the long term care insurance [kaigo hoken] and its impact on society and health care system in japan...
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The Long Term Care Insurance [KaiThe Long Term Care Insurance [Kaigo Hoken] and its Impact on Society go Hoken] and its Impact on Society and Health Care System in Japanand Health Care System in Japan
AtoZ OKAMOTO, MD, MPH
National Institute of Public Health
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BackgroundDevelopmentImplementationOutcomeConclusions
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Why was the LTCI developed?Why was the LTCI developed?Rapidly aging population and growing
need for LTC–Elderly population >65 will be 25%
of the populationStructural overhaul of the fragmented
health insurance systemEffective integration of medical and
non-medical services
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Structural flaws of Japan’s heStructural flaws of Japan’s health insurance systemalth insurance system
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Age distribution and health insurance stAge distribution and health insurance statusatus
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Financial Redistribution Mechanism by the EldFinancial Redistribution Mechanism by the Elderly Health Care System [EHCS] since 1983erly Health Care System [EHCS] since 1983
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Medical vs. Non-medical Services bMedical vs. Non-medical Services before the LTCIefore 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)
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BackgroundDevelopmentImplementationOutcomeConclusions
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Tax vs. PremiumTax vs. PremiumAgreement: 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
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Campaign for the LTCICampaign for the LTCI
German LTCI started in 1995Opinion Poll-> 86% support the LTCIConversion of the Nordic faction
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Technical Development(1)Technical Development(1)-Need Assessment Tool-Need Assessment Tool
Evidence-based development (one-minute time study)
Methodologically similar to the U.S. MDS and RUG
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Technical Development (2)Technical Development (2)-Care Management-Care Management
British Community Care Act 1990
Coordination between medical and non-medical services
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BackgroundDevelopmentImplementationOutcomeConclusions
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Administrative StructureAdministrative StructureAdministered 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
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BeneficiariesBeneficiariesCovers half of the population ( as opp
osed to health insurance)Beneficiaries category I: aged 65 or o
lder (17% of population)Beneficiaries category II: aged 40-64
(33% of population)Originally planned to cover 20 years
or older
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Beneficiaries and FinancingBeneficiaries and Financing
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Need AssessmentNeed AssessmentApplication (a sharp contrast to health
insurance)On-site survey by qualified care managers
using a uniform assessment tool (73 items)Attending doctor’s professional opinionPreliminary assessment by computer
(dismiss, borderline, level 1-5)The need assessment review committee
makes final judgment
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How the need assessment review How the need assessment review committee altered the preliminary committee altered the preliminary
assessmentassessment
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BenefitBenefitInstitutional 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)
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Integration of Medical and Non-medical Integration of Medical and Non-medical Services under the LTCIServices under the LTCI
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Benefit in monetary terms according to Benefit in monetary terms according to the level of care needthe level of care need
(unit 10-10.72 yen, subject to 10% copayment) (unit 10-10.72 yen, subject to 10% copayment)
Monthly “cap” for home care
Per diem cost for SNF
Borderline 6150 Not permitted
Level1 16580 880
Level2 19480 930
Level3 26750 980
Level4 30600 1030
Level5 35830 1080
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Double Talk in Home CareDouble 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.
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Controversy over cash benefitControversy over cash benefitWhether cash benefit should awarded
to family care givers who do not use external services–No!—women citizen group–Yes—economists, medical
associationDecision---NO
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BackgroundDevelopmentImplementationOutcomeConclusions
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Boom and BustBoom and BustGovernment’s worry about shortage o
f servicesDeregulation to encourage for-profit c
orporations into home care “industry”Kaigohoken BoomLess than expected demand -> Bubble
Burst
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Saga of Nichii Gakkan (TSE quotes)Saga of Nichii Gakkan (TSE quotes)
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Service UtilizationService Utilization in the first year in the first year
Total reimbursement:3.2 trillion yen (84% of expected)
Home care vs Institutional care = 1:2Gradual but steady increase of services
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Service Utilization [1]Service Utilization [1]Home vs. Institutional CareHome vs. Institutional Care
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Service Utilization [2]Service Utilization [2]Institutional CareInstitutional Care
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Service UtilizatiService Utilization[3]on[3]
Home careHome care
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Growth of Elderly eligible for benefitGrowth of Elderly eligible for benefit
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Plight of Visiting NursesPlight of Visiting Nurses
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Price Competition between Home Help Price Competition between Home Help and Visiting Nursingand Visiting Nursing
(price for 30min to 1 hr, unit 10-10.72 yen, subje(price for 30min to 1 hr, unit 10-10.72 yen, subject to 10% copayment)ct 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
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Care Managers:Care Managers: to whom they report? 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
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BackgroundDevelopmentImplementationOutcomeConclusions
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What have we learned?What have we learned?Increased awareness of people about
welfare and social servicesPrompted a national debate over the
goal to which we achieveA great social experiment to create and
implement a new systemA model for Asian countries to cope
with aging population?