Long-term Care Insurance Research Articles

Becoming Eligible for Long-Term Care Insurance in China Brought More Ageing at Home: Evidence from a Pilot City.

Person-centered long-term care systems, integral to healthy ageing, should empower older people to achieve ageing in place. Yet evidence on the impact of the design of long-term care systems on older people's choice of places of ageing, especially that from developing countries, is limited. Taking the introduction of Long-Term Care Insurance (LTCI) in City X of China as a policy shock, we examined the impact of becoming eligible for LTCI on program beneficiaries' choice of places of ageing-institution or home-before they started to receive any actual benefit. Based on our analysis of the administrative data of all LTCI applicants between July 2017 and September 2020 from City X, we found that becoming eligible for LTCI increased an older-person's probability of choosing home as her place of ageing even before she received any benefit by around 16 percentage points, and this positive impact was larger for those insured of higher education level or of higher disability grade. By bring more ageing in place, the LTCI in City X promoted healthy ageing. Our study suggests that the specifics of the LTCI program like who could receive subsidies, family values, and family members' engagement in labor market could all work together to shape the substitution pattern between home and institutional care.

Projecting Long-Term Care Costs Among Older Adults With ADL Disabilities and Cognitive Impairment in China.

Mounting evidence suggests that cognitive impairment is strongly associated with disability in activities of daily living (ADL disability) and long-term care (LTC) costs. However, studies forecasting future LTC costs often overlook these relationships. Consequently, this study aims to more accurately project future LTC costs in China over the next 20 years by considering the intertwined association between disability and cognitive impairment on future LTC costs. Data were from 10 959 adults ≥65 years from the 2005-2018 waves of the Chinese Longitudinal Healthy Longevity Surveys. We used the Markov model to project the population of China and track the transition of older adults in the next 20 years between 4 disability-cognition states. We employed a 2-part model to estimate LTC costs (direct and indirect LTC costs) per capita. The proportion of disabled older adults with cognitive impairment was projected to increase from 1.4% in 2021 to 3.4% in 2040, while that of those without cognitive impairment was projected to decrease from 4.7% in 2021 to 4.5% in 2040. The direct and indirect LTC costs were projected to increase from 0.3% and 0.2% of gross domestic product (GDP) in 2021 to 1.4% and 0.7% in 2040 for disabled persons without cognitive impairment and from 0.1% and 0.1% of GDP in 2021 to 1.3% and 1.3% in 2040 for those with cognitive impairment, respectively. Policy-makers could include the assessment of cognition in the LTC needs assessment and allocate more compensation to LTC insurance participants with cognitive impairment.

Forecasting Financial Expenditures for Long Term Care Insurance Evidence from the Typical Pilot Cities in C

Purpose: This study aims to provide decision-makers with a reference by predicting the financial expenditures and trends of long-term care insurance in China over the next thirty years. Approach/Methodology/Design: This study employs Markov chains and overall simulation model to forecast the extent of financial expenditures on long-term care for employees and residents. It examines the financial outlay levels under various entitlement payment scenarios and estimates the discrepancies in financial expenditures between employees and residents from 2021 to 2050. Findings: The results show that (1) The number of disabled elderly employees aged 60 and above will be about 14,288 thousand, and the number of disabled elderly residents will be about 68,176 thousand in 2050. (2) Under the low scenario, the financial expenditures of elderly employees and residents in 2050 will reach 29,636.87 million yuan and 17,597.92 million yuan respectively, which are 2.86 and 10.24 times as much as those in 2021. The total financial expenditures under the medium and high scenarios will be 2.38 and 5.51 times as much as those under the low scenario respectively. (3) The scale of financial expenditure on long-term care insurance for residents far exceeds that of employees, and the trend is expanding. Practical Implications: This study may provide theoretical support for the full implementation of long-term care insurance policies. Originality/value: This study uses Markov models and overall simulation models, along with typical representative plans from pilot areas in China, to differentiate the insurance identity of elderly employees and residents and to estimate the scale and trend of financial expenditures for long-term care insurance in China from 2021 to 2050.

Chronic pain in older adults with disabilities is associated with cognitive impairment-a prospective cohort study.

Chronic pain may be an important factor influencing cognitive impairment; however, there is limited research on that link in older adults with disabilities. We aimed to determine the association between chronic pain and cognitive impairment in older adults with disabilities. This 24-month prospective cohort study involved 143 Japanese older adults (≥65 years of age) with long-term care insurance. Chronic pain was defined as pain persisting for ≥3 months, and cognitive impairment was defined as a Mini-Mental State Examination score ≤ 23. We employed logistic regression analysis with chronic pain as the independent variable and cognitive impairment as the dependent variable after propensity score matching (PSM). Sixty-six participants were selected using PSM, and logistic regression analysis showed that chronic pain was significantly associated with cognitive impairment (odds ratio: 4.103, 95% confidence interval: 1.455-11.567, P = 0.008). To prevent cognitive impairment in older adults with disabilities, the management of chronic pain should be considered, as they are related.

Association between self-reported weight loss and new long-term care insurance certifications: A 9-year Japanese older adult cohort study.

This cohort study aimed to assess weight loss associated with new long-term care insurance (LTCI) certifications over a 9-year period, accounting for the competing risk of death. We analyzed data from 3749 Japanese individuals aged ≥65 years in Kami Town, Hyogo Prefecture, Japan. Weight loss was assessed using the Kihon Checklist during the baseline survey. Data regarding LTCI certifications were collected until March 2022. Cox proportional hazards models were used to calculate adjusted hazard ratios (HRs) of 9-year LTCI certification because of weight loss, adjusted for confounding factors. To exclude the effect of competing risks, Fine-Gray regression was used to estimate subdistribution HRs. Subgroup analyses were carried out after the examination of potential interactions between subjective cognitive function, body mass index categories and weight loss. The incidence rate of new LTCI certifications was 5.16 per 100 person-years overall - broken down into 7.02 for those with weight loss and 4.97 for those without. The adjusted HR for weight loss to new LTCI certifications was 1.35 (95% CI 1.15-1.59). Considering mortality as a competing risk, the adjusted subdistribution HR was 1.37 (95% CI 1.16-1.61). Conversely, no interaction was observed between weight loss and subjective cognitive function or body mass index categories. Excluding the effect of mortality, weight loss was identified as a risk factor for new LTCI certifications. However, no interaction was observed between weight loss and subjective cognitive function or body mass index categories. Geriatr Gerontol Int 2024; ••: ••-••.

Calculation of Life Insurance Premiums with Markov Chain Applications for Patients with Pulmonary Tuberculosis Disease in Indonesia

This study aims to calculate the premium for Long Term Care (LTC) insurance on Annuity as A Rider Benefit products with a multi-status model. Pulmonary Tuberculosis is one of the major infectious diseases that contribute significantly to morbidity and mortality rates. Therefore, it is necessary to calculate insurance premiums that consider the health risks of sufferers. In this study, Markov chains are used to model the health status transition of individuals with Pulmonary Tuberculosis over time, considering several health states, such as healthy, sick, and dead. Tuberculosis epidemiological data in Indonesia is used to estimate the transition probabilities between health states. The case study used in this research is a 35-year-old man who participates in LTC insurance with a coverage period of 5 years. It is known that the value of compensation when a person dies is IDR 100,000,000. The interest rate used is 5%. The calculation results obtained annual premium for LTC insurance on Annuity as A Rider Benefit product is Rp294,333. Then the calculation of the annual net premium of this insurance is also calculated based on age and gender. When age increases, the premium will be greater, this is influenced by the greater chance of death when age increases. In addition, based on gender, it is found that the male premium is more expensive than the female gender. This is influenced by the chance of death of men is greater than women.

Factors associated with malnutrition in demented and non-demented elderly residing in the community of Korea: a cross-sectional descriptive and analytical study

Objectives: This study aimed to investigate and compare factors associated with malnutrition according to the presence or absence of dementia in community-dwelling elderly people. Methods: Needs assessment data from 311 long-term care insurance (LTCI) recipients (dementia group 203; non-dementia group 108) that participated in the second pilot program of the integrated care model in community care settings under the Korean LTCI system were used. Descriptive statistical analysis, independent t-test, and analysis of variance were conducted on the sociodemographic characteristics, health and functional status, and nutritional status of the dementia and non-dementia groups. Logistic regression analysis was conducted to identify factors associated with malnutrition in the dementia and non-dementia groups. Results: Malnutrition occurred in 33.5% and 26.9% of participants in the dementia and non-dementia groups, respectively. In the dementia group, living with family rather than living alone (odds ratio [OR]: 3.81; 95% confidence interval [CI]: 1.50–9.66; P = 0.031), increase in Korean Activities of Daily Living (K-ADL) score (OR: 1.35; 95% CI: 1.17–1.55; P < 0.001), and increase in the Neuropsychiatric Inventory-Questionnaire score (OR: 1.02; 95% CI: 1.01–1.03; P = 0.005) were associated with a higher risk of malnutrition. In the non-dementia group, the risk of malnutrition increased as the K-ADL score increased (OR: 1.20; 95% CI: 1.04–1.39; P = 0.011) and in the depressed group (OR: 2.84; 95% CI: 1.04–7.74; P = 0.042).Conclusions: The study results confirmed the necessity of nutritional management for community-dwelling LTCI recipients. When developing a nutritional management program, considering the differences in factors related to malnutrition between the dementia and non-dementia groups is important. This study proposes policies for improving the LTCI system in terms of nutritional management and the utilization of community resources.

Issue uncertainty and selections of policy instruments in policy pilots: evidence from China’s long-term care insurance

ABSTRACT Policy pilots have been instrumental in governing China’s economic and social development. Prior research has primarily concentrated on examining the types of policy pilots and their promotion strategies through the lens of central-local dynamics, and analysing the organizational models of policy pilots within specific contexts. However, there’s a gap in understandinghow the central government employs policy instruments to foster organizational learning within pilots. In complex policy pilots, there is often uncertainty regarding objectives, pathways, and outcomes. Using China’s Long-Term Care Insurance (LTCI) pilot as a case study, this research reveals that policy pilots utilize distinct sets of policy instruments during the organizational learning process, contingent upon the context. The first set of instruments indicates a shift in the central government’s intervention intensity, ranging from weak to strong, employing autonomous, advocacy, and directive policy instruments in sequence. The second set of instruments shows an evolution in the depth of the central government’s engagement with the policy issues, progressing from shallow to deep, with the use of booster, framework, and calibrated policy instruments, respectively. This study highlights how policy pilots employ a diverse array of instruments to navigate the intricacies of policy implementation when confronting complex social policy challenges.

Developing a battery of physical performance tests to predict functional disability in Japanese older adults: A longitudinal study from the Kasama study.

Preventing functional disability benefits the quality of life of older adults and mitigates the economic burden of an aging society. However, the most effective physical performance tests and optimal cut points for identifying older adults at risk of functional disability remain unclear, and Japan lacks physical function-based assessment tools. We aimed to identify the physical performance tests related to functional disability and to develop a predictive test battery for it. We included 975 older adults (mean 72.8 ± 5.2 years, 55.4% women) in Kasama City, Japan. Functional disability was defined as certification of care level 2 or above based on the long-term care insurance system. Cox proportional hazards analysis examined the association between physical performance tests and incident functional disability. During a mean follow-up of 8.6 years (maximum 14 years), 236 participants (24.2%) developed functional disability. After adjusting for covariates, higher performances in grip strength, single-leg balance with eyes open (SLB), timed up-and-go (TUG), five-repetition sit-to-stand (5-STS), and 5-m habitual walk were significantly associated with a lower risk of functional disability. In a stepwise model, SLB, TUG, and 5-STS were key predictors of functional disability. Receiver operating characteristic analysis determined optimal cut points of 32.6/32.7 s for SLB, 6.5/6.6 s for TUG, and 7.8/7.9 s for 5-STS. We developed a predictive battery combining these cut points (area under the curve = 0.78). The developed battery of physical performance tests predicts future functional disability and is useful for screening older adults at high risk. Geriatr Gerontol Int 2024; ••: ••-••.

Mental health impacts of spousal caregiving intensity in the US.

In the US, spouses are a major source of informal care for older adults and, therefore, key to the US national strategy to provide long-term care to the growing population of older adults. Understanding the mental health impacts of spousal caregiving is therefore critically important. Existing studies on the topic have often been limited by methodological limitations, and most overlook the role of caregiving intensity. In this study, we assess the impact of providing different intensities of caregiving to a spouse on mental health outcomes using data from the Health and Retirement Study. We address the endogeneity of the decision to provide different caregiving intensities using an augmented inverse probability weighted (AIPW) estimator adapted to handle multivalued treatments. We check the robustness of our estimates to the AIPW's identifying assumptions by re-estimating the model using a dynamic fixed effects estimator. We find strong evidence that becoming a caregiver is associated with worsened mental health outcomes for women, while the evidence for men is weaker. When disaggregating by caregiving intensity, we find that transitions into high-intensity caregiving lead to large increases in depression symptoms and the probability of exhibiting major depression for both men and women. The overall mental health impact of transiting into caregiving is driven almost exclusively by the negative impact of high-intensity caregiving, as transitions into low- and moderate-intensity caregiving are not associated with worsening mental health in most specifications. This study provides timely insights that can inform the targeting of long-term care policies and programs aimed at supporting family caregivers of older adults.

Impacts of chronic diseases and multimorbidity on health-related quality of life among community-dwelling elderly individuals in economically developed China: evidence from cross-sectional survey across three urban centers

ObjectiveAs the ageing process in China further accelerates and the average life expectancy increases, chronic disease prevalence and multimorbidity rates are constantly rising, especially among elderly individuals. However, few previous studies have explored the impacts of chronic diseases and multimorbidity on health-related quality of life (HRQoL). This study aimed to investigate this association among community-dwelling elderly individuals in China.MethodsA cross-sectional study was conducted in communities in three cities (Suzhou, Qingdao, and Guangzhou). The basic characteristics, chronic diseases and HRQoL of participants were collected, and HRQoL was measured by the EuroQol 5-Dimensions 3-Level version (EQ-5D-3L). Logistic regression, Tobit regression and generalized linear models were used to assess the impacts of chronic diseases and multimorbidity on HRQoL.ResultsApproximately 83.2 percent of the 1,218 respondents had chronic conditions, with 30 percent having multimorbidity. After controlling for sociodemographic and health behaviour factors, patients with stroke were more likely to report problems in all five dimensions of the EQ-5D and had a lower EQ-5D utility index (UI) (b = -0.342) than patients with other chronic conditions. Patients with chronic pulmonary obstruction had a lower EuroQol Visual Analog Scale (EQ-VAS) (b = -11.169) than patients with other chronic conditions. Furthermore, patients with multimorbidity had worse HRQoL (P < 0.001).ConclusionsBoth chronic condition probability and multimorbidity rates were high among Chinese community-dwelling elderly individuals. Different disease types had varying degrees of impact on HRQoL, and patients with multimorbidity had worse HRQoL. This study proposes that the government enhance the quality of life of community-dwelling elderly individuals with multimorbidity by establishing long-term care insurance and expanding comprehensive community-based home health care services.

Retraction Note: The impact of long-term care insurance on household consumption and sustainability among aged people in China

Retraction Note: The impact of long-term care insurance on household consumption and sustainability among aged people in China

Does Social Support Alleviate the Caregiving Burden of Adult Children? Evidence from Chinese Long-Term Care Insurance Pilot Program

ABSTRACT In China, and many other developed nations, public long-term care insurance (LTCI) is a commonly adopted approach to meet long-term care needs, but its impact on the burden of family caregivers remains uncertain. This study investigated whether a parent having LTCI alleviates the caregiver burden for the adult child caregiver. Data derived from the 2011, 2013, and 2018 China Health and Retirement Longitudinal Study (N = 4595 adult child caregivers). Guided by the stress-appraisal model, Difference-in-Difference (DID) methods were used to investigate the spillover effects of LTCI on caregiver stressors and burden. The results show that having public LTCI in place in a location is associated with reduced caregiver burden among adult child caregivers through its effects on secondary stressors (wealth, health, and sleep problems) and hours of caregiving. Findings suggest that the LTCI is an effective form of social support for aiding family caregivers and alleviating their burden.

The prevention and response to infectious diseases in long-term care facilities in Korea: a nationwide survey.

Long-term care facilities (LTCFs) are communal environments for patients with chronic diseases or older adults, making them particularly susceptible to significant harm during infectious disease outbreaks. Nonetheless, LTCFs have historically been subject to less stringent infection prevention and control (IPC) mandates. This study aimed to assess the current state of LTCFs and to develop an IPC system tailored for these facilities following the coronavirus disease 2019 (COVID-19) pandemic. We conducted an online survey of 11,366 LTCFs in Korea from December 30, 2022 to January 20, 2023, to evaluate the components of IPC in LTCFs. The infectious diseases targeted for IPC included COVID-19, influenza, and scabies. Additionally, we compared institution-based and home-based long-term care insurance facilities. Overall, 3,537 (31.1%) LTCFs responded to the survey, comprising 1,819 (51.4%) institution-based and 1,718 (48.6%) home-based facilities. A majority (87.4%, 2,376/2,720) of these facilities experienced COVID-19 outbreaks. However, only 42% of home-based facilities, in contrast to 90.6% of institution-based facilities, were equipped to manage concurrent COVID-19 cases. Similarly, while 92.1% of institution-based facilities were capable of managing influenza, only 50.5% of home-based facilities could do the same. The incidence of scabies was significantly higher in institution-based facilities than in home-based ones (26.1% vs. 4.3%). Additionally, 88.7% of institution-based facilities managed scabies cases effectively, compared to only 42.1% of home-based facilities. Approximately half of the LTCFs had a basic capacity to respond to infectious diseases. However, there were differences in response capabilities between institution-based facilities and home-based facilities.

Preference of urban and rural older people in Shandong Province for long-term care insurance: based on discrete choice experiment.

Severe population ageing and weak long-term care support systems has spurred China's pilot program for long-term care insurance (LTCI). This study aimed to provide references for optimizing long-term care insurance policies in Shandong Province by measuring the preferences of urban and rural older people for LTCI. Based on the discrete choice experiment, a questionnaire survey was conducted on urban and rural older people from Shandong Province. A mixed logit model was used for data analysis and the relative importance of attributes, willingness to pay, and preference heterogeneity based on residence type, number of children, chronic conditions, gender, education level and financial situation were further estimated. The results showed that individual premium, reimbursement rate and whose provision of home-based care can be reimbursed had a significant effect on the LTCI preference of urban and rural older people in Shandong Province. Benefit package and government subsidy lost statistical significance in full sample but played a role in certain subgroups. There were also differences in preferences for individual premium among different groups of older people. Optimizing the policy design of long-term care insurance based on the actual needs of the older adults can help increase the utility of them and promote the smooth implementation of long-term care insurance.

The impact of long-term care insurance on healthcare utilization and expenditures among middle-aged and older Chinese adults: a quasi-experiment study

BackgroundLong-term care insurance (LTCI) is essential to alleviate the challenges of rapid aging. Research on LTCI in developing countries is limited and conclusions remain controversial. This study aims to empirically evaluate how the LTCI pilot in selected cities influences healthcare utilization and expenditures among middle-aged and older Chinese adults.MethodsData was from 2013, 2015, and 2018 China Health and Retirement Longitudinal Study. 167 LTCI and 8225 non-LTCI group participants were identified. Propensity score matching difference-in-difference method was used to evaluate the net effect of LTCI. The robustness of the findings was tested using a placebo test.ResultsIn the pilot cities, around 17.8% of the population had LTCI coverage, with approximately 59.9% participating in urban employee medical insurance and 81.4% being urban residents. LTCI significantly reduced the monthly out-of-pocket outpatient expenditure by 313.764 yuan (P < 0.05), but had no significant effects on the inpatient utilization and expenditure. Further analysis of vulnerable subgroup revealed that LTCI decreased monthly outpatient visits frequency, total outpatient expenditure, and out-of-pocket outpatient expenditure by 0.523 times, 643.500 yuan, and 302.367 yuan, respectively (P < 0.05). Robustness tests confirmed the stability of these results.ConclusionsThe LTCI coverage rate has remained low. While LTCI has contributed to reducing outpatient utilization and expenditure, its impact on controlling inpatient-related outcomes is limited. It is recommended to broaden LTCI coverage beyond existing participants to encompass more vulnerable populations, and improve awareness and quality of LTCI services to achieve a significant effect on inpatient care.

Long-Term Care in Germany in the Context of the Demographic Transition—An Outlook for the Expenses of Long-Term Care Insurance through 2050

Demographic aging results in a growing number of older people in need of care in many regions all over the world. Germany has witnessed steady population aging for decades, prompting policymakers and other stakeholders to discuss how to fulfill the rapidly growing demand for care workers and finance the rising costs of long-term care. Informed decisions on this matter to ensure the sustainability of the statutory long-term care insurance system require reliable knowledge of the associated future costs. These need to be simulated based on well-designed forecast models that holistically include the complexity of the forecast problem, namely the demographic transition, epidemiological trends, concrete demand for and supply of specific care services, and the respective costs. Care risks heavily depend on demographics, both in absolute terms and according to severity. The number of persons in need of care, disaggregated by severity of disability, in turn, is the main driver of the remuneration that is paid by long-term care insurance. Therefore, detailed forecasts of the population and care rates are important ingredients for forecasts of long-term care insurance expenditures. We present a novel approach based on a stochastic demographic cohort-component approach that includes trends in age- and sex-specific care rates and the demand for specific care services, given changing preferences over the life course. The model is executed for Germany until the year 2050 as a case study.

Multidimensional Poverty and Disability of Older Adults in China: Will Long-Term Care Insurance Make a Difference?

Multidimensional Poverty and Disability of Older Adults in China: Will Long-Term Care Insurance Make a Difference?

From Institutions to Families? The Changing Allocation of Responsibility for Cognitively Disabled Children in Dutch Postwar Long-Term Care Policies

Who is responsible for health care? Neoliberal policies since the 1970s seem to place this responsibility increasingly on the individual, in a process that is called responsibilization. The recent literature on neoliberalism, however, has questioned the preference of free-market liberalism for individual responsibility and shows how neoliberals often made common cause with communitarian conservatives on social policies. Melinda Cooper, for instance, has argued in her book Family Values that free-market liberals and social conservatives in the US both identified the family as a ‘wholesale alternative to the 20-century welfare state’. This article investigates whether this coalition of neoliberals and social conservatives, who agree on the importance of familial solidarity in addition to market freedom, has also played a role in the making of Dutch health care policies. By tracing how responsibility for long-term care has been allocated in the postwar Netherlands in the specific case of children with (cognitive) disabilities, the author will show how ‘the family’ has increasingly been embraced by policymakers as the main responsible party. This is remarkable because the Dutch postwar welfare state sought to loosen family ties in favour of individual arrangements. However, attempts by different stakeholders to deinstitutionalize Dutch health care during the 1990s unintentionally moved the state's responsibility for long-term care not so much onto individuals as onto families.

Does Dialysis Therapy Cause Cognitive Impairment in Older Adults? A Propensity Score Matching Retrospective Study From a Japanese Long-Term Care Insurance Certification Survey.

This study explores the longitudinal connection between dialysis therapy in older adults and the incidence of cognitive impairment, and trends of general abilities. We conducted a retrospective propensity score matching (PSM) analysis of data from the care-needs certification survey in City A, Japan, spanning 2017 to 2021. Our sample comprised 11 443 initially cognitively intact older adults from the baseline year 2017. Among them, individuals had received dialysis therapy at baseline, and 216 individuals were included after PSM. The dialysis group had a significantly lower incidence of cognitive impairment during follow-up than the control group (P = 0.02). The competing risk of death was significantly higher in the dialysis group than in the control group (P < .001). Both groups showed a decline in their comprehensive ability over the time. There have been several reports of a negative association between dialysis and cognitive impairment, but more detailed investigation of the longitudinal relationship may be needed. Comprehensive support remains critical for both dialysis and non-dialysis older adults.