1. SHA based National Health Account Hiroyuki SAKAMAKI, MBA Institute for Health Economics and Policy (IHEP) Tokyo, Japan Meeting of Experts in National Health Accounts Organisation for Economic Co-operation and Development (OECD) Directorate for Employment, Labour and Social Affairs Chateau de la Muette, Paris, 27-28 October 2003

2. SHA Member Manabu YAMAZAKI Koki HAYAMIZU Sumie IKEZAKI Masahiro TASHIMA

3. Outline of Presentation Overview of the NHA estimates in 2000 LTC System and Estimating Expenditure of LTC Key Issues

4. Trend of National Medical Expenditure (NME) 0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 19901991199219931994199519961997199819992000 Bio Yen Shifted to LTC

5. The Structure of National Health Accounts (Billion Yen, 2000) (Billion Yen, 2000) Total Expend. on Health 39,534 Total Expend. on Health 39,534 Current Expend. 37,306 Current Expend. 37,306 Investment 2,227 Investment 2,227 Personal Expend. 35,283 Personal Expend. 35,283 Collective Expend. 2,022 Collective Expend. 2,022 Prevent. & Public Health 1,165 Prevent. & Public Health 1,165 Admin. &Insurance 875 Admin. &Insurance 875 Medical Services 27,724 Medical Services 27,724 Medical Goods 7,559 Medical Goods 7,559

6. LTC Welfare services NME as currently defined. HC.7 Indirect NME as currently defined. Administration of health insurance system HCR.1 Public expenditures on medical institutions. Subsidies, Public payments, etc. Spending on medical-related services HC 6 Preventive health and health Promotion Medical services OTC drugs,Private-duty nursing,etc. Medical-related services Personal dental services, Special meals,etc. HCR. Sub-systems supporting the medical system education, R&D, etc Structure of SHA Personal Expenditure

7. Estimation in 2001 is tentative data Trend of Personal Health Expenditure and NME

8. Current Expenditure by Function 247 (0.7%) 269 (0.7%) 343 (0.9%) 857 (2.3%) 1,165 (3.1%) 3,517 (9.4%) 7,216 (19.3%) 23,691 (63.5%) -5,00010,00015,00020,00025,000 HC.4 Ancillary services to health care HC.2 Services of rehabilitative care HC.5.2 Therapeutic appliances and other medical durables HC.7 Health administration and health insurance HC.6 Prevention and public health services HC.3 Services of long-term nursing care HC.5.1 Pharmaceuticals and other medical non-durables HC.1 Services of curative care Bil Yen 2000

9. Current Expenditure by Financing 124 (0.3%) 593 (1.6%) 4,518 (12.1%) 6,570 (17.6%) 25,501 (68.4%) -5,00010,00015,00020,00025,00030,000 HF.2.2 Private insurance enterprises HF.2.5 Corporations HF.1.1 General government excluding social security funds HF.2.3 Private household out -of-pocket expenditure HF.1.2 Social security funds (Billion Yen, 2000)

10. Current Expenditure by Provider 93 (0.3%) 247 (0.7%) 857 (2.3%) 1,088 (2.9%) 1,165 (3.1%) 2,559 (6.9%) 4,566 (12.2%) 7,860 (21.1%) 18,871 (50.6%) -5,00010,00015,00020,000 HP.3.6 Providers of home health care services HP.3.9 Other providers of ambulatory health care HP.3.9.1 Ambulance services HP.6 General health administration and insurance HP.2 Nursing and residential care facilities HP.5 Provision and administration of public health programmes HP.3.2 Offices of dentists HP.4 Retail sale and other providers of medical goods HP.3.1 Offices of physicians HP.1 Hospitals Bil Yen, 2000

11. LTC System and Estimating Expenditure of LTC -Long Term Care-

12. Public Long Term Care Insurance Act In effect since April 1, 2000. To allow those in need of care and support to lead their daily lives as independently as possible making use of the capabilities. To provide long term care by integrating health, medical care and welfare services as select by the user.

13. Medical insurers Mechanism of LTC Insurance System No.1 Insured (65 and over) No.2 Insured (from 40 to 64) municipalities Deducted from pension Social Insurance Medical Care Fee Payment Fund Premiums of elderly (17%) Premiums of non-elderly (33%) Public expenditure State (25%) Prefecture (12.5%) Municipality (12.5%) Prefecture Federation of National Health Insurance Associations Premiums Lump-sum paymentNational pool Transfer Premiums 30% 70% Aid to municipality Examinations, payments,etc.

14. Domiciliary Service Home-visit services Home-visit services Home help service / Bathing service / Nursing / Home rehabilitation Short-term stay services Short-term stay services Day service (at day care center) / Outpatient rehabilitation (at medical care facility) / Short stay therapy / Group therapy to counter dementia (home for senile dementia patients) / Long term care for residents of special facilities Others Others Home treatment management and guidance / Leasing of welfare appliances/Provision for purchase of home care welfare appliances / Provision for home improvements associated with care / Home help service support

15. Facility Services Long Term Care Welfare Facilities for the Elderly (Special Nursing Homes for the Elderly) Long Term Care Health Facilities for the Elderly (Facilities of Health Care Services for the Elderly) Long Term Care Medical Treatment Facility Medical treatment beds Beds for treatment of senile dementia Long Term Care strength building hospital

16. LTC Services include SHA and Categories by ICHA-HC home-visit nursingHC.3.3 long-term nursing home care home-visit rehabilitationHC2.4 rehabilitative home care commuting rehabilitation servicesHC.2.2 rehabilitative day care medical care service through a short-term stayHC.3.1 long-term nursing in-patient care management guidance for in- home careHC2.4 rehabilitative home care health care facility services for the elderly requiring long-term careHC.3.1 long-term nursing in-patient care sanatorium type medical care facility services for the elderly requiring careHC.3.1 long-term nursing in-patient care

17. Types of Institutes providing LTC and SHA categories by ICHA-HP Long term care welfare facilities for the Aged [ LTCW ] Not Appreciable Not Appreciable Long term care health facilities for the Aged [LTCH] HP.2 HP.2 nursing and residential care facilities Long term care medical treatment facilities [LTCM] Medical treatment beds HP.1 HP.1 Hospital Beds for treatment of senile dementia HP.1 HP.1 Hospital LTC strength building Hospital HP.1 HP.1 Hospital GP Clinic HP.3 HP.3 ambulatory health care providers Dental Clinic HP.3 HP.3 ambulatory health care providers Home visiting nurse station HP.3 HP.3 ambulatory health care providers

18. LTC Services by Function and Providers HP.1 Hospital HP.2 Long term care health facilities HP.3 ClinicHome visiting nurse station HC 2.2 commuting rehabilitation services HC 2.4 home-visit rehabilitation HC 2.4 management guidance for in-home care HC 3.1 medical care service through a short-term stay HC 3.1 health care facility services for the elderly requiring long-term care HC 3.1 sanatorium type medical care facility services for the elderly requiring care HC 3.3 home-visit nursing

19. LTC funding HF.1.1.3 Municipalities (12.5%) HF.1.1.2 HF.1.1.2 Prefecture (12.5%)HF.1.1.1 State (25%) HF.1.2 Social Security Funds (50%) HF.2.3 HF.2.3 Out of Pocket Public Expenditure Insurance Premium

20. Personal Expenditures for Medical Care and LTCs Billion Yen, 2000

21. LTC Expenditure by Providers Billion Yen, 2000

22. LTC Expenditure by financing Billion Yen, 2000

23. Key Issues. Expenditure for amenities, advanced med care (ie. ESWL) HC.2.3 Non-Insured Acupuncture and JUDO reposition. HC.6Educational interventions for health promotion. Expenditure for the public health center admin. HC.7Expenditure for the general government admin. HCR.1 Capital investment for specialized hospitals. HCR.2,4-7 Not available. Items those are not counted in the National Expenditure on Health by SHA definition due to lack of data. Following data are NOT available, therefore cause for underestimation:

24. Conclusion The total expenditure on health in Japan 2000 is about 700 billions of Yen (22%) higher than the value based on the National Medical Care Expenditure In 2000, 293,916 Yen per capita – that is 7.3 % of GDP – were spent on total expenditure on health. Public funds financed 80% of the total expenditure. Between 1996 and 2000, the growth of total expenditure on health varied between 1.5% (1996/1997) and 4.4% (1999/2000) per year.

25. Thank you for your attention Tea Ceremony Kimono Kinkaku-Ji:The Golden Temple