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Executive Summary from "EldercareOn the Auction Block"
published by: Consumers' Association of Canada (Alberta)
Since the 1990s, dramatic changes to Alberta's long term care
sector have unfolded with little media notice. Confusing jargon, mixed
messages, lack of data, and widespread differences among the
province's 17 regional health authorities have disguised much of the
restructuring.
Yet the changes have not gone unnoticed by families. Today,
more and more adult children and elderly spouses are finding
themselves trapped in the bewildering grip of Alberta's heavily
privatized LTC environment. What they find is rarely what they expect
- or need.
In 2002 the Alberta Chapter of the Consumers' Association of
Canada decided to investigate these changes. Our research found that
both residential and in-home care for the elderly have become costly
and inaccessible arenas for many people.
Quality is often grim, staffing levels are marginal. The promise of
innovative models of care has been largely eclipsed by limited access
and decreasing coverage of the costs associated with care. Many
families now face an untenable choice: either give up a salary to care
for a loved one at home, or spend savings and assets to purchase
private services. Indeed, so much of the burden and cost of care has
been offloaded to families that the Long Term Care Association of
Alberta is quietly advising people to purchase private LTC insurance to
protect their income and assets.
If this sounds like American-style health care, it is. And just as
the administrative costs of the U.S. system are much more expensive
than Canada's, Alberta is now spending more money managing an
increasingly fragmented LTC sector, leaving less money for actual
care. Between 1997/1998 and 1999/2000, the actual money spent on
administration by regional health authorities increased by 15.2 percent
- more than for any other identified category except research and
education.
Background
Alberta began cutting public coverage of LTC in the early 1990s,
first in the name of deficit reduction, then in the name of tax cuts to
encourage business to fill the void. Construction of new nursing homes
and auxiliary hospitals ceased. Between 1988 and 1998, acute care
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hospital beds dropped from over 14,000 to 6,300. Existing LTC beds
were used to deal with the acute care shortage; as a result traditional
LTC clientele were turned away and many terminally ill cancer patients
found themselves paying per diem charges. Long-promised home
supports never materialized.
The reduction in public LTC options created a large gap between
what was needed and what was available to Alberta seniors. This gap,
in turn, created immense opportunities for real estate investors.
Developers imported a new retirement housing concept from the
United States called "Assisted Living."
These complexes bore little resemblance to the Assisted Living
model pioneered in Oregon in the late1980s. Originally, Assisted Living
was a progressive approach to caring for seniors and other persons
with limited abilities. The model called for a home-like setting that
gave residents control over their private space and enabled them to
maintain their capacity for self-care. The program could also include a
basic package of meals, housekeeping, and help with personal care; it
could also offer the option to add on extra services.
In Alberta today, the term Assisted Living usually refers to multi-
unit apartments with varying amounts of on-site personal supports
and care - all available for a hefty price. The original vision has been
co-opted by commercial interests. Residents are often vulnerable due
to their physical and cognitive limitations, yet the province says it has
no responsibilities for licensing, tracking, or monitoring these facilities.
Faced with a severe shortage of public LTC beds, some Alberta
health authorities are resorting to a new hybrid model, often referred
to as "Designated Assisted Living". The health authority contracts with
housing owner/operators for access to living units; the contract also
covers access to 24-hour personal care, provided by the operator.
Seniors placed in these units are responsible for the largely
unregulated price of their lodging, food, utilities, and many other
support expenses. Designated Assisted Living is part of Alberta's
overall strategy of unbundling and offloading the costs normally
associated with long term care.
Key concepts behind the changes
The alterations to Alberta's LTC environment were based on several
key inter-related concepts.
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ˇ Distinguishing between "core" and "complementary"
services: Theoretically, this distinction would enable the public
healthcare system to save money by limiting the number of
services it covers (i.e., core services). Clinics, hospitals, and
nursing homes would then be free to earn extra income by selling
related services or products at unregulated prices (i.e.,
complementary services).
ˇ Separating "health" from "housing:" Alberta has gradually
limited its LTC funding obligation to a very narrow range of direct
healthcare services, while withdrawing from support costs such as
housing, meals, housekeeping, maintenance, utilities, and so on.
ˇ The level playing field: This means making seniors in LTC
facilities bear the same costs as seniors at home. In other words, if
a senior in their own home pays for drugs, personal care, medical
devices, incontinence supplies, housing, meals, and other costs of
living, they would also pay for these in a LTC setting. In reality,
level playing field means dragging public coverage of residential
care down to the ever-declining level of home care.
ˇ Unbundling services: Unbundling is the process used to
operationalize the concepts above. The more a service can be
broken down into its component parts, the more opportunities for
reducing the basic healthcare package, contracting out services,
and offloading costs to individuals and families. Not only can
healthcare be unbundled from housing, but housing and support
services can be atomized and unbundled further.
A number of false assumptions, unsupported by the evidence,
regarding the merits of pursuing these policies have also fuelled many
changes. These include perceptions about the wealth of seniors and
their adult children, the affordability of private care and private
insurance, and the costs to society from pursuing these strategies.
Conclusion and Recommendations
Alberta families are increasingly trapped in a high-priced LTC
market with few real choices. Worse still, the battered public sector
has adopted many of the expensive habits of risk-adverse private
insurers, driving up the costs of administration and leaving less money
for care.
Since failure to address this situation will have grave ramifications
for Alberta families, employers and communities, the Consumers'
Association recommends that the province of Alberta:
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ˇ Restore and expand universal public coverage for long
term care supports, regardless of the setting. Ensuring
timely and affordable access to a wide range of quality public
LTC services is an essential step Alberta can take to enhance the
determinants of health among the elderly and their families.
ˇ End the unbundling of services. Efforts should be made to
re-integrate services, functions, organizations, and payments.
Not only will this benefit individuals and families in need, it will
also reduce administrative costs and maximize opportunities for
wholesale purchasing.
ˇ Ensure full disclosure about LTC services. Albertans have a
right to open and complete information about availability and
eligibility requirements for LTC services and about the costs and
obligations of agencies and operators supplying services.
Without this information, Alberta families and communities
cannot make responsible choices or hold suppliers and plan
administrators accountable.
ˇ
License, regulate, and monitor supportive housing and
Assisted Living settings. At a minimum, supportive housing
and Assisted Living operators should be licensed regardless of
their ownership status. Formal and informal complaint and
appeal mechanisms need to be visible and effective, and
community groups should be supported to take an active role in
acting as advocates.
NOTE: In 2003, the provincial government discontinued daily charges
in long term care facilities for individuals designated as "palliative
care". At the same time, per diems for other residents were
dramatically increased.
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