1. The Long Term Care Insurance [Kaigo Hoken] and its Impact on Society and Health Care System in Japan AtoZ OKAMOTO, MD, MPH National Institute of Public Health

2. Background Development Implementation Outcome Conclusions

3. Why was the LTCI developed? Rapidly aging population and growing need for LTC – Elderly population >65 will be 25% of the population Structural overhaul of the fragmented health insurance system Effective integration of medical and non-medical services

4. Structural flaws of Japan s health insurance system

5. Age distribution and health insurance status

6. Financial Redistribution Mechanism by the Elderly Health Care System [EHCS] since 1983

7. Medical vs. Non-medical Services before the LTCI Medical---health insurance and EHCS financed by premium – Not restricted by budget -> cost inflation – Dictated by doctors prescription->not need-based Non-medical---welfare system financed by tax – Restricted by budget -> frugal use of services – Restricted by income -> social stigma Result: unusual shift of LTC toward medical services – Prolonged hospital length of stay (40 days)

8. Background Development Implementation Outcome Conclusions

9. Tax vs. Premium Agreement: Create a new system rather than expanding the old one. Economists: Why not social insurance? Prime Minister Hosokawa (1994): National Welfare Tax – Ended up in fiasco and he resigned

10. Campaign for the LTCI German LTCI started in 1995 Opinion Poll-> 86% support the LTCI Conversion of the Nordic faction

11. Technical Development(1) -Need Assessment Tool Evidence-based development (one-minute time study) Methodologically similar to the U.S. MDS and RUG

12. Technical Development (2) -Care Management British Community Care Act 1990 Coordination between medical and non-medical services

13. Background Development Implementation Outcome Conclusions

14. Administrative Structure Administered by municipal governments (cities, townships and villages depending on population size) Advantage over fragmented health insurance system – Larger risk pool and more stale actuarial operation – Enabling municipal governments to develop regional, long range plans

15. Beneficiaries Covers half of the population ( as opposed to health insurance) Beneficiaries category I: aged 65 or older (17% of population) Beneficiaries category II: aged 40-64 (33% of population) Originally planned to cover 20 years or older

16. Beneficiaries and Financing

17. Need Assessment Application (a sharp contrast to health insurance) On-site survey by qualified care managers using a uniform assessment tool (73 items) Attending doctors professional opinion Preliminary assessment by computer (dismiss, borderline, level 1-5) The need assessment review committee makes final judgment

18. How the need assessment review committee altered the preliminary assessment

19. Benefit Institutional care – Geriatric hospitals (medical) – Skilled Nursing Facilities (medical) – Nursing homes (non-medical) Home care – visiting nursing, day care (medical) – home help, day service (non-medical)

20. Integration of Medical and Non-medical Services under the LTCI

21. Benefit in monetary terms according to the level of care need (unit 10-10.72 yen, subject to 10% copayment) Monthly cap for home care Per diem cost for SNF Borderline6150Not permitted Level116580880 Level219480930 Level326750980 Level4306001030 Level5358301080

22. Double Talk in Home Care The LTCI law : same kind of home care services shall be bundled under the same budgetary limit (=monthly cap) The Medical laws: medical services shall not be rendered by non-qualified personnel. They also shall be prescribed by doctors.

23. Controversy over cash benefit Whether cash benefit should awarded to family care givers who do not use external services – No!women citizen group – Yeseconomists, medical association Decision---NO

24. Background Development Implementation Outcome Conclusions

25. Boom and Bust Governments worry about shortage of services Deregulation to encourage for-profit corporations into home care industry Kaigohoken Boom Less than expected demand -> Bubble Burst

26. Saga of Nichii Gakkan (TSE quotes)

27. Service Utilization in the first year Total reimbursement:3.2 trillion yen (84% of expected) Home care vs Institutional care = 1:2 Gradual but steady increase of services

28. Service Utilization [1] Home vs. Institutional Care

29. Service Utilization [2] Institutional Care

30. Service Utilization[3] Home care

31. Growth of Elderly eligible for benefit

32. Plight of Visiting Nurses

33. Price Competition between Home Help and Visiting Nursing (price for 30min to 1 hr, unit 10-10.72 yen, subject to 10% copayment) Home Help – Chiefly domestic services->153 – Mixed->278 – Chiefly personal care->402 Visiting Nursing – Hospital or clinics->550 – Independent Visiting Nursing Stations [IVNS]->830

34. Care Managers: to whom they report? Care Managers are expected to act as an agent of clients Reality: majority of them are sales representatives of service providers Need to establish them as independent professionals

35. Background Development Implementation Outcome Conclusions

36. What have we learned? Increased awareness of people about welfare and social services Prompted a national debate over the goal to which we achieve A great social experiment to create and implement a new system A model for Asian countries to cope with aging population?