Preferences for long-term care services: Willingness to pay estimates derived from a discrete choice experiment
Introduction
Ageing populations, a broadening social definition of health and the increasing prevalence of chronic diseases intensify pressure on health care budgets (WHO, 2005). While these changes may affect all types of health care, long-term care may be most affected because long-term care expenses increase markedly with old age (de Meijer, Koopmanschap, Koolman, & van Doorslaer, 2009). Keeping long-term care affordable while raising quality to meet expectations will be a big challenge (Miller et al., 2008, OECD, 2005).
Effective response seems to be thwarted because the relative values of available services and supply methods for different persons have not been documented. Although evaluations on effectiveness of long-term care products are plentiful (e.g. Bouman et al., 2008, Thompson et al., 2008), information about the yield of individual services in terms of improving consumers' well-being is lacking. Consequently, it is not easy to determine how resources can best be allocated over beneficiaries, services, and/or modes of service delivery. Therefore, achieving efficient resource allocation decisions requires us to learn how individuals place value on particular aspects of long-term care.
Resource allocation decisions in curative care are often guided by the outcomes of economic evaluations (Ham and Robert, 2003, Rutten and Busschbach, 2001). This is not common practice in long-term care, probably because suitable outcome measures are lacking. Support and care for people with physical, mental or sensory handicaps and/or illnesses is often needed for years or even the rest of their lives. As much of long-tem care is not aimed to improve health outcomes, measures used in curative care – such as Quality Adjusted Life Years – are less suitable for outcome valuation. Consequently, evaluations of long-term care typically focus on the extent to which services produce the intended effects. Rehabilitation programs, for example, are evaluated by their effects on physical functioning, and feeding policies by improvement in nutritional status (Arinzon et al., 2008, Forster et al., 2009). Impacts of such improvements on well-being remain unknown. The few available studies on the value of long-term care services regrettably do not allow for a cross-service comparison (Howell-White et al., 2006, Markle-Reid et al., 2006, Mitchell et al., 2006).
Research efforts need to be directed at developing tools that are suitable to compare long-term care needs across populations and to measure benefits of various services. In this regard, Ryan and colleagues developed the older person's utility scale (OPUS) to evaluate the needs for (or the effects of) social care in the elderly, regardless of their condition (Ryan, Netten, Skatun, & Smith, 2006). Another example is the ICECAP measure, which produces a quality of life index for elderly in a similar manner as the OPUS (Coast et al., 2008). Both measures may serve to evaluate improvements on well-being as related to provision of long-term care services. Furthermore, their generic nature allows for assessing the relative values of those services. But as of yet, evidence of validity of the two measures is still rather limited, and relative values of different services for different people have not been established. For that, it seems we must wait until the ICECAP and OPUS techniques have gained wider acceptance. In the short run, however, valuation of long-term care services is still needed.
In this article we present the results of a discrete choice experiment (DCE) performed to elicit preferences for long-term care. The DCE exercise required respondents to choose between long-term care scenarios for several hypothetical patients. The scenarios were characterized by absence or presence of particular services and by specific modes of services delivery. A cost attribute addressed willingness to pay (WTP) for the scenarios and marginal WTP for their attributes. Thus, welfare gains related to long-term care could be indirectly assessed. The results of our study may guide resource allocation decisions across alternatives and/or across groups of beneficiaries, and improve understanding of how services affect quality of life of different patient subgroups.
Section snippets
Theory underlying attribute selection
In long-term care settings, a wide range of services may be offered in various ways. In the current study, it is impossible to evaluate added value of each one. We focus on services and modes of service delivery with the largest potential to affect well-being – identified using the Social Production Function (SPF) theory (Lindenberg, 1996, Lindenberg, 2001, Nieboer et al., 2005). Below we first present this theory and next describe how we used it to identify services and modes of service
Study design
The DCE involved choices between two hypothetical but realistic long-term care scenarios, described by attributes derived from SPF theory. Experimental design techniques served to decide which attribute level combinations would be presented, in order to ensure that information about attribute importance could be retrieved from the collected data.
Attributes and levels
The SPF framework identified ten types of care services and modes of delivery that probably contribute to well-being of the beneficiaries of long-term
Respondents
In total 1859 (out of 3870 invited people) were administered the online survey (48%), but 777 (20%) did not complete the questionnaire. Accordingly, 1082 completed questionnaires were obtained (28%). This is a normal response rate for this panel (personal communication, SSI). The obtained sample had the same distribution of gender, age, and education groups as the general Dutch population in this age group: 51% was female, mean age was 56.5 years (SD 4.2), 43% had a fulltime job, 72% was
Discussion and conclusion
This paper examined the relative values of long-term care services across beneficiaries. The results showed that well-being may be improved by services providing for physical and social needs. Given a minimum level of physical well-being, care services that contribute to social well-being received high value. Extra hours of personal and domestic care – in addition to the minimum of 4 h – were assigned less value. Organized social activities and transportation services for physically frail
Acknowledgements
The project was funded by the Federation of Patients and Consumer Organisations in the Netherlands (NPCF). The views in the paper are those of the authors.
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