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%
1,244,0002.1%
445,000
Aged.S
Super Aged.S
20.0%
4,736,000
7.5%
1,773,0007.1%
1,490,000
Ageing Society
aged65andover(
％
)
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.
aged65andover(
％
)
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/GDPNHE/GDP
%

Developing a Long-term Care System
2008 2010 2012 2014 20172016
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

-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、ComprehendCommunication
•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 BurdenCaregiver 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

-Source of financing
• Copayment
exemption for the
poor, near poor…
• Co-payments are
subject to a ceiling
amount
Co-payment
Premium
Levy through
NHIATotal 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
Extremely
Approval
Approval No Comment Disapproval Extremely
Disapproval
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

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20150428 LTCI scheme