Effect Evaluation of the Long-Term Care Insurance (LTCI) System on the Health Care of the Elderly: A Review

Figures & data

Table 1 Long-Term Care Insurance in Part of LTCI Pilot Cities in China (Unit: RMB)

City	Start Time	Institution Care Expenditure	Home Care Expenditure	Community Care Expenditure
Qingdao	July, 2012	65 yuan/person/day	50 yuan/person/day	1600 yuan/year
Chongqing	March, 2018	26 yuan/day for severely disabled persons, 20 yuan/day for moderately disabled persons.	–	30 yuan/day for severely disabled, 25 yuan/day for moderately disabled.
Changchun	May, 2015	LTCI pays 70% and reimburses 750 yuan for the whole month	25 yuan/person/day	LTCI pays 70% and reimburses 750 yuan for the whole month
Qiqihar	October,2017	LTCI pays 55%,25 yuan/person/day	LTCI pays 50%	LTCI pays 50%,20 yuan/person/day
Jingmen	December, 2016	LTCI pays 75%,100 yuan/person/day	40 yuan/person/day	LTCI pays 80%,100 yuan/person/day
Chengdu	July, 2017	LTCI pays 70%	LTCI pays 75%	–
Nantong	January, 2017	50 yuan/person/day	–	1200 yuan/month
Guangzhou	April, 2017	LTCI pays 75%, 120 yuan/person/day	LTCI pays 90%	LTCI pays 75%
Anqing	January, 2017	LTCI pays 50%,40 yuan/person/day	750 yuan/month	750 yuan/month
Ningbo	December, 2017	60 yuan/person/day	50 yuan/person/day	50 yuan/person/day
Shanghai	January, 2018	LTCI pays 85%	LTCI pays 90%	LTCI pays 90%

Note: The results were summarized according to the pilot program of pilot cities.

Figure 1 Data extraction process (PRISMA).

Note: Adapted from Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Review and Meta-Analyses:The PRISMA Statement. PLoS Med 6(7):e1000097.11

Figure 2 Classification of publication by country studied.

Table 2 Literature Related to the Impact of LTCI on Caretakers and Their Families

Author, Date	Publication	Sample	Methodology	Sample Period	Key Findings
Purpose 1: Effects of LTCI on the health and quality of life of the caretakers
Choi and Joung (2016)^Citation17	Arch Gerontol Geriatr	Korea	Cox proportional hazard regression	January 2009–April 2012	They used Cox models to identify the effect of service utilization on mortality while adjusting for covariates. It is found that the hazard ratio of participant death of those using long-term care services was significantly lower than for those who did not use these services.
Lee et al (2019)^Citation18	Int J Geriatr Psychiatry	Korea	Logistic regression	2008–2009	The propensity score matching method was used, yielding 416 participants in each group. Paired samples t‐tests and logistic regression analyses were conducted and found that cognitive function and disability declined less in the LTCI care group.
Milte et al (2019)^Citation19	Ageing & Society	Argentina	Qualitative methodologies	2016–2017	The paper conducted a clandestine audit by older people living in the community and found that there has been a rapid growth in the availability of formal services, but that there are many gaps in provision, especially for older people with complex care needs.
Purpose 2: Effects of LTCI on the financial burden on the caretakers and their families
Sugiyama et al (2018)^Citation20	Geriatrics & Gerontology International	Japan	Cross-sectional analysis	2010	The present study was a cross-sectional analysis of nationally representative data in Japan (2010 Comprehensive Survey of Living Conditions). It is found that, facilitating health check-up participation for family caregivers of care recipients with higher care-need levels might be an effective intervention for decreasing the gap in health behavior possibly caused by informal caregiving.
Iwamoto and Saito (2010)^Citation21	Journal of the Japanese and International Economies	Japan	Investigation	2001	They only use the sample of households whose household head is an employee. It is found that, publicly financed home care may have limited impact among the abler, but that it may be both more cost-effective and beneficial than institutional care for the least prepared.
Tamiya (2011)^Citation22	The Lancet	Japan	Systematic review	1998–2004	They used the data from academic published work to review the effect of the long-term care insurance system in Japan and found that increasing the use of formal health care at lower family costs has had mixed results for career well-being.
Chen Fei (2013)^Citation23	Times finance	China	Qualitative analysis	2011	Long-term care insurance can effectively reduce the cost of providing for the aged and reduce the double burden of family economic life.
Kim and Lim (2015)^Citation24	Journal of Public Economics	South Korea	Regression discontinuity design	2008–2010	They used administrative data to estimate the first-year impact of subsidies for formal home and institutional care on informal care use and medical expenditures. It is found that, publicly financed home care may have limited impact among the abler
Purpose 3: Effects of LTCI on nursing workforce providers
GeyerandKorfhage (2015)^Citation25	Health Econ	Germany	Structural model	2001–2010	They use a mixed logit with random coefficients to estimate the random utility maximization and found that benefits in kind have small positive effects on labor supply. Labor supply elasticities of cash benefits are more significant and negative.
Sakka (2019)^Citation26	Geriatr Gerontol In	Japan	Cross-sectional study	March 2015 - July 2016	They used structural equation modeling (SEM) and found that the decrease in care burden is significant for employed family caregivers to reduce their FWC and maintain their work-life balance.
Umegaki et al (2014)^Citation27	Arch Gerontol Geriatr	Japan	x2 analysis	April 2010	Lower age of caregivers, a more advanced need classification level, and more satisfaction with the services were independently associated with a reduction of the care burden.
Purpose 4: Effects of LTCI on the choice of different types of care
Schmitz and Westphal (2015)^Citation28	J Health Econ	Germany	Propensity score method	2002–2010	They used the model of Rubin (1974) to estimate the effect and found that there is a considerable negative short-term effect of informal care provision on mental health, which fades out over time.
Gao (2019)^Citation29	Chinese medical insurance	China	Logistics regression	From July to September 2017	There are three phenomena in adult long-term care: first, more than half of the interviewees have experienced long-term care; second, more than half of the interviewees support the view that young people should be prepared for long-term care; third, more than half of the interviewees prefer home (community) care.
Coe, et al (2015)^Citation30	J Health Econ	USA	Microscopic investigation	1998–2006	It test if expectations about future informal care receipt, and LTCI purchase decisions vary between individuals whose parents or in-laws have used LTC versus those who have not. They found parental use of a nursing home decreases expectations that one’s children will provide informal care. Nursing home use by either a parent or in-law increases LTCI purchase probability by 0.8 percentage points.
Tsai (2015)^Citation31	J Health Econ	USA	Empirical research	1999–2000	They used the Second Longitudinal Study of Aging (LSOA II) and found that, as retirement incomes rise, older people are increasingly using formal care and relying less on informal home care provided by their children.
Lehnert, et al (2018)^Citation32	Eur J Health Econ	Germany	Preferences Discrete choice experiment	2015.12–2016.06	Preferences and marginal willingness to pay (WTP) for HCBS were assessed with respect to five HCBS attributes. It is found that in light of the great importance of high care quality to respondents, reimbursement for services by HCBS providers could be more strongly linked to the quality of services.

Table 3 The Influencing Factors are Limiting the Development of LTCI

Factors	Representative Article	Results
Price rise factors	Eggink and Woittiez (2016)^Citation45	Expected price increase in the future will lead to an annual increase of 3.5% in real future expenditure on long-term care in the Netherlands.
The rate of elderly disability that cannot be accurately predicted	Ding and Yan (2019)^Citation43	It’s higher to measure the rate of elderly disability used IADL than ADL as a measuring tool.
Change in labor supply market factors	Geyer and Korfhage (2015)^Citation25	Benefits in kind and benefits in cash have different effects on the labor market for long-term care services.
Other insurance such as private long-term care insurance and Medicare insurance	Sun (2018)^Citation44	Qingdao long-term care insurance funds are limited to basic medical insurance by urban workers
	Lin et al (2013)^Citation46	Public LTCI and private LTCI have some alternatives.
	Kim and Kwon (2015)^Citation49	Compared with families and communities, hospitals remain the foundation of long-term care services for the elderly.
	Brown and Finkelstein (2008)^Citation50	The interaction of public and private insurance

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