care agencies that are contractually linked to health insurers. When home care is prescribed by general practitioners, the healthcare elements of LTC delivered by home care agencies are financed by the public health insurance system. A fee-for-service mechanism is used for the remuneration of healthcare provided by home care agencies. In-patient health care services for long-term patients are provided in healthcare institutions or in residential social care institutions. Only nursing care is provided in residential social care institutions. Healthcare provided by social care institutions is paid by health insurers based on reimbursement of health operations. Establishments for long-term patients are predominantly financed by health insurers. Discrepancies in payment for patients in healthcare facilities for long-term patients and in residential social care institutions is one of the weak points in the long-term care system in the Czech Republic. Social services are provided either by informal carers (family members so called social care assistants) or by professional providers of social services or by a combination of both. Providers of social services must be registered and have to follow the price regulation imposed by the Ministry of Labour and Social Affairs, but they also become eligible for public subsidies. The price regulation stipulates maximum prices for individual social services. The current share of public financing of long-term care comes to around 0.8 % of GDP. According to prognoses under different scenarios 2 the share of public funding of long-term care would grow to between 1.3 and 1.6 % of GDP in 2060 provided current policies are continued. Reimbursement of costs for the social services according to 72 and 73 of Act No. 108/2006 Coll., on Social Services, as amended: Social services are provided; Without payment; Partial reimbursement of costs; Full reimbursement. In residential social service the maximum amount of payment for accommodation, meals and social care is prescribed by the Regulation of the Ministry of Labour and Social Affairs No. 505/2006 Coll., as amended. The amount of reimbursement for social services has to be negotiated in the contract for services between the service providers and users. The sources of funding of social services A. Private funding Disability pension or old-age pension - paid by the Czech Social Security Administration on the basis of decision for disability or old-age pension, this is a mandatory expenditure from the state budget; 2 See Long-term care in ageing societies - Challenges and policy options, Commission staff working document, Brussels,

3 Other income of service users - what can be considered as income is determined in accordance with 7 of the Act No. 110/2006 Coll., on the subsistence minimum; Financial participation of another person: After paying of all costs for accommodation and food services provided in residential homes for people with disabilities, homes for the elderly, homes with special regime, institutional health care service, users must remain with at least 15 % of their income (Section 73, para. 3 of the Act No. 108/2006 Coll., on social services, as amended); If the service user is receiving insufficient income to cover the costs of social service, the provider may agree on a financial cost sharing with a person close to the service user or another person ( 71, para. 3 of Act No. 108/2006 Coll., on social services, as amended); Donations from individuals or legal entities - financial, material. B. Cash benefits for persons with disabilities The care allowance - is governed by 7-30 of the Act No. 108/2006 Coll., as amended Stage I IV; Obtaining of the care allowance is decided by the regional branch of the Labour Office at the request of the person to be granted; It is intended to cover the costs of social care provided; the service provider uses 100 % of the amount of the care allowance; A person older than 1 year, who is due to long-term health condition dependent on the help of another person, is entitled to care allowance. C. Subsidies from the state budget Adjusted of the Act No. 108/2006 Coll., as amended, on social services, its amendment valid from the 1st of January 2014, transferred responsibility for the distribution of subsidies to providers from the Ministry of Labour and Social Affairs to the regions. The region decides on allocation of subsidies to the social service providers on the basis of the Act No. 250/2000 Coll., on territorial budgeting rules and regulations of the EU and on the basis of Act No. 129/2000 Coll., on regions; It is intended to registered providers to ensure the provision of social services D. Programmes funded from the EU Structural Funds Based on the established priorities for the concrete period of time; Operational programme coordinated by MOLSA. E. Funds acquired from foundations, public collections etc. F. Reimbursement of performances by health insurers The Ministry of Labour and Social Affairs of the Czech Republic together with the Ministry of Health of the Czech Republic plans in 2015 to prepare a draft Act on long-term care, which should bring the following changes in funding: should balance the payments from health insurance for healthcare in social service institutions (Discrepancies in payment for patients in healthcare facilities for longterm patients and in residential social care institutions are one of the weak points in the long-term care system in the Czech Republic.). The social service workers will be providing social care services (the content is almost like nursing care) in the 3

4 healthcare institutions/facilities and the new regulation will allow to pay for these services from the social system budget. 3. What is your experience with private (voluntary or compulsory) long-term care insurance? Have there been attempts of introducing private long-term care insurance in the past or are there any plans for the future? In the Czech Republic there is no experience with private voluntary or compulsory long-term care insurance. There have not been any attempts of introducing private long-term care insurance neither in the past nor in the future (it is not planed). 4. What share of the costs of LTC has to be borne by the person in need of care? What forms does this cost-sharing take? Has the extent of cost-sharing evolved over recent years or are any changes under preparation? Social services provided for remuneration, see 73 of Act No. 108/2006 Coll., on social services, as amended (1) For residential services provided in: a) Week-care centres; b) Homes for people with disabilities; c) Homes for the elderly; d) Homes with special regimes; e) Medical devices of inpatient care. a person shall pay for accommodation, meals and care provided in the agreed range. (2) The care for the purposes of determining the amount of activity means basic services (sanitation, current affairs, activation, therapeutic activities, etc.). The maximum amount of reimbursement for accommodation and meals is enacted by legislation (Regulation No. 505/2006 Coll.). (3) After the payment for accommodation and meals while using residential services in the week-care centres, a person must remain with at least 25 % of his/her income, the provision of residential services referred to in paragraph 1. b) to e) the person must remain with at least 15 % of his/her income. (4) Payment for care is determined while providing: a) residential services, with the exception of week-care centres, in the amount of care allowance granted; b) residential services in week-care centres in the maximum amount of 75 % of the care allowance granted. Example: the client of services of a home for people with disabilities has a disability pension (income) of monthly 9,500 CZK (approx. EUR 345) and care allowance in stage II, i.e. 4,000 CZK (approx. EUR 145). According to the contract with the social service provider the monthly payment for meals is for example 5,500 CZK (approx. EUR 200), while the payment for accommodation is 5,200 CZK (approx. EUR 189) which comes to a total of 10,700 CZK (approx. EUR 389). The income of the client, however, is 9,500 CZK (approx. EUR 345). There must remain 15 % of his/her income (if no other income), i.e. 1,425 CZK (approx. EUR 52); 9,500-1,425 = 8,075 CZK (approx. EUR 293). 4

5 The client pays only 8,075 CZK and the rest is offset by the state subsidies. The care provided by the staff - helping during operations, hygiene, etc. therefore pay the full amount of the care allowance, i.e. in this case 4,000 CZK (approx. EUR 145). 8, ,000 CZK = 12,075 CZK (approx. EUR 438) per month is what the client pays, the rest is subsidised by the state. The costs of social services are continuously evaluated. The state determines the maximum payment for most types of services, i.e. those that are charged to users, including units. From January 2015 on the maximum reimbursement will increase slightly. Health care costs are covered by the compulsory health insurance. The patients share the costs of medicines and currently meals service in a hospital in case of hospitalisation. The patient also pays the regulatory fee for a health check (or visiting the emergency room) and for a prescription. These fees, however, will be cancelled in Which relatives/household members are responsible for a dependent person s care needs (providing care or by financing it)? To which extent are their assets and income protected against catastrophic care costs? Tools of the welfare state to ensure proper care for a child or adult 1. Child - responsibility for ensuring the proper care has the parent (including a maintenance obligation), foster parent, guardian In violation of the rights of the child - the tool of elimination: a) Neglecting of Care - Social department of the relevant municipal authority; b) Abusing the Czech Police, the obligation of reporting (e.g. schools, doctors, service providers); c) The global problematic of not meeting the needs of the child and failure in parental responsibilities the courts. If a child's upbringing is seriously endangered or seriously impaired and other upbringing measures did not lead to rectification or if other serious reasons that parents cannot ensure their child's upbringing, the court may order institutional care or child entrust into care facilities for children in need of immediate assistance. Institutional education can be ordered for a maximum period of 3 years. It can be prolonged if the reasons for institutional care still exist, repeatedly, but always for a maximum period of 3 years. 2. Adult person with a disability, who is unable to act for himself/herself or is limited in capacitation New Support Tools: a) Preliminary Statement; b) Assistance in decision making; c) Representation by a household member; d) Guardian of a person unlimited in legal capacity; e) Trust Fund; f) The Guardian Council; 5

6 g) Remains the original instrument - guardian of a person with legal capacity constraints. Assistance in decision making Contract on assistance approved by the court; Based on a relationship of trust between the proponent and the person supported; The proponent advises and assists the person supported, participating in meetings, etc., the person supported decides himself/herself. Representation by a household member The representative may only dispose with the income of the person represented to the extent necessary for the provision of common matters, according to the living conditions of the person represented; As for the means on the bank account of the person represented, the representative may handle with it only to the subsistence level (3,410 CZK (approx. EUR 124)) a month. The Guardian a) A natural person (e.g. family member); b) The public guardian - the competent Municipal Authority. A guardian is required to maintain the person placed in guardianship in an appropriate manner and to the extent needed regular contact, show a genuine interest in the person placed in guardianship and care about their health condition and take care of fulfilling the person's rights and protecting their interests. 6