Title from first page of PDF document. Includes bibliographical references (p. 20-21).

Cette thèse se propose d’étudier l’existence de freins au développement du marché privé de l’assurance dépendance en France. Nous étudions ici tour à tour trois candidats dans l’explication de ce faible développement : les préférences individuelles, les comportements d’auto-assurance et la myopie des agents. Pour cela, nous exploitons les enquêtes « Préférences et Patrimoine vis-à-vis du risque et du temps » et « Santé et protection sociale » qui ont toutes deux introduit des modules spécifiques dépendance dans les vagues d’enquêtes mobilisées dans cette thèse. Nos analyses économétriques confirment le rôle d’obstacle de ces trois déterminants de la demande d’assurance dépendance. Si l’existence d’une mauvaise perception du risque dépendance plaide pour l’intervention de l’Etat dans la relation des français à la planification de leurs pertes d’autonomie, le rôle des préférences individuelles et les comportements d’auto-assurance mis en évidence dans cette thèse révèle un choix économiquement rationnel de ne pas recourir à une assurance dépendance. / This thesis aims at better understanding long-term care insurance puzzle. Three determinants of the long-term care insurance market low development are studied here: individual preferences, self-insurance and myopia. To do so, we use two surveys that have introduced dependency-specific modules: “Preferences and patrimony against time and risk” and “Health Care and Insurance”. The results highlight the role of these three determinants of long-term care insurance demand in the low development of the market. If myopia advocate for a government intervention in French citizens long-term care planning, the impact of individual preference and self-insurance behaviors suggest that the nonpurchase of long-term care policies is economically rational.

The purpose of this study was to determine the extent to which nursing home organizational structure and cultural variables were related to the outcomes reported by the Health Care Finance Administration public use data set (HCFA-NHCD). A second purpose was to examine the effects of a new style of nursing home management called the Eden Alternative™ concept. A related purpose was to test the usefulness of the HCFA-NHCD in predicting the quality of care for residents in federally approved nursing homes. Secondary data analysis was conducted on the HCFA-NHCD, as published in December 2001. Descriptive statistics and measures of association were used to assess the degree of relationship between the organizational structure and culture variables and the eight clinical health indicators of the HCFA-NHCD. Multiple regression analyses were conducted to measure the impact of the organizational structure and culture variables on the quality of care for residents in federally approved nursing homes. When compared with previously collected statistics, these findings suggest that there is a nationwide trend towards smaller nursing homes; smaller Eden homes were associated with a higher level of individualized attention. Smaller Eden homes with council representation had better scores on a majority of the eight clinical health indicators when compared to their counterparts with no council representation. Council representation was inversely related to a nursing homes' reliance on RN and LPLVN services. However, a regression model assessing the impact of organizational structure and cultural variables on the quality of care for residents in federally approved nursing homes had very limited predictive power (R2=2.2%). The findings of this study suggest that quality improvements in the HCFA-NHCD are needed in order to better serve families.

No description available.

人口老化是全世界共同面對的問題，台灣對於國民的老年生活，該如何保障？除了目前正研議中的年金保險，高齡人口的醫療保健問題，更顯重要。近年來，台灣開始討論有關高齡者的長期照護問題，不過該以何種體制，尚未有所定論。觀諸先進國家之經驗，對於長期照護制度有多種建制方式。本論文以鄰近之日本為對象，研究以社會保險作為社會安全制度核心的日本，如何繼德國之後，將長期照護保險法作為其第五大社會保險制度。 本論文分為六章，約九萬字。第一章緒論，就問題緣起與研究範疇說明。第二章敘述日本實施長期照護保險法之經社背景及當時之社會安全法制背景。第三章針對日本建制長期照護保險法之過程中，論述其學術界之討論與行政上之規劃及其而後之立法過程及相關的過渡措施。第四章說明日本現行之長期照護保險制度，內容包括長期照護保險之適用對象、保險給付、保險財務、長期照護保險之組織、支付制度及長期照護保險爭議之處理。第五章為日本實施長期照護保險制度後之檢討與評估。第六章則先論述台灣目前之經社背景及長期照護體系，且說明其缺失。最後，以日本實施長期照護保險法之經驗，論述其對台灣之啟示。 在台灣，社會安全為憲法所明文規定之國家政策，並為政府歷次政策宣示所強調。從德國及日本陸續於原有之四大社會保險之外，另行實施長期照護保險，而擴增為五大社會保險，更顯示社會保險制度所獲之廣泛信賴與支持。據此發展，亦可見以社會保險為核心之社會安全制度，非但有退縮現象，甚且百尺竿頭更進一步。在2002年全國社會福利會議中，已提出以建立長期照護保險制度為目標，並於10年內完成之分組報告。台灣未來如何抉擇制度之走向，尚待觀察。

La mise en place de Solvabilité II conduit les actuaires à s'interroger sur la bonne adéquation entre modèles et données. Aussi, cette thèse a pour objectif d'étudier plusieurs approches statistiques, souvent méconnues des praticiens, permettant l'utilisation de méthodes multi états pour modéliser et gérer les risques individuels en assurance. Le Chapitre 1 présente le contexte général de cette thèse et permet de faire positionner ses principales contributions. Nous abordons les concepts de base liés à l'utilisation de modèles multi-états en assurance et décrivons les techniques d'inférence classiques adaptées aux données rencontrées, qu'ils soient markoviens ou non-markoviens. Pour finir, nous présentons comment il est possible d'utiliser ces modèles pour la gestion des risques de crédit. Le Chapitre 2 se concentre sur l'utilisation de méthodes d'inférence non-paramétriques pour la construction de lois d'incidence en assurance dépendance. Puisque plusieurs causes d'entrée sont susceptibles d'intervenir et d'intéresser les actuaires, nous nous concentrons sur une méthode utilisée pour l'estimation de modèles multi-états markoviens en temps continu. Nous comparons, dans un second temps, ces estimateurs à ceux utilisés classiquement par les praticiens tires de l'analyse de survie. Cette seconde approche peut comporter des biais non négligeables car ne permettant pas d'appréhender correctement l'interaction possible entre les causes. En particulier, elle comprend une hypothèse d'indépendance ne pouvant être testée dans le cadre de modèles à risques concurrents. Notre approche consiste alors à mesurer l'erreur commise par les praticiens lors de la construction de lois d'incidence. Une application numérique est alors considérée sur la base des données d'un assureur dépendance / With the implementation of the Solvency II framework, actuaries should examine the good adequacy between models and data. This thesis aims to study several statistical approaches, often ignored by practitioners, enabling the use of multi-state methods to model and manage individual risks in insurance. Chapter 1 presents the general context of this thesis and positions its main contributions. The basic tools to use multi-state models in insurance are introduced and classical inference techniques, adapted to insurance data with and without the Markov assumption, are presented. Finally, a development of these models for credit risk is outlined. Chapter 2 focuses on using nonparametric inference methods to build incidence tables for long term care insurance contracts. Since there are several entry-causes in disability states which are useful for actuaries, an inference method for competing risks data, seen as a Markov multi-state model in continuous time, is used. In a second step, I compare these estimators to those conventionally used by practitioners, based on survival analysis methods. This second approach may involve significant bias because the interaction between entry-causes cannot be appropriately captured. In particular, these approaches assume that latent failure times are independent, while this hypothesis cannot be tested for competing risks data. Our approach allows to measure the error done by practitioners when they build incidence tables. Finally, a numerical application is considered on a long term care insurance dataset

近年來，隨著我國國民的壽命持續增長，人口老化愈加明顯。預期臺灣在2021年將進入人口零成長，2025年65歲以上人口比例也將超過20%（來源：國家發展委員會2014年人口推估）。人口老化帶來許多問題，如老年生活、醫療、以及長期照顧等需求，其中照顧需求與年齡正相關，預期需求將隨壽命延長而增加，需要及早規劃及因應，這也是今年通過長期照護法的原因。由於各國國情不同，對於長期照護的定義、補助及需求也不盡相同，有必要發展適用於臺灣特性的，推估長期照顧需求的所需之資源。重大傷病中的許多疾病與失能、甚至長期照護有關，由於全民健保實施至今已逾20年，重大傷病的認定標準及程序相對客觀、中立，受到民眾、學術、政府各界肯定。 有鑑於此，本文以全民健保資料庫的重大傷病資料庫為基礎，挑選八類引發長照的重大傷病，作為規劃長期照護保險的參考。本文以這些傷病的發生率、罹病後死亡率、罹病後存活率等，結合國發會所人口推估的結果，利用年輪組成法(Cohort Component Method)推估長期照顧的未來需求。研究發現：未來需求人口從2013年約10萬人，迅速增加至2060年的21萬人，增加速度相當快。而參考「長期照顧保險法」草案的給付內容，若聘請一名外籍看護每月20,000元計算，每人分擔將從2012年的$530元/月升至2060年的2,728元/月；若不調整保費且以隨收隨付計算，每人每月繳交400元長照保費，長照給付將從2012年每月13,353元降至2060年每月3,556元，由此可知壽命延長、人口老化將造成長照保險的財務問題。另外，本文考量的八項重大傷病較為保守，沒有加入老化、遺傳等因素的長照需求，預期將不足以因應實際需求，未來有必要引入商業保險來彌補社會保險的不足。 / In recent years, with the sustainable growth of the life expectancy in our country, population aging becomes more apparent. Taiwan’s population of ages 65 and over will exceed 20% within 10 years, before 2025. (Source: National Development Council - Population Projection on 2014). The population aging an prolonging life incurs a big demand for caring the elderly, such as the economic need after the retirement, medical cost, and long-term care. Among these needs, the demand of long term care was under-estimated and is only recognized recently. Thus, this study focuses on predicting the need of long-term care in Taiwan. Specifically, the definition and standard (as well as types and amounts of subsidy) for juding whether one needs long-terma care is not yet determined, although Taiwan’s government passed the long-term care law (Long-Term Care Insurance Law) earlier this year. We should adapt the notion of catastrophic illness (CI) and use certain CI categories, which are related to long-term care, to design the long-term care insurance. Catastrophic illness (CI) is one of the key features of Taiwan’s National Health Insurance (NHI), and the definition and process of evaluating if one is with the CI is quite complete. We choose eight categories of CI and use the NHI database to obtain their incidence rates, mortality rates, and survival probability. Together with the population projection from National Development Council in 2014 and the cohort component method to predict the long-term care demand in Taiwan. The syudy result shows that the population needing long-term care will rise from about 100 thousands in 2013 to about 210 thousands in 2060. Moreover, if the long-term care insurance is funded via pay-as-you-go, the individual premium required will rise 5 times from 2012 to 2060. This indicates that the long-term care might be too expensive and the commercial insurance can play an important role as a supplement.

This research provides a comparative study of the Japanese and German nursing home sectors. Faced with aging populations, both countries share similar long-term care policies based on social insurance. However, descriptive statistics indicate significant differences in the outcomes and costs in their respective nursing home sectors. This research aims to identify the reasons for this state of affairs by examining demographic and policy differences between the two countries. To shed light on the subject from multiple angles, we conduct three types of empirical analysis—regression, the Blinder-Oaxaca decomposition, and data envelopment analysis—on regional data from the past decade. Our findings indicate that the different outcomes are driven by both demographic and policy differences where policy relates to long-term care as well as to additional welfare aid. In terms of policy, a key difference is found in the designs of the welfare programs for low-income elders. In Germany, our results are consistent with moral hazard due to the generous design of the welfare program, while in Japan, our results do not indicate moral hazard, which may be due to strict nursing home admission rules for welfare recipients.

No description available.

在高齡少子化的浪潮下，家庭照顧機能與國家公共長照服務體系之界限逐漸浮現，不論是採稅收制或是社會保險制的國家，均紛紛發動改革，發展新型的照顧服務體系，更有效率地結合社會中各種資源，並且透過報酬支付制度的設計，回應長期照顧需求的多元性，以達成充實長期照顧服務量能、發展創新並符合在地需求之照顧服務。本文以日本介護保險制度自2000年創設以來，在服務供給體系與支付制度上之轉變作為比較對象，觀察其社會價值理念的變遷如何反應到法制設計層面，同時報酬支付制度是如何回應社會現實的需求與政策方向；擬自日本介護保險經驗中萃取值得我國參考借鑑之處，減少台灣長期照顧體系發展過程中可能產生的試誤成本。 本文首先對我國長期照顧服務提供體系之法制發展進行分析，包括釐清長照服務提供之法律關係、長照服務供給體系之構造，以及在長照十年計畫下，政府與民間服務提供者合作模式之建構等；並具體地以數份國內地方政府公布之服務提供契約範本為例，嘗試勾勒出台灣長照服務體系公私協力法律關係之圖像，同時探討我國長照服務提供體系與報酬支付制度現存之問題。 在日本介護保險制度部分，本文歸整介護保險法之制定和改革歷程及其基本構造、初探日本介護保險制度與其他社會保障制度之連動性，並集中分析其服務提供者指定制度之法制設計與問題。接著本文將對比台灣長照體系之發展軌跡與挑戰，分析台日兩國公共長照服務供給體系的幾個議題，包括：總體面的公共長照體系理念變遷、國家資源的公平分配、服務品質之管理等。最末於結論歸納日本介護保險經驗值得我國借鏡或反思之處，並簡評目前我國長期照顧服務法修正，以及長期照顧十年計畫2.0之內涵，是否足以回應社會中的長期照顧需求，並有助於實現在地老化之理想。