The impact of the expanded long-term care insurance out-of-pocket expenses reduction policy on long-term care and medical utilization

Abstract

Background: The expansion of the long-term care insurance (LTCI) out-of-pocket expenses (OOPs) reduction policy was implemented in August 2018 to reduce the burden of long-term care (LTC) service utilization for low-income recipients of LTCI and to broaden their coverage. As a result, the standard for reduction of OOPs, which was reduced by 50% for those in the 25% or lower income decile of insurance premiums, was expanded to 60%, and a new 40% reduction was applied to the 26−50% group. This study aims to analyze the changes in the utilization and expenses of LTC and medical services due to the expansion of the LTCI OOPs reduction. Methods: Data from the National Health Insurance Service-Elderly sample Cohort between 2014 to 2019 were used in this study. The participants of this study were LTCI beneficiaries who had the same income decile in 2017 and 2019 and used long-term care services in both years. After the implementation of the policy, it was divided into two case groups according to the reduction rate of OOPs (an additional 10% group and 40% reduction group) with a control group that did not receive OOPs reduction. The control group was selected through 1:3 propensity score matching according to gender, age, LTC grade, Charlson comorbidity index, and disability of each case group. As a dependent variable, LTC and medical services utilization and expenses were analyzed together. The study model was the difference-in-differences method (DID), focusing on the interaction terms of the case groups and control groups before and after the implementation of the policy, and the generalized estimation equation model was used as a statistical analysis method. Results: The expanding LTCI OOPs reduction policy was related to changes in the utilization and OOPs of LTC and medical services, and these changes differed depending on the amount of OOPs reduction. As a result of DID analysis, regarding LTC services, compared to each control group, the additional 10% group had a 15.7% decrease in OOPs (p<.0001), and the 40% reduction group had a 5.8% increase in LTC services utilization (p=0.0084), a 14.6% decrease in OOPs (p<.0001), and a 5.5% increase in total expenses (p=0.0077). Regarding medical utilization, only in the 40% reduction group, the total medical OOPs decreased by 20.5% (p =0.0021) and the total medical expenses decreased by 21.4% (p =0.0028). As a result of subgroup analysis, the additional 10% group decreased the length of stay (LOS) by 18.9% (p =0.0217). On the other hand, in the 40% reduction group, the number of outpatient visits increased by 9.6% (p=0.0044), outpatient OOPs increased by 11.6% (p=0.0163), and outpatient total expenses increased by 10.9% (p=0.0491). In addition, LOS decreased by 35.3% (p=0.0009), inpatient OOPs decreased by 29.3% (p=0.0025), and total inpatient expenses decreased by 27.9% (p=0.0043). In addition, there was no change in the hospitalization LOS in acute hospitals, but in long-term care hospitals (LTCHs) the LOS decreased by 30.2% (p=0.0182) in the additional 10% group and by 45.8% (p=0.0053) in the 40% reduction group compared to each control group. Furthermore, there was no change in total LTC and medical expenses, while total LTC and medical OOPs decreased by 11.8% (p<.0001) in the additional 10% group and by 17.7% (p<.0001) in the 40% reduction group compared to each control group. Conclusions: The expansion of the LTCI OOPs reduction policy reduced not only LTC services for low-income beneficiaries but also OOPs for medical services. Furthermore, the utilization of LTC services and outpatient services increased and the utilization of inpatient services decreased. However, since these effects may vary depending on the amount of OOPs reduction, it is important to consider all possible consequences of how this policy will change the utilization of LTC or medical services through various research. Under circumstances where the role of LTC services is expected to increase due to population aging, our study has made a meaningful contribution to Korea’s expansion of the LTCI OOPs reduction policy by identifying the effects of the expansion by dividing it into LTC and medical service utilization. In the future, we expect that various policy grounds for improving the economic accessibility of service utilization will be presented through active research to derive appropriate OOPs for the utilization of LTC services by low-income populations. 서론: 2018년 8월부터 노인장기요양보험 저소득층 수급자의 의료서비스 이용 부담을 줄이고 보장성 강화를 위해 노인장기요양보험 본인부담금 감경제도가 확대되었다. 이에 따라 본인부담금 감경율이 보험료 소득분위 25% 이하 군에서 50%에서 60%로 확대되었고, 보험료 소득분위 26-50%군에는 감경율 40%가 새롭게 적용되었다. 이 연구는 노인장기요양보험 본인부담금 감경제도 확대에 따른 장기요양 및 의료서비스 이용과 비용의 변화를 분석하고자 하였다. 연구방법: 이 연구는 국민건강보험공단 노인코호트 데이터베이스 2014-2019년 자료를 활용했다. 연구대상자는 2017년과 2019년의 소득분위가 동일하고 장기요양서비스를 이용한 장기요양보험 수혜자로 제도시행 후 본인부담금 감경율에 따라 2개의 실험군(추가 10% 감경군, 40% 감경군)과 감경받지 않는 대조군으로 구분하였다. 대조군은 각 실험군의 성별, 연령, 장기요양 등급, 동반질환지수, 장애여부를 고려해 1:3 성향점수 매칭으로 선정하였다. 종속변수로는 장기요양서비스 및 의료서비스의 연간 이용량과 비용을 분석하였다. 연구분석 모델은 이중차분법 (difference-in-differences)으로 제도 시행 전·후 실험군과 대조군의 교호작용항을 중심으로 확인하였으며 통계분석 방법으로 Generalized estimation equation model 을 활용하였다. 연구결과: 노인장기요양보험 본인부담금 감경제도 확대는 장기요양서비스 및 의료서비스의 본인부담금과 이용에 영향이 있었고 이러한 변화는 본인부담 감경률에 따라 차이가 있었다. 이중차분법 분석 결과, 장기요양서비스의 경우 추가 10% 감경군은 대조군에 비해 본인부담금이 15.7% 감소(p<.0001)하였고, 40% 감경군은 대조군에 비해 이용은 5.8% 증가(p=0.0084), 본인부담금은 14.6% 감소(p<.0001), 총 비용은 5.5% 증가(p=0.0077)하였다. 또한 의료서비스는 40% 감경군에서만 대조군에 비해 총 본인부담금이 20.5% 감소(p=0.0021), 총 비용은 21.4% 감소(p=0.0028)하였다. 하위 그룹 분석 결과, 각각의 대조군에 비해 추가 10% 감경군에서는 재원일수만 18.9% 감소(p=0.0217)하였고, 40% 감경군에서는 외래횟수는 9.6% 증가(p=0.0044), 외래 본인부담금은 11.6% 증가(p=0.0163), 외래 총비용은 10.9% 증가(p=0.0491)하였고, 재원일수는 35.3% 감소(p=0.0009), 입원 본인부담금은 29.3% 감소(p=0.0025), 입원 총비용은 27.9% 감소(p=0.0043)하였다. 또한 입원이용의 경우 급성기병원은 변화가 없었으나, 요양병원에서는 각각의 대조군에 비해 추가 10% 감경군은 재원일수가 30.2% 감소(p=0.0182)하였고, 40% 감경군에서는 45.8% 감소(p=0.0053)하였다. 나아가 장기요양과 의료를 합한 총 의료비용은 변화가 없었으나, 총 본인부담금은 각각의 대조군에 비해 추가 10% 감경군은 11.8% 감소(p<.0001), 40% 감경군은 17.7% 감소(p<.0001)하였다. 결론: 노인장기요양보험 본인부담금 감경제도 확대에 따라 저소득층의 장기요양서비스 뿐만 아니라 의료서비스 본인부담금이 감소하였다. 나아가 장기요양서비스와 외래서비스 이용은 증가한데 비해 입원서비스 이용은 감소하였다. 그러나 이러한 효과는 본인부담금 감경율에 따라 차이가 있을 수 있음으로 다양한 연구를 통해 본인부담 정도에 따른 장기요양 및 의료서비스 반응을 고려할 필요가 있다. 이 연구는 고령화에 따라 장기요양서비스의 역할이 더욱 커질 것으로 예상되는 상황에서 노인장기요양보험 본인부담금 감경제도 확대에 따른 효과를 장기요양 및 의료서비스 이용으로 구분하여 분석함으로서 장기요양보험 보장성 강화정책 설계에 중요한 기초자료가 될 수 있다. 향후 이 연구를 바탕으로 저소득층의 장기요양서비스 이용을 위한 적정 본인부담금 연구를 통해 장기요양 및 의료서비스 이용의 경제적 접근성 향상을 위한 다양한 정책이 마련될 수 있기를 기대한다.