1. A comparison between LTC in Japan and Sweden 2002 -2010 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

2. The system of long-term care of the elderly in Japan A National Long-Term Care Insurance system financed by premiums was introduced in 2000. 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

3. 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

4. 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.

5. 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

6. 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%)

7. 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

8. 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

9. Data sources: Needs by age-group and gender Japan: ADL-dependency by age-group and gender according to five waves of the NUJLSOA-study, 1999 -2009. In total 19602 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), 2000 - 2011. In total 9 433 obs.

10. Data sources: Provided services by needs Japan: Data from registrations in the LTC insurance system in nine municipalities, 2001 - 2011, connecting provision of services to functional limitations, in total 81 608 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 10 000 obs.

11. Number of persons 65+ by age-group, Japan 2000 -2010, milj.

12. Number of persons 65+ by age-group, Sweden 2000 -2010, 1000nds

13. Proportion of dependent by age-group, Japan, 2000-2010, percent

14. Prevalence of ill-health by age-group, Sweden, 2000-2010

15. Provision of home-based LTC by level of dependency, Japan 2000 - 2010 s2000200520062010 65-74 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% 75-84 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%

16. Provision of institutional care by level of dependency, Japan 2000 - 2010 2000200520062010 65-74 years No or slight dependency0,1% 0,0% Dependent15,0%16,1%17,4%15,8% All0,6%0,5% 0,4% 75-84 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%

17. Provision of LTC in Japan by level of dependency, Japan 2000 - 2010 2000200520062010 65-74 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% 75-84 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%

18. Provision of home-based LTC by level of ill-health, Sweden 2000 - 2010 200020052010 65-74 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% 75-84 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%

19. Provision of institutional care by level of ill-health, Sweden 2000 - 2010 200020052010 65-74 years No to moderate ill-health0,3% Severe ill-health4,3%6,0%8,0% All0,7%0,9% 75-84 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%

20. Provision of LTC by level of ill-health, Sweden 2000 - 2010 200020052010 65-74 years No to moderate ill-health2,6%2,2%2,6% Severe ill-health15,0%14,6%16,4% All3,9%3,4% 75-84 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%

21. Annual costs for home-based LTC by age and degree of dependency, Japan,2000 -2010, bill.yen Percentage increase 200020052000/2005200620102005/20102000/2010 65-74 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% 75-84 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%

22. Annual costs for institutional care by age and degree of dependency, Japan,2000 -2010, bill. yen Percentage increase 200020052000/2005200620102005/20102000/2010 65-74 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% 75-84 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%

23. Annual costs for LTC by age and degree of dependency, Japan,2000 -2010 Percentage increase Percentage increase 20002005 2000/200 5200620102005/20102000/2010 65-74 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% 75-84 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%

24. Annual costs for home-based LTC by age and level of ill- health, Sweden,2000 -2010, mill. SEK Perc. increase Perc. increase 200020052000/2005 20102005/2010 2000/2010 65-74 years No to moderate ill-health20521826-11,0%236329,4% 15,1% Severe ill-health22151772-20,0%197011,2% -11,1% All42673597-15,7%433220,4% 1,5% 75-84 years No to moderate ill-health60015296-11,8%55564,9% -7,4% Severe ill-health69565621-19,2%58133,4% -16,4% All1295710916-15,8%113684,1% -12,3% 85- years No to moderate ill-health605763284,5%720613,9% 19,0% Severe ill-health84417721-8,5%78121,2% -7,5% All1449814049-3,1%150186,9% 3,6% All age groups No to moderate ill-health1411013449-4,7%1512512,5% 7,2% Severe ill-health1761215114-14,2%155943,2% -11,5% All3172228563 -10,0% 30719 7,5% -3,2%

25. Annual costs for institutional care by age and level of ill- health, Sweden,2000 -2010, mill.SEK Perc. increase Perc. increase 200020052000/2005 20102005/2010 2000/2010 65-74 years No to moderate ill-health1444163012,9%1623-0,4% 12,4% Severe ill-health2312308233,3%451246,4% 95,2% All3756471225,5%613530,2% 63,3% 75-84 years No to moderate ill-health720273982,7%6617-10,6% -8,1% Severe ill-health12633135417,2%140183,5% 11,0% All19835209405,6%20635-1,5% 4,0% 85- years No to moderate ill-health115781275610,2%134355,3% 16,0% Severe ill-health23874248184,0%250320,9% 4,9% All35452375746,0%384672,4% 8,5% All age groups No to moderate ill-health20224217847,7%21675-0,5% 7,2% Severe ill-health38819414416,8%435625,1% 12,2% All5904363226 7,1% 65237 3,2% 10,5%

26. Annual costs for LTC by age and level of ill-health, Sweden,2000 -2010, mill.SEK Perc. increase Perc. increase 200020052000/2005 20102005/2010 2000/2010 65-74 years No to moderate ill-health34963456-1,2%398515,3% 14,0% Severe ill-health452748547,2%648233,5% 43,2% All802383103,6%1046726,0% 30,5% 75-84 years No to moderate ill-health1320312694-3,9%12173-4,1% -7,8% Severe ill-health1959019162-2,2%198303,5% 1,2% All3279231856-2,9%320030,5% -2,4% 85- years No to moderate ill-health17635190848,2%206418,2% 17,0% Severe ill-health32315325390,7%328440,9% 1,6% All49950516233,4%534853,6% 7,1% All age groups No to moderate ill-health34334352342,6%367994,4% 7,2% Severe ill-health56431565550,2%591564,6% 4,8% All9076591789 1,1% 95956 4,5% 5,7%

27. 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.

28. Conclusions 2 Rate of increase in the period 2000 - 2010 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 2000. 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.

29. That’s all folks! Thanks for your attention!!