Public Long-term Care Insurance Program Research Articles

Controlling Spending For Health Care And Long-Term Care: Japan's Experience With A Rapidly Aging Society.

As the Japanese population has aged rapidly, Japan's experience has implications for other high-income countries, including the United States. The aging of Japan's population, coupled with the government's decision to implement a public long-term care insurance program in 2000, has increased the nation's expenditures. In acute care, costs have been relatively contained by biennially revising the fee schedule for all physician and hospital services and by lowering pharmaceutical prices. The fee schedule not only sets prices but also controls volume by setting the conditions of billing for each item. This fee schedule is applied to all social health insurance plans (which enroll all permanent residents of Japan) and to virtually all providers. In contrast, despite the use of a similar fee schedule, spending in long-term care insurance has increased more than spending in health care. This is both because long-term care became an entitlement and because aging has had a greater impact on long-term care insurance spending than on health insurance spending. In this article we analyze Japanese expenditure data to provide essential information to the US as the percentage of its population ages sixty-five and older continues to rise. A key lesson that the US can learn from Japan's experience is that as its population ages, the need for long-term care will increase, necessitating better control of acute care spending.

Association between urinary N-acetyl-β-glucosaminidase activity-urinary creatinine concentration ratio and risk of disability and all-cause mortality.

Recent studies have suggested that chronic kidney disease is associated with cardiovascular disease, dementia, and frailty, all of which cause disability and early death. We investigated whether increased activity of urinary N-acetyl-β-glucosaminidase (NAG), a marker of kidney injury, is associated with risk of disability or all-cause mortality in a general population. Follow-up data from the Hidaka Cohort Study, a population-based cohort study of members of a Japanese rural community, were obtained via questionnaires completed by participants or their relatives. Multivariable analyses were used to investigate relations between urinary NAG activity-urinary creatinine concentration ratio and risk of disability or all-cause mortality. A total of 1182 participants were followed up for a median of 12.4 years. The endpoints were receipt of support under the public long-term care insurance program, and all-cause mortality. A total of 122 participants (10.3%) were reported to be receiving long-term care and 230 (19.5%) had died. After adjustment for cardiovascular risk factors along with physical activity, and using the quartile 1 results as a reference, the odds ratio (OR) for disability was 2.12 [95% confidence interval (95% confidence interval [CI]), 1.04-4.33; p = 0.038) and the hazard ratio (HR) for all-cause mortality was 1.65 (95% CI, 1.05-2.62; p = 0.031) in participants with urinary NAG/creatinine ratio in quartile 4. Similar results were obtained in participants without proteinuria: OR for disability, 2.46 (95% CI, 1.18-5.16; p = 0.017); and HR for all-cause mortality, 1.62 (95% CI, 1.00-2.63; p = 0.049). Increased urinary NAG/creatinine ratio was associated with risk of disability or all-cause mortality in a general population.

Incorporating discrete choice experiments into policy decisions: Case of designing public long-term care insurance.

Discrete choice experiments (DCEs) have been widely used to elicit preferences in the health economics field but recent reviews found that DCE results are rarely incorporated into health policy decisions. We conjecture that one reason is most health policy practitioners only focus on estimating marginal willingness to pay, the measure that is not directly applicable for policy-related questions. We show that when designing a new program, translating preference information into the demand for packages and benefits of alternative schemes (the choices made available) can make the DCE results more policy relevant. This concept is illustrated using data collected to evaluate the benefits of introducing a public long-term care insurance program to a middle-income country, Thailand. The stratified sample consisted of 2019 households from all regions, and the interview took place between October and December 2017. We find that preferences are very heterogeneous, implying that no one-size-fits-all solution exists. The estimates from the preferred model are then used to calculate benefits and losses (based on the consumer surplus measure) for plausible implementation scenarios such as different universal schemes, multiple-tier schemes, and schemes in which premium are subsidized for low-income households.

The emerging market for supplemental long term care insurance in Germany in the context of the 2013 Pflege-Bahr reform

The growing cost of long term care is burdening many countries’ health and social care systems, causing them to encourage individuals and families to protect themselves against the financial risk posed by long term care needs. Germany’s public long-term care insurance program, which mandates coverage for most Germans, is well-known, but fewer are aware of Germany’s growing voluntary, supplemental private long-term care insurance market. This paper discusses German policymakers’ 2013 effort to expand it by subsidizing the purchase of qualified policies. We provide data on market expansions and the extent to which policy goals are being achieved, finding that public subsidies for purchasing supplemental policies boosted the market, although the effect of this stimulus diminished over time. Meanwhile, sales growth in the unsubsidized market appears to have slowed, despite design features that create incentives for lower-risk individuals to seek better deals there. Thus, although subsidies for cheap, low-benefit policies seem to have achieved the goal of market expansion, the overall impact and long-term sustainability of these products is unclear; conclusions about its impact are further muddied by significant expansions to Germany’s core program. The German example reinforces the examples of the US and France private long term care insurance markets, to show how such products flourish best when supplementing a public program.

Regional Supply of Nursing Home and Hospital Beds Determine Discharge Destination of Nursing Home Residents in Japan

ObjectivesJapanese special nursing homes provide permanent residence to elderly people under the public long-term care insurance program. However, a quarter of discharges occur via death in hospital, and a fifth occur via admission to hospital. The objective was to identify factors associated with discharge destinations for residents of Japanese special nursing homes. DesignA retrospective design for data collected in 2007, 2010, and 2013. SettingWe used data from the Survey of Institutions and Establishments for Long-Term Care, which is a nationally representative cross-sectional survey that assessed discharge from special nursing homes in September every 3 years. ParticipantsThere were 2426 discharged residents included in the analysis. MeasurementsDischarge destination was categorized as death at facility, death in hospital, hospital admission, and another care setting. Multivariate multinomial logistic regression analysis was conducted with discharge destination as the dependent variable. ResultsOf the 2426 discharged residents included in the analysis, 874 (36.0%) were deceased at the facility, 773 (31.9%) were deceased in hospital, 652 (26.9%) were admitted to hospital, and 127 (5.2%) were admitted to another care setting. Residents of facilities in the regions with fewer nursing home beds or more hospital beds were more likely to be discharged via admittance to hospital or another care setting relative to being deceased at the facility. ConclusionThe regional supply of nursing home and hospital beds could have affected end-of-life care locations for residents of special nursing homes. To promote end-of-life care in special nursing homes, regional supply of nursing home beds should be reinforced while controlling oversupply of hospital beds.

Discharge Destination of Dementia Patients Who Undergo Intermediate Care at a Facility

ObjectivesIntermediate care for patients with dementia has important implications for aging in place as long as possible. In Japan, geriatric intermediate care facilities provide institutional rehabilitation services to patients under the public Long-Term Care Insurance program and aim to discharge the patients to home from the hospital. The aim of this study was to determine the association between dementia and discharge destination of patients in geriatric intermediate care facilities in Japan. DesignThis study was conducted using a retrospective study design for data from 2007, 2010, and 2013. SettingWe used data from the Survey of Institutions and Establishments for Long-Term Care, which is a nationally representative cross-sectional survey that assessed discharges from geriatric intermediate care facilities in September. ParticipantsThere were 9992 discharged patients included in the analysis. MeasurementsDischarge destination was categorized as home, facility, hospital, or death. Primary disease was based on ICD-10 codes. Diagnosis of dementia included F00 (Alzheimer), F01 (vascular), F02 (other), and F03 (unspecified). Multilevel multinomial logistic analysis was used for discharge destination, with discharge to home as the reference group. ResultsOf the 9992 discharged patients, 2483 (24.8%) had dementia as the primary disease. Of the 2483 patients with dementia, 1090 (43.9%) were hospitalized, 624 (25.1%) were admitted to another facility, 605 (24.4%) were discharged to home, and 164 (6.6%) were discharged by death. Patients with dementia were more likely to be admitted to hospital (adjusted odds ratio [OR] 1.47; 95% confidence interval [CI] 1.25–1.73; P < .001), transferred to another facility (adjusted OR 1.94; 95% CI 1.64–2.29; P < .001), or discharged by death (adjusted OR, 1.46; 95% CI 1.13–1.89; P = .004) than discharged to home. ConclusionIntermediate care in residential settings might have limited effectiveness in discharging patients with dementia to home. The national dementia plan should explore intermediate care for dementia at other care settings rather than facilities.

Labor market outcomes of informal care provision in Japan

This paper examines the labor supply outcomes of family care provision for Japanese households in 2010, ten years after the introduction of the public long-term care insurance (LTCI) program. We found that family care provision for parents adversely affected labor market outcomes of main caregivers at home in terms of the probability of working, employment status and hours worked. The adverse effect was found to be more serious for female caregivers than for male caregivers. Moreover, our results suggest that the public LTCI program seems to only partially mitigate the disadvantages of the main caregivers for both males and females.

“Ageing in Place” Policy in Japan: Association Between the Development of an Integrated Community Care System and the Number of Nursing Home Placements Under the Public Long-Term Care Insurance Program Among Municipal Governments

In Japan, an “Integrated Community Care” model has been introduced into the public long-term care insurance (LTCI) system to help persons ageing in place. The aim of the present study was to examine the association between the development of an Integrated Community Care system and the number of nursing home placements under the LTCI program among municipal governments in Japan. Development of the Integrated Community Care system was assessed by a paper questionnaire distributed to each municipality. The annual number of elderly nursing home placements was obtained from published national statistics data over a 10-year period from 2001 to 2010. The sample consisted of 612 municipalities (35.1 % of all municipalities) that responded to the questionnaire. A multilevel linear regression analysis for panel data revealed significantly smaller annual numbers of nursing home placements per 1000 elderly persons among municipalities that had larger number of agencies joining in multiple service networks of the Integrated Community Care system. A significantly greater number of nursing home placements was also observed among municipalities that had a larger elderly population rate, lower annual number of elderly individuals in intermediate care per 1000 elderly persons, and smaller number of elderly individuals in congregate housings per 1000 elderly persons. The national “ageing in place” policy should explore a revised model of the Integrated Community Care system that is applicable for areas with limited resources.

노인장기요양보험 방문간호 권고군의 방문간호 이용과 의료 이용의 관계

Background: This study aimed to examine the relationship between home-visit nursing services and health care utilization under the public long-term care insurance program in Korea. Methods: We analyzed the long-term care need assessment database and the long-term care and the health insurance claim databases of National Health Insurance Service between July 2011 and June 2012. The sample includes a total of 20,065 home-visit nursing recommended-older beneficiaries who use home-visit nursing and/or home-visit care, based on a standard benefit model developed by the Health Insurance Policy Institute of National Health Insurance Service. The beneficiaries were categorized into home-visit nursing use and non-use groups, and the home-visit nursing use group was again divided into high-use and low-use groups home-visit nursing, based on their total annual home-visit nursing expenditure. Two-part models and negative-binomial regression models were used for the statistical analysis. Results: The home-visit nursing use was negatively associated with the number of outpatient visit and cost, while adjusting for all covariates. The home-visit nursing use was also negatively associated with the inpatient cost among the high home-visit nursing use group. Conclusion: The findings implies home-visit nursing use prevents health care utilization. Further studies and policy strategies that can promote and strengthen home-visit nursing services under the public long-term care insurance are necessary in Korea.

Systems Development and Difficulties in Implementing Procedures for Elder Abuse Prevention Among Private Community General Support Centers in Japan

The present study examines differences in systems development and difficulties in implementing procedures for elder abuse prevention in 1,119 private and 606 public community general support centers under the public long-term care insurance program in Japan. The private community general support centers showed more difficulty implementing procedures than the public community general support centers. Controlling for the type of municipality, progress in systems development did not differ between the private and public community general support centers. Further research should examine how the characteristics of municipal governments are related to systems development in community general support centers.

Utilization of long-term care services under the public long-term care insurance program in Korea: Implications of a subsidy policy

ObjectivesSouth Korea introduced public long-term care insurance (LTCI) in 2008. This study examined the patterns of and factors associated with public long-term care (LTC) utilization among older LTCI beneficiaries in Korea, with special attention to the policy for subsidizing the co-payments of lower income populations. MethodsUsing a 5% national representative sample of 280,290 older people aged 65 or older obtained from the 2010 national LTCI claims database, we examined socio-demographic and health factors associated with service utilization decisions, service type chosen, and the intensity of service use. ResultsAbout 5.48% of older adults in 2010 utilized the LTC provided under the Korean public LTCI, among which about 26.1% received a subsidy. Compared to their counterparts, the subsidized users were more likely to be low-income, female, and living alone. They were more likely to choose institutionalized care and spend to their monthly benefit limit while paying a lower co-payment. The factors associated with pattern and intensity of LTC utilization were not the same between subsidized and non-subsidized users. ConclusionThe findings imply the subsidy policy promotes equity of access to public LTC services. Further evaluation is necessary on the impact of the policy on the effectiveness of LTC utilization by socially marginalized populations.

P.5.008 Prevalence of dementia in St. Petersburg and Leningrad Region (Russian Federation), 2000–2004

Intermediate care for patients with dementia has important implications for aging in place as long as possible. In Japan, geriatric intermediate care facilities provide institutional rehabilitation services to patients under the public Long-Term Care Insurance program and aim to discharge the patients to home from the hospital. The aim of this study was to determine the association between dementia and discharge destination of patients in geriatric intermediate care facilities in Japan.This study was conducted using a retrospective study design for data from 2007, 2010, and 2013.We used data from the Survey of Institutions and Establishments for Long-Term Care, which is a nationally representative cross-sectional survey that assessed discharges from geriatric intermediate care facilities in September.There were 9992 discharged patients included in the analysis.Discharge destination was categorized as home, facility, hospital, or death. Primary disease was based on ICD-10 codes. Diagnosis of dementia included F00 (Alzheimer), F01 (vascular), F02 (other), and F03 (unspecified). Multilevel multinomial logistic analysis was used for discharge destination, with discharge to home as the reference group.Of the 9992 discharged patients, 2483 (24.8%) had dementia as the primary disease. Of the 2483 patients with dementia, 1090 (43.9%) were hospitalized, 624 (25.1%) were admitted to another facility, 605 (24.4%) were discharged to home, and 164 (6.6%) were discharged by death. Patients with dementia were more likely to be admitted to hospital (adjusted odds ratio [OR] 1.47; 95% confidence interval [CI] 1.25–1.73; P < .001), transferred to another facility (adjusted OR 1.94; 95% CI 1.64–2.29; P < .001), or discharged by death (adjusted OR, 1.46; 95% CI 1.13–1.89; P = .004) than discharged to home.Intermediate care in residential settings might have limited effectiveness in discharging patients with dementia to home. The national dementia plan should explore intermediate care for dementia at other care settings rather than facilities.

Disparities in systems development for elder abuse prevention among municipalities in Japan: Implications for strategies to help municipalities develop community systems

In April 2006, a national elder abuse prevention and caregiver support law was enacted in Japan, where elder abuse prevention is carried out by municipalities, and caregiver support and intervention are provided by a public long-term care insurance program. The aims of this study were (1) to examine factors at baseline affecting disparities in the progress of systems development for elder abuse prevention among municipalities, and (2) to determine what kind of support municipalities request from prefectural or national governments to help municipalities develop systems for elder abuse prevention. Written questionnaires were administered to the most knowledgeable person in the department responsible for reporting elder abuse in each municipal government between December 2006 and October 2008. The final sample for analysis consisted of 489 (26.6% of 1840) municipalities that provided complete information. Municipalities that achieved a high level of implementation originally had a higher rate of reports of abuse per 1000 elderly persons and greater involvement by police and advocacy groups at baseline. Since cities were the largest type of municipality, they had the greatest number of activities as of 2 years after implementation of the law. The results highlight that the prefectural or national government should offer different types of support according to the kind of municipality: sharing and using experts in an extended association for municipalities with limited resources and smaller size (towns and villages) and aggregating information on difficult cases for larger municipalities (cities). Further research should investigate specific strategies that the prefectural or national government can implement to help promote systems development for municipalities with low rates of reported cases of elder abuse, such as training programs to ensure that all care providers can recognize the signs and symptoms of elder abuse.

Finding Major Patterns of Aging Process by Data Synchronization

We developed a method for extracting feature patterns from multivariate data using a network of coupled phase oscillators subject to an analogue of the Kuramoto model for collective synchronization. Our method may be called data synchronization. We applied data synchronization to the care-needs-certification data, provided by Otsu City as a historical old city near Kyoto City, in the Japanese public long-term care insurance program to find the trend of the major patterns of the aging process for elderly people needing nursing care.

Collective synchronization as a method of learning and generalization from sparse data

We propose a method for extracting general features from multivariate data using a network of phase oscillators subject to an analogue of the Kuramoto model for collective synchronization. In this method, the natural frequencies of the oscillators are extended to vector quantities to which multivariate data are assigned. The common frequency vectors of the groups of partially synchronized oscillators are interpreted to be the template vectors representing the general features of the data set. We show that the proposed method becomes equivalent to the self-organizing map algorithm devised by Kohonen when the governing equations are linearized about their solutions of partial synchronization. As a case study to test the utility of our method, we applied it to care-needs-certification data in the Japanese public long-term care insurance program, and found major general patterns in the health status of the elderly needing nursing care.

Data Synchronization in a Network of Coupled Phase Oscillators

We devised a new method of data mining for a large-scale database. In the method, a network of locally coupled phase oscillators subject to Kuramoto's model substitutes for given multivariate data to generate major features through phase locking of the oscillators, i.e., phase transition of the data set. We applied the method to the national database of care needs certification for the Japanese public long-term care insurance program, and found three major patterns in the aging process of the frail elderly. This work revealed the latent utility of Kuramoto's model for data processing.

Prediction of Care Class by Local Additive Reference to Prototypical Examples

The public long-term care insurance program for the elderly in Japan set out in 2000 toward establishing a new system whereby citizens can be assured that they will receive care and be supported by the society as a whole. The insurance program includes computer-aided certification processes to estimate the needs for nursing care for clients. In this work, we show the applicability of an adaptive local nonlinear approximation method associated with the Japanese national database for automatic inference of the care class.

The effect of a subsidy policy on the utilization of community care services under a public long-term care insurance program in rural Japan

This cross-sectional study investigated the effect of an interim subsidy policy for low-income beneficiaries to buy home help services under Japanese long-term care insurance (LTCI) for the service utilization of home help and other community care services. Claims records during the period from October to December 2001 were reviewed to compare the monthly amounts for each service and out-of-pocket copayment for subsidized ( n = 137) and non-subsidized ( n = 124) beneficiaries. A multivariable linear regression analysis was conducted to control for age, gender, household size, length of care, and care eligibility level. Compared with the non-subsidized beneficiaries, the subsidized beneficiaries used 1.53 times as much home help service ( p < 0.001), and spent 0.70 times as much on out-of-pocket copayments ( p < 0.001), while they used fewer adult daycare services (0.71 times as much as the non-subsidized did, p = 0.063). The results strongly indicated that the interim subsidy for low-income beneficiaries alleviated the economic burden, but also resulted in service overuse and the substitution of home help services for other community care services. The policy implications of these findings were discussed.

Social Services for the Elderly Based on the New Rurality: The Japanese Experience

Since the 1920s, Japan has changed from being a relatively youthful society, with an average age of about 26, to an elderly society with an average age of over 40 (Fordyce, 1999). The number of elderly is rising and the number of births is falling. Concurrently, the health and infrastructure needs of many of the retired elderly are increasing while, for the same retirees, their contribution to productivity and revenue is diminishing (Fordyce, 1999). As the population ages, inevitably the burdens of taxes, pensions, public medical insurance and social services have been rapidly increasing. To meet the challenges of these changes in population structure, Japan has established policies such as the Gold Plan and the Public Long-term Care Insurance Program and it has expanded social services into rural agricultural areas. This article examines those policies and the care services and productive aging programs that have developed due to population aging and new rural patterns in Japan.