Public Long-term Care Insurance Research Articles

Sustainability of Public Long-term Care Insurance System and Difference between Municipalities

Sustainability of Public Long-term Care Insurance System and Difference between Municipalities

Aiming Higher: Advancing Public Social Insurance for Longterm Care to Meet the Global Aging Challenge Comment on "Financing Long-term Care: Lessons From Japan".

Globally, aging populations are driving the demand for long-term care (LTC) services for a growing number of older people with disabilities or chronic illnesses. A key challenge for policy-makers in all countries is to find a comprehensive solution to financing LTC services to make them widely accessible, affordable, and equitable for all in need. In this commentary, we make a case for LTC policy-makers and reformers across countries to take a long-term vision toward establishing a public, mandatory social insurance model of LTC financing. We first take a hard look at the LTC financing problems and the limitations of existing financing options. We then argue for a public social insurance approach to LTC financing and offer insights into several top-level insurance design features that are key to successful implementation of a public social insurance model, building on the experiences and lessons learned from Japan and other countries that have already "gotten there." We conclude with additional thoughts on the future of public LTC insurance in a global context, including the prospect of spreading this model to middle-income countries.

Financing Long-term Care: The Role of Culture and Social Norms Comment on "Financing Long-term Care: Lessons From Japan".

Based on the experiences of Japan and Germany, Ikegami argues that middle-income countries should introduce public long-term care insurance (LTCi) at an early stage, before benefits have expanded as a result of ad hoc policy decisions to win popular support. The experience of the Netherlands, however, shows that an early introduction of public LTCi may not prevent, but instead even facilitate later extensions of public coverage. We argue that social norms and cultural values about caring for the elderly might be the main driver of expansions of LTCi coverage. Furthermore, we posit that this expansion may reinforce the social norms supporting it. Hence, politicians and policy-makers should be aware of this possible self-reinforcing effect.

POSITIVE PSYCHOLOGICAL DETERMINANTS OF DEMENTIA IN JAPAN

We examined the effects of sustained levels of happiness on dementia incidence among Japanese elderly from the Japan Gerontological Evaluation Study. Data were from 12,051 community-dwelling participants aged 65 and over, free from dementia or other chronic conditions at baseline (2010). A survey was conducted in 31 administrative districts from Japan. Participants were followed-up for six years, and the incidence of dementia or death was assessed through National Public Long-Term Care Insurance and Resident Registry, Japan. We conducted survival analysis using the Cox proportional hazard model with a competing risk analysis accounting for death. The adjusted differences in days for dementia onset were estimated using Laplace regression models. In this analytical sample, we observed 520 men and 693 women with dementia and found that higher levels of sustained happiness were associated with reduced risks of onset of dementia among Japanese elderly. These findings suggest a protective role of psychological mood.

DO THE PRESENCE OF ADULT CHILDREN AND THEIR MARITAL STATUS MATTER FOR ACCESS TO THE PUBLIC LONG-TERM CARE SYSTEM?

Knowing how the presence of family affects access to the public long-term care system is important for evaluating the adequacy of the system. This study examined the relationship between the presence of adult children and their marital status, and access to a public system by examining the gap between self-reported care needs and the official certification as needing care under the Japanese public long-term care insurance system. Data from Japan’s 2016 Comprehensive Survey of Living Conditions were used. A total of 23,466 older adult claimants, aged 65 years and older were analyzed. Outcomes were whether or not claimants were officially certified as needing care under the system, and the relationship of the presence of both live-in and live-out children and their marital status were examined controlling for claimants’ age, gender, education, financial status, and physical and cognitive conditions. Females comprised 64.8% of the sample, and the average age was 83 years (SD=7.8). The percentage of claimants living with a single or married child were 25.2% and 26.9%, respectively, and 60.1% were parents of children who lived independently. The percentage who were officially certified as needing care was 68.5%. Logistic regression analysis revealed that claimants with a live-in child were less likely to be officially certified as needing care, and claimants with live-in a single child were less likely to be officially certified compared with those with a married child. Live-in single children may provide long-term care by themselves, and the excess burden on them needs to be further investigated.

THE ROLE OF POLICY CONTEXT IN INDIVIDUAL LONG-TERM CARE DECISIONS IN OECD COUNTRIES

While family caregiving of the elderly has long been part of the cultural life of most OECD countries, longer life expectancy combined with low fertility rates has increased the share of the population dependent on current workers and minimized the available population of informal caregivers. The demand for expanded public provision of long-term care (LTC) resulting from this demographic shift prompted reforms in many OECD countries in the 1990s and 2000s. Differences in these reforms provide an opportunity to examine how individual choices between formal and informal care types are shaped by the policy context. I use longitudinal data on elders in three OECD countries, Sweden, Germany, and Japan, to examine LTC decisions under three varied approaches to population aging. The direction of LTC reforms in each country has been shaped by the existing model of care provision and financial constraints. In response to cost pressures, Sweden introduced need-based provision, financial devolution, and market-based approaches to its universal care model. Germany and Japan, in contrast, widely expanded restricted LTC coverage through public LTC insurance models. I use three multinomial logistic models of the LTC decision to test how differing policy schemes influence choices between formal and informal care. Using longitudinal Global Gateway to Aging data for each country, I model the LTC decision in each country as a factor of demographic and need characteristics of the elder experiencing limitations, characteristics of their family, and eligibility for publicly-provided LTC.

ASSESSING THE EFFECTS OF LONG-TERM CARE INSURANCE ON EQUITY AND EFFICIENCY: A CASE STUDY OF QINGDAO CITY IN CHINA

The demand for equitable and efficient long-term care (LTC) has risen rapidly, and finding a suitable mechanism to finance LTC has become a pressing policy concern for many countries. A number of high income countries have chosen to use a social LTC insurance to fund the LTC system, but empirical assessments on such an insurance in low-and middle-income countries are limited. Using China as an example, this paper empirically assesses the performance of newly-piloted LTCNI by evaluating its impact on equity and efficiency in financing. We draw data from 47 in-depth interviews conducted with local government, care providers and family members of the LTCNI participants in Qingdao in 2016. We found that there remain sizable disparities in financial burden among LTCNI participants, despite of its emphasis on ensuring access to care based on people’s needs; care providers are incentivised to provide care at the least cost even this care is deemed as insufficient or inadequate due to fixed payment for their services. Our paper offers critical insights into the potential and challenges in applying LTC insurance model to a LMIC, where critical lessons can be drawn for public LTC insurance in other LMICs.

Association between improved adherence to the Japanese diet and incident functional disability in older people: The Ohsaki Cohort 2006 Study.

Although it has been reported that the Japanese dietary pattern is associated with a lower risk of incident functional disability among older people, the potential benefits of improving adherence to the Japanese diet remain unclear. The aim of the present study was to evaluate the association between 12-year change in adherence to the Japanese diet and the subsequent risk of incident functional disability in older people in Japan. We analyzed 10-year follow-up data from a cohort study of 2923 Japanese older adults (age ≥65 years) in 2006. We collected dietary information using a validated 39-item food frequency questionnaire at two time points (1994 and 2006). Adherence to the Japanese diet (high intake of rice, miso soup, seaweeds, pickles, green and yellow vegetables, fish, green tea; low intake of beef and pork, and coffee) was assessed using the Japanese Diet Index (JDI), which ranges from 0 to 9. Participants were categorized into five groups according to changes in the JDI score at these two time points. Data on incident functional disability from December 2006 to November 2016 were retrieved from the public long-term care insurance database. The Cox proportional hazards model was used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) for incident functional disability. During 22,466 person-years of follow-up, 1093 cases of incident functional disability were documented. Compared with participants in the group with the largest decrease in the JDI score (≤-2), the multivariate-adjusted HR (95% CI) of incident functional disability was 0.77 (0.61-0.98) for those in the largest increase group (≥+2). Improved adherence to the Japanese diet was associated with a significantly lower risk of incident functional disability in older people in Japan.

Community social capital and the onset of functional disability among older adults in Japan: a multilevel longitudinal study using Japan Gerontological Evaluation Study (JAGES) data

ObjectiveThe present study examined the association between community social capital and the onset of functional disability among older Japanese people by using validated indicators of social capital and a prospective...

Albumin and Hemoglobin Trajectories and Incident Disabling Dementia in Community-Dwelling Older Japanese

Background: Serum albumin and hemoglobin levels are independently associated with subsequent cognitive deterioration in older adults. This prospective study used repeated measures analysis to identify aging trajectories in serum albumin and hemoglobin levels and investigated if these trajectories were associated with incident disabling dementia among community-dwelling older Japanese. Methods: A total of 2,005 adults aged 65–90 years participated in annual geriatric health assessments during the period from June 2002 through July 2017; the total number of observations was 9,330. A review of a municipal database of the Japanese public long-term care insurance system identified 1,999 of 2,005 adults without dementia at baseline, 278 (13.9%) of whom developed disabling dementia during the follow-up period (June 2002 through December 2017). Results: We identified three trajectory patterns (high, moderate, and low) for serum albumin and hemoglobin levels for the age period 65 through 90 years. After controlling for potential confounders, participants with moderate and low trajectories for serum albumin level had hazard ratios of 1.27 (95% confidence interval 0.94–1.72) and 2.07 (1.37–3.11), respectively, for the development of incident disabling dementia, with the high trajectory group as reference. The respective hazard ratios for hemoglobin level were 1.31 (0.93–1.85) and 1.58 (1.04–2.40), respectively. Conclusion: Dementia risk was higher for individuals with low trajectories for serum albumin and hemoglobin levels. This finding highlights the importance of interventions that improve nutritional status and control relevant diseases in middle-aged and older adults with low serum albumin and hemoglobin levels.

Combined Healthy Lifestyle Behaviors and Disability-Free Survival: the Ohsaki Cohort 2006 Study.

Previous studies have suggested that a healthy lifestyle (HL) may prolong the years of life spent in good health. However, the impact of HL on disability-free survival (DFS) among the elderly is still uncertain. To investigate the relationship between HL and DFS in the general elderly population. Prospective cohort study with a 10-year follow-up (2006-2016). 9910 community-dwelling elderly people (≥ 65years). A HL index derived by summing the number of HL behaviors. Data on incident disability were retrieved from the public Long-term Care Insurance database. Multivariate-adjusted 50th percentile differences (PDs) in age at disability or death (months) and their 95% CIs were estimated with the Laplace regression model. During the 10years, 4562 disability or death events occurred. Participants who adhered to all three HL behaviors lived 17.1 (95% CI 12.7, 21.5) months longer without disability than those who adhered to zero or one. Each 1-point increase of the index score conferred 8.8months additional life without disability. The tendency for the 50th PDs to increase with a higher HL index score did not differ according to age (< 75 or ≥ 75years), sex, or the presence of chronic conditions (none, or ≥ 1 chronic condition). A combination of HL behaviors may substantially increase DFS, even for late-elderly (≥ 75years), or elderly people with chronic conditions.

The Behavioral Effect of Insurance Coverage and Its Health Consequences: Evidence from Long-Term Care

How does the generosity of social insurance coverage affect demand for healthcare and health outcomes of elderly people? This paper examines the effects of insurance coverage on long-term care (LTC) utilization and its health consequences using novel administrative data of the public long-term care insurance (LTCI) system in Japan. In LTCI, a recipient's health score determines their insurance coverage limit, and thresholds of the score generate discontinuous changes in the level of coverage limits. I implement a regression discontinuity design and find that the coverage expansion significantly increases recipients' LTC utilization even without changing the prices they face. Moreover, using more LTC has little effect on health outcomes. Together, these results suggest that generous LTCI coverage can induce excessive utilization, mainly because of behavioral biases, without having health benefits.

The relationship between body mass index and disability-free survival in elderly Japanese: the Ohsaki Cohort 2006 Study.

The relationship between body mass index (BMI) and disability-free survival (DFS) remains unclear. We conducted a 10-year prospective cohort study of 12,666 Japanese individuals aged ≥ 65 y. Information on BMI and lifestyle factors was collected via a questionnaire in 2006. Functional disability data were retrieved from the public Long-term Care Insurance database. Subjects were divided into seven groups according to BMI (<19, 19-21, 21-23, 23-25, 25-27, 27-29 and ≥29). Fiftieth percentile differences (PDs) and 95% confidence intervals (CIs) in the DFS period (differences of period until the first 50% of the composite outcome (disability or death) occurred in each of the BMI groups) were calculated using the Laplace regression model. There was a U-shaped relationship between BMI and the risk of incident composite outcome, with a BMI nadir of 25-27. Based on BMI 25-27 as a reference, the 50th PDs (95% CIs) (in months) in age at disability or death (median DFS) were -20.8 (-26.4, -15.2) (P < 0.001) months for BMI <19, -13.5 (-18.2, -8.7) (P < 0.001) months for BMI 19-21, -9.8 (-14.2, -5.4) (P < 0.001) months for BMI 21-23, -2.9 (-7.5, 1.7) (P = 0.21) months for BMI 23-25, -2.7 (-8.4, 2.9) (P = 0.34) months for BMI 27-29, and -11.5 (-19.6, -3.5) (P = 0.005) months for BMI ≥ 29. These relationships did not differ by sex. Older individuals with a BMI of <23 or ≥29 have a significantly shorter DFS period than those with a BMI of 25-27. It is suggested that the optimal BMI range for maximization of disability-free life expectancy in the elderly population is 23-29.

Factors Related to the Institutionalization of Older Aged Individuals Using Home- and Community-Based Care Services: Data From the South Korea Long-Term Care Insurance Program, 2008–2013

ABSTRACTSouth Korea introduced a public long-term care insurance (LTCI) program in response to its rapidly aging population. This study analyzed the association between living arrangement and caregiver type with institutionalization in LTCI grade 1 (very severe limitations), 2 (severe limitations), and 3 (moderate limitations) beneficiaries using data from the LTCI cohort, 2008 to 2013. The dependent variable was alteration status from home to institutional care within 1 year of receiving home service. Independent variables were living arrangement and primary caregiver type. The analysis was conducted using the generalized estimating equation model. Higher likelihoods of institutionalization were found in individuals living with a non-family member compared to individuals living with their spouses. Individuals without a caregiver or with a paid caregiver were also more likely to experience institutionalization than individuals with a spouse primary caregiver. Our findings underscore the importance of monitoring identified vulnerable groups of individuals to attain LTCI sustainability and enhance elderly quality of life.

Moral hazard under zero price policy: evidence from Japanese long-term care claims data.

We evaluate the presence and magnitude of moral hazard in Japan's public long-term care insurance (LTCI) market. Using monthly LTCI claim records from January 2006 to December 2015 linked to concurrent death records, we construct a sample by propensity score matching insured individuals who co-pay 10% of their fees to those with no required copayments, and we implement fixed-effect estimations. We find that a ten-percentage-point reduction in the copayment rate increases monthly costs by 10.2 thousand yen, corresponding to a price elasticity of about - 0.1. Insured individuals with no copayments tend to use more services and have more utilization days than those with copayments do. Furthermore, we find that insured individuals who die from cerebral (myocardial) infarction increase their service use more in response to a reduction in the copayment rate than those who die from senility do, indicating a positive association between ex-ante health risks and ex-post service use. We verify that a cost-sharing adjustment is a valid solution for soaring LTCI expenditures. These findings could provide broad implications for the rapidly aging world.

Joint impact of seven risk factors on incident dementia in elderly Japanese: the Ohsaki Cohort 2006 Study.

This cohort study estimated the population attributable fraction (PAF) of seven combined major risk factors for incident dementia. We conducted a cohort study of 8563 community-dwelling individuals aged ≥ 65years. In a baseline survey (2006), we collected data on major seven risk factors: diabetes mellitus, hypertension, obesity, physical inactivity, severe psychological distress, smoking, and low educational attainment. The total number of risk factors was applied as an exposure variable. Subjects were categorized into four groups according to the total number of risk factors they possessed (0, 1, 2, ≥ 3 risk factors). Data on incident dementia were retrieved from the public Long-term Care Insurance database. Hazard ratios (HRs) and 95% confidence interval (95% CI) were estimated using the Cox proportional regression model. We also calculated the PAF using HRs and the prevalences in our cohort data. The number of cases of incident dementia was 577 (6.7%). A dose-response relationship between the total number of risk factors and incident dementia was observed; in comparison with no risk factors (reference), the age- and sex-adjusted HRs(95% CIs) were 1.25 (0.92-1.70) for one risk factor, 1.59 (1.18-2.15) for two, and 2.21 (1.62-3.01) for three or more (P trend < 0.001). If subjects had adhered to none of the risk factors, the PAF would have been 32.2%. If subjects had improved toward one better category, the PAF would have been 23.0%. Our findings suggest that reducing the combined number of risk factors would contribute significantly to reducing the incidence of dementia.

Reduced long-term care cost by social participation among older Japanese adults: a prospective follow-up study in JAGES

ObjectivesReducing costs related to functional disabilities and long-term care (LTC) is necessary in ageing societies. We evaluated the differences in the cumulative cost of public LTC insurance (LTCI) services by...

Socioeconomic status and improvement in functional ability among older adults in Japan: a longitudinal study

BackgroundRecovery from functionally disabled status is an important target of public health measures for older adults. This study aimed to examine socioeconomic inequalities in the improvement of functional ability among older adults stratified by the level of disability at baseline.MethodsIn the Japan Gerontological Evaluation Study, we conducted a mail survey of community-dwelling older adults (1937 men and 2212 women) who developed functional impairment during 2010–2014. The survey data were individually linked to the longitudinal records of changes in the levels of functional disability based on the Public Long-Term Care Insurance System.ResultsThe mean (standard deviation) follow-up period was 316 (269) days. During follow-up, 811 participants (19.5%) showed improved functional ability. Among those with severe disabilities at baseline, men with 13 or more years of education were more likely to improve functional ability than men with 9 or fewer years of education (hazard ratio: 1.97, 95% confidence interval: 1.12–3.45). A similar association was observed among women (hazard ratio: 2.16, 95% confidence interval: 1.03–4.53). Neither income nor occupation was statistically associated with improved functional ability.ConclusionsThere are education-related inequalities in the improvement of functional ability, especially among older adults with severe disabilities. Health policy makers and practitioners should consider the educational background of individuals with reduced functionality in formulating strategies to improve their functional ability.

Neighborhood Food Environment and Dementia Incidence: the Japan Gerontological Evaluation Study Cohort Survey

IntroductionInterventions targeting built environmental factors may encourage older people to engage in favorable behaviors and decrease dementia risk, but epidemiologic evidence is limited. This study investigated the association between neighborhood food environment and dementia incidence.MethodsA 3-year follow-up (2010–2013) was conducted among participants in the Japan Gerontological Evaluation Study, a population-based cohort study of older adults aged ≥65 years. Dementia incidence for 49,511 participants was assessed through the public long-term care insurance system. Availability of food stores (defined as the number of food stores selling fruits and vegetables within 500 meters or 1 kilometer of residence) was assessed for each participant using objective (GIS-based) and subjective (participant-reported) measurements. Data were analyzed from 2017 to 2018.ResultsA total of 3,162 cases of dementia occurred during the follow-up. Compared with the highest quartile for objective availability of food stores, the hazard ratio adjusting for age and sex was 1.60 (95% CI=1.43, 1.78) for the second-lowest quartile. Compared with the highest subjective availability of food stores, the hazard ratio was 1.74 (95% CI=1.49, 2.04) for the lowest category. After successive adjustment for sociodemographic characteristics, health status, and other geographic neighborhood factors (availability of restaurants, convenience stores, and community centers), the hazard ratio remained statistically significant.ConclusionsLower food store availability was associated with increased dementia incidence. Given that food shopping is a routine activity and a main motive for going out among older adults, increasing the availability of food stores may contribute to dementia prevention.

Estimating nutrition intake status of community-dwelling elderly people requiring care in disaster settings: A preliminary cross-sectional survey.

There are a lack of disaster preparedness measures that target populations with dysphagia. In particular, disaster response plans frequently overlook differences in textures between emergency foods and regularly consumed foods. The aim of this study was to estimate the number of community-dwelling elderly care recipients requiring specific food preparations, including the population at risk of aspiration when solely consuming common emergency foods. A cross-sectional study. Community-dwelling elderly care recipients who were certified by the public long-term care insurance system in Japan and registered at one of 77 care managing offices in Shinjuku city. Special needs regarding food intake and risks associated with receiving emergency foods were assessed by government-certified care managers. Data were acquired from 1,271 care recipients. Notably, 23.1% of the sampled population had special needs regarding food intake at all times (e.g. non-oral intake or need for texture-modified foods). An additional 11.5% were estimated to experience difficulty when ingesting common emergency foods, despite the ability to consume regular foods. A relatively large portion of community-dwelling elderly people will be at risk of aspiration due to the intake of commonly distributed emergency foods following a disaster. Appropriate preparation based on an assessment of special needs regarding food intake is therefore required when planning for future disasters.