Does home and community-based services use reduce hospital utilization and hospital expenditure among disabled elders? Evidence from China.

Introduction: In the background of aging in place, home and community-based services (HCBS) have been playing an increasingly important role in long-term care (LTC) security systems. However, it is still uncertain whether and how HCBS use affects hospital utilization and the corresponding expenditures. Methods: Using data from the China Health and Retirement Longitudinal Survey (CHARLS) and the China City Statistical Yearbook, the instrumental variable (IV) approach is applied to identify the causal effects of HCBS use on hospital utilization and hospital expenditure among disabled elders. Results: We find that HCBS use significantly reduces the probability of being hospitalized, the times of hospitalization, and the length of inpatient stay, as well as the total, out-of-pocket and reimbursement inpatient expenditures, demonstrating not only the substitution impact of HCBS for hospital care but also the effectiveness of medical expenditure control in LTC security systems. Heterogeneity analysis shows that the impacts of HCBS use on hospital utilization and hospital expenditure concentrate on disabled elders who are younger, male, living in urban areas, or from higher-income households; both healthcare and spiritual consolation services have significant negative effects, while the anticipated effects of daily care service use are not supported. The possible mechanisms are the substitution of HCBS for hospital care and the improvements in both the physical and psychological health of disabled elders. However, the mechanism of adverse events decrease is not verified, which needs to be investigated further with more proxy variables. Conclusion: This study provides empirical evidence that HCBS use can not only reduce hospital utilization and hospital expenditure among disabled elders but also improve their physical and psychological health. Policy designs should emphasize the orientation of HCBS, ensure the fundamental and central position of HCBS in the formal care service system, pay more attention to the accessibility and affordability of HCBS for fragile groups, and diversify and optimize the development of the health service and the spiritual consolation service.