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Making 24h care at home more accessible

Country: 
Austria
Partner Institute: 
Institute for Advanced Studies (IHS), Vienna
Survey no: 
(10)2007
Author(s): 
Hofmarcher, Maria M.
Health Policy Issues: 
Long term care, Funding / Pooling, HR Training/Capacities
Reform formerly reported in: 
Long Term Care Policy
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no yes yes no no

Abstract

In July 2007 Austria implemented a new Home Care Law (HCL) which complements existing arrangements. In recent years 24h home care has become a fourth pillar in long-term care provision. This policy aims at ensuring access to 24h care by permitting contractual relations between carers and recipients, by increasing the working time of carers and by granting subsidies. In the context of this legislation sanctions against illegally practicing care workers have been deferred until the end of 2007.

Purpose of health policy or idea

24h home care provided by illegally practicing care workers has become a fourth pillar in the Austrian long-term care sector and evolved where family care became insufficient to ensure comprehensive home care. Service delivered by mostly "alien" care workers is mainly help with activities of daily living. Probably five percent of long-term care recipients, approximately 380 000 in 2007, use this service. Foreign long-term care workers are often coming from neighbouring new EU member states, are normally not registered in Austria, have no work permit and thus do not pay social insurance contributions. Their qualifications and training levels are often unknown.

Objectives

  • to establish statutory provisions for 24h care provided at home by amending current labor market, social insurance and professional regulations
  • to grant public subsidies for those in need of 24h care, means-tested excluding property, i.e. income threshold 2.500 Euros per month excluding the LTC allowance and permitted savings of 7000 Euros.

Content

  • Applies to recipients in care categories 3 to 7 and to recipients in lower categories where mental health states ("dementia") justify permanent surveillance.     
  • Home care may be provided by self-employed and employed care workers. Care workers may be employed by recipients or by family members. Support may be rendered with activities of daily living but may not involve medical help.
  • Working hours may not exceed 64 per week[1] and breaks are granted. The employment contract ends with the death of the care taker even if the family member is the employer. For public and other organizations selling 24h care services current working time regulations do not apply. Rather stipulations of this law apply.        
  • No specific quality assurance measures apply. However, the care giver must follow instructions by the care taker; further the amendment of regulations for self-employed persons specifies to some degree tasks to be delivered by a 24h care giver. In this context the caregiver is required to cooperate closely with other care professionals involved or family members. A model contract issued by the Ministry of Social Affairs proposes a list of tasks ranging from home help to social tasks and which may be ticked in completing a contract. By July 2008 all 24h caregivers are required to have received training as a home-help worker.

[1] Regular working hours for health professionals may - according to the EU working time directive - not exceed 48 hours per week within a period of 17 weeks.

Main points

Main objectives

  • to establish statutory provisions for 24h care provided at home by amending current labor market, social insurance and professional regulations
  • to grant public subsidies for those in need of 24h care, means-tested excluding property

In the context of this legislations, sanctions against illegally practicing care workers have been deferred until the end of 2007.

Type of incentives

  • public subsidies between 800 and 250 Euros per month are granted if monthly income of recipients is not higher than 2500 Euros and savings do not exceed 5000 Euros
  • financial penalties for recipients if care givers are not registered and no social insurance is paid 

Groups affected

patients and families, long-term care workers, provider organisations

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Characteristics of this policy

Degree of Innovation traditional rather innovative innovative
Degree of Controversy consensual controversial highly controversial
Structural or Systemic Impact marginal neutral fundamental
Public Visibility very low high very high
Transferability strongly system-dependent system-dependent system-neutral

Reflecting the degree of controversy in the course of preparation of the draft legislation this policy is rather innovative as no explicit restrictions are made regarding the status of a caregiver. Thus, family carers could also deliver care in formal arrangements. To this end family members may be employed by recipients or may enter into a contract with them as self-employed caregivers. This in turn would imply putting a market value on family help. The law does not require family carers to be employed by a care recipient but it provides for a "foot in the door", even though formal arrangements between family members may contradict the subsidiarity principle of family responsibility on which the Austrian social model is based.

Austria was one of the first OECD countries to recognize the need for balanced long-term care provision. In contrast with other countries (though many are now following her lead in this respect) she acknowledged freedom of choice and flexibility as being important ingredients for adequate care provision in this area. However, since its introduction in 1993 the long-term care allowance has only been raised once, in 2005, leading to a real loss of value of the transfer for many recipients. This restrictive adjustment contributed to financial sustainability but had prevented legal home care options from evolving. If the Austrian long-term care model is to continue to fund adequate care, routine adjustments for inflation of the cash allowance and additional funding of 24h care is thus needed. In so far, policy development in this area is rather system-dependent. 

Political and economic background

The Austrian long-term care policy is rooted in values of the underlying welfare model where family responsibility has primacy over public provision (subsidiarity principle). In 1993, Austria introduced a universal cash payment program at the federal and Länder level to provide financial help with both institutional long-term care and home care. This universal system of care allowances (Pflegegeld) largely replaced and unified existing programs and aims at helping individuals to remain at home as long as possible and to live independent lives (see survey (2)2002).

Entitlements for the long-term care allowance are granted in seven categories where care needs are defined as "average time involved for regular care and assistance". About one third of recipients are in care category two implying help for more than 75 hours per month. While the inflow of recipients in high care categories (ie. those with high care needs) remained largely unchanged since 1999 the share of recipients receiving benefits in category one and four increased. This may reflect a restrictive categorization policy to ensure that people in need for care receive benefits but on a low level. It also reflects easier switching from category 3 to 4 which was made possible in 1999, i.e. reducing the amount of care needed in category 4 from 180 hours to 160 per month.

Since its introduction in 1993 the long-term care allowance has only been raised once in 2005 leading to a real loss of value of the transfer for many recipients. This restrictive adjustment contributed to financial sustainability but had prevented legal home care options from evolving.

The Austrian government has recognized the significance of informal caregiving in light of increased female labor force participation and the smaller family size combined with population aging, and made efforts to improve the situation of informal care givers. To this end, various measures have been adopted such as regular counseling to reduce the strain on care givers and improved social security. For example, to improve the situation of family members providing care, a preferential insurance scheme was recently introduced for persons who had to terminate employment in order to provide care for a close relative who is eligible for a long-term care benefit.

Total direct cost for long-term care services in the formal sector was 1.9 billion in 2006 which corresponds to about 1.5 percent of GDP. This share would probably be about double if informal caregiving and "illegally" provided services were delivered at current market prices; at this level the spending share in Austria would reach current spending levels, as measured in percent of GDP, in Denmark or in Sweden (OECD 2005).

In essence the new home care law aims at increasing working time for health care workers and at ensuring caregiving on a legal basis. Its implementation may also be seen in light of recent European initiatives, which permit for "free movement for certain occupational groups, including health care workers" (European Commission 2006). For example, this legislation ensures that migrating care workers, coming to Austria, may expect Austrian pay levels and social security standards which apply for Austrian health care workers. This in turn requires the payment of social insurance contributions. Estimates suggest that about 215 million Euros of contributions are foregone on an annual basis (Marschitz 2006); this corresponds to approximately 11 percent of total expenses on long-term care.

Change of government

Long-term care has been put on the agenda of the center-left government in its policy paper.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no yes yes no no

Origins of health policy idea

Reflecting much of the intent of the LTC law from 1993 four in five recipients receive services in informal care arrangements. About one fifth is cared for in nursing homes or receives formal home care service.

Where family caregiving has been insufficient and other home care is unavailable ensuring 24h care and surveillance where needed a "black market" has evolved. Estimates suggest that currently about 40 000 persons are illegally practicing long-term care workers (Arbeitskreis 2006, Annex). This would suggest that about every second care giver in the long-term care sector is some type of illegal migrant worker. Such service has also been provided within the family of the former prime minister and the president of the republic. In some federal states law suits against families "employing" illegal care workers were filed in spring 2006 and in the context of the 2006 election campaigns a fierce discussion about problems in the area of long-term care broke out. This led to policy proposals aiming at legalizing "live-in" care provided to households. The home care law 2007 and accompanying measures to defer sanctions for illegal alien workers until the end of 2007 is the outcome of these policy debates.

Initiators of idea/main actors

  • Government
  • Providers
  • Payers
  • Patients, Consumers
  • Civil Society
  • Scientific Community
  • Media

Approach of idea

The approach of the idea is described as:
new:

Stakeholder positions

In the 2006 policy paper, the center-left government defined a comprehensive agenda for long-term care policy:

  • Ensure care infrastructure to meet preferences of patients and families, by e.g developing 24 hour care and more hospice care options at home
  • Make care more affordable, by e.g recognizing the need of further resources needed to ensure quality caregiving, by aiming at harmonizing entitlements across different regions and at enhancing measures to grant social security of caregiving family members
  • Support family carers and neighborly help by e.g. suggesting to develop consulting programs for caregivers and a greater role of welfare organisations
  • Enhance future options for employment in this area by e.g.harmonizing profiles of home help personnel across federal states, by increasing within sector mobility for care workers and by making working arrangements for qualified nursing staff more flexible.

By and large all actors and stakeholders are in favour of developing long-term care and enhancing service quality. Notwithstanding this broad consent there have been debates about the scope and the speed of the introduction of legalized 24h home care.

  • First,  the policy was very much pushed by media reports in spring 2007 as law suits have been filed where families received help from illegal care workers.
  • Second, the Minister of Economy, who belongs to the conservative party, in tandem with welfare organisations have been lobbying for liberalizing employment regulations in this area including improved options for self-employment.
  • Third, this in turn was opposed by the Minister of Social Affairs, who had to balance claims from trade unions to maintain current professional regulations in this area with rising expectations and high demand for such type of care.
  • Fourth,  organisations of pensioners have constantly claimed that the legislation is not sufficient to alleviate the care burden for families. Only recently campaigns were organized to defer sanctions for hiring illegally practicing care workers further beyond 2008. Some federal states signalled already that sanctions will be deferred further inspite of provisions in this law.
  • Finally, in the context of financial equalisation across federal states and the central government due to be implemented in December 2007 discussions were fierce around the funding model. This led to an increase in the level of permitted savings from Euros 5000 to Euros 7000. However, some federal states have already announced that they wont comply with means testing and that they plan to abolish savings treshholds

Actors and positions

Description of actors and their positions
Government
Minister of Social Affairsvery supportivesupportive strongly opposed
Minister of Economyvery supportivevery supportive strongly opposed
Providers
Welfare organisationsvery supportiveopposed strongly opposed
Payers
Ministry of Financevery supportivesupportive strongly opposed
Patients, Consumers
Patients and familiesvery supportivesupportive strongly opposed
Civil Society
Austrian Chamber of Commercevery supportivevery supportive strongly opposed
Austrian Chamber of Laborvery supportiveopposed strongly opposed
Scientific Community
Experts and researchersvery supportiveneutral strongly opposed
Media
Papers-television-radiovery supportiveneutral strongly opposed

Actors and influence

Description of actors and their influence

Government
Minister of Social Affairsvery strongstrong none
Minister of Economyvery strongstrong none
Providers
Welfare organisationsvery strongstrong none
Payers
Ministry of Financevery strongvery strong none
Patients, Consumers
Patients and familiesvery strongweak none
Civil Society
Austrian Chamber of Commercevery strongstrong none
Austrian Chamber of Laborvery strongstrong none
Scientific Community
Experts and researchersvery strongweak none
Media
Papers-television-radiovery strongvery strong none
Minister of Economy, Austrian Chamber of CommercePatients and familiesMinister of Social AffairsMinistry of FinanceExperts and researchersPapers-television-radioWelfare organisations, Austrian Chamber of Labor

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

The strain on family resources to cover 24h care cost is surely alleviated when subsidies are granted. While the income threshold for entitlement (2.500 Euros per month) well exceeds maximum statutory pension for males - being at approximately 1.700 Euros per month - it nevertheless appears that the take-up of the program is slow. According to press releases, from July 2007 until October 2007 not even 100 people have applied for funding. This slow take-up may be a result of the low level of permitted saving, defined as being 7000 Euros. This threshold is calculated on the basis of the spread of permitted savings for entitlement for social assistance for nursing home care across federal states being in the range of 3.500 and 10.000 Euros. In addition, regress policies regarding income and savings of extended family members differ across federal states with some states having no regress policy at all.

Many people probably have savings which exceed 7000 Euros and may thus be reluctant to reveal them. However, entitlement criteria of both care options - moving to nursing homes and 24h care - are now on a similar legal footing. This implies that 24h care has potential to develop into a close substitute for nursing home care. Probably more important for the low take-up rate are deferred sanctions for illegal employment until the end of 2007 losening the incentive to register 24h care persons and to apply for funding.

In October 2007 the central government and the federal states signed a statutory treaty where financing terms for the new policy was clarified. Of an estimated amount of 40 million Euros per year needed to ensure 24h care, federal states contribute with 40 percent of cost (capped), the central government will contribute 60 percent. As the transitional period for deferring sanctions for illegal workers will also end at the end of the year, applications for subsidies in 2008 will probably rise sharply. Some federal states have already signalled to aid also persons whose savings exceed the federal treshold.

Expected outcome

In regulating 24h informal care at home, the 2007 law has recognized the need to formally introduce a further pillar for service provision in the area of long-term care. This policy complements and legalizes home care arrangements which have emerged under current regimes. These regimes provide cash transfers ("Pflegegeld") based on the extent of disability. They were intended to stimulate private supply of services, including informal care giving from family members. 

The Austrian long-term care policy is rooted in values of the underlying welfare model where family responsibility is given primacy over public intervention (subsidiarity principle). While the LTC care law from 1993 largely reflects this, the new home care law could create a market value for "family help". For example, it aims at establishing contractual relations between care givers and care takers and does - in principle - not exclude informal family care givers from entering in this kind of formal arrangement. In light of the fact that most informal care is rendered by wives and daughters with relatively low levels of educational attainment, this policy may increase options for "formal labor market participation" of women.

While such a development is not unlikely, the policy has important social and economic implications in the short term.

  • First, although 24h care becomes more affordable most extended families may still need to contribute substantially either from savings or from the income of other family members to maintain living standards. Income of many recipients (including the LTC allowance and additional subsidies) is most likely lower than expenses necessary for legalised 24h care. 
  • Second, this policy increased weekly permitted working hours for carers and made working arrangements more flexible. This may weaken the role of trade unions in this area by setting the scene for further erosion of current employment regulations.
  • Third and in this context, the law opens the labor market for "alien" care workers further. Even in a situation where services are provided by self-employed individuals a minimum price has to be paid which still may exceed pay levels in exporting countries.
  • Fourth, notwithstanding quality concerns sometimes raised in the context of around-the-clock arrangements, home caregiving may become safer as all care givers will be required to attain a certain level of training if the 24h care subsidy is granted (home-help). Also, surveillance of quality becomes possible.
  • Fifth, the policy may promote the development of home care in general by permitting for more flexible working arrangements in this setting. This is much needed in light of slow adoption of home care plans in federal states. 
  • Finally, the legalisation of 24h care generates tax revenues which hopefully will be used to improve service and support for care recipients and care givers.

Impact of this policy

Quality of Health Care Services marginal neutral fundamental
Level of Equity system less equitable neutral system more equitable
Cost Efficiency very low neutral very high

While this legislation and accompayning statutory agreements foresee some measures to make home care safer the degree of implementation of harmonized training standards is uneven across federal states. This situation is not likely to change in the short-term. Thus the impact of this policy on the quality of service provision may remain unchanged. 

We assume that the level of equity is also not likely to change if remaining on current levels at all. First, eligibility for social assistance remains diverse across federal states. This impacts on the eligibilty for additional funding of 24h care: eligibility is still uneven, thus maintaining current levels of horizontal inequity. Second, the level of funding may be too low to make legal 24h care better affordable for a large part of recipients.  

As with cost efficiency, we anticipate that in the short term it will remain unchanged. First, it is uncertain which care option will prevail in the market. The model where self-employed care workers deliver services seems to be the most affordable option from the recipients point of view. But this will depend on the development of pay levels in this area being a function of wages of foreign care workers, which, not least in the context of robust demand, are likely to converge. Second, 24h home care possibly evolving as a lower cost substitute to nursing home care would imply down-sizing capacity in the latter. However, nursing home costs may well rise as the case mix in this setting may become more severe, thus over-compensating any savings made through balancing capacity across care settings. 

References

Sources of Information

  • Arbeitskreis "Zukunft denken". Pflege und Altenbetreuung, Abschlussbericht des Arbeitskreises, Oktober 2006.
  • BMSGK (Federal Ministry of Social Affairs (Ed). Ausbau der Dienste und Einrichtungen fuer pflegebeduerftige Menschen in Oesterreich. Wien: OEBIG. 2004.
  • HCL Home Care Law - Hausbetreuungsgesetz - HBeG 2007, 78 der Beilagen zu den Stenographischen Protokollen des Nationalrates XXIII. GP
  • Marschitz, W. "24-Stunden - Betreuung in Privathaushalten, Moegliche legale Antworten auf die illegale Herausforderung", in "Zukunft denken", Pflege und Altenbetreuung, Abschlussbericht des Arbeitskreises, Oktober 2006.
  • OECD. Long-term care of older people. Paris: OECD. 2005.
  • Hofmarcher, M.M. "Austria´s new Home Care Law: An assessment in the context of long-term care policy". OECD Working Paper, to be published.

Reform formerly reported in

Long Term Care Policy
Process Stages: Implementation, Evaluation

Author/s and/or contributors to this survey

Hofmarcher, Maria M.

Suggested citation for this online article

Hofmarcher, Maria M.. "Making 24h care at home more accessible". Health Policy Monitor, October 2007. Available at http://www.hpm.org/survey/at/b10/1