How Has The National Policy To Prevent The Metabolic Syndrome Been Developed In The

Japanese Ministry Of Health?

-To Facilitate The Healthier Longevity Society-

At ECOSAC Regional Ministerial Meetingon Financing Strategies for Health Care

16-18 March 2009Colombo, Sri Lanka

Kiyotaka SEGAMI, M.D., Ph.D.Executive Board-Director

Welfare and Medical Service Agency The former Minister’s counsel in health

segami-k@umin.ac.jp segami200819@wam.go.jp

Aging Population

Issues

Medical Concerns –Better Health

Financial Concerns -Containment of --

Soci

al C

once

rns

-Be

tter

QO

LBusiness Concerns -

Finding Chances

Sustainability in PolicyFeeling Not Unhappy, Not in Poverty among Citizen

28 Sept 06/ Segami, K

Other ConcernsOther

Concerns

Other Concerns

Other

Concerns

Increase of medical Expenditure

Increase of Medical Expenditure of the elderly is a Major FactorAging of the populationPer Capita Medical Expenditure of the Elderly1.5 ratio of elderly to non-elderly

Large Variation of Per Capita Medical Expenditure for the elderly （ Average \750,000, Highest ： \900,000, Lowest ： \600,000 ）

Increase of Outpatient Medical Expenditure per Patient

Prevalence of Lifestyle-related Disease in Outpatient

Increase of Patients with Life Style-Related Disease due to Visceral Obesity / Adipose Tissue

Increase of Inpatient Medical Expenditure per Patient

Large number of Beds (Long Average LOS ）

Low Home Care Rate

Anal

ysis

of f

acto

rs

Depiction of Medical Expenditure GrowthDepiction of Medical Expenditure Growth

＜ Acute ＞＜ Chronic ＞

Inpatient Medical

ExpenditureO

utpatient Medical

Expenditure

Reduce the incidence of diseases

Decrease of Average Length of Stay

Home Visit for Patients with patients with duplicate care and Frequent Outpatient Visit

Containment of M

edical Expenditure Grow

thFunctional Specialization and Referral System According toAcute Phase, Rehab Phase,Nursing Care Phase and Home Care Phase of illness

Conversion of Long-termin-patients to Nursing Care

＋

Promotion of Home Care

Improvement of Residence Other than Home

Referral System at Discharge

Promotion of Terminal Care at Home

　　 Reduce Admission Rate byPreventing the occurrence of Severe Diseases

Prevention of Lifestyle-Related Diseases（ Medical Check-ups and Health Advice by Insurers etc. ）

Japanese Trial in Various Methods of Controlling Medical Expenditure

　

Control of Medical Expenditures involving All Stakeholders

・

Providers

・ Achieving Early Discharge,Reduction of he Number of Beds

・Creating Incentives for Patients to Pass Away at Home or Nursing Facilities by Improving Home Care

Insurers・ Implementing Health Checkup and

Health Education to Prevent Life-style Related Disease

NationalGovernment

Prefectures

・ Review of the universal fee scheduleto produce effective health care

・ Budgetary steps for Prefectures toguide healthcare providers

Reduce Prevalence Rate of Life-style Related Disease

Shorten average Length of Stay (LOS)

・ Guidance of Municipalities

Municipalities

Containment ofHealth Care

Expenditures

・ Promotion & Education of prevention of life-style related disease

・ Enhancing the provision of nursing care as a foundation of home care

・ Planning & implementing plan for Medical Expenditures Control, and Health Promotion Planning, Health Care Planning, Long-term Care Insurance Planning Steps for Promoting Effective Health Care

Effective Health Care・Patient

(Insured)Effort to Improve Lifestyle

Appropriate Physician Visit

Metabolic Syndrom

e

Development of Stages of Life-style Related Diseases and Medical Care Expenditure in 2004

Hypertension5,939,000 patients receive medical careMedical Exp:8 Billion USD

Diabetes2,284,000 pMed Exp:12 B USD(7,400,000 Suspected+ 8,800,000 Possible)

Cerebrovascular D.1,374,000 p Annual Death: 130,000Annual Occur: 234,000Med Exp: 17 B USD

Arteriosclerosis

Ischemic H. D.911,000 p Annual Death: 72,000Med Exp: 6.8 B USD

Hemodialysis from Renal Failure230,000 pAnnual Incr: 14,000Med Exp: 3.4 B USD

Diabetic Nephropathy

Amputation fromDiabetic NeuropathyAnn. Registry: 3,000

Vision Loss from Diabetic RetinopathyAnn. R.: 3,000

Smoking accelerates all stages of development and

more damages

Physical Inactivity Unhealthy Diet

Visceral Obesity50% / Male 40yrs+

20% / Female Sleep Apnea

(For Reference)Malignant Neoplasm1,280,000 pAnnual Death: 305,000Med Exp: 21.4 B USD

47.2 B USD

Cardiovascular/Renal Cardiovascular/Renal ComplicationsComplications

Genetic Genetic FactorFactor

HypertensionHypertension

Insulin ResistanceInsulin ResistanceRAS ActivitySNS ActivitySNS Activity

Salt Sensitivity

Salt IntakeSalt IntakePhysical InactivityPhysical Inactivity

Mental StressMental StressVisceral ObesityVisceral Obesity

Drugs Life StyleLife StyleModificationModification

Kamide K, et al.Jp Heat J 2004

(30-50% influence)

Medical Concerns on Hypertension

Numbers of Patients and Latent ones

Medical Expenditure in Future

Cost of Medical Care

Financial Concerns

Status of the paralyzed

after stroke

Status of the sight-lost

after retinal hemorrhage

Number and Status of Renal Failure and the

Dialyzed Social Concerns

PREVENTION Public Health

Approach

Status Quo: Hypertension in Japan

• Receivers of medical services– 5,939,000 are under the medical care due to

Hypertension. (2004)– 9.2% of total “receivers”

• Medical Expenditure for Hypertension – 946 BJY (=8,085 MUSD) in 2004

• 19.9% for Inpatient, 80.1% for Outpatient– 7.8% of Total Medical Expenditure (12,106 BJY)

• Latent Patients estimated– Patients are estimated 31,000,000– persons at risk are also estimated 20,000,000

• Hypertension is not only the medical issue, but also the national financial one

Health adjusted Life Expectancy and Years Lost of Life Expectancy

due to Hypertension

0.12.13.87.5Years Lost of

Life Expectancy

7.612.118.777.1Health

Adjusted LE Hypertension

7.714.222.584.6Life

Expectancy in 1995

８５ yrs７５ yrs６５ yrs０ yrsFemale

1.11.31.39.4Years Lost of

Life Expectancy

4.79.416.268.3Health

Adjusted LE Hypertension

5.810.717.677.7Life

Expectancy in 1995

８５ yrs７５ yrs６５ yrs０ yrsMale

Segami, K(2006)

Life Table Analysis of Hypertension in Female Japanese

Years of Life Lost from Hypertension is 569,237 person-years at 65yrs of

female.In other words, the differences of life expectancies are 3.8 years from 22.5

years at age 65.(From Life Table and Vital Statistics in 2000)

Age 30's 50's 60's 70's 80'sPower 5.0 Times 2.2 Times 2.1 Times 2.4 Times 1.0 Times

Power of Mortality at the age of Diagnosis of Hｙpertension

From the JAPAN DATA by Okayama et al.

By Segami, K 2006

Total measures of controlling Visceral Obesity and Diabetes and other Risk Factors will cause suppressing the Medical Expenditure for the Elderly

（ Preventive measures are effective for suppressing the Medical Expenditure of Diabetes, which will cause the complication after 25 yrs to 70% of patients.)

Threshold of onset Ri

sk F

acto

rs fo

r Ons

et (P

reve

ntab

le)

Aging

Med

ical

exp

endi

ture

per

Cap

ita

Output: Suppressing increment of ME for the Elderly

Suppressing Aggravation of Dis.

Suppressing Onset of Dis.

Health Promotion

Depiction of Medical Expenditure GrowthDepiction of Medical Expenditure GrowthNecessity of Systematic Measures

Countermeasures to Suppress Life Style Related Diseases

①Spread of Integrated and Consistent Health Promotion by Insurers and Regional Officials (Significant is to increase their motivation.)

②Complete and Efficient Medical Check ups (Based on evidence from mega cohort study.)

③Individual Health Advice for High-Risk Groups (By well-trained Health Personnel.)

1,325M USD to be allocated in 2007

Functional Specialization and Referral System of Medical Facility

Respect for Local Daily Activity of the elderly

referral

Nursing Care System

Acute Stage

Rehabilitation

Chronic Stage

Home Care

Systemic Approach to change Mechanism of delivery of Health Services

[Subacute/ Recovery Phase][Acute Illness]

Living at Home

Community Emergency Care

Services

Rehab Function(Recovery Phase)

Use of Longterm Care insurance

(if necessary)

Care Function(Including

Rehab)

Living at Nursing Facility

(Care house, Nursing home

etc.)

Discharge

Onset of

Disease

Schematic Image of Medical Coordination(in case of stroke)

Primary Care Function (Clinic, Hospital etc.)

Home Care（ Continuity

care ） Management, Education

(Discharge Coordination)

(Transfer Coordination)

(Discharge Coordination)

(Referral Coordination)

(Referral Coordination)

(Discharge Coordination)

Discharge Discharge Discharge

The theoretical understanding of the visceral obesity as the starting point of most of those diseases

Countermeasures toward the more effective prevention of these diseases

Diabetes, Hyper-lipidemia

Diabetes Care 19, 287, 1996

Metabolism 36, 54, 1987

Am J Cardiol 64, 369, 1989

Hypertension 16, 484, 1990Hypertension 27, 125, 1996

Atherosclerosis 107, 239, 1994Int J Obesity 21, 580, 1997

J Int Med 241, 11, 1997

Insulin Resistance

Left Ventricular Dysfunction

Sleep ApneaCoronary DiseasesHypertension

All by Prof. Matsuzawa Y. et alWith complimentary regards

Visceral Obesity

Bio-active Mediators from Adipose Tissue

Prevention of Onset and Progression Prevention of Onset and Progression of Lifestyle-Related Diseasesof Lifestyle-Related Diseases

○High blood glucose, High blood pressure, Hyperlipidemia do not progress separately. These are like ”The tips of a single iceberg”.

○Medication (ex. Hypoglycemic agent) merely reduces the size of ”one tip of the iceberg”.

○It is necessary to reduce the size of “whole iceberg” by improving life style, such as adherence to physical exercise and improved diet.

Appropriate blood sugar, pressure, lipid

Reducing caloric intake, Balanced Nutrition

Increase of energy consumption, Cardiovascular

activity

Feeling of Well Being 　　　

Continuation

Improved Diet

Reduction in weight and waist circumference

Activation of Metabolism / Reduction of visceral fat（ Good Hormone↑ , Bad Hormone↓ ）

High Blood sugar

High Blood Pressure

High Blood Lipid

Adherence to physical exercise

Malfunction of Metabolism

Visceral fat

One medication merely reduces the size of one tip of iceberg. It does not cure the whole disease.

Smaller Iceberg!

1.Exercise1.Exercise

2. Diet2. Diet

3.Non-Smoking3.Non-Smoking　　

Drug is last resortDrug is last resort

・・ Adherence to ExerciseAdherence to Exercise・・ Improved DietImproved Diet・・ Quitting SmokingQuitting Smoking

Improvement of Life Style

Comprehensive Implementation of Medical Expenditure Control 1. Ensuring a Balance between rising health care costs and the public financial burden

Rising Health Care Costs

Moderation in Health Care Cost in the mid-and-long term (Decrease the number of metabolic syndrome patients, at-risk group, decrease the

Average Length of Stay etc.)

Review of the coverage policies of public health insurance etc. (Short-term Policies ）

IncrementalEffects

Evaluate from an economic perspective

Ensuring Secure and Reliable Health System

Moderating Public Burden

Present a clear estimate of medical spending in the future including mid-& long-term prospects for about 5 years

Use as a way to examine the rising health care costs＝

Examine the effectiveness of the control policies by comparing the estimated and actual costs

Future review of policies

Evaluate from both

perspective

Ensuring consistency with the New Health Promotion Plan, new Health Care Planning

after a certain period of time

The national government and prefectures must work together in;

• Promulgating systematic measures to control medical expenditures, including of long-term hospitalization those regarding lifestyle-related disease prevention and those for rectifying the problem.

(2) Taking steps to support plan implementation. Formulating such plans in a manner consistent with health promotion plans and long-term care insurance will ensure coordination between policy actions.

(3) Conducting examinations to verify that the plan is being implemented.

* Excerpt from Outline of Health Care Reform Policy

Comprehensive Implementation of Medical Expenditure Control 2. Promoting Plans for Medical Expenditures Control

For Longevity and Healthier Life

• Death is inevitable, but a life of protracted ill-health is not.

• A half but most, in future, of cardiovascular diseases do/will not result in sudden death.

• Rather, they are likely to cause people to become progressively ill and debilitated, especially if their illness is not managed correctly.

• Prevention and control of Cardiovascular disease helps people to keep longer and healthier lives.

The speaker appreciates your kind attention.

See you soon.

Something else• Lest of all, just for your sight….

Status Quo: Cardiovascular diseases in Japan

Background of policy-making toward the prevention of the metabolic syndrome

Population, Birth, and Death in Japan

0

20,000,000

40,000,000

60,000,000

80,000,000

100,000,000

120,000,000

140,000,000

0

400000

800000

1200000

1600000

2000000

2400000

2800000

2030

Death est. 1,600 T

In 2006 Population12

7,720 T

Over 65 yrs 26,400 T (20.7%)

Increment of Cardiovascular Deaths

161, 764

165, 478

146, 741

159, 625

171, 000

123, 505

121, 944

132, 529

129, 055

132, 000

162, 317

217, 413

295, 484

320, 358

324, 000

275, 215

315, 470

386, 899

419, 564

450, 000

0 500, 000 1, 000, 000

1980

1990

2000

2004

2005

CVD Stroke Mal i gnant Neopl asm Others

15.9%15.9% 12.3%12.3% 30.1% 30.1% 41.8%41.8%

15.5% 12.5%15.5% 12.5% 31.1% 31.1% 40.8% 40.8%

15.3%15.3% 13.8%13.8% 30.7% 30.7% 40.2% 40.2%

CVD + Stroke ： Inpatient310T 、 Outpatient850TMal Neoplasm ： Inpatient140T 、 Outpatient110T

CVD + Stroke: 303,000 and 28% of total deaths in 2005

0

3000

6000

9000

12000

15000

７５～

７９

８０～

８４

８５～８９

９０ yrs

+

Annual Incident Rate of Cardiovascular Diseases

Prevalence Rate of Cardiovascular Diseases

0

1000

2000

3000

4000

5000

０ year

１～４

５～９

１０～

１４

１５～

１９

２０～

２４

２５～

２９

３０～

３４

３５～

３９

４０～

４４

４５～

４９

５０～

５４

５５～

５９

６０～

６４

６５～

６９

７０～

７４

７５～

７９

Anua

l Pre

vale

nce

Rat

e (e

stim

ated

) / 1

00 0

00 Physician Visit Admission

Ann

ual I

ncid

ent r

ate

of th

e fir

st p

hysi

cian

vis

its (p

er 1

00,0

00)

1 year after Cerebrovascular Events1 year after Cerebrovascular Events

Annual Occurrence234,352 (100%) 　

Death 48,511 （ 20.7 ％）

Alive 185,841 （ 79.3 ％）

Institutionalized 13,195 （ 5.6 ％）

Bed-bound at Home 17,469 （ 7.4 ％）

Home help needed 30,850 （ 13.2 ％）

Independent （ Partially ） 67,460 （ 28.8 ％）

Recovery 57,053 （ 24.3 ％）

To be decreasedin future

To be increased

Outline of Health Care Reform Policy（ Government and Ruling Parties Council on Health Care Reform (December 1st, 2005)

<Contents>Ⅰ Guiding Principles for the Reform

1. Ensuring safe and reliable healthcare while emphasizing prevention2. Comprehensive Implementation of Cost Containment3. Creating a new health insurance system accounting for the aging of society

Ⅱ Ensuring safe and reliable healthcare while emphasizing prevention1. Ensuring safe and reliable healthcare2. Emphasizing prevention

Ⅲ 　 Comprehensive Implementation of Cost Containment

Ⅳ 　 Creating a new health insurance system accounting for the aging of society

Ⅴ　 Reviewing the universal fee-schedule etc.

Ⅵ 　 Reform timing

Ⅱ. Ensuring safe and reliable healthcare while emphasizing prevention

Basic structure Ⅱ - 1. Policy Outline “Ensuring Safe and Reliable Healthcare” → (1) Establishing a new structure capable of providing safe, secure and high-quality health care upon the

consumers’ perspective

Ⅱ - 2. of the Policy Outline “Prevention as a centerpiece” → (2) Establishing a new structure focused on prevention of lifestyle-related diseases

- Information collection and release by prefectures--> Instituting a structure under which a medical institution can register its available healthcare service offerings with the prefecture, which then disseminates such information in an easy-to-understand way.- Clearly presenting to residents and patients at the regional level, in the form of a health care planning, the healthcare services which are available, as well as the details of inter-institution coordination.- Widening the range of information advertised.

Assistance in healthcare decision-making by providing healthcare information

- Enabling people to receive safe and high-quality healthcare -

- Establishing a system of regional healthcare coordination for respective fields of healthcare, such as stroke, cancer and pediatric emergency care, by reconsidering the health care planning.- Providing, within a system of regionally coordinated healthcare, unfragmented healthcare through the wider application of networked critical pathways.

* Regional coordinated critical pathwaysA treatment plan up until a patient goes home after being treated in an acute-care hospital and then a rehabilitation

hospital. Information-sharing between the patient and his or her medical institution leads to the provision of efficient and high-quality healthcare as well as the patient's peace of mind

Provision of unfragmented healthcare by promoting specialization and coordinating provision of healthcare services

- Enabling people to obtain sufficient healthcare information -

Ensuring appropriate healthcare provision even takes into account a patient’s care after discharge or transfer.

(1) Establishing a new structure capable of providing safe, secure and high-quality health care upon the consumers’ perspective

Improved quality of life (QOL) for patients through well-developed home healthcare services

- Enabling people to recover quickly and return home

Projection after reform 27.5 (trillion)

% of National Income 7.3% 7.4% ～ 7.7% 8.0%～ 8.5% 8.8% ～ 9.7% % of GDP 5.4% 5.4% ～ 5.6% 5.8%～ 6.1% 6.4% ～ 7.0%

Without Reform (status quo) 28.5 (trillion)

% of National Income 7.6% 7.9% ～ 8.2% 8.7%～ 9.2% 10.3%～ 11.4% % of GDP 5.5% 5.8% ～ 5.9% 6.3%～ 6.6% 7.5% ～ 8.2%

National Income 375.6 (trillion) 403 ～ 420 (trillion) 432 ～ 461 (trillion) 492 ～ 540 (trillion)

GDP 513.9 (trillion) 558 ～ 576 (trillion) 601 ～ 634 (trillion) 684 ～ 742 (trillion)

(Assumption of the estimate)

31.2 (trillion) 37 (trillion) 48 (trillion)

Forecast of Medical Expenditure(Estimate based on reform plan, January 2006)

FY2006 FY2010 FY2015 FY2025

1. “Without Reform” refers to the projected expenditures under the current health insurance law with an unrevised universal fee schedule. The increase of Medical Expenditure per capita is extrapolated from past data (2.1% for people below 70 and 3.2% for people above 70)

2. “After Reform” refers to the Budget in 2006 and when the revision of health insurance law etc. and the revision of the universal fee schedule are implemented

3. Nominal Economic Growth used in the calculation of National Income and GDP is based on two cases, “Basic Case” and “Risk Case”. Both cases are using the same assumption of “Reform and Prospect 2005 (Draft)” (until 2011) and “Recalculation for Pension Finance 2004” (from 2012)

33.2 (trillion) 40 (trillion) 56 (trillion)

Changes in Nominal Economic Growth2006 2007 2008 2009 2010 2011 2012 ～

Basic Case 2.0% 2.5% 2.9% 3.1% 3.1% 3.2% 1.6%Risk Case 2.0% 1.9% 2.1% 2.2% 2.1% 2.2% 1.3%

(Budget)

Status Quo: Diabetes in Japan

Background of policy-making toward the prevention of the metabolic syndrome

Diabetes SuspectedDiabetes DiagnosedDiabetes SuspectedDiabetes Diagnosed

Male

2002 Diabetes Survey by Ministry of Health

Age

Prev

alen

ce

Rat

e

20 〜 29 30 〜 39 40 〜 49 50 〜 59 60 〜 69 70 〜

40

35

30

25

20

15

10

5

0

Female

Prevalence of Diabetes in Japan

Incident Rate of the first Physician Visits from Diabetes (per 100,000 capita)

Mor

talit

y R

ate

from

Ren

al F

ailu

re (p

er 1

00,0

00 c

apita

)Correlation between Physician Visits for Diabetes and Mortality

from Renal Failure (Correlation Coefficient: 0.721)

R2 = 0.5192

10

14

18

22

100 120 140 160 180 200 220 240 260 280 300Prevalence Dibabetes

Incident Rate of the first Physician Visits from Diabetes (per 100,000 capita)

Mor

talit

y R

ate

from

Pne

umon

ia (p

er 1

00,0

00 c

apita

)Correlation between Physician Visits for Diabetes and Mortality

from Pneumonia (Correlation Coefficient: 0.638)

R2 = 0.4069

50

80

110

100 120 140 160 180 200 220 240 260 280 300

Status Quo: Hypertension in JapanBackground of policy-making toward the prevention of the metabolic syndrome

Status Quo: Hypertension in Japan

• Receivers of medical services– 5,939,000 are under the medical care

due to Hypertension. (2004)– 9.2% of total “Patients”.

• Medical Expenditure, burden of cardiovascular diseases

– 946,000,000,000JY (=8,085 MUSD) in 2004 for Hypertension

» 187,9 BJP for Inpatient» 758,1 BJP for Outpatient

– 7.8% of Total Medical Expenditure (12,105,600 MJY)

Correlation between Physician Visits for Hypertension and Mortality from Renal Failure (Correlation Coefficient: 0.753)

Mor

talit

y R

ate

of fr

om R

enal

Fai

lure

(per

100

,000

cap

ita)

Incident Rate of the first Physician Visits by Hypertension (per 100,000 capita)

R2 = 0.5678

5

9

13

300 350 400 450 500 550 600 650 700 750 800

Correlation between Physician Visits for Hypertension and Mortality from Cerebral Infarct (Correlation Coefficient: 0.653)

Mor

talit

y R

ate

from

Cer

ebra

l Inf

arct

(pe

r 10

0,00

0 ca

pita

)

Incident Rate of the first Physician Visits by Hypertension (per 100,000 capita)

R2 = 0.4266

30

60

90

300 350 400 450 500 550 600 650 700 750 800

Correlation between Physician Visits for Hypertension And Decreases of Mortality in 5 years (1997-2002)

from Cerebral Hemorrhage and other minor Cerebral D. (Correlation Coefficient: -0.327 )

Incidence of the first Physician Visits for Hypertension

Decr

ease

of

Mor

talit

y in

5 y

ears

(199

7-20

02) f

rom

Cer

ebra

l Hem

orrh

age

R2 = 0.1071

-4

-3.5

-3

-2.5

-2

-1.5

-1

-0.5

0

0.5

300 350 400 450 500 550 600 650 700 750 800

Correlation among these diseases

Background of policy-making toward the prevention of the metabolic syndrome

The prevention from the starting point as the most appropriate countermeasure

Countermeasures toward the more effective prevention of these diseases

• To prevent Visceral Obesity, Risk Factor Control by individual behavior changes;– Spread of Integrated and Consistent Health Promotion by

Insurers and Regional Officials (Significant is to increase their motivation.)

– Complete and Efficient Medical Check ups (Based on evidence from mega cohort study.)

– Individual Health Advice for High-Risk Groups (By well-trained Health Personnel.)

• 1,325M USD to be allocated in 2007

What can we do as the population approach?

From the desk plan to the social movement

The dawn of the national policy on Metabolic syndrome Group

– Stepping in to the academic round-table conference on making the Japanese version of diagnostic standard of metabolic syndrome

– The achievement of agreement among the high officials in the Ministry of Health on what-to-do

– Involvement of the stakeholders– Discussions on the Ministerial Council– The appropriation to the budget compilation of the

National Government and exploitation– To the deliberations on Congress

The dawn of the national policy on Metabolic syndrome Group

• The characteristics of the Japanese version of metabolic syndrome: Abdominal perimeterMale: 85cm, Female: 90cm

(From the employee based cohort study with MRI, only accomplished in Japan)