Cash, customers, and care: the experience and meaning of differential payment for high care places in aged care facilities.

Tilse, Cheryl

A remarkable boost in the percentage of the population over 80 years of age, together with the projected increase in this age group, has forced the issue of the financing of long term care of older people onto the policy agendas of OECD countries (Hennessy and Weiner 1996). In Australia, the high levels of residential care, the increased levels of disability of those entering residential care, the continued demand for high care places, the projected increase in this demand, and the need to upgrade stock to meet current standards of care have led to considerable pressure on traditional funding sources (Gibson 1998). In 1997-98 the Commonwealth government policy response was to increase resident contributions to the cost of high level care through the introduction of asset and income tested fees and charges for high care (nursing home) level residents (Aged Care Act 1997). The changes have been couched in the language of freedom of choice, deserts and paramountcy of need (George and Napier 1997).

As part of the marketisation of health and welfare services, user contributions linked to income and assets have been both strongly advocated and contested (Fine & Chambers 2000; Healy 1998; Evers 1994). Core arguments in support are linked to raising revenue, enhanced consumer choice, improved service delivery through competition, and the empowerment of user/customers. The empowerment argument is that paying confers a sense of ownership and control and implies a right to voice objections (Healy 1998: 49). Arguments against user pays policies are linked to social justice concerns of equity and access. Of central concern is that user charges will create a two tiered system whereby those unable to afford the charges will receive a base level of care while more affluent consumers will be able to pay extra for more and better services (Valentine 2000; George & Napier 1997). A second concern is that those who pay higher fees will be given priority.

The new charges and fees add to the complexity of charges in Australian aged care facilities. Currently a limited two tier system operates in that there is provision within the system for a small (and capped) number of extra service places where residents pay more for a higher level of amenity. The vast majority of high level care residents, however, are in not in extra service places. Until 1997 high care residents paid a basic daily care fee indexed in line with the aged pension. The initial proposal for additional charges for these residents was for an accommodation bond paid on entry for high care residents to be financed by the sale of family home. This was highly contentious among the older population, service providers and welfare groups. As a result there were delays in implementing the policy and substantial changes in arrangements. The revised arrangements comprise first, accommodation payments which are a contribution to the costs of accommodation and second, changes in daily care fees which are a contribution to the costs of care (Commonwealth Department of Health and Aged Care 1999: 7). The accommodation charge introduced in November 1997 is determined by assets. A maximum charge of around $4,800 per year is paid for a maximum of five years and applies to people with more than $25,500 in assets at the time of entry. The family home is not considered an asset if there is a spouse, long term carer or other relative eligible for income support living in the home. The maximum charge applies to residents with assets of more than $41,000. The income tested care fee introduced in March 1998 applies to non and part pensioners. A maximum charge of around $18.58 per day applies to people with a private income of about $30,000. An Agreement signed at the time of entry sets out the terms of residency, rights and obligations and the fees and charges agreed on.

A focus on the macro implications of user pays policies in the literature has resulted in little understanding of the impact of these changes on individuals, on service provision, and on the complexity of relations within care environments. A review of the literature points to few arguments based on research findings, little research in the Australian context and no research within residential settings. The research set out to look closely at what happens in relation to access, equity and empowerment in residential environments when some residents pay more for the same level of care and accommodation. The research focuses specifically on residents who are not in extra service places.

Research Plan, Methods and Techniques

The research aimed to provide an in-depth examination of the experiences and meanings attached to these changed financial arrangements by key stakeholders in aged care facilities--high level care residents, their families, front line staff and managers. The aim was to explore whether the new charges have empowered those who pay by providing a sense of entitlement to more extensive services, greater choice in amenities, greater participation in decision making and a willingness to raise objections. It also aimed to explore whether those who do not pay the charges are disempowered by limited access, expectations and choice regarding resources and participation in decision making. The research focused on exploring the impact of the accommodation charge. This charge applied to all residents entering high level care alter November 1997 and was the most contentious in that it was initially linked to the asset of the family home. It is argued that as a result it was more likely to recognised and recalled by residents, families and staff.

The design comprised semi-structured interviews with management, families and residents in three aged care facilities. The interviews with front line care staff were brief open ended survey interviews to facilitate the participation of busy care workers. All interviews explored knowledge of the accommodation charges and who had paid-them, arrangements relating to the charges, views on the charges and potential use of the extra income. A sense of entitlement and empowerment linked to payment was explored through questions of what the fees should pay for, experiences and expectations of choice, and willingness to assert needs and interests and express complaints. Residential aged care environments have two broad components:

a. the provision of nursing and personal care services which include therapy, assistance with bathing, dressing and mobility. Residents assessed as in need of high level care require an extensive level of this care.

b. the provision of amenities such as private rooms, ensuite bathrooms, choices in menu. The identification of limitations of these resources in most facilities (Gregory 1993) provided the impetus for changes in funding arrangements and new standards of amenity to be met by 2008 (Aged Care Act 1997). As many existing facilities strive to meet these standards, amenities within facilities vary and allocative choices are made.

The interviews sought to clarify whether the new charges influenced expectations and allocation relating to both care and amenities. All residents who entered high level care in the three aged care facilities after November 1997 (and their families) were approached to be part of the study regardless of whether they had or had not paid the new charges.

The in-depth nature of the study limited the research to three facilities. The facilities were selected to provide diversity in terms of size, auspice, location and complexity. No claims can be made as to representativeness. The sites comprised a private sector stand alone high care facility, a not-for-profit facility that was part of a large complex of independent living units and high and low care units, and a high care wing attached to a community hospital in a rural town. All facilities were older facilities with a varied quality of amenities such as single rooms and some two, three and four share rooms. Table 1 provides an overview of the number of interviews in each site.

The semi-structured interviews were audio taped and fully transcribed. The Ethnograph software program facilitated the identification of common themes and divergence across and within interviews. The front line staff survey interviews were coded and analysed qualitatively for the range of views and experiences and quantitatively to identify trends.

Results

Residents

The limited number of residents being subject to the new charges, high levels of disability which precluded interviews and the inclusion of a small rural facility resulted in only nine residents participating. Although three residents had very detailed knowledge of the charges, most residents did not know whether they had paid the charge. There was, therefore, little foundation for any sense of entitlement to extra services or for asserting themselves relating to the charges. All residents were confident that the payment of fees would not affect staff care practices. All reported little choice in the facility entered or in the room allocated.

 Where else could I go? I couldn't go anywhere

 You have to go wherever the bed is available

A minority of residents felt that payment of extra charges should provide some entitlement to extra amenities such as more personal space and an improvement in meals. For those who were aware that they had paid the charges, the impact was related more to the personal and emotional losses associated with selling the family home rather than the financial strain of the charges. The sale of the family home was reported as a major loss irrespective of whether residents had paid the accommodation charge. Of the three residents who were aware that they had paid the charges, two residents reported a strong sense of inequity in relation to other residents.

 I'm about the only one in the dining room round the table
 (who has paid), but that's not fair, because you saved. Everyone
 has the same opportunity; I worked all my single days and saved
 everything

 People who were here before a certain date, I don't think it
 affected them at all. To me it doesn't seem fair. Even though
 they have a lot more money than I have ... the whole thing is
 grossly unfair

Few residents reported a willingness to voice complaints. For some it was because they were happy with the care provided and had `no complaints'. For most, however, it was because they were afraid of being labelled a `wringer', were unwilling to assert themselves or had little hope that it would make a difference.

 You've just got to take it, that's all there is to it

 There's nothing you can do

Those who were willing to assert themselves did it on the basis of feeling secure with a particular staff member or reporting it as a personality trait to speak up rather. than any sense of entitlement founded on financial contributions.

 she'll listen to you

 that's just the way I am

Families

Because of their high care needs, residents are rarely involved in entry negotiations. Family members usually organise the negotiation of the Agreement and the payment of the charges. They reported varied experiences, arrangements and attitudes. Many reported having difficulty in accessing reliable information and consistent advice particularly in the first six months of the policy introduction. The most common arrangement to Bay the charges was the sale of the family home. For some, the transition is not financially complex but for other families the entry to a high care place comes after a series of decisions about accommodation (such as the purchase of a retirement village unit or serviced apartment, followed by hostel entry and the payment of a bond) that have complex financial implications.

Family members generally held Enduring Powers of Attorney or had less formal mechanisms in place for managing the assets of the resident. This meant that some families had complex asset management tasks to negotiate at the time of entry such as deciding whether to sell or rent the family home and to comprehend the implications of this for the accommodation charge, other income tested fees, pension eligibility, superannuation arrangements and the taxation system. In these situations some families reported difficulty in accessing appropriate advice at the time of entry.

Families described considerable variation in access to financial advice at the time of entry. At site 1 management viewed the charges as requiring complex advice and the business manager was involved in the entry processes. This resulted in a number of family members reorganising their financial arrangements and accessing financial advice. In the other facilities, families were given the appropriate forms/brochures and generally viewed the charges as `we just had to pay'. One family who took up the option of financial advice from Centrelink reported that they were able to optimise their finances as a result.

 We saw a financial adviser to see what's the best way to organise
 her finances so that they would last--perhaps for next 20 years.
 We sold the independent living unit. The advice was to reduce her
 capital so we took out $10,000 in a year gifted to ourselves,
 and I invest that to get $4000 in return to pay the fees. It has
 not happened as yet so in the short term I am paying out of my
 own pocket and working extra nights.

 We were told the fees and that was it

 We try to reduce assets, we talked to Centrelink and gifted and
 invested money, no one tells you about that unless you ask.

High care placement can be the outcome of a series of accommodation changes all of which have financial implications. Those seeking to sell retirement village units to finance high care were the most disadvantaged. All families reported that the placement was made under duress in that it was not the desired outcome for either the resident or family members. At this highly emotional time financial aspects were not viewed as a priority. Most reported little choice regarding facilities and amenities within facilities and pressure to make decisions quickly from assessment teams (ACATs), hospitals or interim care facilities or the facility itself. Hence, they rarely negotiated around fees and charges and most had signed Agreements without seeking financial advice. For all, the financial impact of the placement was secondary to emotional impact of the placement a partner, a parent or a grandparent in residential care.

 It was complicated enough without thinking of bloody money. We
 had 24 hours notice to move, ACAT put us through hell, pressure
 from hospital, put us on a guilt trip so much uncertainty ...
 working in the dark wasn't easy. We had one day's notice there
 was pressure from the hospital

Key concerns expressed by family members were related to the quality of care rather than the financial aspects. Most, but not all, expressed concerns about the quality of care. Willingness to complain, however, was not necessarily related to having paid the extra charges. Many families who paid the charges expressed a strong sense of inequity based on a view that the resident was being penalised for saving and no extra services or amenities were being supplied. In spite of this most families felt that the extra charges should pay for general improvements such as more staff and more varied social activities that would benefit all residents. There was a common view that care should not be income/asset tested and should be of a quality standard for all. However there was also a view among some families that extra amenities such as a single room or an ensuite bathroom could be provided for those who paid more.

Clear information and individualised advice were highly valued as families sought to negotiate the taxation, pension and superannuation, and aged care systems while under pressure to make decisions quickly. The brochures provided by Commonwealth Department of Health and Aged Care and Centrelink were sufficient for many families with relatively straightforward circumstances. However, families with more complex arrangements who had no prior contact with financial advisers needed access to more detailed and individualised advice. Highly educated sons and daughters reported inconsistent information and difficulties in understanding the systems in place, particularly how they intersected. Some systems are viewed by some families as too dependent on self report and not sufficiently formalised to protect them and others from inequitable treatment.

 if Mum's bank account goes down by another few thousand, it seems
 to be a simple matter of going to the secretary of the nursing home
 and saying. `The bank account is only this much money now' and she
 says, `oh we'll reduce the accommodation fee'. I don't think that is
 a good idea. There doesn't appear to be any check on it. There's a
 system there that can be manipulated or rorted ... and I don't like
 that because I'm still a taxpayer.

Management

Care managers/Directors of Nursing reported a major impact was at the time of the policy change and related to the misinformation, anxiety and confusion about the form and nature of the charges. In response, facilities had to provide extensive information and revise entry procedures. Most care managers reported that high care beds were in short supply and thus families were pressured to make decisions quickly and in no position to negotiate special arrangements linked to differential charges. The high level of disability of high care residents was also seen as a barrier to residents asserting the need for special attention linked to the payment of the charges. However, all reported some instances of family and resident expectations that the payment of the charges should bring extra services or amenities. There was strong evidence that facilities did not respond to these pressures. This had resulted, however, in some families who were paying the charges going elsewhere in search of better amenities.

Care managers, administrative assistants and the business manager were confident that they were the only staff with knowledge of who had paid the charges and reported that care was well separated from financial issues. All sites had systems in place to insulate front line staff from financial information. However, care managers in two of the facilities reported that expectation of extra amenities for those who pay the charges was a developing issue.

 Could become an issue if we let it.

 It's gradually changing so that it's going to become an issue.

There was a range of attitudes regarding the fairness of the payment of extra charges for the same level of care and amenity. In one facility there was a sense that some extras should be provided for those paying the charges. The language used by the care manager in this facility also suggested a developing potential for some differential allocation based on payment of the charges.

 We tend to have people in our private rooms now that are paying the
 accommodation charges because you feel a bit guilty yourself that
 they're paying an accommodation charge.

In the context of discussing the allocation of a single room to resident who had paid the accommodation charge, this care manager commented that the woman ...

 ... was a private person with lots of stuff and she liked to make
 phone calls and she was a proper paying patient (emphasis added)

One manager reported that she would consider providing extra amenities if there was more separation of residents so differential access to particular amenities such as menu choices could not be observed by other residents.

Front line staff

Staff members reported that the introduction of the charges has not had a major impact on the delivery of care in high care facilities. The majority of front line staff (74%) did not know who had/had not paid the charge. Those who did know had been informed by the resident or a family member. Some staff reported that the payment of the charges had made some families more concerned about money but it was the sale of the family home that was traumatic for residents. This sale can occur irrespective of whether residents are subject to the extra charges. There were only two reports of residents being more demanding as a result of paying the charges. There were also reports of families being concerned about finances and two reports of families being more demanding perhaps because they had paid the charges.

A more detailed analysis suggests however that staff have a range of attitudes about the charges that vary from not needing to know because `it is irrelevant to my work'; `I give high care anyway' to a concern about equity and fairness. Staff reposed concerns about the inequity relating to long term residents who were exempt from the charge, the level of the assets test that severely disadvantaged people on the margins, and value for money for those who paid the charges. A common concern was that older people who saved were being penalised.

All front lines staff members interviewed had a greater interest in expressing their concerns about the quality of care and the need for more resources to deliver quality care than in discussing fees and charges. Among some staff members there are some attitudes, which could support the introduction of extra amenities for those who paid extra charges. These attitudes were related to a sense of unfairness that some people paid more for no extras and that those who had saved were being penalised.

 Seems-wrong, you work all your life to obtain a home only to give it
 back-to the government and your children get nothing.

 It's unfair--they should get more if they pay more

Opinions such as these were counterbalanced by the views of some staff that there should be a set fee and that care should be the same no matter what residents had paid.

 I prefer all pay a set fee

 Everyone should receive the same level of care. I don't believe in
 user pays--we are all entitled to be looked after.

Conclusions

Key findings relate to access, empowerment and equity. There was a strong view across all groups that care should not be linked to financial contributions. Systems in place effectively separated resident financial information from front line care staff. There was, however, variation in the views of staff, managers, families and residents relating to the allocation of amenities. This is in keeping with current policies and practices in retirement villages, private hospitals, low level (hostel) care and extra service residential aged care places where higher charges purchase higher levels of amenity. In one facility there was some evidence that residents paying the charges were more likely to be offered a single room, in another there was the suggestion that if there was more physical separation of residents, some changes in meals and amenities could be considered. This, combined with attitudes of some staff, residents and families, suggests a potential for the development of an informal two tiered system in the allocation of amenities within facilities. Care managers play a key role in the allocation of amenities. Leadership, education and a culture that supports a strong ethos of both care and amenities being unrelated to financial contribution are important in countering these subtle changes.

In the three facilities in the study, access to high care places was not determined by a capacity to pay the charges. Concern regarding the `creaming' of the most profitable consumers appears to have been addressed in the Australian legislation in that aged care facilities are required to accept a proportion of financially disadvantaged consumers and are subsidised for these residents. There was some limited evidence of potential for a two tiered system to operate between facilities. An old facility with a poor level of amenity had to be excluded from the study as no resident had paid the accommodation charge. The view of staff was that residents/families able to pay the charge did not consider this facility. Additionally, managers in the facilities in the study reported some families withdrawing their interest when no extra amenities were offered as a result of payment of the charges. This suggests the potential for an informal two tier system operating between facilities in addition to the standing differentiation associated with designated extra service places. It also indicates some form of empowerment of consumers in excising choice. However, this is probably a very limited form of empowerment given the rationing of high care places and the pressure to find appropriate places quickly.

Although a few families were reported as asserting claims in relation to room allocation, the findings over all indicate that the payment of the charges has not empowered either residents or families by providing a sense of entitlement, ownership and control in facilities. This was partly related to limited knowledge of who had and had not paid the extra charge. Most families and residents were unwilling to complain about aspects of care. Although for some this was because they were happy with the provision, for most, the scarcity of high care places, the complex power relationships within residential environments and high levels of disability militated against the assertion of complaints or any sense there is room to negotiate.

Issues of equity were raised in relation to people with limited financial assets whose financial arrangements were more transparent than others, differential access to systems that inform and support families making complex asset management decisions, and, in one facility, limited monitoring of information provided to facilities regarding assets. At the time of entry, some residents/families address complex financial arrangements when they are under pressure to make what is reportedly a traumatic decision quickly. This leaves little time or emotional energy to attend to the terms of the Agreement and the financial aspects of the move. The Agreement appears to have limited utility as a tool for negotiation around fees and charges at the time of entry for the residents and family members.

It is of note that some families made complex asset management decisions with very little monitoring of whether the decisions were in the best interests of older person. In the current system, there seems to be very little support for family members and limited protection of vulnerable older people in this area of asset management. The services of Centrelink financial advisers could be more actively promoted to families who are substitute decision makers and asset managers for older people.

Financial issues were secondary to quality of care issues for all groups and there were few reports of financial strain relating to the charges. Although some families and some residents expressed no concern about the quality of care offered, most families reported concerns about some aspect of care. These related primarily to the lack of individual attention, limited stimulation and activities, casual staff and poor communication between staff and families. Front line care staff in facilities also expressed concern about the limited time and attention they could devote to high care residents, and the poor level of amenities in facilities. This was particularly strong in one facility. Staff, residents and families did not report any improvement in services and amenities as a result of the new charges. Some families paying the charges commented that the payment of the extra charges was not translated into improved care, resources or amenities and sought greater accountability from facilities.

This in-depth exploration of the operation of a contentious new policy direction in facilities for residents with high care needs is small in scale and the findings cannot be generalised to all facilities. Positive findings are the separation of financial contributions from the delivery of care and access to high level places. However, the potential for differential allocation of amenities related to payment of the charges needs to be monitored over time and across a larger range of facilities. A more broadly based study would seem particularly important as facilities are currently being upgraded for accreditation purposes providing managers and providers with a wider range of amenities to allocate to residents. The research highlights the complexity of financial decision making by some family members for high care residents and the need for appropriate advice. Overall, there is little evidence that payment of these charges have conferred customer status on residents and families that allows them to assert choice regarding entry, provides a sense of control and supports the assertion of complaints about aspects of care of concern to them. A continuing concern remains the quality of care and resources available to older people with high level care needs in residential environments.

Table 1.
Number and type of interview by site

 Site 1 Site 2 Site 3 Total
Type of interview Not for Private Attached
 profit sector to a
 complex facility rural
 hospital

Resident 5 3 1 9
Family 7 9 5 21

Care Managers/Directors
 of Nursing 2 1 1 4
Administrative/business
 officers 2 1 1 4
Front line care staff 10 14 7 31

Totals 26 28 15 69

Acknowledgements

The paper is based on research supported by a Small ARC 1999-2000 research grant. The author would like to thank residents, families, care managers and staff in the three facilities for generously sharing their time, views and experiences.

References

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Cheryl Tilse is in the School of Social Work & Social Policy, University of Queensland.