Are community-living and institutionalized dementia patients cared for differently? Evidence on service utilization and costs of care from German insurance claims data

Dementia patients are often cared for in institutional arrangements, which are associated with substantial spending on professional long-term care services. Nevertheless, there is little evidence on the exact cost differences between community-based and institutional dementia care, especially when it comes to the distinct health care services. Adopting the perspective of the German social security system, which combines Statutory Health Insurance and Compulsory Long-Term Care Insurance (payer perspective), our study aimed to compare community-living and institutionalized dementia patients regarding their health care service utilization profiles and to contrast the respective expenditures.

We analysed 2006 claims data for 2,934 institutionalized and 5,484 community-living individuals stratified by so-called care levels, which reflect different needs for support in activities of daily living. Concordant general linear models adjusting for clinical and demographic differences were run for each stratum separately to estimate mean per capita utilization and expenditures in both settings. Subsequently, spending for the community-living and the institutionalized population as a whole was compared within an extended overall model.

Regarding both settings, health and long-term care expenditures rose the higher the care level. Thus, long-term care spending was always increased in nursing homes, but health care spending was comparable. However, the underlying service utilization profiles differed, with nursing home residents receiving more frequent visits from medical specialists but fewer in-hospital services and anti-dementia drug prescriptions. Altogether, institutional care required additional yearly per capita expenses of ca. €200 on health and ca. €11,200 on long-term care.

Community-based dementia care is cost saving from the payer perspective due to substantially lower long-term care expenditures. Health care spending is comparable but community-living and institutionalized individuals present characteristic service utilization patterns. This apparently reflects the existence of setting-specific care strategies. However, the bare economic figures do not indicate whether these different concepts affect the quality of care provision and disregard patient preferences and caregiver-related aspects. Hence, additional research combining primary and secondary data seems to be required to foster both, sound allocation of scarce resources and the development of patient-centred dementia care in each setting.