This site is intended for people involved in or otherwise concerned by the long-term care of functionally dependent elderly persons — as the care-receiver or the caregiver, as a professional in the home care service sector, as a state or non-state actor in the social policy process, or simply as a citizen.
|Public support for dependent elderly people raises critical questions for public policy. In particular, the amount of out-of-pocket payments which remain the responsibility of the beneficiaries when they use professional home care services may have an effect on their consumption of public aid. An analysis of the effect of out-of-pocket payments on the consumption of professional care services is interesting from the point of view of support for public action directed towards dependent elderly people, as well as the progress of scientific knowledge. To understand these issues, it is helpful to be clear on the definition of some important terms.|
|<< Scientific challenges||Some definitions|| Back to Issues >>
|Regarding home care services|
|Formal care, informal care||Formal care is paid professional care supplied to a dependent person either by a home care and assistance service provider (French SAAD) or by a person that the dependent individual hires as an employee. Informal care is the help provided by the entourage of the dependent person (usually, family members).|
|Elasticity of demand for professional care
with respect to out-of-pocket cost
|This is the responsiveness of the volume of professional care consumed to a change in the out-of-pocket cost to the individual (i.e. the change in the volume of care demanded resulting from a change in the out-of-pocket cost).
If demand is “elastic”, a change in the out-of-pocket cost results in a change in the volume of care consumed. For instance, an increase in the out-of-pocket cost decreases the number of hours of professional home care service demanded/consumed.
If demand is “inelastic”, a change in the out-of-pocket cost does not change the volume of care demanded/consumed. (NB: this last definition corresponds to “perfectly inelastic demand” in economics textbooks.)
|Regarding the Personalised Autonomy Allocation (French APA)|
|The APA programme||Created in 2001 (Act No. 2001-647 dated 20 July 2001) and implemented in 2002, the Personalised Autonomy Allocation (APA) is the main public aid programme for the dependent elderly in France. This allowance, co-financed by the French National Fund for Solidarity and Autonomy (CNSA) and the Departmental Councils, subsidises a portion of the cost of care required by elderly persons who are dependent to some extent. Beneficiaries must be at least 60 years old and living at home or in an institution. For those at home, the APA can be used to help finance the cost of professional services for cleaning, grocery shopping and meal preparation, in addition to the activities of daily living such as personal hygiene and grooming.|
|GIR and AGGIR||The GIR (Iso-Resource Group) is the assessed level of dependency of the elderly person, measured using a national evaluation tool called the AGGIR (Autonomy Gerontology Groups Iso-Resources) at the stage where an individual files an application for APA benefits. Based on an individualised assessment by the medical-social worker personnel of the Departmental Council, each APA applicant is placed in one of six categories, from GIR 6 (least dependent) to GIR 1 (most dependent). Only people in GIR 1 to 4 are eligible for the APA allowance.|
|Individualised care plan
|Once an applicant for APA is regarded as eligible (age and residency criteria, and between GIR 1 and 4), the medico-social team of the Departmental Council draws up a personalised care plan. It lists the activities for which the individual requires professional help and the number of hours required for the performance of these activities. This volume of hours of assistance is then converted into euros using a specific tariff (see definition, infra) adopted by the Departmental Council. The total cost of the individualised care plan thus calculated is subject to the legal limit set by the law governing the APA programme (i.e. the care plan cost is reduced to the legal limit if the calculated cost exceeds the legal limit).|
applicable to eligible expenses (plafond légal)
|The total cost of care services eligible for APA subsidy varies from one individual to another, depending on each individual's needs as outlined in their personalised care plans. The total cost however must remain within the limits of a ceiling set by law, with a different ceiling amount for each assessed degree of dependency. Since 1 March 2016, the maximum allowable expenditure for a person classified GIR 1 is 1,713.08 euros per month. The other ceilings, for GIR 2, 3 and 4 respectively, are €1,375.54, €993.88, and €662.95.|
|The difference between an individual's total expenditure on professional care services and the subsidy provided under the APA programme. The hourly out-of-pocket payment corresponds to the proportion of the hourly price of professional care services consumed that is borne by the APA beneficiary.|
|Subsidisation of the care plan|| Once the APA applicant is considered as eligible, and the medico-socialwork team of the Departmental Council has drawn up the individual's personalised care plan as well as ensured that the total cost of the care plan does not exceed the legal maximum applicable for the assessed degree of dependence (see “Valuation of the care plan”), the team will proceed to calculate the APA allowance. This process, called “subsidisation of the care plan” involves calculating the beneficiary's financial contribution towards the total cost of his care plan. To evaluate the total cost, the Departmental Council's team uses either a reference rate fixed by the Departmental Council itself or the per hour fee charged to the APA beneficiary by the chosen service provider. In the case of a reference rate, the difference between the price charged by the service provider and the reference rate is called a “dépassement” (excess fee). Some Departmental Councils provide an additional subsidy to pay for this excess fee, while others leave it to the APA beneficiary to bear the difference.
NB: In the vast majority of departments, the rate used to calculate the subsidisation of the care plan is the same as that used in the valuation of the care plan.
(taux de participation)
|The law fixes the proportion of the cost of the individualised care plan which remains the responsibility of the APA beneficiary. This copayment rate is a function of the individual's income (couple's income divided by 1.7, for those living with a spouse). The copayment rate increases linearly from 0% for people with income not exceeding € 799.73 per month, to 90% for people whose income exceeds € 2,945.22 per month (as at 1 March 2016).|
|Reference rate||To calculate the total cost of the care plan (see “Valuation of the care plan”) so as to compare it to the legal ceilings, or to calculate the amount of the APA allowance (see “Subsidisation of the care plan”), the Departmental Council may use a reference rate that is independent of the fee that the beneficiary will in fact be charged by his service provider for each hour of service rendered.|
|Valuation of the care plan||
During its visit to the home of an APA applicant, the medico-socialwork team of the Departmental Council lists the activities for which the elderly person needs assistance, and the respective number of hours of service required, so as to draw up the individual's personalised care plan. To compare the total cost of the individual's care plan to the legal ceiling amounts set for APA beneficiaries, the team needs to convert the number of hours into an amount in euros. To carry out this valuation of the care plan, the team uses either a reference rate established by the Departmental Council or the per hour fee charged by the individual's chosen service provider.
(1) The personalised care plan however is always stated in terms of the number of hours of care approved and not an amount in euros.
(2) In the vast majority of departments, the rate used in the valuation of the care plan is the same as that used to calculate the subsidisation of the care plan.
|Regarding the professional home care service providers|
|Services d'Aide et d'Accompagnement à Domicile (SAAD)||The SAAD are the organisations (whether associations, private companies or private organisations) that provide home care and support services, which includes help in the activities of daily living such as personal hygiene and grooming, as well as housekeeping. Medical/skilled care services are excluded, as these are provided by licensed home nursing service providers based on medical prescription.|
|Service provider (prestataire)
Direct hire (gré-à-gré)
|Individuals obtain professional home care services via one of three modes of contractual service:
- Service provider: the individual buys the services offered by the service provider; the caregivers that perform the services in the home of the client are employees of the service providers (i.e. the service provider is responsible for the legal obligations as employer);
- Agent: the individual is legally the employer of the person that performs the home care service, but mandates an organisation to handle the administrative formalities such as recruitment and legal obligations;
- Direct hire: the individual himself hires a person to perform the home care services for him, and there is a direct employer-employee relationship in the eyes of the labour law.
|Authorized service providers (services autorisés)
Accredited service providers (services agréés)
|There are two types of professional home care service providers:
- Regulated service providers: regulated by the Departmental Council, and in general, obliged to charge their clients the hourly service fees as fixed by the Departmental Council. Regulated providers come under the ambit of the French Code de l’action sociale (régime de l’autorisation, loi du 2 janvier 2002).
- Accredited service providers: accredited by the national government, and subject to the French Labour code. Accredited providers are free to set their prices, on condition that they respect a maximum annual rate of change set by the Prefect (régime de l’agrément, loi du 26 juillet 2005).
|Regarding the French territorial administration|
|The 13 administrative regions in metropolitan France are subdivided into 96 departments. Each department is governed by a Departmental Council, which is responsible for various policy areas such as education and culture and in particular, social policies targetting vulnerable segments of the population (young children, people living with a handicap, the elderly).|
|Prefect||A Prefect in France is a civil servant who is the national government's representative at the departmental and the regional levels (departmental prefect, regional prefect). The Prefect of the department that is the capital of a region is concurrently the Prefect of that region.|
|<< Back to Issues||Support for public policy||Scientific challenges >>|
|Towards a reform of the long term care of the elderly||Dependence and financing of its management affect a large
part of the population, both directly (the dependent elderly, whose
share in the population is increasing) and indirectly (the dependent
persons' entourage, employees in the service sector assisting the
dependent elderly, etc.). In addition, from 2025 onwards, if public
policy remains as it is today, demographic changes are expected to lead
to a significant increase in the proportion of public spending that
goes towards the dependent elderly (approximately 0.30 percentage
points of GDP in 15 years). The reform of public policies for the long
term care of the elderly is thus a major concern in contemporary social
|Determining the sensitivity of demand to out-of-pocket payments in order to anticipate the impact of public policies||The recently introduced reform
of public policies for the management of old-age dependence focuses on
a change in the parameters of the APA program,
since the APA is the main public aid scheme for dependent elderly
persons in France. Details of the reform announced thus far include
changes to the schedule of co-payment rates and to the legal ceiling
amounts available under APA. The result of these changes is a reduction
in the total out-of-pocket payments that APA beneficiaries will be
responsible for, and this is expected to have non-negligible
consequences on the consumption of home care services for dependent
An analysis of the elasticity of demand for professional home care services involves several questions:
|<< Support for public policy||Scientific challenges||Definitions >>|
|Understand the implementation of a partly decentralised social policy||Considered as the “leaders” of public social action since 2004 (resulting from the “decentralisation law” enacted that year), the French departments are in large part responsible for the implementation of public policies towards the dependent elderly. The governing councils of the departments are responsible for the allocation and management of the APA aid scheme within their respective departments. It is they in particular who decide on certain programme parameters which determine the out-of-pocket cost to APA beneficiaries (see 'Calculating the out-of-pocket payment'). A study of the modes of organisation and the room for manoeuvre in policy parameters under the control of the departmental councils therefore improves our understanding of the implementation of social policies by the departments in the context of the different levels of social policy actions in France (national, regional and departmental).|
|Improve the availability of data and test new methods for econometric identification||There are very few studies to date on the demand for professional home care services amongst elderly dependent persons in France. The main explanation for this lies in the difficulties involved in collecting the necessary data for such analyses. To remedy these shortcomings, the MODAPA team uses several types of statistical data and qualitative analyses (see 'Data used'). In addition, the specificity of the context and the data we have managed to obtain open up the possibility of testing the benefits of using partial identification methods recently developed and as yet not widely implemented in the field of applied economics (see 'Econometric Strategies').|
|Studying the sensitivity of the demand for professional home care services to out-of-pocket payments involves several questions:|
|- how do we calculate the out-of-pocket (OOP) payments borne
beneficiaries within the framework of a partly decentralised public
- what are the appropriate data needed to reconstruct the out-of-pocket payments?
- what econometric strategies permit an estimation of the effect of out-of-pocket payments on the demand for professional home care services amongst the dependent elderly?
|<< Back to Approach||Calculating the out-of-pocket payment||Data used >>|
|How do we calculate the out-of-pocket payments borne by APA beneficiaries within the framework of a partly decentralised public policy?|
|The out-of-pocket payment depends on the price charged for an hour of service and on the APA amount granted||The APA is a partial aid; it covers only part of the total expenditure on professional home care services. For each hour of home care service consumed, the APA beneficiary pays an hourly out-of-pocket payment. This out-of-pocket payment depends on the price charged by the service provider, and the allowance that the APA beneficiary receives to cover part of the hourly cost of the service. These two elements are themselves functions of several parameters.|
|What determines the price charged for one hour of home care?||The price charged for an hour of home care service depends on:
|What determines the APA allowance amount?
The parameters defined by law
| The allowance received by an APA beneficiary depends on both parameters fixed at the national level (by law) and parameters established by the Departmental Council governing the beneficiary's department of residence.
At the national level, the law determines:
|What determines the APA allowance amount?
The parameters set by the Departmental Council
|The governing Council of each Department is responsible for the implementation of APA procedures within the department and the definition of a number of essential parameters:
The Departmental Council is also the regulatory authority for the professional home care services sector within the department, granting the status of “Authorised” to certain service providers and, for the majority of Councils, fixing the tariffs to be charged by these Authorised providers.
|<< Calculating the out-of-pocket payment||Data used||Econometric strategies >>|
|What are the appropriate data needed to reconstruct the out-of-pocket payments?|
|Quantitative data from various sources|| The variety of the data used is
one of the strengths of the MODAPA project. Indeed, our work is based
on econometric analyses of several types of data (the majority of which
is confidential and made exclusively available for research within the
|Participation in the development and monitoring of a national survey||The MODAPA research team also participates in the development, monitoring and exploitation of data from the ad hoc survey Capacité, Aides et Ressources des Seniors (CARE; “Capacity, Aid and Resources for Seniors”), conducted by the DREES. This survey will provide data, from the year 2015, on the volume of care and out-of-pocket payments for a sample of 15 000 persons in metropolitan France.|
|Qualitative data from surveys||Beyond the above standardised data, research within the MODAPA project also benefits from field studies previously conducted within the framework of a research project on the management of dependence due to handicap or old age. The MODAPA project relies in particular on eight monographs on departmental practices, elaborated on in partnership with sociologists since 2010 (Enquête Territoire–Territoire Survey).|
|<< Data used||Econometric strategies||Back to Approach >>|
|What econometric strategies permit an estimation of the effect of out-of-pocket payments on the demand for professional home care services amongst the dependent elderly?|
|Three alternative strategies for estimation||Using the data described above, three strategies are being implemented:
|Towards simulations of the effects of various changes in public policy||These estimation strategies will allow us to simulate the impact of changes in the modalities of calculating the out-of-pocket payment (e.g. modification of the schedule of co-payment rates, changes in the legal ceiling amounts, adjustment of the prices set for Authorised services, evolution of market prices for home care services) on public funding of aid towards dependent elderly persons in France.|
|Results from the project are presented in various formats:|
|- MODAPA Notes, which offer 4-page syntheses of studies carried out within the framework of the project (in French) ;|
|- Articles published in scientific journals;|
|- Working Papers, which present pre-publication results;|
|- Reports, which present results from specific studies for specific partner organisations.|
|You can also find here other resources produced by the MODAPA project:|
|- the Territoire Survey devoted to French Departmental policies for the management of dependent elderly persons living at home (in French).|
|- the statistics relating to the results from the Territoire Survey (forthcoming).|
|<< Retour à la page Publications||Notes Modapa||Les articles >>|
|<< Notes Modapa||Les articles||Les documents de travail >>|
|<< Les articles||Les documents de travail||Les rapports >>|
|<< Les documents de travail||Les rapports||Retour à la page Publications >>|
|The “Handicap and Dependence” seminar series is jointly organised by the researchers in the Medips project (directed by Florence Weber) and the Modapa project (directed by Agnès Gramain). The objective of this seminar series is to bring together researchers in social sciences interested by the challenges involved in public management of dependence and handicap in society.
The seminars take place once a month, on a Thursday, from 17:00 to 18:30, at the Jourdan campus (48 boulevard Jourdan, 75014 Paris).
The seminars are generally in French.
|The MODAPA research project brings together faculty, PhD students and research engineers who share their knowledge of the field, the data available or to be collected, and their experience in econometric methods.|
is a Professor of Economics at the University of Lorraine (France), and
a member of the Bureau for Economic Theory and Applications (Bureau
d'Economie Théorique et Appliquée, UMR 7522 / CNRS) research lab.
Research topics: health economics (long term care), social policies (support for the unemployed), and public policy interventions (decentralisation, evaluation of public policies).
Bourreau-Dubois is a Professor of Economics at the University
of Lorraine (France), and a member of the Bureau for Economic Theory
and Applications (Bureau d'Economie Théorique et Appliquée, UMR 7522 /
CNRS – Université de Lorraine) research lab.
Research topics: public economics, economics of social policies, economics of family and labour laws.
Arnault is a postdoctoral research fellow in economics at the
health economics department (EMOS) of the Bordeaux Population Health
Research Center (UMRS 1219), who undertakes his professional activity
in Paris at the statistics department of the French Ministry of Health
(DREES). He analyses data from several statistical surveys about the
APA program, which aims at fostering the utilization of professional
care services by the elderly requiring assistance in the activities of
daily living. He defended his PhD thesis in 2015, supervised by Pr.
Thesis subject: the role of the relatives and the effect of public policies on the care of dependent elderly persons in France.
Bontemps is a Director of Research at the Ecole Nationale de
l'Aviation Civile (ENAC) and at the Toulouse School of Economics (TSE).
Research topics: econometrics, statistics, economic theory.
Fontaine is a research at the French Institute for Demographic
Research topics: economics of health and dependence, economics of the family.
is a project manager in the Fédération Nationale de la Mutualité
Française (FNMF). He defended his thesis in 2018 under the supervision
of Agnès Gramain
Thesis subject: The regulation of the home-care market for the disabled elderly.
|Helen Lim has a PhD in economics from McGill University (Montreal, Canada). She has taught at various universities as adjunct lecturer, and is currently a researcher on contract with the University of Lorraine.|
Roquebert is a post-doctoral candidate at the LIRAES, a research
unit devoted to health economics at Université Paris Descartes (EA
4470). She defended her thesis in 2018, under the supervision of Lise
Rochaix and Jérôme Wittwer, on the formal and informal care
arrangements for the disabled
elderly in France.
Research topics: health economics, long term care, economics of the family.
|Olivier Supplission is a double degree student at the ENSAE ParisTech and HEC Paris. He made an internship with the team in the summer 2016. Since then, he has worked with the team on the study he began,comparing a semi-structural estimate standing on the classical assumptions of the consumer theory with an alternative set of assumptions taking into account a random optimization error. He recently started working on estimating the formal home care out-of-pocket elasticity when prices are unknown but known to be in a given set of values.|
Tenand is a postdoctoral researcher at the Erasmus School of
Health Policy & Management in Rotterdam (the Netherlands). She
investigates into the impact of the Dutch public long-term care
insurance and its recent reforms on the use of formal care. Marianne
defended a PhD in Economics, which was conducted under the supervision
of Pierre-Yves Geoffard and Agnes Gramain, in June 2018.
Research topics: health economics, applied microeconomics, long-term care, socio-economic inequalities and equity in long-term care use, private long-term care insurance.
Wittwer is a Professor of Economics at the University of
Bordeaux and carries out his research activities at the Institut de
Santé Publique d'Epidémiologie et de Développement (ISPED).
Research themes: long term care, the demand for health insurance.
Xing is a doctoral candidate at the Centre Maurice Halbwachs
(UMR 807 / ENS - EHESS - CNRS) under the direction of Agnès Gramain and
Thesis subject: governing by the distribution of public funding instruments, the pricing of establishments and providers of home care and support services for the elderly and disabled adults.