【作者】 李红；

【导师】 王新军；

【作者基本信息】 山东大学 ， 保险学， 2021， 博士

【摘要】 人口老龄化以及老年带残余寿的延长催生了大量的长期护理需求,与此同时生育率降低、女性劳动参与率不断提升以及老人独居比例的增加极大的降低了非正式护理资源的可及性,我国面临不断增长的长期护理需求与不断短缺的护理资源之间的巨大矛盾,短缺的非正式护理资源以及高昂的正式护理费用给失能老人的健康福利以及经济基础带来了严重损害和冲击,要妥善解决好失能老人的长期护理问题,不仅需要增强其护理服务的可及性,同时还需要建立长期护理风险分散的长效机制。促健康、保民生是我国政府在国家治理和战略部署中的重要内容。例如党的十九大、十九届四中全会以及2020年最新的两会均强调提高和完善民生保障的水平和力度。在这种背景下,我国于2016年开启首批长期护理保险试点政策,于2020年开启第二批试点政策,但目前的覆盖范围仍然很有限,全国660多个城市中仅有49个地区在开展试点工作,这还不包括未实施试点政策的广大农村地区,这说明我国长护险的发展形势不可谓不严峻。要解决失能老人普遍存在的长期护理问题,不仅要从微观上对失能老人长期护理需求的发展形势进行远期预测以准确掌握我国失能老人未来的整体态势,同时需要从失能老人的护理需求偏好出发,探讨正式护理与非正式护理的相关关系。当个体处于失能状态需要寻求护理服务并选择护理模式时,他们不仅关注护理费用还关注自己的心理诉求(护理偏好)。两种护理模式之间是否存在显著的替代关系,它决定了非正式护理资源短缺的情况下正式护理资源能否被有效利用。长护险的实施虽然能够有效分散正式护理的高额成本,但它并不能对正式护理服务需求产生绝对性的引导作用,其政策实施的科学性和有效性仍依赖于正式护理与非正式护理的替代程度。因此,正式护理与非正式护理是否存在显著的替代关系极大的影响长护险试点政策实施的必要性和科学性。此外,长护险试点政策的实施效果关系着失能老人长期护理问题能否得到妥善解决。相对于2020年新公布的扩大试点政策,首批试点政策自公布之日起己实行四年多的时间,其试点的政策效果亟待评估。对长护险试点政策进行评估不仅能够提高长护险政策制定的科学性,同时也是现代化公共政策升级和优化的内在要求。为了妥善解决失能老人的长期护理问题、巩固长护险试点政策的发展成果,本文以长期护理需求及其保险试点政策评估研究为选题开展了研究,得到的主要结论为:第一,我国失能老人的长期护理需求和长期护理费用均增长迅速。预测数据显示,2020至2060年我国失能老人总规模以及重度失能老人总规模的波动范围分别为4258～22877万人以及343～5522万人,我国失能老人长期护理费用的波动范围为728～182335亿元。以上数据表明必须建立失能老人长期护理风险分散的长效机制,这也同样揭示了开展长护险政策试点的必要性和紧迫性。第二,正式护理和非正式护理之间存在显著的替代关系。具体而言,非正式护理与家政服务利用以及入住养老院之间存在显著的替代关系,在替代程度上,家政服务与非正式护理的替代效应大于养老院服务与非正式护理。失能程度并不影响家庭照料与正式护理的替代关系,这是由于正式护理的成本较高,超过了很多中等收入家庭的负担能力。开展长护险地方试点之后,正式护理的高额成本将被长护险有效分散,失能老年人未被满足的护理需求将通过对正式护理服务的利用而得到补偿。也就是说长护险试点政策的实施可能会通过优化失能老人的护理结构从而改善他们护理服务的可及性;另外,长护险试点政策的开展可能会通过对失能老人就医与护理的分流而治有效减少老年护理对医疗资源的过度利用;最后,长护险试点政策实施的基本原则是提高人们的健康水平。基于以上分析可知,长护险试点政策的积极效果可能有三点:一是能够提高失能老年人护理服务的可及性;二是减少社会性入院过度挤压医疗资源的低效率配置;三是改善失能老年人的健康水平。本文将在第五章对此进行一一验证。第三,长护险试点政策效果显著。开展长护险降低了试点地区失能老年人对医疗资源的过度利用;具体而言,实施长护险试点政策能够使得失能老年人每月门诊费用以及看门诊次数分别减少316元和0.819次,使得失能老年人年住院费用以及年住院次数分别减少5262.1元和0.464次。其次,开展长护险提高了试点地区失能老年人的健康水平;具体而言,实施长护险试点政策使得失能老年人的慢性病个数减少0.136个、使得他们的健康自评得分减少0.128(健康自评赋值越小,健康水平越高)。最后,开展长护险改变了试点地区失能老年人的护理结构,提高了失能老年人护理服务的可及性。具体而言,实施长护险试点政策使得失能老年人被照料的可能性提高了 8.75%、非正式护理使用的可能性减少了20.9%。第四,对比长护险首批十五个试点城市的发展实践发现我国长护险还存在一些问题。大部分试点地区的多元化筹资模式只是停留在表面,长护险基金的筹资主力仍为医保基金结余,没有体现出个人和单位的缴费责任;在待遇给付方面,只有少部分地区(四个)真正秉承了试点指导意见中“鼓励居家护理以及社区护理的”的理念;失能评估标准五花八门的现状不利于未来长护险的统一和发展,由于广州、成都、荆门以及青岛市的失能评估办法基本上与国际接轨,因此未来长护险的失能评估办法应该重点借鉴这四所城市的经验。第五,对比分析日本、德国以及我国长护险的发展实践认为我国长护险的发展和完善需要从以下三个方面进行着手:构建可持续的长护险筹资机制;构建多层次、多功能型的长期护理服务体系;加快和完善长护险相关的法制建设。第六,政策建议。长护险试点政策的实施推动了家庭护理向社会护理的转变,由于我国家庭护理基础越来越薄弱,长护险试点政策无疑保障了老年人在失能状态下普遍存在的长期护理服务需求,提高了失能老年人的福利水平。另外,长护险试点政策解决了因社会性入院引发的医疗资源短缺的难题,同时提高了失能老年人的健康水平。这些结论为长护险试点政策的进一步开展提供了一定的借鉴意义和数据支撑。本文在前人的研究成果基础之上实现了以下改进工作:一是通过国内外的对比分析更加科学的界定了长期护理需求的概念,并综合国内十五个首批试点城市的失能等级评估办法,创新性的基于Barthel指数评定量表来界定失能老人的失能状态和失能等级。这为失能老年人长期护理需求规模的精确预测奠定了理论基础;二是在对失能老年人长期护理需求规模进行预测分析时,本文在科学界定长期护理需求关键影响因素的基础上充分考虑失能群体存在的异质性特征对失能老人长期护理需求规模进行了较为准确的分类预测。这对准确、合理的判断失能老人长期护理需求的总体规模和整体态势以及揭示长护险试点政策开展的迫切性和必要性提供了最新的本土化数据支撑;三是在讨论非正式护理与正式护理的相关关系时,本文率先采用工具变量法进行实证分析,并讨论失能程度对二者关系的异质性影响,工具变量法的使用能够精准识别失能老人两种护理模式的替代关系。通过准确识别失能老人两种护理模式的替代关系,为长护险试点政策实施的科学性提供了较为可靠的现实依据;四是在对长护险地方试点进行政策评估时,精准识别失能老年人为研究对象,首次对我国十一个首批试点城市长护险的政策效果进行评估,并率先讨论了开展长护险与失能老年人护理结构、护理服务可及性的关系。这对长护险扩大试点政策以及长护险制度的全面建设提供了较为可靠的参考依据。更多还原

【Abstract】 The aging of population and the extension of the life span of the old with disability have created a large number of long-term care needs,at the same time,the decline in fertility,the growth rate of women’s labor participation and the increase in the proportion of the elderly who living alone have greatly reduced the accessibility of informal care resources,China is facing a huge contradiction between the ever-increasing demand for long-term care and the continuous shortage of care resources.The shortage of informal care resources and the high cost of formal care have brought serious damage and impact to the health and welfare of the disabled elderly and their economic foundation.To properly solve the problem of long-term care for the disabled elderly,it is necessary not only to enhance the accessibility of care services,but also to establish a long-term mechanism of risk dispersion of long-term care.Promoting health and protecting people’s livelihood is an important part of our government’s national governance and strategic deployment.For example,the 19th National Congress of the Communist Party of China,the Fourth Plenary Session of the 19th Central Committee,and the latest two sessions in 2020 all emphasize to improve and perfect the level and intensity of people’s livelihood security.Under this background,our country launched the first batch of long-term care insurance pilot policies in 2016 and the second batch of expanded pilot policies in 2020.But we must deeply understand that the current coverage of China’s long-term care insurance is still very limited.Among 660 cities in China,only 49 regions are conducting pilot projects,though it is not yet included in the vast rural areas,this shows that the development of long-term insurance in China is very seriousIn order to solve the common long-term care problems of the disabled elderly,we should not only to make a long-term forecast of the development situation of the disabled elderly’s who have long-term care needs from the micro perspective,so as to accurately grasp the overall situation of the disabled elderly in the future in China,but also to explore the relationship between formal care and informal care from the perspective of the preference of the disabled elderly’s care needs.When individuals are disabled and need to seek care service and choose care mode,they not only pay attention to the cost of the care,but also pay attention to their psychological demands(care preference).Whether there is a significant alternative relationship between formal care and informal care determines whether formal care resources can be effectively used when informal care resources are in short supply.Although the implementation of long-term care insurance can effectively disperse the high cost of formal care,but it can not guide the demand for formal care absolutely.The scientificity and effectiveness of its policy implementation still depend on the substitution degree of formal care for informal care.Therefore,whether there is significant substitution between formal care and informal care has a great impact on the necessity and scientificity of the pilot policy of long-term insuranceIn addition,the implementation effect of the long-term care insurance pilot policy is related to whether the long-term care of the disabled elderly can be obtained and properly settled.Compared with the newly announced expansion pilot policy in 2020,the first batch of pilot policies has been implemented for more than four years since the date of announcement,and the effects of the pilot policies need to be evaluated urgently.The evaluation of the long-term care insurance pilot policy can not only improve the scientificity of long-term care insurance policy formulation,but also an inherent requirement for the upgrade and optimization of modern public policies.In order to properly solve the problem of long-term care for the disabled elderly and consolidate the development results of the long-term care insurance pilot policy,this article has carried out research based on the long-term care demand and its insurance pilot policy evaluation research,and the main conclusions are as followsFirst,the long-term care needs and long-term care costs of the disabled elderly in my country are growing rapidly.Forecast data show that the total scale of disabled elderly and the severely in my country will fluctuate between 42.58 and 228.77 million and 3.43-55.22 million respectively from 2020 to 2060.The fluctuation range of long-term care costs for disabled elderly in China is 72.8～18,233.5 billion yuan.The above data shows that it is necessary to establish a long-term mechanism for dispersing the risk of long-term care for disabled elderly people,which also reveals the necessity and urgency of carrying out long-term care insurance policy trials.Second,there is a significant substitution relationship between formal care and informal care.Specifically,there is a significant substitution relationship between informal care and the utilization of domestic services and the admission to nursing homes.In terms of the degree of substitution,the substitution effect of domestic services and informal care is greater than that of nursing home services and informal care.The degree of disability does not affect the alternative relationship between family care and formal care.This is because the cost of formal care is higher,which exceeds the affordability of many middle-income families.After the local pilot program of long-term care insurance is launched,the high cost of formal care will be effectively dispersed by long-term care insurance,and the unmet need for care of disabled elderly people will be compensated through the use of formal care services.That is to say,the implementation of the long-term care insurance pilot policy may improve the accessibility of nursing services by optimizing the care structure of the disabled elderly;In addition,the development of the pilot long-term care insurance policy may be implemented through medical treatment and nursing care for the disabled elderly separately to reduce the over-utilization of medical resources by elderly care effectively;Finally,the basic principle of the implementation of the long-term care insurance pilot policy is to improve people’s health.Based on the above analysis,it can be seen that the positive effects of the long-term care insurance pilot policy may have three points:one is to improve the accessibility of care services for the disabled elderly;the second is to reduce the inefficient allocation of medical resources that is excessively squeezed by social admissions;and the last is to improve the health of disabled elderly people.This article will verify this one by one in chapter five.Third,the pilot policy of long-term care insurance is effective.The implementation of long-term care insurance has reduced the overuse of medical resources by disabled elderly people in the pilot areas;Specifically,the implementation of the pilot policy of long-term care insurance can reduce the monthly outpatient expenses and the number of outpatient visits by the disabled elderly by 316 yuan and 0.819 times respectively.The annual hospitalization costs and the number of hospitalizations for the disabled elderly were reduced by 5262.1 yuan and 0.464 times respectively.Secondly,the development of long-term care insurance improved the health of disabled elderly in the pilot area;Specifically,the implementation of the long-term care insurance pilot policy reduced the number of chronic diseases of disabled elderly by 0.136 and reduced their health self-assessment score by 0.128(the smaller the health self-assessment value,the higher the health level).Finally,the development of long-term care insurance has changed the long-term care structure of disabled elderly people in pilot areas and improved the accessibility of care services for disabled elderly people.Specifically,the implementation of the long-term care insurance pilot policy has increased the likelihood of disabled elderly being cared for by 8.75%,and reduced the likelihood of informal care use by 20.9%Fourth,comparing the development practice of the first batch of 15 pilot cities for long-term care insurance,it is found that there are still some problems in long-term care insurance in my country.The diversified financing mode of most pilot areas is only on the surface,and the main financing source of long-term care insurance fund is the surplus of medical insurance fund,which does not reflect the payment responsibility of individuals and companies.In terms of benefits,only a small number of regions(four)truly adhere to the concept of "encouraging home care and community care" in the pilot guidelines;The diversity status of disability assessment standards is not conducive to the unification and development of future long-term care insurance.As the methods of disability assessment of Guangzhou,Chengdu,Jingmen and Qingdao are basically in line with international standards,the future disability assessment methods of long-term care insurance should focus on the experience of these four citiesFifth,a comparative analysis of the development practice of long-term care insurance in Japan,Germany and China,we believe that the development and improvement of my country’s long-term care insurance system need to be carried out in the three following aspects:to build a sustainable financing mechanism for long-term care insurance;to build a multi-level and multi-functional long-term care service system;and to speed up and improve the long-term care insurance and legal system construction related to long-term care security.Sixth,policy recommendations.The implementation of the long-term care insurance pilot policy has promoted the transition from home care to social care.As the foundation of home care in our country is getting weaker,the long-term care insurance pilot policy undoubtedly guarantees the widespread demand for long-term care services for the elderly in the state of disability and also improve the welfare level of disabled elderly.In addition,the pilot policy of long-term care insurance solves the problem of shortage of medical resources caused by social admissions,and at the same time improves the health of disabled elderly people.These conclusions provide certain reference significance and data support for the further development of long-term protection insurance pilot policies.Based on the previous research results,the following improvements are achieved in this paper.The first is to define the concept of long-term care needs more scientifically through comparative analysis at home and abroad,and integrate the evaluation methods of disability grades in the first batch of 15 pilot cities in China,and innovatively define the disability status and the level of disability of the disabled elderly based on the Barthel index rating scale.This lays a theoretical foundation for the accurate prediction of the scale of the long-term care needs of the disabled elderly;Secondly,when predicting and analyzing the scale of long-term care needs of the disabled elderly,based on the scientific definition of the key influencing factors of long-term care needs,this paper fully considers the heterogeneity characteristics of the disabled group,and makes a more accurate classification and prediction of the scale of long-term care needs of the disabled elderly.This provides the latest localized data support for judging the overall scale and overall situation of the long-term care needs of the disabled elderly accurately and reasonably,as well as revealing the urgency and necessity of the long-term care insurance pilot policy;Thirdly,when discussing the relationship between informal care and formal care,this paper takes the lead in using instrumental variable method for empirical analysis,and discusses the influence of the degree of disability on the heterogeneity of the relationship between them.The use of instrumental variable method can accurately identify the alternative relationship between the two care modes for the disabled elderly.Through the accurate identification of the alternative relationship between the two care modes for the disabled elderly,it provides a more reliable practical basis for the scientific implementation of the pilot policy of long-term care insurance;The fourth is to accurately identify the disabled elderly as the research object in the policy evaluation of the local pilot of long-term care insurance.For the first time,we evaluated the policy effect of long-term care insurance in 11 pilot cities in China,and take the lead in discussing the relationship between the development of long-term care insurance and the care structure and the accessibility of care services for the disabled elderly.This provides a more reliable reference for the expansion of the pilot policy and the comprehensive construction of long-term care insurance system.更多还原