Integration of Medical Care and Endowment：A New Exploration of Endowment Mode in the Context of Population Aging

Xinpeng XU，Xiaopeng FU

School of International Business，Research Center for International Business and Economy，Sichuan International Studies University，Chongqing 40004，China

1 Introduction

China is entering into rapid development stage of population aging.Endowment and medical care become pressing problems to be solved.The population base of Chinese elderly people is large and the growing speed is high.What's worse，their overall health condition is not optimistic.Morbidity rate of chronic diseases，number of cases per capita，limitation rate of activity and incidence of disability are higher than the world average level.In size，the population of elderly people reached 23 million in 2013 and the population of disabled elderly people grew to 37.5 million；in structure，chronic disease elderly people and empty-nested elderly people exceeded 100million.Due to a lower mortality rate and the one child policy，as well as accidental death of children，elderly people without children or losing the only child are more and more，and diagnosis and treatment pressure of hospitals and parent support pressure also constantly increase.

These indicate China's population aging takes on following characteristics：large population base，rapid aging，and rapid increase of disabled elderly（those who can not take care of themselves）.In this situation，China's current elderly service system already fails to satisfy dual demands of endowment and medical care.Therefore，it is required to combine medical care and endowment institutions and establish and improve combined endowment and medical care service mode.

2 Current situations of endowment and medical care of the elderly in China

2.1 Difficult to seek medical adviceWith the advent of aging society，absolute population of the elderly rises and difficult to seek medical advice becomes their major metal suffering.The elderly are weak in health and their diseases are difficult to diagnose and treat.Endowment institutions generally provide life care due to financial，personnel and organization factors.Some well equipped institutions just have simple medical facilities.Most institutions do not have standardized medical management team.In sum，most institutions fail to satisfy medical service demands of the elderly，and there is still a large gap in quantity compared with actual demands.

According to statistics of Ministry of Public Health，the morbidity rate of chronic diseases of the elderly older than 60 years old is3.2 times the whole population；the rate of disability of the elderly is 3.6 times the whole population；the health resources consumed by the elderly are 1.9 times of the resources consumed by the whole population.The morbidity rate of the elderly is high，most are chronic diseases，many diseases coexist together，there are complications，the state of diseases change rapidly，and many elderly people become disabled for a long time.In large medical insurance designated hospitals，elderly people move with difficulty and can not endure bump when get ill and thus need better medical care.As a result，the sick elderly people occupy sick beds for a long time.Some elderly people stay in hospitals for years and take hospitals as nursing home.

2.2 High vacancy rate of beds in nursing home and shortage of sick bedsBy the end of 2012，China had 42 000 adopting welfare institutions and 2.954 beds，increasing 16.9%compared with the same period of last year.They adopted the elderly，disabled and orphans for 2.088million yuan，10.4%higher than the same period of last year.There were 23 000 welfare enterprises，dropping 0.7%compared with the same period of last year［2］.Even so，one third beds in nursing homes are still not fully and effectively used，showing higher vacancy rate of beds.In Zhengzhou City，all endowment institutions have 5 000 beds，about 1 200 beds are vacant（the vacancy rate higher than 30%），most apartments for the elderly people are＂hungry＂.In Wuhan，existing 140 endowment institutions have more than 10 000 vacantbeds.In Shenzhen，the largest private nursing home，Shenzhen benevo-lence nursing home RENDA，provides 500 beds，but it has suffered losses for 4 consecutive years.At present，there are 100 vacant beds in RENDA nursing home.Hong Kong Jockey Club Shenzhen Society for Rehabilitation Yee Hong Heights can hold 300 old people，but only 110 old people stay，the vacancy rate is up to two thirds.Besides，hospitals are short of sick beds because many elderly people occupy sick beds for a long time.This forms a sharp contrast of high vacancy rate of beds in nursing homes.Reasons for the above situations include high bed and nursing charges，profound influence of traditional family endowment mode，low comprehensive ability of nursing staff in nursing homes，as well as simple and crude medical facilities.

2.3 Great pressure of children for supporting parentsFamily endowment is a tradition in China，but such tradition is changing with aggravation of population aging，increase of population mobility，and changes of peoples' ideas，and functions of the family endowment are obviously weakening.Many elderly people have several kinds of diseases，they are not immune to diseases，their living quality is low and some have serious physical and psychological disorder.However，in rapid life and work style of modern society，their children have little time to care for them.At present，there are 162million old people in China，accounting for 12.79%of the whole population.On average，7 to 8 people care for one old person.According to estimation，by2020，there would be 248 million elderly people older than 60 years old，accounting for 17%of the whole population（on average，4 to 5 people will support one old person）；by 2050，less than 3 people will support one old person.In some only-child families，such situation will be quite prominent.A young couple will have to support4 or6 elderly people and one child［3］.Such unbalance is deteriorating and gradually becomes heavy burden of families and huge pressure of the society.According to statistics of National Health and Family Planning Commission of the People's Republic of China，the only child quantity is near 100 million and the endowment problem approaches to the parents of earliest generation only-child.

In sum，the above＂separation of medical care and endowment＂mode leads to un optimistic prospect of living guarantee of the elderly（especially disabled elderly）and social welfare undertaking.When they can not take care of themselves，they fail to be treated effectively in time，and they have to move to and fro between houses，hospitals and endowment institutions，which not only delays the treatment，and increases costs，but also increases family burden.Through analysis of current situation，it is easy to find that the elderly people are difficult to seek medical advice，vacancy rate of the nursing homes is high，hospitals are overcrowded，and the problem of occupation of beds is prominent.These problems are closely interrelated.To cope with these problems，we should take full advantage of resources，make optimum allocation，and combine medical institutions and endowment organizations.This not only solves basic problem of seeking medical advice，but also alleviates the problem of overcrowded hospitals，reduces great pressure of occupation of sick beds，to realize winwin of three parties.

3 Feasibility analysis of the integration of medical care and endowment by SWOT method

3.1 Strengths of the integration of medical care and endowmentIn traditional endowment mode of China，medical institutions and endowment organizations are independent from each other and have own system.As a result，when the elderly can not take care of themselves，they fail to be treated effectively in time，and they have to move to and fro between houses，hospitals and endowment institutions，which not only delays the treatment，and increases costs，but also increases family burden［5］.Relevant data indicate that medical care and nursing demands are the most essential and fundamental demands of the elderly.Zhu Baoanet al.surveyed 2 196 old people through questionnaire.In the questionnaire，＂difficult to seek medical advice＂is the biggest worry of the elderly people，accounting for 56.7%of all respondents（as shown in Fig.2）.There are few special hospitals for diseases of the elderly people and common diseases of some elderly people fail to be treated promptly and effectively［6］.In comparison，the integration of medical care and endowment mode is a new endowment mode in the context of population aging.Specifically，it integrates medical care，health care and endowment，combines products and services（as shown in Fig.3），it is a complete system covering whole life cycle，and it can adapt to social changes and satisfy demands of the elderly people.In addition，through pilot projects in many areas of the whole country，this mode has received concern and high opinion of social circles.For example，Qinggang Nursing Center in the First Hospital Affiliated to Chongqing Medical University［4］not only starts the practice of public hospitals marching into the endowment field，but also proves strengths of the integration of medical care and endowment mode.

3.2 Weaknesses of the integration of medical care and endowmentOn the whole，compared with developed countries，China is faced with dual selection and pressure of realizing sustainable economic and social development and ensuring happiness of the elderly people.Firstly，financial burden of the state is heavy.China has a big pension gap，but the project of integration of medical care and endowment is great.It lasts a long time and needs large fund，so it brings heavy burden for current financial situation of China.Secondly，the family burden is great.For individual families，the integration of medical care and endowment is not general and needs high family income.However，most families in China are＂421＂structure.With aging parents and young children，most families have great pressure of medical care and endowment.

3.3 Opportunities of integration of medical care and endowmentChina enters the stage of population aging in the situation of getting old before getting rich.The whole society is not well prepared in economy，organization and management.Medical care and endowment resources are inadequate，the distribution is not balanced，and structure and function are imperfect.In consequence，it leads to demands of the elderly people for medical care and nursing failing to be satisfied，so the social endowment becomes an urgent and hard undertaking.On the one hand，from service functions of communities and nursing homes，most endowment service institutions and communities lack medicines.Once the elderly people get ill，improper treatment may lead to danger.On the other hand，from service functions of medical institutions，most hospitals do not have such service item.For large hospitals，building endowment wards is waste of limited medical resources.For small hospitals，especially those township hospitals without enough patients，implementation of＂endowment through medical care＂can attract some elderly people，and alleviate the situation of difficulty in development due to limited medical level，insufficient patients，idle manpower and wards.Besides，most elderly people in nursing homes are weak and ill.Through cooperation with township commune hospitals，it is able to provide convenient medical services，increase reception of patients of township commune hospitals，and improve competitiveness of nursing homes.Thus，it is win－win result.The integration of medical care and endowment is the product of foreign advanced endowment security system combined with national conditions of China.It indicates characteristics of China，and it is perspective and practical.It can fundamentally solve elderly people's difficulty in movement and employment and reduces great pressure of children.

3.4 Threats of the integration of medical care and endowmentThe integration of medical care and endowment starts later and the system is not mature.Compared with traditional endowment mode，it needs higher cost and medical care personnel should have high quality.However，China is lack of specialized nursing people and the gap between rich and poor is high in north and south.Also，families willing to consume and having ability to consume are few.Therefore，in fund，personnel and market，this mode is faced with great threats and challenges.

From the above analysis，the current social endowment undertaking remains the transition stage from family endowment to social endowment.In this process，introduction of＂integration of medical care and endowment，and constant care＂is helpful for gradually solving various problems resulted from the population aging，reducing burden of children，and making children better serve the society and make more contribution to the society.

4 Specific recommendations

4.1 Establishing long-term medical service stationsMedical service functions of traditional endowment institutions are considerably weak，while the elderly patients need long time of treatment，nursing，and recovery period.Many elderly patients with chronic diseases occupy large hospitals to receive better medical services，leading to waste of medical resources to some extent.It is recommended to establish long-term medical service stations，for example，medical care type nursing homes.Hospitals establish long-term cooperative mechanism with nursing homes and combine medical care and endowment.Hospitals can go to nursing homes to examine physical condition of the elderly people.When the elderly people in nursing homes catch serious diseases and need further treatment，ambulance awaiting orders around the clock will send them to cooperative hospitals immediately and related departments provide sick beds unconditionally，to ensure safety and health of the elderly people.In this way，the elderly people not only enjoy endowment services，but also obtain medical security.Besides，it increases occupancy of nursing homes，reduces their occupation of sick beds in large hospitals，alleviates the problem of short sick beds，and realizes optimum resource allocation.

4.2 Clear labor division of civil administration，geracomiums and medical institutionsHealth，civil administration，labor and social security departments should strengthen horizontal connection，break the barrier between different departments，and provide policy support for medical and endowment institutions operating in the way of integrating medical care and endowment.Besides，they should provide assistance in financial input and site distribution，as well as establishment and standardization of systems.In addition，they should guide and encourage medical and endowment institutions to operate with the concept of integrating medical care and endowment，to make elderly people obtain better care，health guardianship，and medical treatment，or even palliative care，and to realize win-win of economic and social benefits.At the same time，integrating the reform of endowment insurance and medical insurance system，incorporating the integration of medical care and endowment into designated hospitals，and strengthening supervision，will be favorable for organic combination and reasonable use of pension fund and medical insurance fund，making the elderly people enjoy basic endowment and medical services in advance，and reducing burdens of society，companies，and families.Related medical institutions should actively cooperate with nursing homes and geracomiums，establish health archives for each elderly person，regularly arrange free patrol diagnosis for the elderly people，including testing blood pressure，examining functions of heart and lungs，health consultation and psychological counseling，to know latest physical conditions of the elderly people in time.Nursing homes and geracomiums can provide excellent and comfortable convalescent environment，better nursing service，and specialized medical security，which realizes seamless connection of medical care，recovery nursing，and endowment，and provides the elderly people with safe and comfortable convalescent environment.

4.3 Strengthening construction of endowment talent teamsCaring disabled elderly people is a long and arduous work，including daily life，medical care matters，or even alleviating worries of the elderly people.The construction of endowment talent teams is the foundation of development of the endowment industry.Without specialized endowment talents，there will be no healthy and perfect endowment market.Overall advance of the construction of talent teams must（i）establish training base of endowment attendants.It is recommended to provide proper training for corresponding personnel and formulate a series of standardized system，such as lecture，practice and examination，and strictly require going to post with certificate according to national standards and market demands.（ii）Introduce specialized social services.It is recommended to develop and setup social service post，encourage social workers and university and college students to undertake endowment service works，remove difficulties and alleviate sufferings of the elderly people，and improve living conditions of the elderly people.（iii）Strengthen construction of volunteer service teams.Through dissemination and appeal，it is recommended to strengthen the volunteer service team，improve the volunteer service system，launch various public welfare activities，to provide public welfare services for the elderly people.

4.4 Reasonably determining responsibilities of families，government and societyFamily endowment is a tradition of China.But such tradition is changing with aggravation of population aging，increase of population mobility， and changes of peoples' ideas and functions of the family endowment are obviously.The endowment is not merely the internal problem of families，but a major social problem concerning people's livelihood.This means that government and society should assume more endowment responsibilities and stick to the principle of government leading and joint participation of the whole society.However，based on basic national condition of natural instincts，national tradition，and getting old before getting rich，the family endowment is still foundation of endowment.In view of these，we must clearly determine responsibilities of families，government and society，change＂family dependent endowment＂to＂family based endowment＂.Besides，we should give spiritual consolation to the elderly people and it is required to formulate that the state should establish and improve support policy for family endowment，to consolidate fundamental position of family endowment.In addition，we should further make clear and strengthen responsibilities of government and society from plan making，fund guarantee，organization and coordination，policy support，propagation and education，social insurance，social assistance，social welfare，charities，endowment service，social preferential treatment，and social development participation，and legal responsibilities.

4.5 Learning advanced experience of western endowment systemPopulation aging is a challenge faced by the whole world.Although practice of all countries depend on theoretical basis，economic and social environment，it guarantees life of the disabled elderly people's remaining years in varying degrees and conforms to demands of the population aging.When the integration of medical care and endowment just starts in China，many developed countries have entered the aging communities and have established rich and mature medical care and endowment integrated social security system for the elderly people.China should improve the endowment system，reduce pressure of society and finance，cut down unnecessary waste of resources，and take the new road of sustainable development of integration of medical care and endowment.

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