A study of long-term health care in Canada may point the way to a new approach for the United States' $26-billion nursing home industry--which eventually will serve one in every four Americans who survive to age 65.
"The Feasibility of Universal Long-Term Care Benefits: Ideas From Canada," reported today in the New England Journal of Medicine, concludes that Canada provides more humane care for senior citizens at a lower cost than does the United States.
Yet "the nursing home is not a bad buy here," said Rosalie A. Kane, who has a doctorate in social work and who collaborated in the Rand Corp. study with her husband, Robert Kane, a physician specializing in public health and geriatric medicine.
The big difference in the two nations--similar in geography, age distribution of population and federal forms of government--is that Canada in 1978 concluded that its universal health care insurance available to everyone should be expanded to include long-term care. That idea is not yet generally accepted in the United States, where the system differentiates between two classes of clients: those who pay and those being supported by the government, with limits on their assets restricting qualification for government help.
Yet of the $26 billion spent on nursing home care in 1984, $13 billion was public money, according to the U.S. Health Care Financing Administration.
"We have an orthodoxy in this country that says universal benefits would be unaffordable," Rosalie Kane said from her office at Rand in Santa Monica. "We are already concerned about the costs of Medicare; it is very, very expensive.
"In Canada there is a different kind of precept: Money is money, whether it is public or private. The feeling there is that we can lower total costs with a universal benefit while we also eliminate some of the difficulties. It is a matter of social philosophy."
The study, which focuses on the Canadian provinces of Ontario, Manitoba and British Columbia, finds that they have the same kind of health care providers as the United States: fee for service, nonprofit voluntary hospitals and proprietary nursing homes and home health agencies.
Availability and quality of facilities are similar in the two countries but not necessarily alike, Kane said.
"The average quality of a nursing home in Canada probably exceeds the average quality here," she said, "and in both countries there are always bottlenecks when looking for nursing homes.
Difference in Choice
"The significant difference is that the user seems to have more choice in the three Canadian provinces we studied. The client could go home (from an acute hospital) with a substantial amount of care.
"The Canadian system also enables those who want to stay at home to do so, although no province would pay more to keep a person at home than in a nursing home. Home care is not always less expensive. It depends on two things: The level of disability and the amount of help in the environment; a man with a wife and/or family members would probably need less outside help.
"But by and large, people prefer to be at home, and they are better off at home."
In Canada the federal government provides funds to the provinces under a system similar to a block grant. While the provinces are in charge of the programs, much of the control comes through smaller governmental entities.
Mixing and Matching
"Case managers working at a more local level supervise the actual mixing and matching of services," Kane said. "This is useful on the level of a city or county.
"It also is very useful to have an entity that everybody knows, one place to call where the case managers know about services and can work out arrangements for the care needed. The case managers know the players--the agencies, homes, available services--very well.
"In some places such as small towns or rural areas, the case managers know the people (clients seeking health care) also; perhaps they were teachers in high school, or well known in the community. The net result is good.
"We found that case management at the local level also is very useful for allocating resources--home care, homemaking services, the home handyman. People say these things don't exist, but they do, and they will develop once funds to pay for them materialize. It is important to get a handle on the quality and quantity of services."
The Kanes also found that the provinces studied developed controls over health care, both in the matter of payment and authorizing service and on the building of facilities such as nursing homes. British Columbia, for instance, requires all new nursing homes be designed with single rooms.
The study, supported by a grant from the Henry J. Kaiser Family Foundation, also found that "a balance between proprietary and nonprofit providers seems to be good for both," Rosalie Kane said. "It makes each more efficient and more effective."
The Kanes' research indicated that in 1982 the cost per year for each nursing home bed in British Columbia--the most expensive of the three provinces--was $15,400, as contrasted with $18,200 average annual cost of a nursing home bed in the United States. (Money amounts are in U.S. dollars.)
The Canadian system also leaves even the poorest person with some discretionary income. A nursing home resident in Ontario in 1984, for example, paid $15.68 per day, with the government paying the rest. That left $96 monthly to someone dependent solely on the smallest government income maintenance, an amount three times greater than the most generous state Medicaid program in the United States.
"I clearly think long-term care is ripe for some reform here," Kane said. "I think we can conclude that it is possible to develop home-based services and eligibility for a disability level without swamping the system.