「軽度化」批判で迷走 「要介護認定」

■調査項目数は74、「評価軸」など導入
　今年4月の要介護認定の見直しに向けた議論は2006年10月、厚労省の「要介護認定調査検討会」でスタートした。介護技術の進歩などを要介護認定に反映させるため、同検討会では認定調査項目の見直しを実施。06年4月以降の全82項目から、「じょくそう」や「飲水」、「火の不始末」など14項目を除外し、新たに「独り言・独り笑い」や「買い物」など6項目を追加した。
　また、コンピューターによる一次判定で要支援2と要介護1を「要介護1相当」と判定し、介護認定審査会の二次判定で分けるとしていた従来のプロセスを見直し、一次判定で要支援2と要介護1に分けることに。こうした変更点を盛り込んだ一次判定ソフトも新たに作成し、各市町村に導入した。
　さらに、同検討会とは別の場で、認定調査員テキストの見直しも進められた。厚労省は、07年度研究事業の「要介護認定調査の質向上を目途とし作成された新マニュアルと旧マニュアルとの相違に関する検討事業」で、認定調査方法を検討。この研究結果に基づき「要介護認定テキスト作成検討会」が、「能力」「介助の方法」「障害や現象(行動)の有無」の3つの評価軸を導入するなどの改訂を行った新テキストを作成した。

■新制度に批判、検証・検討会開催へ
　しかし、新方式による要介護認定には、利用者団体などから批判の声が相次いだ。「認知症の人と家族の会」は今年3月、新方式では「買い物」の項目で、無駄な買い物をしていても、商品を選んでお金を払うことさえできていれば、「できる(介助なし)」とされることなどを挙げ、「非常識だ」と批判。「介護保険を持続・発展させる1000万人の輪」も、舛添要一厚労相(当時)に対し、国民の理解が得られるまで新制度を凍結するよう求める要望書を提出した。
　施行直後の4月2日には、小池晃参院議員(共産)が参院厚生労働委員会で「厚生労働省の内部資料」を示し、厚労省が自治体に対し、要支援2と要介護1の割合を7対3にするよう指導していたのではないかと指摘。意図的な軽度化への疑いが深まる事態となり、厚労省は13日、新方式開始からわずか2週間で「要介護認定の見直しに係る検証・検討会」を開くことになった。
　同日の初会合では舛添厚労相(当時)が、更新申請者の要介護度が下がった場合、申請者が希望すれば以前の要介護度を適用できるとする経過措置を行う方針を発表。「内部資料」については宮島俊彦老健局長が、厚労省の担当者が打ち合わせで使用した資料だと認めたものの、要支援2と要介護1の割合を自治体に指導した事実は確認されなかったと説明した。

■「非該当」の割合が2倍に、テキストの項目6割を見直し
　その後、事態が動いたのは7月28日。この日の検証・検討会の第3回会合で厚労省は、4月以降の新制度で認定を受けた人の判定結果のデータを提示した。これにより、「非該当」と判定された人の割合が過去2年間の2倍以上になるなど、軽度化傾向が見られることが明らかに。また一部の調査項目について、自治体などから質問や意見が多く寄せられる事態も顕在化していたことから、厚労省は認定調査員テキストの見直しによって対応する方針を提案した。
　具体的には、「実際に行われている介助が不適切な場合は、その理由を特記事項に記載した上で、適切な介助を選択」「実際に行ってもらった状況と、調査対象者や介護者から聞き取りした日頃の状態が異なる場合は、より頻回な状況で選択」など、4つの修正方針を提示。また、「座位保持」の項目について、座位が保持できる時間の基準を1分間としていたのを、以前の基準の10分間に戻すなど、個別の調査項目についても修正を提案し、委員らに了承された。
　最終的には、全74項目中43項目について、何らかの変更が加えられることに。厚労省は改訂版テキストを8月17日に各自治体に通知した。

■改訂版テキストで開始、「非該当」への再申請勧奨も
　こうして今年10月、改訂版テキストによる要介護認定がスタート。これに伴い、経過措置も終了した。
　また、厚労省の山井和則政務官は10月1日の記者会見で、4月から新規に要介護認定を受けて「非該当」とされた人や、本人の認識よりも軽度に判定されたと苦情を寄せた人に対し、再申請や区分変更申請を勧奨するよう各自治体に求める方針を発表。こうした非該当者などが10月以降の認定でどう判定されるかについても、「12月中に取りまとめる」とした。

　改訂版テキストによる要介護認定がスタートして約3か月。7月末の検証・検討会の第3回会合では、10月以降の要介護認定の検証を行うため、検証・検討会を再度開く方針を決めている。ただ厚労省の担当者は、現段階で検証・検討会の予定は未定で、年内に開く予定はないとしている。
　10月のテキスト改訂以降、どのような判定結果が出ているのか。現場の認定調査員や審査会関係者、利用者には、どのような影響があったのか―。今後の検証作業が注目される。

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