Informal Care and Medical Care
Utilization in Europe and the United States
Alberto Holly1, Thomas M. Lufkin1,
Edward C. Norton2, Courtney Harold Van Houtven3
Prepared for the Workshop on Comparative International Research
Based on HRS, ELSA and SHARE
RAND, Santa Monica, CA
July, 10 - 11, 2006
1Institute
of Health Economics and Management, University of Lausanne
2Department of Health Policy and Administration, University of North Carolina at Chapel Hill
3Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center
and Department of Medicine, Division of General Internal Medicine, Duke University Medical
Center
Outline
„
„
„
„
„
Introduction
Institutional settings
Results for the United States
Results for Europe
Discussion
Informal Care and Medical Care Utilization in Europe and the United States
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Introduction
„
„
Definitions
Research questions
„ Usual discussion:
„ Separation medical and long term care
„ Reduce the importance of institutional
care with respect to home care for two
main reasons
„ Preferred mode
„ Less costly (also in relation to the
forecast in demographical changes.
Informal Care and Medical Care Utilization in Europe and the United States
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Introduction
„
Our approach is systemic:
„ A systems view of the health sector is
useful in trying to understand health care
and LTC finance
„ Emphasis on substitution effect and
complement effect
„ Informal care by adult children is a
common form of long-term care for older
adults and can reduce medical
expenditures if it substitutes for formal care
Informal Care and Medical Care Utilization in Europe and the United States
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Introduction
„
„
„
„
We build on work by Van Houtven and
Norton (2004)
Compare results from Europe with the SHARE
data to results from the United States with the
HRS/AHEAD data.
Highlight the main institutional differences
between Europe and the United States as a
motivation for our conceptual framework
Importance of endogeneity issue
Informal Care and Medical Care Utilization in Europe and the United States
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Institutional settings
„
„
„
„
„
A detailed description is given in OECD (2005)
European countries offer some public provision of
health care, either through a national health service,
a social insurance scheme or a compulsory private
insurance system.
All of these systems include some long-term care as
part of the basic coverage.
In general, provision of care is only dependent on
need and not on income or wealth.
Supplementary or complementary insurance
schemes provide additional coverage and allow for
more use of services.
Informal Care and Medical Care Utilization in Europe and the United States
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Institutional settings
„
„
„
In the United States the Medicare but offers
limited home health and nursing home care.
There is no universal right to public services
in the United States,
The share of individuals with private longterm care insurance remains small .
Informal Care and Medical Care Utilization in Europe and the United States
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Institutional settings
Long term care
+
Medical care
Home care
Formal care + Informal care
Institutional care
Informal Care and Medical Care Utilization in Europe and the United States
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Results for the United States
„
„
„
Prior studies of the relationship between informal
and formal care in the United States find mixed
results. They did not seem to definitively establish
whether the two types of care were substitutes or
complements.
The few studies that control for endogeneity (Lo
Sasso and Johnson, 2002, Greene, 1983) suggest
that informal care and formal care are substitutes.
Van Houtven and Norton (2004) study the impact of
informal care by children on formal care utilization:
Informal Care and Medical Care Utilization in Europe and the United States
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Results for the United States
„
Their sequential decision model:
„ The children first determine their optimal
level of informal care provision, given their
budget and time constraints and their
parent's health,
„ Then parents choose optimally their formal
care consumption, given their health level
and the available supply of informal care
and subject to their budget constraint.
Informal Care and Medical Care Utilization in Europe and the United States
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Results for the United States
„
„
„
The formal model is then:
Mijt = git (Ait, Hit, Xit, Cit, εijt)
Mijt, the parent's utilization of formal care,
„ is a function of informal care Ait,
„ health Hit,
„ demographic and income characteristics
Xit,
„ and other consumption goods Cit such as
insurance.
Informal Care and Medical Care Utilization in Europe and the United States
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Results for the United States
„
„
The function g is either the probit function or
is linear for the second part of the two-part
model, depending on the availability of data
for each type of formal care.
Hypothesis: the variable of interest, hours of
informal care provided by the children, Ait, is
endogenous
„ They instrument it with children
characteristics, such as the number of
children, especially of daughters.
Informal Care and Medical Care Utilization in Europe and the United States
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Results for the United States
„
Using data from the (HRS) and the Asset and
Health Dynamics Among the Oldest-Old
Panel Survey (AHEAD), they find that:
„ Informal care
„ Reduces home health care use
„ Delays nursing home entry,
„ They detect endogeneity for all utilization
types, but outpatient surgery.
Informal Care and Medical Care Utilization in Europe and the United States
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Results for Europe
„
In our study, given the structure of the
SHARE questionnaire, the analysis is
restricted to individuals
„ who are aged above 50, live alone (as
singles, divorcees, widows)
„ are not institutionalized
„ and have at least one child.
Informal Care and Medical Care Utilization in Europe and the United States
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Results for Europe
„
Bolin, Lindgren and Lundborg (2006) applying the
same model as Van Houtven and Norton’s (2004),
and using the SHARE dataset, showed that
„ Informal and formal home care are substitutes,
„ But that informal care appears to be a
complement to other types of formal care.
„ They also detected endogeneity in the case of
home care,
„ while this was not the case for the other types of
formal care.
Informal Care and Medical Care Utilization in Europe and the United States
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Results for Europe
„
Our model:
„ The modeling of formal and informal care
should take into account the institutional
differences between Europe and the
United States
„ We suppose that parents first make their
decision to use formal care and then the
quantity is decided according to their
medical need.
Informal Care and Medical Care Utilization in Europe and the United States
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Results for Europe
„ Children
then decide whether they will
provide informal care to their parents or
not, depending on the health state of the
parent and the amount of formal care
received, subject to their time and budget
constraints.
„ We thus model the parent’s utilization of
informal care as:
Ii = f (QFi , Hi , Si , Ci , εi)
Informal Care and Medical Care Utilization in Europe and the United States
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Results for Europe
„
„
Where:
„ QFi is the quantity of formal home care.
This
variable
is
assumed
to
be
endogenous
„ Hi is a measure of health
„ Si socio-economic and demographic
characteristics
„ Ci children characteristics
The function f is a probit function because
we use a binary measure of informal care Ii
Informal Care and Medical Care Utilization in Europe and the United States
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Results for Europe
„
Instruments:
„ Objective
measures of health and
behavior as instruments, such as the
number of severe conditions (e.g. cancer,
heart problems, diabetes) a patient has,
„ Some indicators of his or her health
behavior (whether he or she is a former
smoker and the level of physical activity)
„ The number of years of education of the
parent.
Informal Care and Medical Care Utilization in Europe and the United States
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Results for Europe
„
We also use a simultaneous equations
approach (bivariate probit) to model the
relationship between formal and informal
care allowing for the endogeneity of formal
home care:
⎧Ii = f (Fi , Hi , Si , Ci , εi )
⎨
⎩ Fi = g(Hi , Si , Ci ,ηi )
„
Where Fi is a binary measure of formal care
utilization
Informal Care and Medical Care Utilization in Europe and the United States
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Results for Europe
„
Variables
„ Informal care: dummy variable taking the
value 1 if the respondent had received
any type of care and zero otherwise (No
distinction in the type of informal care
received) .
„ Formal care: two variables
„ Binary variable
„ Number of hours that the respondent
has received either professional nursing
care or home help
Informal Care and Medical Care Utilization in Europe and the United States
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Results for Europe
„
Other explanatory variables divided into
three categories.
„ Socio-economic characteristics of the
respondent, such as age, education,
wealth and income and insurance status.
„ Health variables such as the number of
ADL and IADL or self perceived health.
„ Variables concerning the children as
informal caregivers (e.g., number of
children and the number of children living
more than 100 Kilometers away from the
respondent).
Informal Care and Medical Care Utilization in Europe and the United States
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Variable name
informal
loghomecare
age
male
yearsedu
incomecat
wealthcat
insurance
adl
iadl
sphus
proxy
currentsmoker
formersmoker
Description
dummy=1 if individual receives informal care by
his/her children or grandchildren
ln(total number of hours of formal care+1)
age of individual
dummy=1 if individual is a male
number of years of education
income category (min=1, max=6)
wealth category (min=1, max=6)
dummy=1 if individual has complementary and/or
supplementary insurance
number of ADL limitations
number of IADL limitations
self perceived health, US version
dummy for proxy respondent
dummy=1 if respondent is currently a smoker
dummy=1 if individual is a former smoker
Informal Care and Medical Care Utilization in Europe and the United States
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Variable name
nconditions
drinkin2
activities
nbchildren
childagemax
chinherit
cho100km
Description
number of conditions (heart, stroke, hip fracture,
falls, diabetes, cancer, lung, arthritis, incontinence,
eyesight)
dummy=1 if drinking > 2 glasses of alcohol almost
every or 5/6 days a week
frequency of engagement in activities that require
low or moderate level of energy (gardening,
cleaning the car, doing a walk...) (min=1,
max=4.:1=more than once a week, 2=once a
week, 3=one to three times a month, 4=hardly
ever, or never)
number of children (min=1, max=17)
age of eldest child
percent chance of leaving an inheritance of more
than 50,000 Euro
number of children leaving over 100 Km away
(min=0, max=4)
Informal Care and Medical Care Utilization in Europe and the United States
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Table 2: Summary statistics of the variables
Variable
Obs
informal
loghomecare
age
male
yearsedu
incomecat
wealthcat
insurance
adl
iadl
sphus
proxy
nconditions
drinkin2
currentsmoker
formersmoker
activities
nbchildren
childagemax
3892
3892
3892
3892
3892
3892
3892
3892
3892
3892
3892
3892
3892
3892
3892
3892
3892
3892
3892
Mean
0.2207091
0.5054185
69.61074
0.2317575
9.220324
2.625899
2.681912
0.2502569
0.3044707
0.5704008
3.125128
0.0629496
3.640802
0.0760534
0.1929599
0.204779
1.72148
2.397739
38.66675
Std. Dev
Min
0.414778
1.604833
11.24059
0.4220091
4.559293
1.516406
1.633324
0.4332166
0.9145167
1.265125
1.076377
0.2429036
1.63361
0.2651177
0.3946725
0.4035919
1.134049
1.406222
11.77986
Max
0
0
50
0
0
1
1
0
0
0
1
0
1
0
0
0
1
1
5
1
16.117
102
1
22
6
6
1
6
7
5
1
11
1
1
1
4
13
76
Informal Care and Medical Care Utilization in Europe and the United States
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Table 3: Estimation results: biprobit
(1)
informal
homehctot
sphus
proxy
drinkin2
currentsmoker
formersmoker
nbchildren
childagemax
chinherit
cho100km
male
adl
iadl
nchronic
incomecat
wealthcat
insurance
age
yearsedu
rural
Constant
(3) Intercept (Rho)
Observations
-0.946
0.143
0.17
-0.462
0.175
0.055
0.043
0.017
0.002
-0.169
-0.194
0.002
0.193
0.024
0.007
-0.063
0.188
0.016
0.012
-0.026
-3.313
(2.63)**
(5.02)**
(1.32)
(3.86)**
(2.36)*
(0.82)
(2.35)*
(3.77)**
(3.37)**
(4.15)**
(2.79)**
(0.05)
(5.90)**
(1.17)
(0.36)
(3.10)**
(2.37)*
(2.86)**
(1.95)
(0.39)
(9.88)**
0.779
3595
(2)
homehctot
0.179
-0.372
-0.057
0.347
0.078
0.002
0.008
0
0.046
0.027
0.002
0.229
0.085
0.027
-0.078
0.544
0.035
0.014
-0.235
-5.425
(0.380)*
(4.98)**
(2.86)**
(0.45)
(3.90)**
(0.91)
(0.07)
(1.33)
(0.13)
(1.15)
(0.32)
(0.06)
(7.39)**
(4.01)**
(1.11)
(2.97)**
(7.79)**
(5.62)**
(1.77)
(2.74)**
(15.76)**
3595
Absolute value of z statistics in parentheses
* significant at 5%; ** significant at 1%
Informal Care and Medical Care Utilization in Europe and the United States
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Table 4: Estimation results: IVprobit
informal
loghomecare
age
male
incomecat
wealthcat
adl
iadl
sphus
proxy
drinkin2
currentsmoker
nbchildren
childagemax
chinherit
cho100km
Constant
.
0.193
0.005
-0.214
-0.022
-0.056
-0.033
0.033
0.102
0.179
-0.477
0.084
0.049
0.015
0.003
-0.18
-2.145
3884
(2.05)*
(0.86)
(3.31)**
-1.13
(2.80)**
(0.96)
(0.80)
(3.96)**
(1.70)
(4.10)**
(1.23)
(2.76)**
(3.24)**
(4.83)**
(5.11)**
(7.73)**
Observations
Absolute value of z statistics in parentheses
* significant at 5%; ** significant at 1%
Informal Care and Medical Care Utilization in Europe and the United States
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Discussion
„
„
For the European countries: apparent
contradictory results regarding formal and
informal care:
„ Bivariate probit model: could be
interpreted as a substitution effect;
„ IVprobit model: the provisions of informal
and formal care are complements
Possible explanation?
Informal Care and Medical Care Utilization in Europe and the United States
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ρ
Discussion
„
„
Hypothesis to be tested in a future version:
„ Informal care is a substitute to formal care for low
users or individuals with low needs,
„ for parents with very high needs, then informal
care comes on top of formal home care, as
reflected by the positive sign of ρ
This is similar to the findings of Van Houtven and
Norton (2006) that
„ informal care reduces the probability of using
formal care,
„ but does not reduce the level of expenditure on
home care, once long-term care is accessed.
Informal Care and Medical Care Utilization in Europe and the United States
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ρ
Discussion
„
„
Taking the institutional setting into account
makes it difficult to compare directly the
relationship between informal care and
formal care in Europe and in the United
States.
A common feature: endogeneity of informal
care.
Informal Care and Medical Care Utilization in Europe and the United States
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Discussion
„
„
For Europe,
„ Utilization of home health care leads to a
decrease in the probability of receiving
informal care provided by children,
„ But an increase in the number of hours of
home care received tends to increase the
probability of receiving informal care,
While in the United States, informal care is
found to be a substitute to home health care.
Informal Care and Medical Care Utilization in Europe and the United States
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