A comparison between LTC in Japan and Sweden in terms of population, needs, provided services and costs Marten Lagergren Noriko Kurube Yasuhiko Saito Presentation at the REVES conference in Singapore June 4, 2015

The system of long-term care of the elderly in Japan A National Long-Term Care Insurance system financed by premiums was introduced in Major reform in 2005 in order to curb cost increase Traditional emphasis on long-term care in hospitals – now more services in the community and in nursing homes Many elderly persons live with their children - emphasis on relief support

The system of old age care of the elderly in Sweden Social services are provided by the municipality in ordinary or special housing. Health care mainly provided by the country council. Financing by taxes. Many elderly live alone – but with help from their children Principle of ‘Aging in place’ – support in order to be able to continue independent living

Assessment of aged care needs in Japan Very formal assessment of needs through detailed questionnaire and computer calculation. According to law only personal dependency should form basis of decision.

Assessment of aged care needs in Sweden Informal assessment by care managers in the municipality According to the law the entire life situation of the old person should be taken into consideration Detailed decision concerning type and amount of services

Allotment of services in Japan The assessment results in an allotted care level – actual content within that level is decided by the old person in co-operation with a care manager Fairly high co-payments (10%) result in relatively low uptake of services in relation to the allotted care level (40%)

Allotment of services in Sweden Large differencies between municipalities when it comes to coverage and amount of allotted services Very low co-payments – average 4%. High uptake of allotted services Actually executed services may differ from decided

Costs for LTC depend on Population size Needs of support by age-group and gender Level and mix of services by needs Costs by level and mix of services A comparative analysis of LTC costs in Japan and Sweden 2000 – 2010 has been made by decomposing the costs along these lines

Data sources: Needs by age-group and gender Japan: ADL-dependency by age-group and gender according to five waves of the NUJLSOA-study, In total obs. Sweden: Index of ill-health (self-rated, GALI, mobility limitations and chronic disease) by age-group and gender according to three waves of the Swedish Survey of Living conditions (SSLC), In total obs.

Data sources: Provided services by needs Japan: Data from registrations in the LTC insurance system in nine municipalities, , connecting provision of services to functional limitations, in total obs. Sweden: Data collected for the purpose of tax equalisation in eight municipalities (The ”field surveys”) connecting provision of services to level of ill-health, in total around obs.

Number of persons 65+ by age-group, Japan , milj.

Number of persons 65+ by age-group, Sweden , 1000nds

Proportion of dependent by age-group, Japan, , percent

Prevalence of ill-health by age-group, Sweden,

Provision of home-based LTC by level of dependency, Japan s years No or slight dependency0,9%1,5%1,4%1,3% Dependent38,8%55,1%62,5%69,6% All2,2%3,0% 2,8% years No or slight dependency5,2%8,2%7,5% Dependent42,6%60,6%66,9%72,6% All9,2%13,2%13,0%13,2% 85- years No or slight dependency13,6%24,2%21,5%25,1% Dependent42,5%53,6%58,6%62,0% All23,2%34,4% 38,1% All age groups No or slight dependency3,1%5,6%5,1%5,7% Dependent41,7%56,5%62,3%66,7% All 6,5% 10,0%10,1% 11,0%

Provision of institutional care by level of dependency, Japan years No or slight dependency0,1% 0,0% Dependent15,0%16,1%17,4%15,8% All0,6%0,5% 0,4% years No or slight dependency0,7%0,4%0,3%0,2% Dependent25,3%26,1%26,9%25,0% All3,3%2,9%2,6%2,3% 85- years No or slight dependency2,6%2,5%1,2%1,0% Dependent35,4%35,3%37,6%31,4% All13,4%13,9% 11,7% All age groups No or slight dependency0,5%0,4%0,2% Dependent26,9%28,5%30,3%27,1% All 2,7% 2,9%2,8% 2,5%

Provision of LTC in Japan by level of dependency, Japan years ADL-independent1,0%1,6%1,4%1,3% ADL-dependent54,7%70,8%78,9%78,5% All 2,7%3,5% 3,2% years ADL-independent5,9%8,6%7,8% ADL-dependent66,1%83,1%89,7%90,1% All12,5%16,1%16,0%15,5% 85- years ADL-independent15,6%25,5% 21,7%25,1% ADL-dependent84,7%97,7%100,0% All36,6%48,3% 49,8% All age groups ADL-independent3,6%6,0%5,4%5,8% ADL-dependent70,4%87,1%94,6%93,4% All 9,2% 12,9% 13,6%

Provision of home-based LTC by level of ill-health, Sweden years No to moderate ill-health2,2%1,8%2,3% Severe ill-health10,7%8,6%8,4% All3,1%2,5%2,4% years No to moderate ill-health10,3%9,7%9,5% Severe ill-health20,0%19,3%21,7% All12,5%11,1%11,8% 85- years No to moderate ill-health5,7%5,6%5,4% Severe ill-health34,9%33,4%36,8% All34,4%31,5%32,4% All age groups No to moderate ill-health8,3%7,6%7,5% Severe ill-health21,9%20,8%22,2% All 10,9% 9,9% 9,7%

Provision of institutional care by level of ill-health, Sweden years No to moderate ill-health0,3% Severe ill-health4,3%6,0%8,0% All0,7%0,9% years No to moderate ill-health2,3% 2,1% Severe ill-health14,2%17,8%20,5% All4,9%5,3%5,4% 85- years No to moderate ill-health14,0%12,8%11,3% Severe ill-health40,1%42,5%44,9% All24,9%23,8%22,1% All age groups No to moderate ill-health2,4% 2,1% Severe ill-health19,2%22,3%24,1% All 5,6% 5,8% 5,4%

Provision of LTC by level of ill-health, Sweden years No to moderate ill-health2,6%2,2%2,6% Severe ill-health15,0%14,6%16,4% All3,9%3,4% years No to moderate ill-health12,6%12,0%11,7% Severe ill-health34,3%37,1%42,1% All17,3%16,4%17,2% 85- years No to moderate ill-health19,7%18,4%16,8% Severe ill-health75,0%75,9%81,7% All59,3%55,3%54,4% All age groups No to moderate ill-health10,6%10,0%9,6% Severe ill-health41,2%43,1%46,3% All 16,4% 15,7% 15,1%

Annual costs for home-based LTC by age and degree of dependency, Japan, , bill.yen Percentage increase / / / years No or slight dependency 68,6160,0133,1%138,1169,76,1%147,3% Dependent158,7312,296,8%312,2370,118,5%133,2% All227,3472,2107,7%450,2539,814,3% 137,5% years No or slight dependency193,1556,7188,2%464,5677,721,7%250,9% Dependent325,8770,8136,6%807,31076,039,6%230,3% All518,91327,4155,8%1271,81753,832,1%238,0% 85- years No or slight dependency147,7493,2234,0%408,7717,445,5%385,8% Dependent314,2940,7199,4%995,11581,468,1%403,3% All461,91433,9210,4%1403,82298,860,3% 397,7% All age groups No or slight dependency409,41209,8195,5%1011,31564,929,3%282,2% Dependent798,72023,7153,4%2114,63027,649,6%279,1% All1208,13233,5 167,7% 3125,94592,4 42,0%280,1%

Annual costs for institutional care by age and degree of dependency, Japan, , bill. yen Percentage increase / / / years No or slight dependency40,133,3-16,9%17,55,8-82,6%-85,6% Dependent257,8263,52,2%217,6218,3-17,2%-15,3% All297,8296,8-0,3%235,0224,1-24,5%-24,8% years No or slight dependency148,0 135,6-8,4%62,351,0-62,4%-65,5% Dependent731,4909,324,3%754,8885,2-2,7%21,0% 9ll879,41044,918,8%817,1936,2-10,4%6,5% 85- years No or slight dependency147,9193,931,1%70,790,6-53,3%-38,8% Dependent1094,31541,840,9%1384,51711,711,0%56,4% All1242,01735,739,7%1455,31802,33,8%45,1% All age groups No or slight dependency336,0362,88,0%150,4147,4-59,4%-56,1% Dependent2083,42714,630,3%2357,02815,23,7%35,1% All2419,43077,4 27,2% 2507,42962,6 -3,7%22,5%

Annual costs for LTC by age and degree of dependency, Japan, Percentage increase Percentage increase / / / years No or slight dependency108,7193,377,8%155,5175,5-9,2%61,5% Dependent416,4575,738,3%529,7588,42,2%41,3% All525,1769,046,4%685,3763,9-0,7%45,5% years No or slight dependency341,1692,3102,9%526,8728,75,3%113,6% Dependent1057,11680,058,9%1562,11961,216,7%85,5% All1398,32372,469,7%2088,92690,013,4%92,4% 85- years No or slight dependency295,6687,0132,4%479,4808,017,6%173,3% Dependent1408,52482,576,2%2379,73293,232,7%133,8% All1704,13169,586,0%2859,14101,229,4%140,7% All age groups No or slight dependency745,41572,6111,0%1161,71712,28,9%129,7% Dependent2882,14738,364,4%4471,65842,823,3%102,7% All3627,56310,9 74,0% 5633,37555,0 19,7%108,3%

Annual costs for home-based LTC by age and level of ill- health, Sweden, , mill. SEK Perc. increase Perc. increase / / / years No to moderate ill-health ,0%236329,4% 15,1% Severe ill-health ,0%197011,2% -11,1% All ,7%433220,4% 1,5% years No to moderate ill-health ,8%55564,9% -7,4% Severe ill-health ,2%58133,4% -16,4% All ,8%113684,1% -12,3% 85- years No to moderate ill-health ,5%720613,9% 19,0% Severe ill-health ,5%78121,2% -7,5% All ,1%150186,9% 3,6% All age groups No to moderate ill-health ,7% ,5% 7,2% Severe ill-health ,2%155943,2% -11,5% All ,0% ,5% -3,2%

Annual costs for institutional care by age and level of ill- health, Sweden, , mill.SEK Perc. increase Perc. increase / / / years No to moderate ill-health ,9%1623-0,4% 12,4% Severe ill-health ,3%451246,4% 95,2% All ,5%613530,2% 63,3% years No to moderate ill-health ,7% ,6% -8,1% Severe ill-health ,2%140183,5% 11,0% All ,6% ,5% 4,0% 85- years No to moderate ill-health ,2%134355,3% 16,0% Severe ill-health ,0%250320,9% 4,9% All ,0%384672,4% 8,5% All age groups No to moderate ill-health ,7% ,5% 7,2% Severe ill-health ,8%435625,1% 12,2% All ,1% ,2% 10,5%

Annual costs for LTC by age and level of ill-health, Sweden, , mill.SEK Perc. increase Perc. increase / / / years No to moderate ill-health ,2%398515,3% 14,0% Severe ill-health ,2%648233,5% 43,2% All ,6% ,0% 30,5% years No to moderate ill-health ,9% ,1% -7,8% Severe ill-health ,2%198303,5% 1,2% All ,9%320030,5% -2,4% 85- years No to moderate ill-health ,2%206418,2% 17,0% Severe ill-health ,7%328440,9% 1,6% All ,4%534853,6% 7,1% All age groups No to moderate ill-health ,6%367994,4% 7,2% Severe ill-health ,2%591564,6% 4,8% All ,1% ,5% 5,7%

Conclusions 1 Japan and Sweden have somewhat different growth patterns regarding the elderly population. In Japan most rapid increase for the oldest old 85+, in Sweden for the younger old. In both Japan and Sweden prevalence of dependency/ill-health by age-group is reducing but patterns differ. In Japan the younger old are getting more independent, in Sweden the oldest old. Provision of services follows need in both countries. In Sweden the provision in relation to need was stable, in Japan it increased for home-based care and decreased for institutional care.

Conclusions 2 Rate of increase in the period was much slower in Sweden than in Japan. This reflects that Japan and Sweden are in different phases with regard to the development of the LTC system. The more rapid cost increase in Japan may also indicate that cost increase control is much harder to achieve in an insurance-based system than in a tax- based. Japanese cost increase slowed down after the 2005 reform pointing at some success. However, cost increase was still much more rapid than in Sweden. In Japan home-based LTC took a much higher proportion of total LTC costs in 2010 than in In Sweden the proportion stayed more or less the same. The most rapid cost increase in Japan was recorded for persons above 85 with no or slight ADL-dependency. This may reflect changing household patterns.

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