台灣長期照護保險之策略規劃－財務、人力與服務觀點

Due to the trends of the increase in life expectancies and decrement in fertility rates, the world population is moving towards becoming an ageing nation. With the rise in the number of older people, the demand for long-term care services is expected to increase. Long-term care services are ubiquitous in the developed country, especially in the European region as the countries have become the aged nations. Apart from that, the cost for long-term care services differs for individuals based on the level of needs and the service provider, either public or private nursing home for long-term care. Due to the growing cost of long-term care services, a long-term care insurance policy may be seen as an alternative to covering the cost of long-term care services because the risk is mitigated for individuals. However, most Asian countries are not familiar with the long-term care insurance policy as there is no specific insurance policy for long-term care services offered yet in these countries. The essential factor in constructing a long-term care insurance policy is to identify the risks that are insurable to be included in the policy to be used later for pricing long-term care insurance policy in Malaysia. This study provides an in-depth review and understanding of the insurable risks associated with long term care insurance in European and Asian countries.

Financing long-term care is an issue of concern to many Americans, yet private long-term care insurance product sales have experienced slow growth. Pricing problems may in part explain this phenomenon. This study provides the first empirical evidence on pricing in the long-term care insurance market and analyzes the relationship between insurer operating characteristics and premium. The results suggest that prices vary across firms due to size, organizational form, default risk, and tenure in the market, but not due to differences in distribution system. The evidence is also consistent with significant price differences due to contract design variables that control moral hazard and adverse selection. INTRODUCTION Financing long-term care has become an issue of increasing concern to many Americans. Long-term care includes a range of social and medical services needed by individuals unable to care for themselves due to physical or cognitive disability. Care may be provided in nursing homes, at home, in other residential facilities, or at adult day care centers for the elderly or disabled. People of all ages use long-term care, but the need is especially acute for the elderly (i.e., those over age 65). Private long-term care insurance is one solution to the financing issue. However, this product has experienced relatively slow growth in recent years, possibly because price and policy characteristics are not sufficiently appealing to generate strong sales. This study analyzes the relationship between insurer operating characteristics and the price of insurance. In particular, the importance of insurer organizational form, size, financial strength, distribution system, and tenure in the market is documented and analyzed. M oral hazard and adverse selection effects with respect to particular policy design features are also examined. This article begins with a review of the context in which long-term care insurance is sold. Next, the research methods used in the study are discussed, and the data set and the expected results are described. The empirical results are then reported, followed by a discussion of the major conclusions and implications of the study. THE LONG-TERM CARE INSURANCE MARKET Concern about long-term care financing has increased for several reasons. First, demographic trends show that the elderly are the fastest growing age group in the nation. Figure 1 depicts past and projected growth trends for the elderly to the year 2020. Kemper and Murtaugh (1991) estimate that 43 percent of the elderly will use nursing home care, that over half of those in nursing homes will stay for at least one year, and that 20 percent will remain five years or longer. The concern about paying for nursing home care will become more pronounced in the future, as the proportion of younger persons relative to older persons decreases, thereby making family care less feasible for many. Extended life expectancies, due to advances in medical science and increasingly healthy lifestyles, further increase the likelihood that long-term care outside of the family unit will be needed. Concern about long-term care financing arises not only from increasing utilization of services, but from the high cost of such services. Typical nursing home costs range from $35,000 to $65,000 or more per year, and costs are rising faster than inflation. Community-based residential care or home care is less expensive, but can still be prohibitive for middle- and-lower-income families. In 1995, national aggregate long-term care expenditures exceeded $100 billion annually, of which 44 percent was paid by Medicaid, 16 percent by Medicare, and 30 percent by individuals and their families. Private long-term care insurance represented only about 2 percent of benefit payments. [1] Reductions in state Medicaid funding are likely to have a significant impact on the financing of long-term care in the future, and another public sector solution to the problem of funding long-term care is unlikely, given efforts to control federal spending. …

Purpose: The purpose of this study was to demonstrate the effects of visiting nursing services in long-term care(LTC) insurance on changes in health status and physical functions among the elderly. Methods: We analyzed survey data on the living status and welfare needs of the elderly from 2008 and 2011 using the difference-in-difference method with propensity score matching. Results: The subjects were 76 elders including 38 visiting nursing service users(intervention group) and 38 home-based LTC service users (control group). Results from DID analysis confirmed that the subjective health status level of the intervention group was 2.2 points higher (p=.044) andthe depression level was 0.3 point lower (p=.039) than the control group. In addition, the intervention group’s ADL score was 1.9 (p=.027) and IADL 3.9 (p=.030), showing that their health was deteriorated less. Conclusion: Visiting nursing service in LTC insurance was associated with delayed deterioration of subjective health status, depression, ADL and IADL. These findings suggest the need of rebuilding visiting nursing service programs focusing on prevention services, which will be more contributive to elderly health care and the reduction of social costs.

Long-term care insurance has been introduced in Korea a year ago, and we are in a stage requiring to set principles regarding the generosity of coverage and how to gradually extend the coverage. This study empirically analyzes how the long-term care insurance in Korea is operated. Special attention is given to who is the main beneficiary of the long-term care insurance introduction, and what is the factors influencing the elderly`s decision to apply for or use long-term care services. Use of a detailed information of individuals` public health insurance and long-term care insurance from administration data made it possible to control for health status, socioeconomic status including family type, housing tenure, income level. Logit models were employed to analyze the effects of various socioeconomic factors on the likelihood of applying and using long-term care services. Also, this study employed a survey questioning whether to ever willing to take other option as a alternative to residential care or home-care and the level of cash benefit for which they are willing to replace the formal care with informal care. The result indicated that although the poorest elderly population groups are in the greatest need for the long-term care service, they are in difficulty using the service due to economic burden. This implies the copayment amount needs to be adjusted in order for the poor elderly group to be able to get the benefit of the long-term care service.

In comparison to residential care services, home and community care services in Hong Kong remain underfunded and underdeveloped. The government's long-term care policies have resulted in an overreliance on subsidized long-term care services in the form of institutional care services. The quality of services offered by private residential care facilities is a cause for concern. Population aging, evolving family structures, and changes in residential living patterns are expected to continue to put a strain on resources for services for the elderly in the near future. This article provides an overview of the many issues surrounding long-term care in Hong Kong and offers potential directions for the future development of long-term care services.

Background: This study examined the relationships of dementia, stroke, and combined multimorbidity with long-term care utilizations among older people in South Korea. Methods: A nationally representative sample of 10,130 older adults who used long-term care services in 2010 were analyzed. We used the 5% sample of aged 65 years or older linked with National Health Insurance Corporation registry data of long-term care insurance system. The sample was categorized into three groups: dementia only (47.6%), stroke only (36.3%), and both dementia and stroke (16.1%). We estimated the use of institutional care, home care, and total expenditure of long-term care services, adjusting for the severity of each function (such as daily life, behavior or cognitive change, nursing care needs, and rehabilitation care needs) and sociodemographic characteristics. Results: Having dementia symptoms was positively associated with the use of institutional care services, on the other hand, having stroke symptoms was positively related with the use of home care. The total long-term care cost was higher in the group of having both dementia and stroke. Conclusion: Older persons with dementia symptoms and stroke symptoms have different patterns of long-term care utilization, and the multimorbidity increased the overall expenditure of long-term care utilization. These findings imply a need for differentiated management strategy targeting physically and cognitively impaired older persons, and special concerning for persons with multimorbidity conditions for long-term care insurance program in Korea.

Disagreement between a public insurer’s recommendation and beneficiary’s choice of long-term care services in Korea

Introduction: In Japan, since the Long-Term Care Insurance launched in 2000, elderly care has been supported with both medical and long-term care insurance, based on the community-based integrated care system aiming at living in the community to the end of lives. Medical expenses per person aged 75 and older show a decrease from US $8,192 in 1999 to US $7,197 in 2002, however, they gradually increased to US $9,352 in 2019. The long-term care costs also increased from US $4,248 in 2006 to US $5,182 in 2021. Meanwhile, the proportion of deaths in hospitals decreased from 82.4% in 2005 to 67.4% in 2021, showing a shift towards non-hospital settings. (US $1.00 = 102 Japanese yen) Aims, Objectives, Methods: This study focused on the last 5 years of life for 96 individuals aged 75 and older. They received their initial long-term care certification after 2016 and died during the fiscal year 2021. These individuals lived in a small rural municipality with a population of less than 20,000, an aging rate of 37.9%, and a long-term care certification rate of 19% in Japan. Individually, we linked medical fees and records of the long-term care insurance. Ultimately, we identified the location of end-of-life care. Subsequently, we categorized individuals with hospitalization expenses in the last month as ‘hospital-deaths’, while those without hospitalization expenses as ‘community-deaths’. Highlights, Results, or Key Findings: The average total care costs over the last five years amounted to US $116,241, including hospitalization expenses of US $55,250, outpatient expenses of US $25,997, and long-term care costs of US $34,995. The 80-84 age group had the highest total care costs. Places of death comprised 62.5% in hospital-deaths and 37.5% in community-deaths. The final severity of care required (range 0-5) for community-deaths was significantly higher at 3.5, compared to 2.9 for hospital-deaths. The residency at care facilities was significantly longer for community-deaths (8.4 months) than hospital-deaths (3.8 months) . Total care costs were markedly elevated for hospital-deaths, reaching US $129,830, in contrast to US $93,594 for community-deaths. Especially in the last month, total care costs were significantly higher, reaching US $7,616 for hospital-deaths and US $2,796 for community-deaths. Conclusion: This study examined the total care costs for elderly people with long-term care certification in a small municipality over the five years before death and analyzed the places of end-of-life care. The final severity of care required in community-deaths was significantly higher than that in hospital-deaths and the duration of residency in care facilities was significantly longer. This suggests that elderly people with substantial care and medical needs lived in the community to the end of lives. Meanwhile, the total care costs during the last five years were higher in hospital-deaths, particularly in the last month before death. In Japan, the community-based integrated care system since 2006 has facilitated end-of-life care in long-term care services and changed the situation where hospital deaths accounted for over 80% in 2005. This system appears to have gradually improved.

Large increases in the need for long-term care (LTC) services are expected as baby boomers age. Little has been published about patient and caregiver preferences for information about LTC. However, our qualitative research findings suggest that potential consumers may find it difficult to obtain accurate and timely information about LTC programs and services. In-person, semistructured interviews were conducted with 47 subjects, including patients (n = 25) within 90 days of their referral to a LTC placement (including NH, assisted living, home care, and community) and their caregivers (n = 22). Interview questions addressed the events that seemed to trigger their need for a LTC referral, the resources they used to become more informed about LTC options and the issues they confronted with the LTC referral process. Qualitative analyses identified a number of patient and informal caregiver-reported barriers to making decisions about LTC services, including insufficient information about LTC programs and community resources, unclear funding requirements and inadequate funding, and difficulty knowing how to plan for LTC or make LTC decisions. A potential solution may be an online LTC Guide designed to provide accurate information about the range of LTC services, with an emphasis on home and community-based services. This Guide was developed to address the gap in comprehensive LTC information identified in the findings of this study.

Increasing aged care requisite has become a serious challenge all over the world. Compared with developed countries, aged care in China still has some limitations, i.e., lack of qualified professionals, aged care system needs to be improved, and lack of aged long term care insurance. This article discussed these points and put forward the corresponding countermeasures. Key words: Geriatric nursing; Aged care; Ageing of population

BackgroundIt is unclear how formal long-term care (LTC) availability affects formal /informal caregiving patterns and caregiver health. We tested the impact of reduced formal LTC availability on formal LTC service use, intensity of informal caregiving, and caregiver health.MethodsUsing a representative, repeated cross-sectional sample of Japanese caregivers providing care to co-resident family members from 2001 to 2016, we applied a difference-in-differences approach by observing caregivers before and after the major reform of the public Japanese LTC insurance (LTCI) in 2006. The reform reduced coverage benefits for non-institutionalized older persons with low care needs, but not for those with high care needs. We analyzed 12,764 caregivers aged ≥30 years (mean age 64.3 ± 11.8 years, 73.5% women) and measured indicators of formal LTC use, hours of informal caregiving, and caregiver self-reported health outcomes after propensity score matching to balance caregivers’ background characteristics.ResultsWe found the 2006 LTCI reform relatively reduced the use of formal LTC services and relatively increased the percentage of experiencing long hours of informal caregiving (> 3 h per day) among the caregivers for seniors with low care needs compared to those for seniors with high care needs. The effects of the LTCI reform for the caregivers for seniors with low care needs were 2.2 percentage point higher on caregivers’ experiencing poor self-rated health (95% confidence interval [CI]: 0.7–3.7; p = 0.01), 2.7 percentage point higher on experiencing symptoms of a depressive state (95%CI: 0.5–4.8; p = 0.03), and 4.7 percentage point higher on experiencing symptoms of musculoskeletal diseases (95%CI, 3.6–5.7; p < 0.001), compared to those for seniors with high care needs.ConclusionsReduced formal care availability under the Japanese LTCI reform increased hours of informal caregiving corresponding to reduced use of formal LTC and deteriorated multiple dimensions of caregiver health. Our findings may highlight the importance of enhancing the availability of formal LTC services for caregiver health.

BackgroundPolicy effect might be multidimensional and spill over to non-recipients. It is unclear how the implementation of Long-Term Care Insurance (LTCI) policy affects depression in non-disabled people and how this effect differs in different non-disabled groups.MethodsUsing time-varying differences-in-differences method and nationally representative health survey data in wave 2011, wave 2013, wave 2015 and wave 2018 from the China Health and Retirement Longitudinal Study, we assessed the effect of LTCI policy on depression in non-disabled people aged 45 years and older, and discussed the heterogeneity of effect across different population characteristics: retirement, financial support and social participation status.ResultsWe found LTCI policy statistically significant reduced depression by 0.76 units in non-disabled people compared to non-pilot cities. Depression in non-disabled people who unretired, with financial support and without social participation was reduced by 0.8267, 0.7079 and 1.2161 units, respectively.ConclusionsDepression in non-disabled people was statistically significant reduced because of LTCI policy in China, and non-disabled people who unretired, with financial support and without social participation benefited more from LTCI policy. Our findings highlight the depression-reducing effect of LTCI policy in non-recipients and suggest that non-disabled people who unretired, with financial support and without social participation should be concerned during LTCI policy progress.

Background. A new public long-term care (LTC) insurance was launched in 2000 in Japan. However, there have been few studies involving factors that increase LTC costs of demented subjects; no follow-up studies involving the Government-Certified Index (GCI) and requisite costs related to the causes of dementia. Method. An epidemiological survey was conducted in a rural area in Japan in 1999, and 271 subjects were diagnosed as dementia patients. Age, sex, mini-mental state examination, clinical dementia rating, activity of daily living, causes of dementia, and coexisting physical disease were confirmed. After the LTC insurance has been launched, we tracked the GCI stages and payment amounts every month for 8 years. Result. 209 subjects were certified to be eligible for LTC insurance; however, 13 did not receive any payment. Only 49 out of 209 were alive after the follow-up period. The most common cause of dementia was Alzheimer's disease (AD), followed by vascular dementia (VaD). There was no significant difference between the mortality rates of the two groups. VaD subjects required higher costs than AD subjects in the total certified period and in GCI stage 5. Conclusion. Our results indicate that causes of dementia can have an impact on the requisite costs for the LTC insurance.

Long-term care insurance: Buy it or not!

We investigate the application of natural hedging strategies for long-term care (LTC) insurers by diversifying both longevity and disability risks affecting LTC annuities. We propose two approaches to natural hedging: one built on a multivariate duration, the other on the Conditional Value-at-Risk minimization of the unexpected loss. Both the approaches are extended to the LTC insurance using a multiple state framework. In order to represent the future evolution of mortality and disability transition probabilities, we use the stochastic model of Cairns et al. (2009) with cohort effect under parameter uncertainty through a semi-parametric bootstrap procedure. We calculate the optimal level of a product mix and measure the effectiveness provided by the interaction of LTC stand alone, deferred annuity and whole-life insurance. We compare the results obtained by the two approaches and find that a natural hedging strategy for LTC insurers is attainable with a product mix of LTC and annuities, but including low proportion of LTC.