Some Aspects of Long-Term Care in Germany 德国长期看护保险 Professor Konrad Obermann MD PhD Rome, May 2019 Konrad Obermann教授，医学博士，博士 罗马 2019年5月

Obermann: LTC in Germany Key issues 要点 1. History and (ethical) principles 历史沿革及（伦理）原则 2. Demography 人口概况 3. Financing 资金支持 4. Finding and retaining qualified staff 寻找和留住具备资质的人才 Obermann: LTC in Germany

Clear ethical foundations in imperial message 帝国诏书打下了明确的伦理基础 The development of social security in an industrializing country 工业化国家社会保险的发展 Clear ethical foundations in imperial message 帝国诏书打下了明确的伦理基础 Message of Kaiser Wilhelm I to the Reichstag November 1881: “Already in February of this year We voiced our conviction that the healing of the social damage cannot only be sought through the repression of social riots, but equally on the positive promotion of the welfare of the workers. We consider it our Imperial obligation to again recommend warmly this task to the Reichstag, and we would look back with much greater satisfaction to all the success with which God has obviously blessed Our government, if we were to raise awareness on this issue and bring the fatherland new and permanent guarantees of its internal peace and to help those in need with greater security and efficiency of the assistance to which they are entitled. ... For such assistance it is a difficult task to find the right ways and means, but also one of the highest responsibilities of any community, based on the moral foundations of the Christianity. The close connection to real life forces of this nation and the merging of the latter in the form of corporate co-operatives under state protection and state support will, as we hope, make the solution of tasks possible that the state alone to the same extent could not provide. Obermann: LTC in Germany

Obermann: LTC in Germany The development of social security in an industrializing country 工业化国家社会保险的发展 1881年11月德国皇帝威廉一世致国会的诏书： “今年二月份，我们已经明确阐述过：要抚平社会创伤不能只靠镇压社会动乱，而同样要增进工人福利。我们认为，将这项举措推荐给国会是帝国的责任；我们应该增强人们对这个问题的重视，从而为祖国内部稳定提供新的永久保障，并对困难的人群给与更有效的援助，这样，日后我们会更高兴地对上帝赐予我国政府的巨大成功。...... 找到正确的援助方式和来源不是一项容易的任务，然而，根据基督教的道德基础，完成这项任务是每个群体的最高责任之一。我国政府与劳动人民联系紧密；我们希望在国家保护和支持下，劳动资源与法人组织相结合，能承担这个由国家独自出力无法完成的任务。” Obermann: LTC in Germany

1995: Long term care insurance The development of social security in an industrializing country 工业化国家社会保险的发展 Development of the “five pillars” of security 社会保障 “五大支柱”的发展 1871: Second German Reich founded: tendency towards centralism, unification, administration 1871年：建立了德意志第二帝国：趋向集中化、一体化、行政化 1926: Unemployment insurance (initially for soldiers): 1926：失业保险（最初为了士兵） 1995: Long term care insurance 1995：长期看护险 1889: Old Age Pension 1889：养老保险 1880 1900 1920 1940 1960 1980 1870 1890 1910 1930 1950 1970 1990 1883: Health insurance: 1883：医疗保险 1885: Accident insurance (paid in full by employers) 1885：意外保险（完全由雇主支付） 1900: BGB (citizens‘ code of law): 1900：BGB(民法典) Obermann: LTC in Germany

Economic principles in post-war Germany 德国战后的经济原则 The Social market economy (Alfred Müller Armack) 社会市场经济（阿尔弗莱德·穆勒·阿尔马克） “A system which allowed business and finance to operate under the conditions of free market trading yet which worked within the legislative framework of industrial democracy at plant, company and industry level and within a statutory social security scheme seemed to enjoy the best of both worlds.” “允许商业和金融在自由市场贸易条件下运作，同时在工厂、企业、产业层面符合工业化民主法律框架以及法定社会保障制度，且能够同时享两种制度优势的经济体系。” (Nigel Reeves, 1995, 213) Obermann: LTC in Germany

The Social Market Economy 社会市场经济 Free market trading 自由市场贸易 The industrial harmony 劳资和谐 Laws of Co-determination 共同决策法 Monetary policy of the Bundesbank (Federal Bank of Germany) 德国央行货币政策 Extensive social security scheme 广泛的社会保障制度 Obermann: LTC in Germany

Obermann: LTC in Germany LTC introduced in 1995 in response to financial problems 1995年引进长期看护险以应对财务问题 Up until 1994 the local councils were responsible for financing LTC 1994年之前，都由当地市政部门负责资助长期看护 Serious financial difficulties were envisaged for the future 预见未来的财务窘境 Long discussion about whether to have another column of “pay-as-you-go” or a “capital-based financing” 围绕是否开展“随收随支”还是“按资本资助”进行了长期讨论 Obermann: LTC in Germany

LTC was attached to social health insurance 长期照护险挂靠社会医疗保险 Eligibility: when ill or disabled 纳入标准：生病或残疾 (Core: the definition “in need of care”, changed in 2017) （核心：“照护需求”的定义，2017年进行修改） Weighted results leads to grading (grade 1-5) 根据加权评估结果进行等级划分（1-5级） Care allowance – home care (in kind) – residential care 照护津贴 – 居家看护 – 护理之家 Benefit levels vary accordingly: from EUR 125 / month (grade 1, care allowance) to EUR 2005 / months (grade 5 – residential care) 福利水平对应有所不同：从125欧元/月（1级，照护津贴）至2005欧元/月（5级；护理之家）不等 Obermann: LTC in Germany

The five pillars of the German social security system 德国社会保障体系的五大支柱 Special systems 特殊系统 for farmers 农民 for miners / seamen 矿工/航海员 for state servants 公务员 (“Beamte”) for soldiers 士兵 for pensioners (SHI) 退休人员 German Social Security System 德国社会保障体系 Statutory Health Insurance (SHI) 法定医疗保险 Pension Insurance 养老保险 Unemployment Insurance 失业保险 Long-term Care Insurance 长期看护保险 Accident Insurance 意外保险 SHI - Social Health Insurance 社会医疗保险 OAP - Old Age Pension 养老保险 AI – Accident Insurance 意外保险 Statutory unemployment insurance  insures employees' livelihood in case of unemployment, Statutory pension insurance insures members in old age as well as in case of reduced earning incapacity and upon an employees' death insures his survivors as well, Statutory health insurance  supports maintenance and restoration of good health and eases the financial consequences of illness, Statutory accident insurance  helps an employee regain his earning ability after a (work-related) accident, Statutory long-term care insurance  provides financial support for those dependent on care and assistance from others. Legal Basis: Social Code Books (SGB) 法律基础： 社会法典（SGB） SGB V SGB VI SGB II/III SGB XI SGB VII Obermann: LTC in Germany

Structures and principles of social security 社会保险的结构和原则 Solidarity and Subsidiarity 团结和权利自主 Solidarity: Western / Christian concept of the stronger ones supporting the weaker ones (e.g. young – old; rich – poor; without children – with children; healthy - sick) 团结原则：西方／基督教概念中，强者应该帮助弱者（例如年轻人－老年人； 富人－穷人; 没有孩子的人－有孩子的人；健康人－病人） Subsidiarity: the most local and smallest of all available institutions, if possible, take care of a problem (family – community – regional state – federal state) 辅助性原则：可能的话，问题尽量通过最地方的和最小的责任机构进行处理 (家庭—社区—州—国家） Obermann: LTC in Germany

Long-term care insurance: € 37 bn Complex financing structure 复杂的融资结构 Social Security System major part of public spending 社会保险系统是主要的公共支出 GNP Germany: € 3,210bn (2017) 2017年德国国民生产总值：3.21万亿欧元 Social insurance system: € 579 bn (2017) 社会保障体系：5.79千亿欧元(2017) Combined state budgets: € 920bn (2017) (federal, states, communities) 国家总预算：9.2千亿欧元（联邦，各州，地区） Old age insurance: € 304 bn 养老保险：3.04千亿欧元 Federal budget: € 329 bn (2017) 联邦政府预算：3.29千亿欧元（2017） Social health insurance: € 228 bn 社会医疗保险：2.28千亿欧元 of which spending on old age pensions: € 100 bn 其中在养老保险的支出为：1千亿欧元 Accident insurance: € 13 bn 意外保险：130亿欧元 of which spending on defense: € 37 bn 其中在国防费用的支出为：370亿欧元 Long-term care insurance: € 37 bn 长期看护险：370亿欧元 Unemployment insurance: € 27bn 失业保险：270亿欧元 Obermann: LTC in Germany

Obermann: LTC in Germany Financing LTC 为长期看护险提供资金支持 2.55% of gross income (2.8% if no children) 总收入的2.55% （如果没有孩子，则为2.8%） Managed by the SHI schemes (currently: 117) 由社会医疗保险统一管理（当前：117） Grade of care formally assessed by the independent Medical Review Board of the Statutory Health Insurance Funds (MDK) 由独立的法定医疗保险基金医疗评审委员会对看护等级进行正式评估 Some control and corruption issues (organised crime in ambulatory and in-kind care) 存在部分监管和贪污问题（非卧床照护及居家照护的有组织犯罪） Co-payment on average about EUR 580 / month (individually set by the institution) 平均分摊费用为580欧元/月（由机构单独设置） Obermann: LTC in Germany

Oral contraception available Challenge 1: Demography 挑战之一：人口分布 1910 2016 Post-war (WW II) 二战后 Post-war (WW I) 一战后 Reunification 东西德统一 Oral contraception available 口服避孕药上市 World War II 二战 Franco-German War 1870/1 德法战争 Obermann: LTC in Germany

Challenge 2: Demography 挑战之二：人口分布

Challenge 3: Coordination 挑战之三：统筹协调 Use of IT Data protection Prevention Management Single window Paying for AAL IT技术的使用 数据保护 预防 管理 一站式窗口 支付居家照护费用 LTC SHI OAP LTC Long-term Care 长期看护险 SHI Social Health Insurance 社会医疗险 OAP Old Age Pension 养老保险 AAL Ambient Assisted Living 居家照护 Obermann: LTC in Germany

A number of sensible legal changes – but the overall strategic direction is missing 一系列合理的法律修订，但缺乏总体策略方向 2009 PSG I Erstes Pflegestärkungsgesetz: Improved services, better focus on dementia care, ambulatory flat-sharing 更好的服务、更关注失智症照护、非卧床共享公寓照护 2015 PSG II Zweites Pflegestärkungsgesetz: New definition of “need for care”; move from 3 levels of care to 5 grades of care External evaluation of residential home care (“Pflege TÜV”) 对“看护需求”重新定义；从三级诊疗迈向五级诊疗；对护理之家看护服务进行外部评估 2016 PSG III Drittes Pflegestärkungsgesetz: Improved local coordination; fighting fraud and corruption 完善地方统筹；严打造假和腐败 In addition 此外 2002 Pflegeleistungs-Ergänzungsgesetz: improved care allowance; testing innovative models 改善照护津贴；试点创新模式 2012 Pflege-Neuausrichtungs-Gesetz: better services for dementia patient; private co-insurance for LTC 为失智症患者提供更好的服务；为长期看护提供商业联合保险 Obermann: LTC in Germany

One thing is for sure: German Angst will not help 可以肯定的是：德国人再焦虑也于事无补 “The Last German” 最后一个德国人

Obermann: LTC in Germany Thank you! 谢 谢！ info@konrad-obermann.de Obermann: LTC in Germany

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