ケアサポート９／ケアマネージャー（介護支援専門員）試験／ＴＯＰへ

厚生労働省は11月25日、社会保障審議会介護保険部会を開催し、11月19日の前回会議で公表した素案の修正箇所を反映した意見書案を提示し、最終的なとりまとめとして委員らの了承を得た。前回会議で日本介護支援専門員協会の木村会長をはじめとする多くの委員から激しい反発を受けた「ケアプランの利用者負担導入」は、賛否の両論を意見書に併記する形となり、結論は見送られた。

なお、ニュース末尾に掲載した報告書は、赤字が19日の前回会議で修正を指摘された箇所、網かけ青字部分が本部会で示された修正箇所となっている。
本部会以後の意見書の修正は山崎泰彦部会長（神奈川県立保健福祉大教授）に一任された。同省は、本素案をもとに法案を作成し来年の通常国会に提出する。

■意見書案に盛り込まれた主な項目
●ケアプランの作成の利用者負担の導入
・ケアマネジャーによるケアプランの作成等のサービスは、介護保険制度の根幹であり、制度の基本を揺るがしかねないこと、利用者負担の導入は必要なサービス利用の抑制により、重度化につながりかねないことなど、利用者や事業者への影響を危惧する強い意見があった。さらに、セルフケアプランが増加すれば、市町村の事務処理負担が増大することなどから慎重に対応すべきであるとの指摘があった。

・一方、制度創設から10年を経過し、ケアマネジメント制度がすでに普及・定着していると考えられること、小規模多機能サービスや施設サービスなどケアマネジメントが包含されているサービスでは利用者が必要な負担をしていること等も考慮し、居宅介護支援サービス及び介護予防支援サービスに利用者負担を導入することを検討すべきであるとの意見があった。これにより、利用者自身のケアプランの内容に対する関心を高め、自立支援型のケアマネジメントが推進されるのではないかとの考え方もある。

●高所得者の自己負担を現行の1割から2割に引き上げ　　
・19日の前回会議で年金収入320万円以上とされた所得金額は削除し「一定の所得」に。
●24時間対応の定期巡回･随時対応サービスの創設
訪問介護と訪問看護の連携の下、短時間の定期巡回型訪問と通報システムによる随時の対応。
●要支援者・軽度の要介護者にかかる給付について　　
・給付削減は適切ではない。
・介護保険制度の給付の対象外とすることや、その保険給付割合を引き下げ、利用者負担を例えば2割に引き上げる。
●処遇改善
現在実施している介護職員処遇改善交付金は平成23年度末で終了。本来的には、これを継続するのではなく介護報酬改定により対応する方向で検討していくべきである。
・平成24年度以降については当該交付金を継続すべき。
・すべて介護報酬改定で対応するのではなく、公費財源も活用しながら除々に制度内に取り込んでいくべき。
●総報酬割
現在の40～64歳が負担する第2号保険料は、その加入する医療保険の加入者数に応じて負担金が決められている。このため、総所得の高い医療保険者は低い保険者と比較して、総所得に対する介護保険料の割合が低率となっている。
・第2号被保険者の保険料について、被用者保険間の負担の公平性を図る観点から総報酬割を導入する必要がある。
・現在の介護報酬における地域係数は、都市部の介護従事者の賃金水準を反映していない。比較的所得の高い都市部の第2号被保険者に負担能力に応じた保険料負担を求めることにより、地域係数を見直し、都市部の介護従事者の賃金引き上げに充当することが必要。・一方、総報酬割の導入については、従来の保険料負担の基本的な考え方と仕組みのルールを大きく変更するものであり、十分な議論なく、財源捻出の手段として導入しようとすることに対して、強い反対意見があった。また、利用者負担の見直し等の必要な見直しを行うことなく、これを導入することについて慎重な対応を求める。
●介護施設の多床室の居住費負担
・今後、利用者負担について多床室についても、低所得者の利用に配慮しつつ、減価償却費を保険給付対象外とする見直しが必要である。
・多床室の減価償却費を利用者負担とすることについては、その居住環境を考慮し、居住費については現状の光熱水費相当を維持すべきであるとの意見があった。

閉会時に挨拶した山崎部会長は、今回まとめ上げた素案について「両論併記の色彩が強いが、現実に委員間で意見の隔たりがあることを反映している。しかし、それは各論についての隔たりであって喫緊の課題である介護職の処遇改善や人材確保などについては意見は一致している」と述べた。
また「一番紛糾したのは給付と負担のバランスだった」と振り返り、「次期改正は厳しい財政面の制約の中でやらざるを得ない。現政権が財源の裏付けのある社会保障ビジョンを早急に策定する必要がある。そのためには強い経済、強い財政、強い社会保障と並んで、強い政治的なリーダーシップが不可欠」と、菅首相のリーダーシップに期待すると語った。

同部会は、今年5月から13回にわたって審議を重ねてきたが、財源確保が見込めないことを理由に踏み込んだ改革案をひねり出すまでには至らず、できあがった意見書は給付と負担を巡る各論の調整案ばかり。高齢者の希望をかなえる制度への見直しに向け、ふさわしい内容になったかどうか、大いに疑問が残る後味の悪い幕切れとなった。

 

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