Annual General Assembly Meeting HomeCare Europe

1
CASH FOR CARE BLACK MARKET IN CARE

• Annual General Assembly Meeting HomeCare Europe
• September 26, 2008

2
Content

• Part 1 Cash for Care
• Part 2 The Black Market in Care

3
PART 1 CASH FOR CARE
4
Content

• Cash for care
• Personal budgets in Belgium
• Persoonlijke-Assistentie Budget (personal
  assistance budget)
• Experiment PGB

5
Cash for Care

• Cash for care money or vouchers given to
  service users to purchase their own care
• Motives for cash for care programmes
• Promote choice and autonomy
• Plug gaps in existing provision
• Create jobs
• Promote efficiency and cost savings
• Promote domiciliary care
• Cash for care is often called a personal budget.

6
Personal budgets in Belgium

• Integratietegemoetkoming (IT) (allowance for
  disabled people)
• Allowance for disabled people living in Belgium
• who experience difficulties with social
  integration
• whose decreased self-efficacy has resulted in
  increased costs
• who have an income below a certain limit
• Not accountable for the way they spend this money
• Intramural care 2/3rd of original allowance

7
Personal budgets in Belgium

• Tegemoetkoming Hulp aan Bejaarden (THAB)
  (allowance for the elderly)
• Similar to IT, but meant for people gt 65 years
  old
• Size THAB allowance lt size IT allowance
• Max. income limit THAB lt max. income limit IT

8
Personal budgets in Belgium

• Vlaamse Zorgverzekering (Flemish Care Insurance)
• Insurance providing allowances for the cost of
  non-medical care to people with a severe need for
  care who
• are receiving home care or informal care at home
• are living in a rest home, a rest and nursing
  home or a psychiatric nursing home
• Makes home care more payable for people with a
  severe need for care, who often have high
  expenses

9
Personal budgets in Belgium

• Persoonlijke-Assistentie Budget (PAB) (Personal
  Assistance Budget)
• Personal assistance budget for people with a
  disability in Flanders
• Budget provided to a person with a disability or
  his or her legal representative for the full or
  partial underwriting of the personal assistance
  and its organisation
• Most similar to the original Dutch personal care
  budget

10
Persoonlijke-Assistentie Budget

• Financial contribution for people with a
  disability, who are living at home
• Advance deposit every 3 months ? organise and
  finance their personal assistance on their own
• Assistant can be an employee, self-employed,
  temporary worker or service provider from an
  institution or organisation
• doesnt need to have certain diplomas or meet
  other quality requirements
• PAB users are accountable for the way they spend
  their personal budget
• Written agreement
• Cost status report
• Registered which activities can be paid with the
  PAB
• Inspections

11
Persoonlijke-Assistentie Budget

• Impact on the home care sector
• Budget regarded as too small ? more attractive to
  hire non-qualified personal assistants
• Could have impacted the home care sector, but
• the number of distributed PABs is still limited
• most PAB-users prefer to rely on both informal
  and formal care providers (Breda et al., 2004)

12
Persoonlijke-Assistentie Budget

• Evaluation of PAB use (Breda et al., 2004)
• Most PAB users employ gt 1 personal assistant
• Responsible for different tasks
• Complementary and supplementary relying on both
  informal and formal care providers
• Certainty and continuity in care provision
• Use of services determined mainly by need for
  care
• Lower budget and consequently lower need for care
  ? lower use of the (additional) formal circuit
• Informal support does not seem to lead to a lower
  user of formal support
• Persons without a paid informal carer, more rely
  on the formal circuit for support in mobility,
  household and other more functional activities
  than do persons with a paid informal carer

13
Persoonlijke-Assistentie Budget

• Evaluation of PAB use (Breda et al., 2004)
• PAB might enable disabled persons to live at home
  for a longer period of time
• Impact on home care sector
• 1 PAB hr cheaper than 1 hr formal care, but
  limited substitution of formal circuit causes
  Flemish government to pay even more
• Extension rather than a substitution of paid care
• PAB seems to be generator of questions or demands
  ? financial manageability?

14
PGB experiment

• Experiment Persoonsgebonden budget
• Personal budget for people with a disability
• Start experiment September 1, 2008
• PGB ? PAB

PAB PGB
Type of care Way of financing care
Limited number distributed Should apply to all people with a disability
Broader choice between a PAB and PGT or a combination
15
PGB experiment

• Experiment will need to give insight into the
• extent to which the PGB will be the best way to
  contribute to
• self-determination
• participation to social life
• quality of life
• extent to which the PGB could function as the
  basic way of financing care for all care and/or
  support providers

16
PART 2 THE BLACK MARKET IN CARE
17
Content

• Black care market in Europe
• Black market in Italy
• Grey market in Austria
• Black care market in Belgium?
• The PAB and the black market

18
Black care market in Europe

• Several European countries have seen a growth in
  the black or grey market in home care
• For example, Austria (grey market) and Italy
  (black market)
• Growth in provision of privately arranged home
  care by immigrants

19
Black market in Italy

• Demand for social services ? ? public policy
  inertia ? recent growth of a large private care
  market
• Low cost labour provided by immigrant women from
  Eastern Europe, Latin America and some Asian
  countries
• Substantial economic advantage for user
• Helps immigrant workers in finding accomodation
  and obtaining work
• allows more people to receive home care and to
  stay at home as long as possible
• - prevents the growth of an Italian organised
  care market
• Cost differential too high
• No adequate controls in place to reduce black
  care work

20
Grey market in Austria

• Pflegegeld personal budget for elderly and
  disabled people
• Receivers are fully free in the way they spend
  their pflegegeld
• Government only randomly checks quality of care
• Pflegegeld is relatively low and insufficient to
  buy professional care ? grey circuit has arisen
• Employees from new EU member states, who are
  willing to work for low salaries

21
Grey market in Austria

• Providing personal budgets to everyone doesnt
  always lead to a market of formal care providers
• Sweden Austria personal budgets ?market of
  individual providers
• Austria recipients not accountable for the way
  they spend their budget? black market has arisen
• Sweden recipients accountable for the way they
  spend their budget ? black market has not arisen

22
Black care market in Belgium?

• Demand gt supply home care ? waiting lists
• Waiting lists lower prices black circuit
  workers ? potential for black care market
• Governmental actions to solve black work in home
  care sector
• For example dienstencheques (service cheques)
• Service cheques ? risk that clients dont receive
  the services they need
• Service cheque division vs family care division
  Familiehulp
• Price service cheque services lt price family care
• Risk people in need of family care choose
  service cheques
• Client receives wrong services or care
• Employees confronted with situations they are not
  prepared and/or educated for

23
The PAB and the black market

• PAB users might find it more attractive to hire
  non-qualified or low-schooled employees
• PAB not expected to cause a large black market in
  Flanders to arise
• Users accountable for way of spending budget
• Associations for budget users and PAB advisors
• Extension PAB ? PGB neither expected to cause a
  large black market
• Choice between PAB and PGT or combination
• PGT dienstencentrum directly receives (part
  of) budget

24
The PAB and the black market

• IT and THAB recipients not accountable for the
  way they spend this money
• Impact on black care market not known