20150428 ltci scheme

Design and Policy Issues of the Universal Long-Term Care Insurance (LTCI) Scheme in Taiwan

Department of Social Insurance Ministry of Health and Welfare

2015.4


Outline

• Background

• Basic Scheme of the LTCI

• LTC need assessment and benefit determination

• Major policy issues

• Conclusions

1


Background

2


Aging population in Taiwan

Reference(data of population after 2014): Taiwan Population projection 2012-2060 (mid-projection),

National Development Council.

0

5

10

15

20

25

30

35

40

45

79 82 101 107 114 145

65歲以上 75歲以上

6.0% 1,411,000

14.6% 3,449,000

22.9% 4,529,000

38.2% 7,548,000

12% 2,809,000

5.3% 1,244,000 2.1%

445,000

Aged.S Super Aged.S

20.0% 4,736,000

7.5% 1,773,000 7.1%

1,490,000

Ageing Society

aged

65 an

d over

(

％)

1990 1993 2014 2018 2025 2056

Above 65 Above 65

3


Reference(data of population after 2014): Taiwan Population projection 2012-2060 (mid-

projection), National Development Council.

aged 65 and over(

％)

Percent of the elderly in selected countries

Japan

Korea

Taiwan

Germany

Italy

France

Britain

United States

Projection

(year)

4


65+yrs

15~64 yrs

1 ______ 6.7

2014

1 _____ 3.4

2025

1 _____ 1.29

2060

Aging index (#elderly*100/#<=15 yrs)will

increase from 83.4% in 2014 to 401.5% in 2060

Growing dependency

（Source： National Development Council,2012）

15.8% 29% 78%

5


Projected number of people live with Disability, MOHW

Reference: The projection is the disability rate from The National Long-Term Care Need Survey (phase I) to multiply the mid-projection number of people in 2012 from Taiwan Population projection 2012-2060, National Development Council.

-

20

40

60

80

100

120

75.5

78

89

120

48 50

62

95

2015 2016 2021 2031 Disability Rate 3.36% 3.45% 3.94% 5.30%

6

Per 10000


The Cumulative Risk of Disability in each age

Source：The statistics is the disability rate from The National Long-Term Care Need Survey (phase I),MOHW

Risk of disability

7


Cost of LTC and NHE as % of GDP

Cost of LTC in OECD countries is 0.1-3.6% of GDP (median 0.9%，1/10 of NHE)

Source:OECD Health Data 2010

8

LTC/GDP NHE/GDP

%

Developing a Long-term Care System

2008 2010 2012 2014 2017 2016

Second Stage: Long-term Care Act (2014)

Long-term Care Network (2015)

Three Stages of LTCS Development


9

Second Stage : Long-term Care Act

Long-term Care Network

Third Stage :

Long-term Care

Insurance

First Stage: Long-term 10-year Care Program


Disabled benefits not only individually, but also the whole family.

According to the need survey result, there are on average 4.58 people in disabled family.

Family population’s definition: it means people who live in the same family, but not including nurse.

Take 2017 for example, if LTCI applies: Insurance objects benefit directly, 800,000 people

It affects caring burden for families who have disabled living together, 2.86 million people

In total of 3.66 million people; which are 15.6% of the total national population 23.51 million people

10


Basic Scheme of LTCI

11


Policy agenda Council of

Economic Planning and Development

(CEPD)

CEPD has proposed a Long-term Care Insurance Scheme (Dec,2009)

Department of Health (DOH)

＊ DOH established the Long-Term Care Insurance Preparatory Task Force in July 2009

＊ The Task Force is responsible for detailed planning work of the long-term care insurance system

Ministry of Health and

Welfare (MOHW)

＊ The Department of Social Insurance is responsible for detailed planning work of the long-term care insurance system after the governmental reorganization in July 2013.

Note：CEPD on January 22, 2014 for the restructuring of the National Development Council（NDC）; DOH on July 23, 2014 for the restructuring of the Ministry of Health and Welfare（MOHW）.

12


Central Authorities

Ministry of Health and Welfare

Insurers National Health Insurance Administration

Related organization

Long-Term Care Insurance Committee

National Health Insurance Dispute Mediation Committee

Name Content

Long-Term Care Insurance Law

Long-Term Care Service Law

For the insurer, the insured, insurance finance, insurance benefits and payments, insurance services institution, general principles and other basic matters of definition and specification

Long-term care service system, institutions and personnel management, service recipients of rights protection, and general principles and other basic matters of definition and specification

Organization Legal system

Organization and legal system

13


Long-term Care Insurance in Taiwan -goals and the system

Goals -Universal coverage (equity)

-Provide basic, affordable & accountable LTC

-Reduce Family burdens

-Facilitate independent living ,maintain or prevent

loss of functions System design

-Social insurance scheme

-Single payer system (NHIA)

14


Basic scheme of LTCI -Coverage decision

• Universal coverage

– Cover all citizens with physical /cognitive/mental functional limitation

• most equitable ,no discrimination against age or type of disability,

• Low adm cost & premium rate, high feasibility

– Those aged over 40 years accounted for 51% population

• Three years waiting period for oversea citizens

15


Basic scheme of LTCI -Benefits

Community&

home care

Institutional

care

Caregiver

support

Others

Home services*

Home nursing

Home Rehabilitation

Day( Night） care

All-day accommodation (for severe cases only)

Respite care

Training courses

Care counseling

On-site visits

Assistive devices

Home- environment improvement

Transportation

New, approved service

*Alternative: cash payment: to facilitate choices, respect care-work, reduce cost, support care-givers, home services may be totally or partially provided by family members and receive cash payment, yet caregivers should render training and monitoring.

16


Netherland Germany Japan Korea Taiwan

Date( pass

Bill/launch)

1967/1968

1994/

1995 1997/

2000

2007/

2008

Enrollment All age All age ≧40yrs All age All age

Beneficiary All age All age

Elderly or

w geriatric

conditions

Elderly or

w geriatric

conditions

All age

Insurer multiple multiple multiple Single

(NHIC)

Single

(NHIA)

Benefit In kind /cash In kind /cash In kind In kind

/cash

In kind

/cash

Social Long-term Care Insurance System： a comparison

17


LTC need assessment and benefit determination

18


Basic Scheme of LTCI -Assessment tools

Develop a multi-dimensional Assessment instrument (MDAI)

Methods Literature review, ICF, focus group, expert group, Delphi

technique

Application National LTC need survey Develop Long-term Care Case-mix system As LTCI Need assessment tool ,to determine the level of

benefit(payment) by computer LTC management: to determine staffing ratio compare

diff in utilization, quality and cost we will adjust and develop the appropriate assessment

instrument for different groups 19


(6 D) Multi-dimensional

Assessment Instrument (MDAI) •ADLs：Feeding、Bathing、Grooming、Dressing、Bowels、Bladder、Toilet

Use、Transfers、Mobility、Stairs

• IADLs：Ability to Use Telephone、Shopping、Food Preparation、Housekeeping、Laundry、Mode of Transportation、Responsibility for Own Medications、Ability to Handle Finances

ADLs & IADLs

•Vision、Hearing、Conscious、Expression、Comprehend Communication

•Health Status、Skin Conditions、Functional Limitation in Range of Motion、Active Diagnoses、Nutritional Status、Special Treatments and Procedures、Pain Assessment、Fall History and Balance、Assistive Technology

Health Conditions and

Special & complex care

•Cognitive(SPMSQ)

•Mood & Behavior Problems(Wandering、Verbal Behavior、Physical Behavior、Disturb Behavior、Repeat Behavior、Rejection of Care、Night & Day Reverse、Self-mutilation & Suicide、Delusional Disorder、Hallucinosis、Phobia & Anxiety、Depression、Aggressive behavior on objects、Other inappropriate behaviors and hygienic concerns)

Cognitive, mental & behavior

Problem

•Living Arrangement、Living Environment

•Social Participation

Environment, social

participation

•Physical Burden、Psychological Burden、Social Burden、Financial Burden Caregiver burden 20


Groups*

Groupn*

Level of Need

Level of resource Use data

Content of care

Basic personal care *# Nursing care*#

Personal care*# Respite care*# Home rehabilitation*#

Group1* *Recruit 5536 samples: Home, community &institution *conduct need assessment by MDAI & collect staff time from all staffs who provide care to the individuals

Tree analysis (case-mix system)

Development of LTC Case-mix System (LTC-CMS)

21


Major policy issues

22


Development of LTCI payment standard Payment standard covers every cost

of providing the services(listed as right)

Collect cost information from service units or institutions that provide long-term care from nation to confirm data to set the payment price.

Services relative inputs: considerations

- Technical difficulty - Need to put in some effort or

mental level - The probability of occurrence of

body injury - Perform the service requires a

minimum number of people - Service Hours

Supplies and

appliances

Equipment expense

Miscellaneous & management fee (including transportation fee)

Employment cost

Other cost

Service

items cost

23


LTCI service delivery process planning

Insured apply

Contact window check the qualification for applicants

and other related applying document Inform

additional document

Or inadmissible

Assessment visits

Computer determines LTC-CMS payment quota and develop care plan

Approve care plan Note1

Connect service

Finish in 30 days

No

Yes The institution branch in counties and cities of

insurer

Accept it or not

Re-evaluation Note.2

Units that responsible

Note1： Care plan includes payment level, payment category, and payment quota and other matters. If insured questions, s/he can apply insurer to re-evaluation.

Note2： Insurer, depends on needs can proceed re-evaluation on insured. If insurance object changes and other factors due to physical and mental function, resulting in long-term care needs change, may also apply for re-evaluation. 24


Basic scheme of LTCI -Source of financing

• Copayment exemption for the poor, near poor…

• Co-payments are

subject to a ceiling amount

Co-payment

Premium

Levy through NHIA Total LTCI

cost

User charge

Government

subsidy

The insured

Employer

25


Financial accountability

• Apply Partial-funding system

• 10-year financial balance premium rate

• Reserve fund equivalent to 8 month premium

• Timely adjustment of premium rate

– Regular：average 3 years based on formula

– Special adjustment: plan approved by LTCI Committee represented by payers, providers and government.

26


Cost containment • Demand-side

– Pre-authorization (need assessment)

– Setting ceiling for LTCI benefits

– Coinsurance

– Out-of-pocket payment

• Room and board in the institutional care

• Supply-side: – Prospective payment per month, visit, pay-for-

performance

– Utilization review, quality monitoring, on-site visit, price disclosure

27


Public Attitude toward LTC Insurance

Source：「 LTCI Public Opinion Survey Report by MOHW 」

More than 70% of the public support LTCI

21

52

9 11

4 2

26

51

8 9

3 2

23

54

7

10

3 3

27

51

3

11

4 4

31

50

3

9

3 3

0

10

20

30

40

50

60

ExtremelyApproval

Approval No Comment Disapproval ExtremelyDisapproval

Unknown

2010（Annual）

2011（Annual）

2012（Annual）

2013（Annual）

2014（Annual）

28

%


Current policy issues

• Political will: fiscal feasibility of the state

• System selection: social insurance vs. taxation schemes

• Worry about shortage of LTC service & personnel-LTC develop fund

• Universal coverage ?

• Attitude of employers to pay premium

• Allow cash payment option ?

29


Conclusions

30


Conclusions • LTCI is a highly supported policy, yet provoke hot

debates among stakeholders

• The design of the LTCI benefits accommodated the opinion of different stakeholders

• The implement of the LTCI will rely on:

– Establishment of regional LTC network & workforce

– Financially accountable LTCI scheme

– The Financial burden of the Government

– The degree of aging population

– Social acceptance 31


Thank you very much for your attention!

32

20150428 ltci scheme

Government & Nonprofit

taiwan population projection

welfare aging population

welfare background

mid projection

care insurance ltci

national development

s super aged

ltci ltc