Shanghai's "Ten Years of Sharpening a Sword" - Persisting in Investment to Lead the Way Nationwide

Ask AI · How can Shanghai’s assessment system improve care accuracy for elderly people with disabilities?

Starting this year, long-term care insurance (LTCI) is being rolled out nationwide. Where the funding comes from is a key focus for all parties. In this year’s central government budget, for the first time, LTCI subsidies have been included. The latest information shows that this funding has already been allocated to all regions. According to the “Plan” issued by eight departments, including the National Healthcare Security Administration, for unemployed urban and rural residents, LTCI funds are raised annually; the funding comes from individual contributions and government subsidies, with a ratio of about 1 to 1. In addition, the government also provides categorized subsidies for people with financial difficulties such as those in extreme poverty and those receiving minimum subsistence. These subsidy funds are jointly borne by the central government budget and local government budgets, and corresponding arrangements have already been made in this year’s central-to-local transfer payment budget. Going forward, as the number of insured people increases, the intensity of fiscal subsidies will continue to be increased.

In addition to the government subsidies mentioned just now, the LTCI premium rate will be uniformly controlled at around 0.3%. Taking unit employees as an example: monthly employee contributions are shared by the employer and the individual in roughly equal proportions—both at around 0.15%. Suppose an employee’s monthly income is 10k yuan; the individual pays 15 yuan per month, and the employer also pays 15 yuan. Retirees, people in flexible employment, and others also follow this premium-rate arrangement.

From a series of institutional arrangements for LTCI, it can be seen that through innovation, it directs funding and resources toward people’s health, family well-being, and related industries, alleviating ordinary people’s worries about their care. This is also the core essence of the “investing in people” philosophy. The nationwide rollout of LTCI is inseparable from the ongoing exploration by pilot cities. As early as 2017, Shanghai served as one of the first batches of pilot cities nationwide, taking the lead in stepping onto the path of exploring “LTCI,” and it remains the only city that has promoted the pilot in every district of the entire municipality. At present, Shanghai has gradually built and improved a five-part institutional system covering assessment, services, operations, payments, and supervision. Among them, the “entry gate”—that is, the LTCI assessment system—is a major highlight in Shanghai. Its conclusions are an important basis for fund payments and benefit entitlements.

Currently, Shanghai has 31 assessment institutions and nearly 7,000 assessment personnel, including 2,000 full-time A-category assessors and 5,000 community doctors. To accurately identify the people covered by the program, assessment institutions in Shanghai regularly conduct training, emphasizing “using a single ruler to measure everyone.”

Currently, Shanghai implements a dual-team model of “A-category full-time assessors + B-category community doctors.” This improves home-visit efficiency while also enabling mutual supervision, making assessments more objective and fairer. In terms of services, Shanghai has innovatively developed an LTCI nursing service system centered on nursing stations and integrating medical care and elder care. It has built an LTCI service model covering home-based, community-based, and institutional settings, providing Shanghai’s experience for nationwide rollout of LTCI.

At 2:00 in the afternoon, Knews reporter [looks on], following full-time LTCI assessor Liu Guifeng and community doctor Ye Xiaojing, they enter an elderly person’s home on Xianxia Road in Changning District. This is the third “end-of-period assessment” they conducted that day. An 76-year-old aunt has Parkinson’s disease and cannot take care of herself in daily life. Her spouse is already over eighty, and caring for her is very difficult. Fortunately, LTCI has helped a great deal—professional caregivers come by regularly to provide services, helping the aunt bathe and trim her fingernails.

According to regulations, Shanghai’s disability levels must undergo an “end-of-period assessment” once every two years. Assessor Liu Guifeng and community doctor Ye Xiaojing must, within half an hour, conduct a comprehensive assessment of the elderly person’s ability for self-care in daily life, cognitive ability, and so on. During the assessment process, the elderly person may also present situations where they do not cooperate. The assessor and community doctor must combine various details from the scene to make an overall judgment. Full-time A-category assessor Liu Guifeng is highly experienced; she has turned a set of assessment procedures into “muscle memory.” She tells the reporter, “In the course of the work, experience accumulates slowly. Maybe the older person thinks that we ask fewer questions than two years ago. Actually, in many cases, we ask a whole chain of questions.”

On Honggu Road in Changning District, an 84-year-old uncle, due to illnesses such as cerebral infarction and for many years bedridden at home, has family members who at the moment cannot find the uncle’s recent outpatient visits or hospitalization records. At this point, community doctors’ experience is even more needed for judgment. “In this medical records booklet you’ve got, the medical history is too thin.” When conducting the assessment for the elderly, Ye Xiaojing—a doctor from the community health service center on Xianxia Subdistrict in Changning District and a B-category assessor—said, “The medicines he is currently taking also show the situation of very dry stools. I’ve recorded all these illnesses for him.”

According to the “Operational Standards,” the LTCI assessment process has requirements for the timeliness of auxiliary examination records. For example, the validity period for auxiliary examinations related to chronic diseases should be within 1 month. In situations like the uncle’s, it is unavoidable that it affects the objectivity of the level evaluation. Ye Xiaojing told the reporter, “It’s possible the elderly person or the family adds that he has coronary heart disease and a cognitive impairment, but we didn’t find that he has done any relevant examinations in his medical history. That may lead to a lack of supporting evidence when we doctors evaluate him.”

If standards are the foundation for fairness, then digitalization is the magic tool for improving efficiency. Over the past years, Shanghai’s assessments have changed from the previous paper-based quality forms to “cloud-based management.” With data doing more of the traveling, both the elderly and assessors worry less. And with “online application + home-based assessment,” even elderly people who have mobility difficulties can apply without having to go themselves. They can apply through the one-network service APP. At most within 15 working days, the assessor will come to the home. For those who can’t use a smartphone, community windows and neighborhood committees can also handle the application on their behalf, truly achieving “enjoying services without leaving home.”

姚红, Director of the Benefits Protection Division of Shanghai Municipal Healthcare Security Bureau, said that at present, it is necessary to build an objective, independent, and professional socialized assessment system; continuously optimize the assessment handling standards; and with a series of measures such as standardized quality control, personnel training, and performance evaluation, ensure the system is safeguarded from the source.

As an ultra-large city with the deepest level of aging nationwide, Shanghai is not only a pioneer for LTCI, but has also accumulated core experience for this system and validated the practical value of it. During the decade of honing one sword, Shanghai’s assessment standards iterated from 1.0 to 2.0, and supervision has grown “eyes that can see a thousand miles away,” enabling every elderly person with dementia to receive precise care, and every yuan of money to be used clearly and properly. This “pioneer answer sheet” not only provides confidence to roll the system out across the country, but also reveals the underlying logic behind it—namely, “investing in people.” LTCI invests in the health and dignity of people with disabilities, especially elderly people; it invests in the stability and vitality of families; it invests in a new silver-economy track that can unlock tens of billions of yuan in funding. Use institutions to escort “dignified aging,” so that every elderly person can be treated gently in the final stretch of life. This is the most vivid footnote to “putting people at the center.”

See Knews reporter: Pan Yaoyao Chen Hongqiu Tang Xiaomeng Che Bingjian

Editor: Cheng Ying

Chief editor: Xia Xin