德國照護保險中的國家監督管理

State Supervision in Long Term Care Insurance in Germany

隨著人口結構高齡化，照護走向公共化成為各國重要的社會福利議題。1970年代以來，基於促進效率、滿足廣大需求及減少政府支出，社會服務走向市場化與多元化，營利與非營利組織皆能參與社會服務的準市場。但市場化容易衍生惡性競爭與品質低落的問題，因此，國家如何進行有效的監督管理成為重要議題。德國照護保險於開辦之初即納入營利與非營利組織提供照護服務，兩者占德國照護服務市場的比例極高且存在競爭，但照護市場運作仍受國家縝密與深入地監管。本研究結果發現，德國透過聯邦政府與各邦政府在照護保險的權責分工、社會保險人具有社會與國家特質的特殊公法社團法律地位，將營利組織透過組合主義的集體協商運作的自我管理機制納入國家管理，並對非營利組織提供許多競爭優勢條件，有效避免惡性市場競爭。此外，並採用健保保險人的醫事服務管理單位作為第三者，進行照護需求者的評估及照護服務的品質監督。這些特徵能有效避免聯邦政府與各邦政府在照護保險管理事項上的重複與意見衝突、使照護保險的財務運作由社會團體自決而不被民主政治過程中的輿論與政黨所左右、市場爭受到非營利組織具有競爭優勢與其他社會團體的合作協商的抗衡；此外，採用第三者進行照護需求評估與服務品質評鑑，使照護體系理性運作，讓德國的國家監督管理在其照護保險市場化成為可能且具成效。

With the wave of aging populations, long-term care service is increasingly available to the public and has become the main issue of the world's states. Since the 1970's, because of services-effectiveness and the increased demand for long-term care, social services have progressed toward marketization and diversification. Private profit and non-profit organizations participate in the quasi-market of social services. However, marketization leads to problems of vicious competition and low quality. Therefore, how can the state promote effective supervision of social services market? In Germany, for profit and non profit organizations are initially accepted as the care service providers for implementing long-term care insurance. Both profit and non-profit organizations account for a high proportion of the market of long-term care service providers, and competition exists. The results of this study showed that competition between profit and non-profit care service providers exists in the German long-term care market but is still under strict state supervision with responsibilities divided between the federal and state governments to avoid the overlap of management concerns. Participation in collective negotiation ac-cording to the role of the long-term care insurer is divided between public and private sectors to achieve the self-determination of social groups. The competitive advents for non-profit organizations; and through the health insurer as a third party to care needs are assessed and service quality is evaluated. These considerations enable the effective state supervision of care service providers in the long-term care insurance market.