Difficulties in promoting the integration of medical care in rural areas
China News Weekly reporter/Li Xiangmao
Published in the 961th issue of China News Weekly on August 24, 2020
Julu County, Xingtai City, Hebei Province is a national-level poverty-stricken county. There are 78,000 elderly people over 60 years old in the county, accounting for 18.2% of the total population, of which more than 4,000 are disabled or semi-disabled. In 2013, Julu County carried out a reform: integrating rural health centers, clinics, rural nursing homes, and happiness homes to improve the quality of medical care and nursing care for the elderly, and to a certain extent satisfy the needs of the elderly. The demand for medical treatment, disease-free recuperation, and medical care for the elderly.
As the country with the largest elderly population in the world, China has already entered an aging society. As of the end of 2019, there were 254 million people aged 60 and over in the country, accounting for 18.1% of the total population. According to estimates by the United Nations, by the middle of this century, there will be nearly 500 million people over 60 in China.
The "China Family Development Report 2016" released by the former National Health and Family Planning Commission showed that more than 80% of fully self-care elderly people prefer to rely on themselves. Only 54.4% of the elderly who do not take care of themselves have other family members. Children are the main caregivers of the elderly who are completely disabled. Nearly 20% of elderly people who are completely disabled lack the care of others. The three biggest difficulties faced by the elderly are the three biggest difficulties faced by the elderly, such as a lot of physical illness, difficulty in living by themselves, and no one to take care of when they are sick. Medical care and nursing care are the most urgent needs of the elderly.
In this context, a new type of old-age care model that combines medical services and old-age security has become a new direction of old-age services that the state focuses on fostering. In many regions of the country, various forms of practice and pilot projects of combining medical care and nursing have emerged one after another. The practice of Julu County is an exploration of the path of integrating medical care and nursing in rural areas.
The road of integration of medical care and nursing in impoverished counties
In the process of promoting the integration of medical and nursing care, the biggest problem facing Julu County is the funding gap. Zhang Jianyi, deputy director of the Julu County Health Bureau, told China News Weekly that in the early days, the country had relatively few specific preferential subsidy policies. At that time, the civil administration system mainly subsidized beds in nursing homes. However, this subsidy is still not enough to cover the costs of integrated medical and elderly care services, which in turn causes the price of integrated medical and elderly care services to be higher. The monthly fee of 3,600 yuan for the completely disabled elderly is unaffordable for ordinary elderly people, especially rural elderly people.
The dilemma faced by Julu has been resolved to a certain extent after the country introduced specific policies. In 2015, the state announced the "Guiding Opinions on Promoting the Combination of Medical and Health Services with Elderly Care". In September 2016, Xingtai City became one of the second batch of 40 pilot units for the integration of medical care at the national level.
What has substantively promoted the integration of medical care in Julu County is the "Guiding Opinions on the Pilot Long-term Care Insurance System" issued by the Ministry of Human Resources and Social Security in June 2016. Two months later, Julu County in Xingtai City became a pilot program for long-term care insurance for severely disabled persons.
In Zhang Jianyi's view, the development of the long-term care insurance pilot program has provided financial guarantee for the integration of medical care in Julu County. Long-term care insurance is a social insurance system that raises funds through social mutual assistance and provides medical care services or financial guarantees that are closely related to life for long-term disabled persons who have been assessed to reach a certain level of care needs. As the sixth type of insurance besides the "five insurances", this type of insurance can effectively solve the problem of long-term care protection for disabled elderly people.
In operation, the payment standard for long-term care insurance is 50 yuan per person per year, of which the urban and rural residents’ medical insurance fund is responsible for 40 yuan, the financial subsidy is 4 yuan, and the civil affairs welfare lottery fund is responsible for 3 yuan, that is, residents only need to pay 3 yuan. If they belong to special people such as urban and rural minimum living allowances, five guarantees, severe disabilities, key preferential care recipients, and poor people, the government will also fully subsidize individual payment. Residents can enjoy three-tier fixed-rate reimbursement for medical care, institutional care and home care after enrolling. Taking medical care as an example, the insured elderly receive combined medical care and elderly care services at the Julu County Hospital, which is a secondary hospital, and pay 3,600 yuan per month. After 65% of the long-term care insurance reimbursement limit is removed, the individual only needs Bear 1260 yuan. In terms of service standards, the county has set three types of fixed reimbursements for medical care, institutional care and home care. Medical specialist hospitals are 90 yuan per person per day, second-level hospitals are 120 yuan per day, institutional care is 50 yuan per person per day, and home care does not have a deduction line of 20 yuan per person per day.
In April 2017, Julu County launched a care insurance for moderately disabled persons. Since then, Julu County has further extended the long-term care insurance system. On the original basis, home care services have been added, so that disabled people who do not want to leave home and have poor financial conditions can enjoy professional care without leaving home.
Zhang Jianyi stated that the reimbursement rate for long-term care insurance is 65% of the fixed amount for those receiving medical care services in the county. The implementation of long-term care insurance has effectively reduced the financial burden of pensions on general income families and the poor. At the same time, the advancement of combined medical and elderly care services has revitalized the resources of primary medical institutions, broadened the scope of services, and formed medical and health institutions (township health centers, village clinics) and elderly service institutions (nursing homes, happy homes, etc.) The integrated management service model of "two hospitals into one" and "two hospitals merged".
At the township level, Julu County has built eight integrated medical and elderly care centers based on hospitals, covering about 200,000 people in the surrounding rural areas and poor people. Another two integrated medical and elderly care centers are under construction or upgrading.
However, long-term care insurance has not completely solved the problems faced by the integration of medical and elderly care. At present, the profit of the combination of medical care and nursing is still very small, and it is still at the level of people's livelihood projects, and there is still a certain distance from industrialization. Zhang Jianyi also said that in Julu, the advancement of the integration of medical and nursing care is mainly based on public hospitals, with less social capital participation. The reason is that the elderly care industry represented by the combination of medical and elderly care has high threshold, low rate of return, large investment, long time period, and the current difficulty of financing and land approval. The solution of these problems depends on the implementation of policies that encourage social capital to enter the integrated medical care and elderly care industry.
In addition, Zhang Jianyi said frankly that the difficulty of recruiting nursing workers is a major problem encountered in the practice of combining medical care at the grassroots level. The local people's perceptions and work conditions are the main obstacles to recruiting nursing workers. At the same time, on-the-job nurses also have the problem of inadequate professional nursing literacy and can only carry out basic life nursing.
Problems to be solved
At present, the long-term care insurance system established as a pilot in Julu County and other places has become the focus of attention in the medical care industry. According to the official website of the Ministry of Human Resources and Social Security, as of the end of 2017, 15 cities across the country had launched pilot projects for long-term care insurance systems, with more than 44 million insured persons, benefiting more than 75,000 people that year.
At present, the source of funding for long-term care insurance is the surplus part of the provincial medical insurance funds. In economically developed areas, medical insurance balances are usually large, and local governments are also willing to use some of the surplus funds to explore long-term care insurance. However, in some economically underdeveloped areas, there is usually a gap in medical insurance funds, so the implementation of long-term care insurance will be restricted. Some insiders say that long-term care insurance will continue to expand the scope of the pilot program, but there is no plan to roll it out in full.
Li Ying, director of Peking University Health Care Integrated Pension Industry Research Center, believes that Japanese nursing care insurance is the most valuable precedent for China's long-term care insurance. Japan promulgated the Nursing Care Insurance Law as early as 1997 and formally established the Nursing Care Insurance System in 2000.
According to the Nursing Care Insurance Law, all nationals over 40 years old in Japan must participate in this insurance, and pay different amounts of premiums according to different income levels. After the insured reaches the age of 65, if there is a need for nursing care, they can apply to the government department, and the relevant departments and professional doctors will investigate and evaluate them, determine the level of care they need, and then receive the corresponding services.
Nursing care insurance is divided into 7 levels from the lowest "needs assistance 1 (be able to go to the toilet and eat independently)" to the highest "needs 5 (bedridden)". According to different levels, the upper limit of monthly expenditure is also different. No matter which level you are in, the individual only pays 10% of the expenses within the upper limit, and the state bears 90%; the part that exceeds the upper limit is fully borne by the individual.
However, referring to Japan's view that long-term care insurance is fully rolled out in Japan, it has also met with opposition from some people in China. Opponents believe that forcing employees and residents to pay the sixth insurance on top of the five insurances will increase the burden on enterprises and individuals, and it will be very difficult to implement.
In this regard, Li Ying suggested that the national and local finances can consider setting the investment ratio of rural medical care and health care services in the annual budget and establish a long-term investment mechanism for rural medical care and health care services. The government can separately establish a fund for the rural medical and health care industry, and make targeted and continuous investment in the upgrading and transformation of rural elderly care facilities, health centers, and nursing homes. Encourage and guide social forces to enter the rural medical care and health care service market, formulate and implement relevant support policies, such as land replacement to drive the transformation and development of enterprises and the construction of rural health care industry, etc., through public construction and private operation, public assistance to private operation, government purchase of services, and preferential treatment Subsidies and other methods.
The supporting policies for the integration of medical and elderly care are not clear enough. When some provinces issued relevant documents on the integration of medical and elderly care, they did not follow up and formulate corresponding implementation rules, which resulted in the failure to implement the preferential policies of taxation and financing in the national documents. Due to various restrictions, some private medical and elderly care institutions are unable to obtain relevant subsidies from medical insurance, civil affairs and other departments, resulting in greater pressure on the operation of private institutions and lack of confidence and motivation. The absence of social capital will also increase the burden on public health care institutions, which in turn will increase government financial pressure.
Li Ying’s team conducted a survey on the integration of medical care in rural areas in some provinces, cities and regions across the country, and found that under the current system, elderly care institutions are managed by the civil affairs department, medical institutions are managed by the health department, and medical insurance reimbursements are managed by the medical insurance department. management. Due to the different definitions of responsibilities between various departments, various policies and standards are not uniform, and the integrated medical care and elderly care institutions are often only sandwiched between various departments. The industry believes that this kind of multi-head management is the biggest obstacle to the "seamless connection" of medical care and pensions.
In August 2017, the National Health and Family Planning Commission issued the "Notice on Deepening the Reform of Decentralization, Administration, and Service" to stimulate investment vitality in the medical field, and introduced 10 key reform measures in the field of health and family planning. The examination and approval of clinics was changed to a filing system. Industry insiders pointed out that this policy will significantly simplify the process and procedures for bidding, but the relevant conditions, standards, and thresholds still exist.
In this regard, Li Ying believes that the development of rural elderly care services needs to be integrated into the poverty alleviation and rural revitalization strategy at the national level, and the overall plan is to be promoted as a whole. In the "Twelfth Five-Year Plan for the Development of China's Aging Career" issued by the State Council in 2011, the prototype of the concept of combining medical care and elderly care was first proposed. The problems exposed in practice also reflect that if the State Council takes the lead in advancing the integration of medical care and elderly care, it may effectively avoid the overlapping of responsibilities and powers among various departments and the problems caused by the dispersion of financial power, human rights, and power.
China News Weekly, Issue 31, 2020
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