Pricing long-term care for older persons

Implementing universal health coverage (UHC) implies ensuring access and financial coverage for care for older persons. In Phase 1 of this research on pricing health care services, we found very different systems in place for financing and access to benefits for services for older persons in comparison with health services. Phase 2 focuses on the organization and financing of long-term care services, and the systems in which services are priced, organized and delivered.

Nine country case studies were commissioned, representing a range of health care systems, experiences in purchasing and price setting, and the commitment to improve financing mechanisms to attain broader policy goals. Each case study describes the organization, coverage, financing and entitlement for facility-based health care, home-based care, residential care and personal care for older persons. The case studies describe long-term care financing, pricing long-term care services, and the policies in place to ensure fiscal sustainability and provide financial protection.

The summary report distils lessons learned from the case studies in long-term care financing and price setting and draws policy lessons to drive country action, particularly in low- and middle-income settings. The report concludes that:

• Public investments in formal LTC systems are important because of population ageing and declines in the availability of family caregivers, many of whom are women.
• The overall objectives of a given LTC system will have an influence on how care is organized and financed in that system.
• A separate funding stream may help ensure that LTC funding is not diverted to other purposes, promotes transparency in management; however, the separation of funding for LTC and health care may pose problems in coordination across health and social care.
• Funding to LTC should be linked with need and the care provided; all of the countries studied use objective needs assessments to determine eligibility, and link prices and payments with health and social care needs.
• Where cost control is the primary objective and eligibility criteria are stringent, unmet needs may emerge. Therefore, needs assessment systems should be monitored to ensure that they enable access to needed care. Similarly, systems of user charges should be formally evaluated as to whether their application results in reduced utilization and unmet need.
• Funding to LTC to should be based on a secure reliable source that reduces any regional inequities in resources available.
• Price adjustments and add-on payments could be used more broadly to foster equity in provider payment.
• Quality measurement in LTC is an important area requiring further policy development, which can be linked to price levels and payment mechanisms.

Lessons learned from countries with mature long-term care systems can be an important resource for middle- and low-income countries, who are facing the challenges of providing appropriate quality health and social care for older populations. An important lesson is that formal investments in financing public LTC are important because of the increased demand for these services with population ageing, and the declining availability of informal caregivers.

The case study from Japan provides important lessons learned for other countries, including the need to consider sustainability in the design of LTC, monitoring the eligibility criteria, enabling informed choice and monitoring equity in access.

Pricing long-term care for older persons

WHO Centre for Health Development (‎Kobe, Japan)‎, Organisation for Economic Co-operation and Development, Barber, Sarah L, van Gool, Kees, Wise, Sarah. et al. (‎2021)‎. World Health Organization. https://iris.who.int/handle/10665/344505. License: CC BY-NC-SA 3.0 IGO

• Full report
• Foreword and Acknowledgements
• Executive Summary
• Chapter 1. Justification for the study
• Chapter 2. Organization and financing of LTC
• Chapter 3. Determining eligibility for public benefits
• Chapter 4. Approaches to setting prices
• Chapter 5. Maintaining a balanced budget, adjustments to prices, and incentives for quality
• Chapter 6. Comparing prices across countries
• Chapter 7. Lessons learned for other settings
• References

Country case studies and policy briefs

Australia
Case study - DOWNLOAD
Wise S, Woods M, van Gool K. Consumer choice and control within a highly regulated, market-based system in Australia. World Health Organization; 2025 (Country reports on purchasing long-term care). https://doi.org/10.2471/B09375

France
Case study - DOWNLOAD
Or Z, Penneau A. The loose connection between pricing, costs and quality with regional inequalities across France. World Health Organization; 2025 (Country reports on purchasing long-term care). https://doi.org/10.2471/B09355

Germany
Case study - DOWNLOAD
Milstein R. Mueller M, Lorenzoni L. Germany’s difficult balancing act: universality, beneficiary choice and quality for older persons. World Health Organization; 2025 (Country reports on purchasing long-term care). https://doi.org/10.2471/B09373

Japan
Case study- DOWNLOAD
Ikegami N. Expanding services, controlling costs and developing new forms of institutional care in Japan. World Health Organization; 2025 (Country reports on purchasing long-term care). https://doi.org/10.2471/B09354

Republic of Korea
Case study - DOWNLOAD
Kwon S. Overcoming coordination challenges between health and social services in the Republic of Korea. World Health Organization; 2025 (Country reports on purchasing long-term care). https://doi.org/10.2471/B09342

Netherlands
Case study - DOWNLOAD
Bakx P, Schut E, Wouterse B. Price setting and contracting help to ensure equitable access in the Netherlands. Geneva: World Health Organization; 2025 (Country reports on purchasing long-term care). https://doi.org/10.2471/B09374

Spain
Case study - DOWNLOAD
Flores M. Increasing beneficiaries and declining informal caregivers in Spain. World Health Organization; 2025 (Country reports on purchasing long-term care). https://doi.org/10.2471/B09362

Sweden
Case study - DOWNLOAD
Lorenzoni L. Ageing in place: how Sweden provides and pays for universal and comprehensive care for older persons. World Health Organization; 2025 (Country reports on purchasing long-term care). https://doi.org/10.2471/B09358

United States of America
Case study - DOWNLOAD
Lorenzoni L. A safety net for care services in the United States of America. World Health Organization; 2025 (Country reports on purchasing long-term care). https://doi.org/10.2471/B09356

Interviews with authors: YouTube link

Related Publications

Barber SL, Ong P, Han ZA. (2020). Long-term care in Ageing Populations. In: Haring R, Kickbusch I, Ganten D, Moeti M (eds) Handbook of Global Health, Springer, Cham. https://link.springer.com/referenceworkentry/10.1007%2F978-3-030-05325-3_65-1
Download here

Special journal issue: call for submissions by September 1, 2022

Barber SL, Ikegami N. Pricing Services: An Underutilized Policy Instrument for Access and Quality. Health Services Insights. 2022;15. doi:10.1177/11786329221127943

Honda A, Cartailler J, Cailhol J, Noda S, Or Z. Factors for Consideration When Setting Prices for Private Healthcare Providers Operating in Public Systems: A Comparison of France and Japan. Health Services Insights. 2023;16. doi:10.1177/11786329231173484

Viriyathorn S, Witthayapipopsakul W, Kulthanmanusorn A, et al. Definition, Practice, Regulations, and Effects of Balance Billing: A Scoping Review. Health Services Insights. 2023;16. doi:10.1177/11786329231178766

Webster SBG, Neville SE, Nobbs J, Ching J, van Gool K. Incorporating Safety and Quality Measures Into Australia’s Activity-Based Funding of Public Hospital Services. Health Services Insights. 2023;16. doi:10.1177/11786329231187891