老年长期照护研究综述

本文对长期照护概念从"长期"和"照护"两个方面进行剖析,从长期照护模式分类、长期照护评估机制、法律法规和保险制度等方面介绍各国研究状况,提出我国发展长期照护制度的建议:满足照护需求,构建合理的长期照护模式;发展老龄产业,培养优质的长期照护人才;健全法律法规,构建长期照护保险制度;提供护理津贴,合理分担财政负担;发展评估,及时干预老年人健康状况。     

基于平等主义文化的瑞典养老服务体系的形成及其对中国的启示

瑞典作为斯堪的纳维亚福利体系的代表国家之一,其养老服务体系被打上了平等主义文化的烙印。瑞典平等主义文化的形成得益于土地改革、贸易联盟和积极的劳动力市场政策等一系列事件。受到平等主义文化的影响,瑞典养老服务体系的演进分为四个阶段:1918年以前,瑞典以家庭养老服务为主,政府只为贫困老年人提供养老服务;1918—1949年,以老年之家为代表的机构养老服务为主,覆盖全体老年人;1950—1989年,居家养老服务成为瑞典最主要的养老服务方式;1990年至今,“消费者选择”提升了瑞典居家养老服务的质量,政府成为养老服务的唯一责任主体。瑞典基于平等主义文化的养老服务体系的发展经验为我国带来以下启示:大力推进城乡养老服务设施与养老服务津贴的全覆盖;以服务质量为导向推动养老服务供给侧竞争;创造平等的就业环境,为养老服务提供人员保障;充分发挥第三方组织在养老服务中的作用。     

Managed Care and Health Care Utilization: Specification of Bivariate Models Using Copulas

This article studies the effect of managed care on health care utilization compared to traditional fee-for-service plans in private health insurance market. To construct our hypothesis, we build a game-theoretic model to study health care utilization under a two-sided moral hazard: of patients and providers. In econometric modeling, we employ a copula regression to jointly examine individuals’ health plan choice and their utilization of medical care services, because of the endogeneity of insurance choice. The dependence parameter in the copula reflects the relation between the two outcomes, based on which the average treatment effects are further derived. We apply the methodology to a survey data set of the U.S. population and consider three types of curative care and three types of preventive care for the measurement of medical care utilization. We find that managed care is in general associated with higher care utilization. Evidence is also found on the underlying incentives of both patients and medical providers.     

日本“医养结合”社区养老模式构建及对我国的启示——基于制度分析视角

为应对2025年超老龄化社会背景下老龄群体疾病类型转变、护理需求剧增的状况,同时减轻医疗与介护保险的财政负担,自2014年起,日本在现有制度基础上进一步探索"医养结合"社区养老模式,成立了社区医疗护理综合确保基金,提出要推动"地域医疗服务体系"和"社区综合护理体系"的协同发展。本文围绕日本"医养结合"社区养老模式的历史演进、主要内容、财务机制等方面展开研究,借鉴日本经验,从制度分析视角探索"医养结合"社区养老模式在中国的发展前景,以期为我国多层次社会保障体系的未来发展以及构建居家社区机构相协调、医养康养相结合的养老服务体系提供有益参考。     

Grenzüberschreitende Gesundheitsleistungen als Handlungsfeld für die Gesetzliche Krankenversicherung

The TK customer survey gives insights in the current experiences of patients with cross-border health care in Europe and illustrates their expectations regarding the future of the German health care system within the EU. Currently emergency care during temporary stays in another member state accounts for the vast majority of cross-border care. The use of care concentrates on a small number of countries. The survey shows that the E111-process has a number of significant practical problems. As a result most cross-border cases are dealt with by cost reimbursement. As mobility of the insured is likely to increase, demand for cross-border care will follow suit. However, even with a liberalisation of the European health care markets following recent ECJ decisions, a boost in demand is unlikely. The findings show that an increase in demand for cross-border care can be expected for highly specialized medical care, medical products, specially pharmaceuticals as well as non-urgent treatments. Patients require significant support when considering a treatment abroad leading to a number of interesting options for statutory sickness funds to develop innovative services and benefits. However, implementation of additional benefits with regard to cross-border care, requires modification of the national legal framework.     

Evolve and integrate: a new imperative for ambulatory care

A highly evolved ambulatory care delivery system possesses four key attributes: high-quality care, exceptional levels of access, outstanding patient and staff satisfaction, and cost-effective delivery of care. Such a system seeks to ease management of the patient care continuum by delivering as many services as possible under one umbrella. High-quality, cost-effective care is achieved through improved care coordination and cost management, resulting from a tight connection between physicians and hospitals and between inpatient and outpatient settings. Improved access is an important means to improving patient satisfaction.     

Time,cash and services: Reforms for a future sustainable long-term care

The elder care sector is at the core of a radical restructuring process as all the European countries strive to cope with demographic and social change. While current and prospective rapid population ageing is expected greatly to increase the demand for elder care services, financial constraints, social change and rising female employment all act as obstacles to the provision of an adequate supply of care labour.In their search for a financially sustainable response to these challenges the EU countries have brought in various reforms designed to mobilise resources and achieve more cost-efficient results. The paper presents an analysis of the main objectives of care reforms – making care affordable, favouring the creation of a care market, and making work pay – as well as their possible trade-offs. In fact, entailing as it does a larger role for the family, greater reliance on home care may clash with the goal of a higher female activity rate; good jobs and decent working conditions in the care sector may run counter to the principle of care affordability for the greatest possible numbers, while subsidising demand may conflict with public finance sustainability. These interactions, and the interdependence between the care market and the rest of the economy, are crucial factors that will need to be considered in order to ensure consistency between goals and policies.     

Health and the welfare of U.S. business

Business leaders continue to blame the skyrocketing cost of health care for jeopardizing the global competitiveness of U.S. industries, and they continue to turn to Washington for the solution. Yet after a study of 16 countries, Wharton researchers David Brailer and R. Lawrence Van Horn have discovered that health care costs do not directly hinder U.S. competitiveness. Their conclusion: there is indeed a health care crisis in the United States as well as a competitiveness crisis. But the two are unrelated, and confusing them makes it difficult to solve either one. The real problem, according to the authors, is the hands-off approach that employers typically adopt when it comes to health care. No matter how Washington responds to the health care crisis, employers must explore their own role in ensuring the health of their work force. And they must realize that their role can be a strategic one. Instead of containing costs by fine-tuning benefits packages, companies can control costs and improve health care delivery by treating health care like any other crucial component of production. Brailer and Van Horn propose three strategies for managing health care delivery: First, companies must intervene in the supply side of the health care market. This may mean creating a clinic alone or with other companies, or joining with other companies to procure health care. Second, companies need to translate corporate health benefits into the most cost-effective set of services at the local level. Finally, companies must encourage and educate employees to participate in decisions regarding health care delivery.(ABSTRACT TRUNCATED AT 250 WORDS)     

农村空巢老年人长期照护体系建设的困境与出路——基于湖南省15个县市的调查

摘要：建立和完善农村老年人长期照护体系,是应对银色浪潮的必然选择。我国农村老年人长期照护体系还处于起步阶段,长期照护的供需矛盾、潜在需求与现实需求的矛盾、资源短缺与服务能力低的矛盾十分突出。借鉴西方经验,建立适合我国农村实际的融经济供养、医疗照护、日常生活护理、精神慰藉于一体的老年人长期照护体系,已迫在眉睫。老年长期照护既是一种制度体现,也是一种服务体系,必须整合各方面力量。其中,政府是主导,家庭是基础,社区是载体、专业服务机构是主体。     

ABC: The Pathway to Comparison of the Costs of Integrated Care

In recent years, health care demand has become increasingly complicated and care has had to be integrated. The main reasons for this are a rising number of chronically ill patients and ageing of populations. Integrated health care is processual so there are continuous changes in care delivery; it incorporates many co–ordinating and co–operative activities which can produce uncertain outcomes; and activities are directed at delivering tailor–made care so there are no standardized or generalized outcomes. These characteristics mean that it is difficult to determine and compare the costs of different integrated care structures. This article argues that using Activity Based Costing (ABC) and integrated care pathways provides the best information possible for decision–making by health care managers, insurers, care suppliers and governments.     

Implications of the Interaction Between Insurance Choice and Medical Care Demand

The gross price elasticity of demand for medical care is decomposed into two separate  observable  components: the medical care gross price elasticity of insurance choice and the cost-sharing elasticity of medical care. When consumers alter their choice of health-care plans, the price elasticity of medical care is no longer equivalent to the cost-sharing elasticity; using the latter as a proxy for the former may produce misleading results. We present conditions under which the medical care price elasticity is  positive , the case of a quasi-Giffen good, and provide a theoretical foundation for extant empirical findings of a positive medical care price elasticity of  insurance  demand.     

The hospital: how will it survive?

The federal government is under pressure to implement and enforce a program to provide economic and social relief from the rapidly escalating health care costs which now consume 8.5% of the Gross National Product. Glick predicts that within the next twenty years, the character of health care institutions will be reshaped and only the most adaptable hospitals, health maintenance organizations and health-related governmental organizations will survive. He urges hospitals to develop appropriate strategies to deal with the problems of cost-containment, state-operated cost review and control agencies, and the competition for limited health care resources. The author warns the health care industry that if it does not adjust to these changes, it runs the risk of becoming heavily rgulated. It is suggested that health care institutions be integrated into comprehensive health care systems and the article includes a model for assigning patients to medical care facilities on a regional basis. Glick forecasts that hospitals will enter into a competition for survival, resulting in mergers of some and the closing of others. He believes that as the number of health care institutions decreases, the remaining ones will become more specialized and geographically dispersed.     

Leaving an unethical managed care plan: an exploratory look at doctors' intentions

To address the problems of unnecessary care and limited resources, managed care health insurance programs have become commonplace. With managed care programs, however, physicians are facing increasing pressures. This article briefly considers four ethical situations that doctors face under managed care systems. The article surveys a national random sample of general practitioners and surgeons to determine how doctors would respond to these dilemmas and the extent to which exposure to such situations influences them to leave a managed care plan.     

Long‐Term Care Across Europe and the United States: The Role of Informal and Formal Care

Large cross‐country variation in long‐term‐care (LTC) policy in conjunction with household‐level data on caregiving provides a valuable laboratory for policy analysis. However, there is a lack of comprehensive cross‐country data on how care is provided. In order to close this gap, we draw on data from the Survey of Health, Ageing, and Retirement in Europe (SHARE) and the Health and Retirement Study (HRS) in the United States. Because care hours are missing for some care forms (especially for nursing‐home residents), we propose a selection model to impute these. The model allows selection into care forms to differ by country. Our estimates imply that nursing‐home residents have higher care needs, even when conditioning on observed characteristics. In contrast to the bulk of the literature, we also take into account care provision from persons in the same household, and we find that this contributes one‐third of all care hours. Informal‐care provision in Europe follows a steep North–South gradient, with the United States falling in between Central European and Southern European countries. The results are robust to alternative imputation schemes.     

美国医疗保险扩面改革之路的里程碑

虽然美国有两大类三大层次的医疗保险体系,但没有实现如其他大多数发达国家那样的全民医保,缺乏一张覆盖全国的社会医疗网络,始终是美国近10年来备受诟病的社会问题.没有医疗保险的问题始终处于社会政策争议的前沿和核心.之前克林顿总统失败的改革方案核心就是实现全民医保,15年后,奥巴马新医改方案又明确将扩大覆盖面作为其改革的重中之重.然而,历经波折得以通过的奥巴马医改法案却依然面临诸多反对和抗议,其中最为核心的是关乎强制参险的条款.2012年6月28日,美国最高法院裁定奥巴马医疗保险改革的大部分条款合乎宪法,最具争议的强制参险也得以保留,这意味着美国在实现全民医保时代的进程中向前迈出了一大步.     

Quality improvement--emerging issues to controlling medical costs

While quality evaluation issues are very important to providers and managed care organizations in marketing their service and managing the care provided, they should also be a focus of any employer or other plan sponsor that is financially responsible for providing managed care benefits. Certainly employers can begin to use information regarding the quality of managed care networks to help determine the better networks to offer participants. In addition, managed care networks are employing a variety of techniques to improve the quality of service that employers can and should try to emulate--and that are explored in this article.     

Optimism and auditor liability

There is strong evidence that individuals are optimistic in the sense that they underrate the probability of a negative event occurring. This paper provides a positive theoretical analysis of how auditor optimism affects their incentives to take care under two liability rules: strict liability and a negligence rule. Under strict liability, auditors are held liable when they cause damages to investors. Under a negligence rule, auditors are held liable when they cause damages and in addition, act negligently, that is, fail to meet the standard of due care specified in legal and professional rules. I find the following results. (1) If due care is sufficiently close to the efficient level, a negligence rule distorts auditors’ incentives less than strict liability. Under strict liability, optimism makes the auditor overestimate the chances of finding material mistakes and thus induces suboptimal care. (2) If due care is too strict, the auditor will not exert due care but the same level of suboptimal care under either liability rule. (3) With increasing optimism and in the absence of punitive damages, strict liability becomes less preferable to a precise negligence rule. This statement also holds for vaguely defined standards of due care if due care is sufficiently strict or if auditor optimism is sufficiently high. (4) Punitive damages counteract suboptimal incentives generated by auditor optimism, especially under strict liability.     

Trust and distrust in a network-style organisation: GPs’ experiences and views of a Scottish local healthcare co-operative

This paper considers the conditions needed for an organisation to function as an effective network. In particular, the concepts of trust and distrust are explored. Looking at the new labour reforms of 1997, evidence is presented by means of interview responses from GPs, that this powerful group in primary health care lacked sufficient trust in health care managers. In fact GPs seemed to often distrust them. It is unlikely, therefore, that a Scottish local health care co-operative, created as a result of the 1997 reforms to act as an interface between GPs and health care managers could be effective in allocating health care resources. As a result, the reforms did little to improve primary health care services in Scotland despite the increased funding allocated over recent years to this sector.     

The Marketisation of Early Childhood Education and Care (ECEC) in Australia: A Structured Response

The marketisation of early childhood education and care (ECEC) offers opportunities to test assumptions about the benefits of a market framework. In Australia, where marketisation included reshaping, extending, and increasing government subsidies, one major listed company (ABC Learning Limited) emerged to dominate child care. Child care prices increased rapidly to become an election issue, and government subsidies increased. ABC acknowledged its economic dependence on government policy and subsidies. Until its collapse in 2008, ABC was the world's largest listed child care operator, and operating internationally. ABC's structured business model separated child care properties (propco) from child care operations (opco). ABC was the opco and leased the child care properties from propcos. As ABC grew and replicated its structured model to other forms of property including intangible assets, the rising child care prices and government subsidies supported a growing array of other enterprises all seeking profitable operations. This paper explains the structured opco‐propco model, identifies its interaction with accounting and lessons to be learned from marketisation.