Although the demand is vast, the development of long-term care insurance still faces challenges at both ends of financing and payment, relying on medical insurance, operating under great pressure on service institutions, and a shortage of talents
Text: Ding Yan
Editor|Yang Rui Zhang Wei
This year is the fourth year that Wang Haining has been paralyzed at home, and 89-year-old Wang Haining, who lives in Yuyao City, Ningbo, Zhejiang Province, is paralyzed and disabled due to cerebral infarction. Wang Haining's daughter is in her 60s, on one side is her mother who is paralyzed and disabled at home, and on the other side is her mother-in-law who lives alone and needs care.
However, starting in 2023, Wang Haining's daughter will be much easier, because Yuyao City, Ningbo has a long-term care insurance project. Professional caregivers will come every day to give Wang Haining limb function exercises, bathing, nail clipping and other care, each time the nursing time is 1 hour, "the nursing staff are more professional in care, and it also reduces our burden to a certain extent."
Long-term care insurance, that is, long-term care insurance, is a social insurance that provides basic life care for people who are disabled due to old age, illness, disability, etc. According to data released by the National Health Commission, the number of disabled and dementia elderly people in China will reach 45 million in 2023.
"The construction of the long-term care insurance system has entered a critical period, and the National Health Insurance Administration will actively do a good job in the comprehensive implementation of the system with greater efforts." On May 27, Lei Wen, director of the long-term care insurance division of the Department of Treatment and Security of the National Health Insurance Administration, revealed at the relevant forum that the next step will be to promote the implementation of unified evaluation standards across the country and promote the cross-regional mutual recognition of assessment results, so as to facilitate the enjoyment of treatment in different places. At the same time, we will study and formulate the criteria for identifying nursing needs that are compatible with the assessment criteria for disability levels, and provide a list of corresponding nursing service plans according to the assessment results, so as to achieve more accurate service and cost protection.
Since 2019, long-term care insurance has been included in the work report of the two sessions of the government for many times, and it is also an important part of inclusive finance as one of the "five major articles". The 2019 government work report pointed out that "expanding the pilot of the long-term care insurance system", and the government work report from 2021 to 2023 mentioned "steadily promoting the pilot of the long-term care insurance system" for three consecutive years. The 2024 government work report directly removed the word "pilot" and directly proposed to "promote the establishment of a long-term care insurance system".
However, although the demand for blue ocean is vast, there are still two major obstacles to the sustainable development of long-term care insurance, one is the financing side, although most urban long-term care insurance is undertaken by commercial insurance companies, but because the financing channels are more dependent on medical insurance funds, long-term care insurance has not yet formed an independent financing system; Second, on the payment side, fund payment is mainly based on the purchase of services, and many long-term care insurance nursing service institutions are currently facing multiple challenges such as greater operational pressure and lack of nursing talents.
At the same time, there are challenges in the regulation of long-term care insurance. According to Xie Qian, head of the medical service department of Yuyao Medical Security Bureau and director of the medical insurance center, most of the long-term care service recipients are disabled and demented, and it is difficult to evaluate the specific behaviors of the caregivers in the service process, and the family evaluation is easy to distort, and most of the families of severely disabled people think that the long-term care insurance service itself is free and does not have high requirements for the specific quality of the service; Secondly, the services involve incontinence care, toilet assistance, catheterization (women), etc., and video surveillance is not possible.
As an important institutional exploration to cope with aging, long-term care insurance has gone through an eight-year pilot road, during which the pilot scope has been expanded to 49 cities, covering 180 million people. In June 2016, China's first batch of long-term care insurance system pilots were officially launched, piloting them in two provinces and 15 cities. In September 2020, the pilot scope of long-term care insurance was further expanded, with 14 new cities; As of the end of March 2022, covering 49 cities with a population of 145 million, a total of 1.72 million people can enjoy long-term care insurance benefits.
Financing solutions: multiple channels and mechanisms
From the perspective of financing, financing difficulties are the primary problem in the development of long-term care insurance, and it is also the key element of whether long-term care insurance can be fully promoted.
According to the Ningbo Yuyao Mayor Care Insurance Pilot, the current Ningbo Yuyao Mayor Care Insurance Pilot is temporarily raised at the standard of 90 yuan per person per year, which is shared by the employer, the individual, the medical insurance fund and the finance. The long-term care insurance premium for employees participating in the medical insurance shall be borne by the individual employee and the employer 45 yuan each, and the retiree shall be borne by the individual and the medical insurance pooling fund 45 yuan each. The 45 yuan borne by the individual shall be withheld and paid from the personal account of the employee's medical insurance on January 1 of each year; The 45 yuan borne by the employer and the 45 yuan borne by the medical insurance pooling fund for retirees shall be transferred from the employee medical insurance pooling fund in a lump sum according to the number of insured persons at the beginning of the year.
The long-term care insurance premium of the urban and rural residents who are insured by the medical insurance shall be borne by the individual, which shall be transferred from the individual payment of the urban and rural residents' medical insurance, and the remaining 60 yuan shall be temporarily transferred from the serious illness insurance fund; Among them, the individual contributions of the insured are fully subsidized by the government (40% of the municipal finance and 60% of the district, county and city finances).
Compared with other long-term care insurance pilot areas, the Ningbo Yuyao Mayor Care Insurance Fund is more sufficient, and it adopts the "non-sense" financing method of medical insurance account transfer. However, according to a person from the Ningbo Yuyao Medical Insurance Bureau, it is difficult to raise funds for inter-provincial migrants in this "non-sense" financing method. At present, the population of Yuyao City, Ningbo is 1 million, and the participation rate of the local registered population is 99.5%, which can basically be insured, but there are more than 200,000 foreign populations in Ningbo, which do not have corresponding guarantees such as medical insurance, so it is difficult for this kind of floating population to raise funds for long-term care insurance.
Judging from the previous visit to the Fuzhou Medical Insurance Bureau, the pilot project of Fuzhou long-term care insurance is financed in the form of "medical insurance fund plus personal account allocation", and the proportion of in-service employee fund payment is 0.25%, and units and individuals share in the same proportion of 1:1; Individual retirees pay 0.125 per cent of the base amount of the basic medical insurance into their personal accounts.
Looking at the overall financing situation of the current long-term care insurance pilot, first of all, the financing channel is relatively single, at present, most areas cut out a piece of medical insurance as long-term care insurance funds according to the fixed amount or proportion, and a few areas are financed through individuals, units, governments and medical insurance. Secondly, the next development goal of long-term care insurance is to expand the target group to urban and rural residents, and the medical insurance pooling fund cannot support such large-scale expenditure.
(Data source: compiled from public information)
Lu Xiaoming, a member of the National Committee of the Chinese People's Political Consultative Conference, said that although in principle, it is stipulated that the fund-raising is mainly paid by units and individuals, and is shared in the same proportion, but in practice, the long-term care insurance fund relies heavily on the medical insurance fund. In each pilot area, the proportion of medical insurance fund contribution is more than 30%, and in some places even 100%. These objectively exacerbate the pressure on the value preservation and appreciation of the medical insurance fund and hinder the effective promotion of long-term care insurance.
Professor Zhu Minglai, director of the Health Economics and Medical Security Research Center of Nankai University, specifically analyzed that long-term care insurance is equivalent to adding the sixth insurance on the basis of the five social insurance insurances. But this is not a sustainable model, and the sustainable model must be separately collected and accounted for, which should be the direction of the next step.
At the same time, at present, the pilot areas of long-term care insurance are mostly aimed at urban employees, and only some cities have achieved coverage of urban employees and urban and rural residents, and the coverage of long-term care insurance is still relatively narrow. In this regard, Zhu Minglai said that if the expansion of some long-term care insurance for residents, the future will adopt a payment model combining individual payment and financial subsidies, which needs to further strengthen the awareness of insurance, reasonably design the payment structure, and do a good job in the financial budget to ensure the sustainability of the fund.
According to an expert who has participated in the design of the long-term care insurance system, the next step of long-term care insurance will be more clear in the financing model, in order not to expand the burden on enterprises and individuals, may adopt a way to reduce the amount of medical insurance contributions and increase the amount of new care insurance, but the long-term care insurance funds must be designed to be collected separately.
Ye Zhimin, professor of health policy and economics at Harvard University and director of the Harvard-China Health Cooperation Program, pointed out that for the sake of fairness, the long-term care insurance system in most developed countries is led by the government, using social security and taxation as the main financing methods. However, since most countries have pay-as-you-go social security systems, the sustainability of long-term care insurance systems will be challenged by demographic changes.
Ye Zhimin suggested that with reference to Singapore's experience, pre-raised savings should be added to the financing method of long-term care insurance, that is, individuals begin to pay premiums when they are of working age, and these premiums continue to accumulate and grow, while the fund pool is only shared with people of the same age group, not across age groups, so as to ensure the affordability of the fund.
In addition, due to the current pain points of policy-based long-term care insurance relying on medical insurance funds and too single financing channels, some industry experts suggest that commercial insurance should play a helping role to make up for the lack of financial support. On January 16, 2024, the General Office of the State Council issued the "Opinions on Developing the Silver Economy and Improving the Well-being of the Elderly", which clearly supports the active development of commercial long-term care insurance, carries out the pilot work of life insurance and long-term care insurance liability conversion business, and strengthens the connection between the research and development of pension financial products and health, pension care and other services.
The solution of the payment side: refined operation and talent expansion
The payment side is the second challenge faced by long-term care insurance, which faces multiple challenges such as high operational pressure and lack of talent in nursing institutions.
At present, the long-term care insurance fund is mainly paid for the purchase of services, which solves the basic life care and medical care expenses closely related to the basic life, and does not directly subsidize or distribute cash to the beneficiary in principle.
According to a visit to the mayor of Yuyao, Ningbo, the long-term care insurance fund is mainly used to pay for basic nursing services, assessment fees, and third-party handling fees. Long-term care insurance services are divided into institutional services and home services, and institutional services mainly include 42 long-term care services based on life care; Home services mainly include 42 life care services and 10 medical long-term care services.
From the perspective of long-term care insurance fund payment, if you choose institutional care, you will pay according to the bed-day fixed rate. The rate of severe disability is 40 yuan/bed day for level I personnel, 50 yuan/bed day for severely disabled level II personnel, and 60 yuan/bed day for severely disabled level III personnel. If home care is chosen, no more than 20 hours per month for severely disabled Level I personnel, 25 hours per month for severely disabled Level II personnel, and no more than 30 hours per month for severely disabled Level III personnel. The tentative price for in-home services is 75/hour, with 80% paid by the long-term care fund.
Compared with other regions, Ningbo Yuyao Mayor Insurance Fund is more abundant. Judging from the current operation of its nursing institutions, it is understood that they were all operating at a loss at the beginning, and some nursing institutions are currently breaking even, and some are in a state of meager profits.
According to the leader of the long-term care inspection team of the medical insurance service center of a branch of a large insurance company, there are two main problems faced by long-term care insurance nursing institutions: on the one hand, it is difficult to expand the market coverage, the replacement of severely disabled personnel is relatively fast, the new number of people is basically the same as death, and the total number of services is difficult to grow; On the other hand, it is also difficult for nursing institutions to supervise nursing staff, nursing services cannot be monitored in real time, and family members do not know enough about long-term care insurance policies, and will put forward some other requirements that are contrary to the policy, such as housekeeping services.
"At present, there are many private long-term care insurance nursing institutions in our area, and almost all of them are operating at a loss." According to a person in charge of a prefecture-level mayor's nursing care agency, high rents and high labor costs are the core reasons for losses.
According to the person in charge of the long-term care insurance nursing agency, "according to the policy, at present, one long-term care insurance nursing staff in our region can only serve 3 disabled elderly people a day, and each person cares for 2.5 hours a day. In the future, the proportion of nursing staff serving the elderly may be gradually increased, which is one of the problems that currently limit the profitability of nursing institutions. ”
Second, it is difficult to recruit caregivers, which is a common problem in nursing facilities at present. Long-term care insurance has high requirements for caregivers, who are not pure caregivers in nursing institutions, but also need to understand medicine. Although the state has introduced relevant policies in recent years to strengthen the training and standardized management of medical care workers, there is still a shortage of long-term care insurance nursing service personnel in subdivided occupations.
According to a survey from a number of nursing institutions and the homes of many disabled patients, it is found that the current nursing staff are all older, and the average age of some nursing institutions is about 55-58 years old. According to a person in charge of a nursing institution, it is very difficult to recruit long-term care insurance caregivers at present, and even some caregivers have exceeded the retirement age, but we have to use them, and we hope to postpone the average age of personnel to about 50 years old.
Li Ying, co-founder and chief operating officer of Yidekang, once said frankly that the lack of talents is indeed a pain point in the nursing industry, and there are too few outstanding talents in the home care industry. Although we currently have a special training school and are constantly cultivating nursing talents, with the prosperity of the pension industry, we find that it is too late to train ourselves, because it is not possible to train talents in an industry in three months, but at least 1-2 years before it can be used.
"Caring for the disabled elderly, the work of the caregiver is not only tiring, but also has to take on the work of picking phlegm and excrement for the elderly, and most young people will not be willing to do this kind of work." According to the person in charge of the nursing care facility, even if the right nursing staff is recruited, there are challenges in retaining them. "At the moment, we have tried all kinds of ways and incentives to retain caregivers."
The person in charge of the above-mentioned nursing institution suggested that the treatment, social status, and post-retirement security of nursing staff should be improved to promote more people to participate in the pension industry. "It is hoped that while the government departments are considering providing subsidies for the elderly with intensive care long-term care insurance, they can also give corresponding encouragement to caregivers who have been trained and approved by the Health Insurance Bureau."
(Wang Haining is a pseudonym in the article; The author is a reporter from Caijing)