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

「処遇改善交付金、介護報酬に包括すべき」
清水紘氏（嵯峨野病院や京都南西病院を運営する財団法人「仁風会」理事長、日本慢性期医療協会副会長）
　居宅介護支援の利用者負担導入は、原則として大反対です。ただし、サービス利用者に対するセルフケアプラン作成援助については、地域包括支援センターが支援するという条件が付くなら、効率的な提案と言えるでしょう。
　情報公開の見直しについては、2011年度より前倒しで行うべきです。特別養護老人ホームを開設できる法人について、社会医療法人に拡大すると述べられていますが、さらに一般医療法人にも認めるべきと考えます。また、介護サービス事業所に対する指導の一部を指定法人に委託すべきという記載もありますが、委託できる内容は、ケアプランのチェックなどに限定すべきです。
　介護職員処遇改善交付金を介護報酬に包括することは大賛成です。利用者負担金等の引き上げを懸念する声もありますが、報酬で人件費をみることは当然のことです。第2号被保険者への総報酬割導入についても、必要な対策と考えます。最後に、高所得者の自己負担率の引き上げを検討すべきとする記述もありますが、それを検討するには、前提として"高所得者"の目安とされる「年金年間収入320万円以上」という基準を、さらに引き上げる必要があるでしょう。

「ペイアズユーゴー原則での議論が、社会保障費の増大招く」
小島美里氏（訪問介護サービスなどを提供するNPO法人「暮らしネット・えん」代表理事）
　介護保険部会が取りまとめた意見では、実際の部会での議論以上に、ペイアズユーゴー原則の下、議論が進められたことが強調されています。また、実際の議論では賛否両論だった居宅介護支援の利用者負担導入や、軽度者への給付削減が前面に押し出されてもいますが、それらの施策を導入すれば、ぎりぎりのラインで保険を利用している人は、必ず利用を差し控えるでしょう。家族が職を辞めて介護に専念することになれば、当然、収入が途絶え、生活が困窮します。つまり、介護保険制度改正という局地的な議論にペイアズユーゴー原則を当てはめるのは、利用の抑制を招き、生活保護など他の社会保障費の増大まで招く可能性が高いのです。意見では、こうした点への配慮が全く欠けています。
　また、小規模多機能型居宅介護に関して触れられた部分があまりにも少ないのが気になります。その一方で、24時間対応の定期巡回・随時対応型サービスやデイサービスでの宿泊サービスの導入の検討など、新たな提案ばかりが目に付きました。小規模多機能には泊まり機能も緊急時訪問もありますが、増えてはいません。今あるサービスについて方向性や課題を示さず、新しい提案を示されても、利用者も従事者も事業者も、ただ戸惑うばかりです。

「軽度者の生活援助切り捨ては言語道断」
飯塚裕久氏（小規模多機能型居宅介護を運営する「ユアハウス弥生」所長、介護職員らで組織するNPO「もんじゅ」代表）
　介護保険10年の最大の汚点は、居宅において生活をすることができなくなる仕組みを推進したことにあります。それだけに、今回の「軽度者に対する生活援助の切り捨て」は言語道断。よりよい生活援助の解禁および復活を望みます。それでも生活援助を切り捨てるというのであれば、利用者の重度化が進み、施設入所待機者はますます増えていくでしょう。それから居宅介護支援への利用者負担導入の検討については、論外としかいいようがありません。
　もう一つの問題があります。28人の部会メンバーが、財政論に巻き込まれた点です。特にペイアズユーゴー原則の下に議論を進めた点は、さらなる格差を助長する選択としか思えません。最後に、介護職員処遇改善交付金が終了した後の処遇改善についても意見が述べられていますが、利用者負担の抑制の観点から、12年度以降も交付金という形で支給されるべきです。

「政治家を交え、歳入増の議論を」
菊地雅洋氏（特別養護老人ホーム「緑風園」施設長）
　今回の部会はペイアズユーゴー原則の下で「給付と負担」ばかりが議論され、本来すべき制度設計の場になっていないという印象を受けました。財源の議論をするならば、政治家を交えて消費税の在り方などを含めて話し合うべきです。歳入増を議論することができないから、サービスを抑える案ばかりが出てくるのでしょう。
　居宅介護支援の利用者負担導入でケアマネジメントの質が上がるとの意見もありますが、とてもそうは思えません。むしろ利用者の意向に沿ったケアプランばかり作成する「御用聞きケアマネ」が増えることが懸念されます。介護職員処遇改善交付金の継続策は、介護報酬でも現行方式でも構いません。ただ、同額では定期昇給に対応できませんから、増額する必要があるでしょう。定期昇給がなければ将来設計も描けません。そんな業界に人材が集まり、質の高いサービスが提供できるでしょうか。増額は難しいでしょうが、公費負担を増やすなどの政治判断で、何とか実現してほしいところです。
　意見書では24時間対応の定期巡回・随時対応型サービスの創設が提言されていますが、むしろ、現在ある夜間対応型訪問介護を充実させるべきです。そもそも、想定される利用者の数を考えると、24時間対応の定期巡回・随時対応型サービスは大都市部でしか成り立たないのではないでしょうか。

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