基于国际经验的我国社会长期护理保险制度构建关键问题探讨

根据融资渠道的不同,长期护理保障制度可分为政府财政筹资模式、社会护理保险模式、私营护理保险模式和医疗保障计划4种模式。从被保险人(缴费人群)、缴费设置、给付对象(待遇享有人群)、护理照顾等级的评定机构和方式、给付方式和内容5个角度,阐述了韩国、日本、德国和荷兰的长期护理保险制度的经验。在此基础上,对覆盖人群选择、财务筹资机制选择、经办管理机构的设置、筹资机制的设置、待遇确定机构和机制、待遇供给机制等6个构建我国长期护理保险制度的关键问题进行了探讨。     

美国长期护理保险制度的经验及借鉴

美国是实施长期护理保险最早的国家,其经验对我国建立长期护理保险制度具有一定借鉴意义。本文在简要介绍美国长期护理保险制度产生背景的基础上,重点阐释了美国长期护理保险制度的主要框架,分别从公共保障计划和商业保险两个方面进行详细介绍。美国长期护理保险制度的多层次性、照护资源体系的完善性及给付方式的灵活性为我国建立长期护理保险制度提供了经验借鉴。在此基础上,本文在构建多层次长期护理保险体系、优化护理服务资源、提高市场化运作水平等方面提出建议。     

德、日两国长期护理保险制度改革路径及对我国的启示——基于国际比较的视角

在人口老龄化日益严重、老年人的护理需求不断增加的背景下,长期护理保险成为一些国家的选择,德国与日本较早就建立了长期护理保险制度,并针对该制度在实施过程中出现的一系列问题进行了数轮改革,取得了良好成效。我国的长期护理保险制度还处于试点阶段。通过对比发现,在适用对象、财务机制、评定标准和待遇给付等方面,我国与德、日两国存在一定的差异。因此,德、日两国相对成熟的护理保险制度改革,对我国长期护理保险制度的探索与完善具有重要的参考及借鉴意义。     

中国长期护理保险:制度实践、经验启示与发展走向——基于青岛和南通模式的比较分析

长期护理保险制度作为应对日益增长的老年长期护理需求的制度支撑,将是我国"十三五"时期社会保障体系建设的重点内容。文章围绕青岛、南通两市长期护理保险制度地方实践的现实背景、模式特征、制度设计进行比较分析。在总结经验启示的基础上,结合发达国家经验提出相应的对策建议,以期为我国长期护理保险制度的顶层设计提供有益的借鉴。     

美日德韩四国长期护理保险制度对我国的启示

运用文献研究法、对比分析法、归纳总结法等方法分析与研究我国长期护理服务需求现状和问题、我国试点城市长期护理保险制度供给与实施现状以及美日德韩等国长期护理保险制度经验,认为我国长期护理保险制度存在着制度设计公平性不足、过度依赖医保基金、年龄限制不符合权利义务对等原则、精神慰藉服务尚未被纳入服务项目、服务提供机构与专业人才短缺以及缺乏法律支持等问题,并提出逐步扩大制度覆盖范围,实现城乡统一;坚持社会化筹资模式,实行多层次的筹资比例;重视评估标准的制定,坚持权利义务对等原则;坚持老年人利益最大化,逐步扩大服务项目;鼓励社会力量全面参与,培养专业人才;建立长期护理保险法,强化政府责任等建议。     

美德日韩4国长期护理保险制度对我国的启示

目前我国尚未建立具体的长期护理保险制度,理论研究取得一定成果,实践上仍处在试点阶段。运用文献研究法,对比分析对法美国、德国、日本、韩国4国长期护理保险制度的建立背景、模式特点与运营机制、资金筹集方式给付方式和服务提供内容展开论述,基于国外的先行经验结合我国社会经济现状提出:实行多渠道的筹资扩大覆盖范围,设立全国统一的长期护理保险需求分级和等级评估标准,鼓励发展商业长期护理保险、补充完善长期护理保险体系等建议,以期为我国建立长期护理保险制度提供参考。     

广州市与深圳市长期护理保险制度的试点经验与思考

广东省长期护理保险制度的试点城市有广州市和深圳市。通过研究广州市、深圳市长期护理保险的参保对象、筹资标准、待遇给付、支付标准等方面,总结广州市与深圳市长期护理保险制度的试点经验,为我国长期护理保险制度的进一步发展提出以下建议：完善线上服务措施,构筑疫情常态化下的长期护理保险制度;科学优化评定内容,提供精细化的护理服务;关注家庭照顾者,将喘息服务嵌入长期护理保险照护服务;加强长期护理保险实施中预防服务的作用,注重中医药特色的发挥。     

“福利三角”理论下广州长期护理保险制度的选择

目的调查广州市长期护理服务现状,分析存在的问题并提出建议,为其长期护理保险制度的选择提供依据。方法通过实地调研、问卷调查等方法收集相关资料并进行统计分析,以"福利三角"理论为框架,从国家、市场和家庭三方面来探讨广州市选择长期护理保险制度的必要性。结果广州市人口老龄化严重,失能率高;失能老人更倾向于养老机构护理;民办养老机构数量明显多于公办养老机构,护理内容不全面且费用较高;家庭长期护理费用负担过重,国家和市场没能很好地履行其提供社会福利的责任和义务。结论广州市应尽快建立长期护理保险制度,强化国家社会养老的责任,充分发挥市场参与功能,同时减轻失能老人家庭经济负担,以实现三者间福利的均衡。     

新加坡长期护理保险制度的建设经验与启示

分析新加坡长期护理保险制度的实施经验，发现新加坡长期护理保险有以下优点：覆盖范围和保障程度不断扩大，筹资渠道多层次化，护理服务全面细致，护理方案定制精准化和个性化，失智护理方案本土化，充分发挥商业保险公司在长期护理保险中的经办作用等。结合我国长期护理保险实际情况以及探索过程中的不足，借鉴新加坡的经验，提出了进一步完善长护险制度顶层设计、丰富政府财政补贴形式、丰富护理服务种类、探索本土化失智人员护理方案、完善长期护理服务体系等建议，以期推动我国长期护理保险制度的完善与发展。     

广州市长期护理保险试点现状、问题及对策分析

广州市自2017年试点运行长期护理保险以来,在参保人群范畴、筹资与待遇、失能认定与护理服务等级划分、护理服务项目、服务定点机构以及监督管理体系等方面进行了积极探索,取得了长护险制度逐步优化、服务主体产业化、社区居家模式逐步成熟、服务及管理水平提升等成效。广州市长期护理保险目前尚存在人口老龄化趋势与长护险定点机构区域发展失衡、部分定点机构服务监管质量欠佳、服务实践覆盖面有待提升等问题。结合国家保险制度政策及信息化发展,提出了优化提升长护险服务主体空间布局、扩大长护险服务保障项目范围、灵活长护险给付制度、监管制度闭环体系和智慧化运行体系等建议。     

中国台湾地区创新医疗技术支付进展及经验

从中国台湾地区二代全民健康保险制度、“卫生福利部健康保险署”对新医疗服务项目的管理流程、全民健康保险按疾病诊断相关分组支付制度下的新增全新功能类别医疗技术因应方案三方面,介绍了中国台湾地区全民健康保险对创新医疗技术支付的做法和经验。在此基础上为我国创新医疗技术支付政策改革提供参考和借鉴,包括构建多渠道的筹资体系、引入第三方评估机制、推进疾病诊断相关分组付费制度下的医疗保险支付改革。     

Long-term care insurance in Germany: analyzing its progress from the perspective of economic indicators

Germany enabled public long-term care insurance (LTCI), a social insurance system, in 1995. This study focuses on the LTCI program in Germany, analyzes progress of LTCI in view of economic indicators in the inland 16 states (“Länder” in Germany), categorizes 16 states, and describes problems concerning the LTCI program. Statistical analysis was conducted using 24 variables of LTCI and the economic index. The 16 states were categorized in five clusters. The results revealed gaps in adoption rates of LTCI care services among 16 states, suggesting that each of the states developed its own service system of LTCI dependent on regional variables such as economic power and size of population. All former East German states tended to have lower economic resources of care. States with many requests for cash benefits tended to offer lower amounts of care services. The characteristics of these 16 states provide useful information for developing LTCI policies in Germany and offer an informative guide to other countries.     

美国专业护理机构以患者为导向的病例分组支付方式研究——从RUG到PDPM

人口老龄化和疾病谱变化带来的长期护理问题已成为世界关注的焦点,我国也在积极探索长期护理的筹资制度。美国于2019年开始了新一轮长期护理保险支付方式改革。本文梳理和回顾了其支付方式发展历程,并对老年医疗保险对专业护理机构最新的支付方式改革进行详细介绍。该支付方式在价值驱动下,以真实成本为基础,根据患者特征和需求将患者划分为不同病例组,并以此分组为依据进行支付,消除"按数量"的付费特征、提高支付的精确性。上述改革可以为我国长期护理保险支付方式进一步精细和科学化提出有益借鉴。     

Physician payment reform in the United States

With the recent strengthening of the physician expenditure cost control mechanisms of the “Gesundheitsstrukturgesetz” of 1993, Germany has again affirmed its belief in the need for and success of global budgeting for physician payments. In 1992 Medicare, the U. S. government-run health insurance program for the elderly, first implemented the new Medicare Fee Schedule based on a point value system, known as the Resource-Based Relative Value Scale (RBRVS), which is very similar to the German “Einheitlichen Bewertungsmaßstab” (EBM) and uses a similar system for budgeting physician payments. Although this policy has only been in place in the United States for two years, many policy makers are considering expanding the payment mechanism to all payers, private and public, in an effort to control costs. In order to inform German health policy makers of this trend in the United States, both the historical and analytical framework of physician payment reform in the United States are described, as well as some insight into its future direction is provided. The first section is on the pressures during thel980’s that led to the new Medicare Fee Schedule and the implementation of the Resource-Based Relative Value Scale on which it is based. Second the analytical methodology and budget considerations are dealt with that were used to implement the Medicare Fee Schedule. Third, the potential affects of the resulting reform on costs, quality, access and individual physician payment are analyzed. Lastly, the role of physician payment in the debate on U. S. health care reform is examined, as well as, the Medicare Fee Schedule’s applicability to other payers     

日本长期照护政策及对我国的启示

本文综述了日本长期照护政策的发展历程、现状、成就和挑战,为我国建立长期照护保险制度提供借鉴。日本长期照护保险覆盖65岁及以上老年人,申请人通过需要照护水平的认证后可获得居家和机构照护两种服务。保险筹资包括政府财政投入、保费筹集和使用者共付三大来源。日本长期照护保险最主要的特点是实现了全面覆盖,但随着日本老龄化和需照护老年人的增多,日本长期照护保险面临费用持续上涨等挑战。最后,建议借鉴日本经验,我国应该建立覆盖所有老年人、以居家照护为主体、社会资本参与的长期照护制度。     

RBRVS的兴起与发展对我国社会医疗保险支付的政策启示

RBRVS具有控制医疗卫生费用过快上涨、以富有激励性的医师费支付消除医务人员行为扭曲的作用,其核心功能与我国当前医改面临的问题十分契合。本文从宏观政策视角对RBRVS展开研究,回顾了RBRVS的兴起背景、发展历程、应用优势及其支撑条件。在对我国学术研究和实践探索展开系统性分析的基础上,明晰当前RBRVS在应用中面临未引起卫生政策制订者的足够重视、对RBRVS的激励相容导向关注不足、运行RBRVS的支撑体系薄弱、缺少基于宏观考量的医务人员薪酬支付体系规划等主要问题,据此提出借鉴RBRVS关于医疗保险支付制度的设计精髄、运用医保支付激励达成卫生政策目标、逐步引入按质量付费导向的支付方式、规划契合我国诊疗服务模式的医师费支付方式以及系统评估将其引入社会医疗保险支付的可行性等对策与建议,旨在为推进我国社会医疗保险支付改革提供参考。     

对基本医疗保险支付改革与医疗联合体建设的利益相关性研究

政策的制定和实施与各方利益相关者利益紧密相关,政策改革必然导致各方利益再分配,从而影响改革进程。文章从利益相关者角度出发,探讨近年我国医药卫生体制改革过程中基本医疗保险支付方式改革与医疗联合体建设的利益相关性,分析出两者有5类共同利益相关,并且通过医疗保险支付方式改革中的按人头打包支付等复合支付方式、结合分级诊疗和家庭医生签约服务制度、健全医疗联合体内协商谈判机制这三项政策支持了医疗联合体建设。但仍有待改善之处,需要继续推进医保政策改革,以打包支付积极推动紧密型医疗联合体的构建,发挥并强化信息技术的支撑作用,从而更有利于推动医疗保险支付方式改革和医疗联合体建设。     

诊断相关组预定额付费(DRGs-PPS)与按项目付费的比较

正确选择支付方式,是支付制度改革的核心问题.本文以“合约理论”为基本分析框架,比较了诊断相关组预定额付费(DRGs-PPS)与按项目付费的定价成本和监督成本.在此基础上,进一步沿用合约理论的分析框架,分析了执行DRGs-PPS时需要应对的主要管理问题,并从监督和维护两个方面提出了政策要点.分析得出的基本认识是,DRGs-PPS相对按项目付费而言,交易费用较低,故从按项目付费向DRGs-PPS转变,将有利于医疗服务市场的良性运转.由于DRGs-PPS对于中国依然是新鲜事物,因此,需要在统筹考虑医疗服务监管和制度维护等配套措施的基础上有序推进.     

Home-based care provision within the German welfare mix

With the introduction of long-term care insurance (LTCI) in 1995/96, Germany established a universal long-term care scheme within a cost containment framework to provide public support in defined situations of care dependency. The scheme aimed to promote ageing in place with an emphasis on public support for family care provision as a precondition. A further aim was the expansion of market-oriented professional care services to offer users a choice between family and professional care provision and care providers. The focus of this study is on the interplay of formal and informal family care provision within the institutional framework of LTCI, as well as the organisation, regulations and mix of different types of formal care services. In a first step, an examination of the interplay of formal and informal care provision shows the largely family-oriented care strategy, the burdened situation of informal carers, the mix of rationalities of service use and their interrelationship with socioeconomic inequality. In a second step, an analysis of the organisation of different types of formal services reveals paid care provision that emerges in the interplay of politicians' strategies to develop professional care services within the framework of LTCI, bottom-up strategies of users to increase the range of services outside the framework of LTCI and efforts of politicians to regulate the latter. Basic orientations of care provision underlying the development process such as user orientation, quality and comprehensiveness guided the process and are used to analyse the development. Finally, the discussion of the situation of care workers reveals a contradictory picture with increasing employment opportunities, a comparably well-qualified workforce and worsening employment conditions. Empirically, the research is based on an institutional analysis of LTCI combined with a literature review and representative statistics.     

Considering long-term care insurance for middle-income countries: comparing South Korea with Japan and Germany

Financing and provision of long-term care is an increasingly important concern for many middle-income countries experiencing rapid population aging. We examine three countries (South Korea, Japan, and Germany) that use social insurance to finance medical care and have developed long-term care insurance (LTCI) systems. These countries have adopted different approaches to LTCI design within the social insurance framework. We contrast their financing systems and draw lessons regarding revenue generation, benefits design, and eligibility. Based on this review, it seems important for middle-income countries to start developing LTCI schemes early, before aging becomes a significant problem and substantial revenues are needed. Early financing also ensures that the service delivery system has time to adapt because most middle-income countries lack the infrastructure for providing long-term care services. One approach is to start with a limited benefit package and strict eligibility rules and expanded the program as the country develops sufficient experience and more providers became available. All three countries use some form of cost-sharing to discourage service overuse, combined with subsidies for poor populations to maintain appropriate access. A major policy choice is between cash benefits or direct provision of services and the approach will have a large impact on the workforce participation of women.