Care-needs certification in the long-term care insurance system of Japan

The introduction of Japan's long-term care insurance (LTCI) system in April 2000 has made long-term care an explicit and universal entitlement for every Japanese person aged 65 and older based strictly on physical and mental status. At the start of the program, more than two million seniors were expected to apply for services to approximately 3,000 municipal governments, which are the LTCI insurers. The LTCI implementation required a nationally standardized needs-certification system to determine service eligibility objectively, fairly, and efficiently. The current computer-aided initial needs-assessment instrument was developed based on data collected in a large-scale time study of professional caregivers in long-term care institutions. The instrument was subsequently tested and validated by assessing data of 175,129 seniors involved in the national model programs before the start of LTCI. The computer-aided initial assessment (an 85-item questionnaire) is used to assign each applicant to one of seven need levels. The Care Needs Certification Board, a committee of medical and other professionals, reviews the results. Three years after implementation, the LTCI system and its needs-assessment/certification system have been well accepted in Japan. Despite the overall successes, there remain challenges, including area variations, growing demands for services, and the difficulty of keeping the needs certification free of politics. The LTCI computer network that links municipalities and the central government is instrumental in continuously improving the needs-certification system. Future challenges include promoting evidence-based system improvements and building incentives into the system for various constituencies to promote seniors' functional independence.     

The health and social system for the aged in Japan

Japan implemented a new social insurance scheme for the frail and elderly, Long-Term-Care Insurance (LTCI) on 1 April 2000. This was an époque-making event in the history of the Japanese public health policy, because it meant that in modifying its tradition of family care for the elderly, Japan had moved toward socialization of care. One of the main ideas behind the establishment of LTCI was to "de-medicalize" and rationalize the care of elderly persons with disabilities characteristic of the aging process. Because of the aging of the society, the Japanese social insurance system required a fundamental reform. The implementation of LTCI constitutes the first step in the future health reform in Japan. The LTCI scheme requires each citizen to take more responsibility for finance and decision-making in the social security system. The introduction of LTCI is also bringing in fundamental structural changes in the Japanese health system. With the development of the Integrated Delivery System (IDS), alternative care services such as assisted living are on-going. Another important social change is a community movement for the healthy longevity. For example, a variety of public health and social programs are organized in order to keep the elderly healthy and active as long as possible. In this article, the author explains on-going structural changes in the Japanese health system. Analyses are focused on the current debate for the reorganization of the health insurance scheme for the aged in Japan and community public health services for them.     

National Long-Term Care Insurance Policy in Japan a Decade after Implementation: Some Lessons for Aging Countries

In recent years, several rapidly aging countries have looked towards the introduction of a national long-term care insurance (LTCI) policy to deal with the needs of their graying population. This article presents a comprehensive overview of the LTCI policy in Japan and the reforms made, and discusses the successes and challenges of the policy over the ten-year period since its implementation in April 2000. The objective is to provide some policy guidelines so that other countries can benefit from Japan??s early experience. All Japanese adults aged 65+ are covered by the LTCI program and are eligible for both in-home and institutional-care services after a systematic and thorough care-level certification process. The utilization of services is planned and coordinated by care managers. The program is financed by a mix of general tax revenues from the three levels of government, income-tested premiums, and standardized co-payments. Reforms in later years included the introduction of preventive services and the levy of charges on accommodation and meals at institutional facilities. A key success of the policy is its universal and comprehensive coverage. Notwithstanding this success, increasing costs continue to remain a challenge as Japan??s population ages further and the number of LTCI users increases.     

Establishing systems of care in Germany: a long and winding road

Since 1995/1996 a long-term care insurance (LTCI), which promised to develop new support structures, in particular for the group of potentially frail elderly people, has been implemented in Germany. It will be shown that this LTCI has undoubtedly improved the social situation of the persons in need of care, even if its scheme is only providing basic support with a ceiling in cash-benefits and benefits in-kind, and privileging home care by informal caregivers. But certain misdevelopments in the LTCI have shown that the present scheme requires further effort to cope with these negative effects and to elaborate new integrated models of care that bridge the still existent gap between medical and social support. This article points to long traditions of separating the social and medical dimensions in Germany which have also resulted in divided institutional arrangements. The current scheme of the LTCI, its organizational principles and its entitlements and benefits are outlined, which gives the opportunity to point out certain deficiencies, e.g., the still inappropriate provision for dementia care which is due to the dominant IADL-orientation of the medical assessment procedure and its implicit negligence of social care elements. The public debate about necessary improvements in benefits for the demented aged has already led to slight revisions of the LTCI, and will develop into a more comprehensive movement to path-bridging models of social and medical care in which the quality dimension will play a decisive role.     

Elderly long-term care in Korea

The national mandatory elderly long-term care insurance (LTCI) was established in Korea in July 2008. One year after introduction of the LTCI, 5.2% of the elderly population aged 65 years and older were beneficiaries. The applicant's caregiver(s) submit an application form along with a statement of a doctor's medical opinion to the National Health Insurance Corporation, after which one or two National Health Insurance Corporation staff members (either a nurse or social worker) visit the applicant's house to evaluate their physical and mental status.The majority of beneficiaries are reported to have one or more chronic conditions. The problem is that national LTCI and national medical insurance are separate now in Korea. However, it is almost impossible to separate long-term care and health care. Even though long-term care facilities contract physicians or hospitals to have physicians visit care facilities regularly, the reward for these physicians is not satisfactory and sometimes they work without pay. Furthermore, contracted physicians cannot properly manage the elderly in long-term care facilities because they are not legally allowed to provide any medical services to long-term care facilities except for prescribing medicine.The efficient linkage of long-term care and health care is a big task in Korea that is under discussion by full-time physicians working for long-term care facilities.     

Cruise ship care: a proposed alternative to assisted living facilities

Options for elderly patients who can no longer remain independent are limited. Most choices involve assisted living facilities, 24-hour caregivers, or nursing homes. State and federal assistance for payment for individual care is limited, and seniors usually pay for most costs out of pocket. For those patients who have the means to afford assisted living centers or nursing homes, "cruise ship care" is proposed. Traveling alongside traditional tourists, groups of seniors would live on cruise ships for extended periods of time. Cruise ships are similar to assisted living centers in the amenities provided, costs per month, and many other areas. This article begins with an examination of the needs of seniors in assisted living facilities and then explores the feasibility of cruise ship care in answering those needs. Similarities between cruise ship travel and assisted living care, as well as the monetary costs of both options, are defined. A decision tree with selections for non-independent care for seniors was created including cruise ship care as an alternative. Using a Markov model over 20 years, a representative cost-effectiveness analysis was performed that showed that cruises were priced similarly to assisted living centers and were more efficacious. Proposed ways that cruise ship companies could further accommodate the needs of seniors interested in this option are also suggested. Implementation for cruise ship care on the individual basis is also presented. Ultimately, it is wished to introduce a feasible and possibly more desirable option to seniors who can no longer remain independent.     

Burden reduction of caregivers for users of care services provided by the public long-term care insurance system in Japan

We surveyed the care burden of family caregivers, their satisfaction with the services, and whether their care burden was reduced by the introduction of the LTCI care services. We randomly enrolled 3000 of 43,250 residents of Nagoya City aged 65 and over who had been certified as requiring long-term care and who used at least one type of service provided by the public LTCI; 1835 (61.2%) subjects returned the survey. A total of 1015 subjects for whom complete sets of data were available were employed for statistical analysis. Analysis of variance for the continuous variables and χ² analysis for that categorical variance were performed. Multiple logistic analysis was performed with the factors with p values of <0.2 in the χ² analysis of burden reduction. A total of 68.8% of the caregivers indicated that the care burden was reduced by the introduction of the LTCI care services, and 86.8% of the caregivers were satisfied with the LTCI care services. A lower age of caregivers, a more advanced need classification level, and more satisfaction with the services were independently associated with a reduction of the care burden. In Japanese LTCI, the overall satisfaction of the caregivers appears to be relatively high and is associated with the reduction of the care burden.     

Comparison of public and private care management agencies under public long-term care insurance in Japan: A cross-sectional study

Aim:   Long-Term Care Insurance (LTCI), which started in April 2000, allowed private business corporations to provide long-term care services which had been provided by social welfare corporations or public agencies in the previous long-term care scheme. This study compared differences in care management plans for community-dwelling frail elderly people between public care management agencies and private care management agencies.
Methods:   The subjects were 309 community-dwelling frail elderly people living in a suburban city with a population of approximately 55 000 and who had been using community-based long-term care services of the LTCI for 6 months from April 2000. The characteristics of the care management agencies (public/private) were identified using a claims database. After comparing profiles of users and their care mix between those managed by public agencies and by private agencies, the effect of the characteristics of care management agencies on LTCI service use was examined.
Results:   Public care management agencies favored younger subjects ( P  = 0.003), male subjects ( P  = 0.006) and people with a higher need for care ( P  = 0.02) than private agencies. The number of service items used was significantly larger in public agencies than in their private counterparts. In multivariate regression analysis, the utilization of community-based long-term care service was significantly greater among beneficiaries managed by private agencies than those managed by public agencies ( P  = 0.02).
Conclusion:   Private care management agencies play an important role in promoting the use of care services, but their quality of care plans might be questionable.     

Population ageing and wellbeing: lessons from Japan's long-term care insurance policy

Japan's population is ageing rapidly because of long life expectancy and a low birth rate, while traditional supports for elderly people are eroding. In response, the Japanese Government initiated mandatory public long-term care insurance (LTCI) in 2000, to help older people to lead more independent lives and to relieve the burdens of family carers. LTCI operates on social insurance principles, with benefits provided irrespective of income or family situation; it is unusually generous in terms of both coverage and benefits. Only services are provided, not cash allowances, and recipients can choose their services and providers. Analysis of national survey data before and after the programme started shows increased use of formal care at lower cost to households, with mixed results for the wellbeing of carers. Challenges to the success of the system include dissatisfaction with home-based care, provision of necessary support for family carers, and fiscal sustainability. Japan's strategy for long-term care could offer lessons for other nations.     

Economic Burden of Ambulatory and Home-Based Care for Adults with Cystic Fibrosis

Objective: The purpose of this study was to measure costs associated with care for adults with cystic fibrosis, from a societal perspective. Methods: Over a 4-week period, 110 participants completed the Ambulatory and Home Care Record, a self-administered data collection instrument that measures costs to the health system, costs to employers, care recipients’ direct out-of-pocket expenditures, and time costs borne by care recipients and their family caregivers. Health system costs were based on the costs incurred through expenditures on physicians, hospital clinics, Pharmaceuticals, and home care agencies. Out-of-pocket costs were obtained using self-reports by care recipients, and time losses were valued using the human capital approach. Results: The annual mean societal costs of ambulatory care for cystic fibrosis was $Can29 885 per care recipient (year 2002 value). Time losses incurred by care recipients and their family caregivers accounted for the majority (72%) of these costs, and system costs accounted for the second highest percentage of costs (21%). Although almost all participants (109) recorded out-of-pocket expenditures, these costs accounted for only a small proportion (3%) of total costs. Conclusion: Measuring societal costs is necessary for practitioners, managers, and policy decision-makers, to ensure that care recipients and their families receive the necessary resources to provide care.     

From HMOs to ACOs: The Quest for the Holy Grail in U.S. Health Policy

The United States has been singularly unsuccessful at controlling health care spending. During the past four decades, American policymakers and analysts have embraced an ever changing array of panaceas to control costs, including managed care, consumer-directed health care, and most recently, delivery system reform and value-based purchasing. Past panaceas have gone through a cycle of excessive hope followed by disappointment at their failure to rein in medical care spending. We argue that accountable care organizations, medical homes, and similar ideas in vogue today could repeat this pattern. We explain why the United States persistently pursues health policy fads-despite their poor record-and how the promotion of panaceas obscures critical debate about controlling health care costs. Americans spend too much time on the quest for the "holy grail"-a reform that will decisively curtail spending while simultaneously improving quality of care-and too little time learning from the experiences of others. Reliable cost control does not, contrary to conventional wisdom, require fundamental delivery system reform or an end to fee-for-service payment. It does require the U.S. to emulate the lessons of other nations that have been more successful at limiting spending through budgeting, system wide fee schedules, and concentrated purchasing.     

Substitute services: a barrier to controlling long-term care expenditures

In many developed countries, long-term care expenditures are a major source of concern, which has urged policy makers to reduce costs. However, long-term care financing is highly fragmented in most countries and hence reducing total costs might be complicated by spillover effects: spending reductions on one type of care may be offset elsewhere in the system if consumers shop around for substitutes. These spillovers may be substantial, as we show using a reform in the budget for municipalities for the most common type of publicly financed home care in the Netherlands, domestic help. This reform generated an exogenous change in the grant for domestic help that does not depend on changes in its demand. We show that the change in budget affected consumption of this care type, but that this effect was mitigated by offsetting changes in the consumption of three other types of home care that are financed through another public scheme and are organized through regional single payers. We find that a 10 euro increase in the grant for domestic help increased use of domestic help and nursing by 0.13 and 0.03 h per capita (4.4 and 5.2% of use in 2007), whereas it decreases use of individual assistance and personal care by 0.03 and 0.05 h per capita (4.1 and 2.9% of use in 2010 and 2007, respectively). As a result, the total spending effect is closer to zero than the effect on domestic help suggests. This finding means that the fragmentation of long-term care financing limits the ability to control expenditure growth.     

Comparative costs of home care and residential care

PURPOSE: This paper reports on Canadian research that examined the cost effectiveness of home care for seniors as a substitute for long-term institutional services. DESIGN AND METHODS: Two Canadian cities were included in the research: Victoria, British Columbia, and Winnipeg, Manitoba. The research computes the costs of formal care and informal care in both settings and ensures comparable groups of clients in both settings by comparing individuals at the same level of care. RESULTS: The results reveal that costs were significantly lower for community clients than for facility clients, regardless of whether costs only to the government were taken into account or whether both formal and informal costs were taken into account. When informal caregiver time is valued at either minimum wage or replacement wage, there was a substantial jump in the average annual costs for both community and facility clients relative to when informal caregiver time was valued at zero. IMPLICATIONS: Nevertheless, the results reveal that home care is significantly less costly than residential care even when informal caregiver time is valued at replacement wage.     

Developing a comprehensive interdisciplinary senior healthcare practice

The PeaceHealth Senior Health and Wellness Center (SHWC) provides primary care coordinated by geriatricians and an interdisciplinary office practice team that addresses the multiple needs of geriatric patients. The SHWC is a hospital outpatient clinic operated as a component of an integrated health system and is focused on the care of frail elders with multiple interacting chronic conditions and management of chronic disease in the healthier older population. Based on the Chronic Care Model, the SHWC strives to enhance coordination and continuity along the continuum of care, including outpatient, inpatient, skilled nursing, long-term care, and home care services. During its development, a patient-centered approach was used to identify senior service needs. The model emphasizes team development, integration of evidence-based geriatric care, site-based care coordination, longer appointment times, "high touch" service qualities, utilization of an electronic medical record across care settings, and a prevention/wellness orientation. This collection of services addresses the interrelationships of all senior issues, including nutrition, social support, spiritual support, caregiver support, physical activity, medications, and chronic disease. The SHWC provides access in an environment sensitive to the special needs of seniors, with a staff trained to meet those needs. The SHWC business model attempts to improve access and quality of care to seniors in a mostly noncapitated healthcare setting, while also attempting to remain financially viable.     

The role of "wound burden" in determining the costs associated with wound care

Because of the tremendous resources they require to heal, patients with severe wounds present significant challenges to our healthcare system. This study was undertaken to introduce the concept of "wound burden" and its predictive value in anticipating the costs associated with inpatient care for patients with wounds. Wound burden is a new concept that can be used to represent the severity of a patient's skin breakdown; it is defined in this study in terms of number, size, and stage. A computerized system of wound cost tracking measured the costs involved in delivering optimal wound care to 240 patients in a long-term acute care facility. Patients were stratified in a system that accounted for "wound burden" to determine the degree to which wound burden is related to costs. Costs that pertained to supplies, specialty beds, nutrition, labs, and extra personnel time required to document and care for the wounds were recorded. The concept of "wound burden" was presented and found to be very important in predicting actual costs. Patients with the highest level of wound burden were found to have significantly higher wound costs and total stay costs (P > 0.0001). As payment systems change, having data available to justify the resources necessary to allow facilities to continue to care for the most highly wound burdened patients will become increasingly important.     

The health and social service needs of gay and lesbian elders and their families in Canada

PURPOSE: This article reports the findings of a study, undertaken in 2000, whose purpose was to gather information about the experiences and realities of gay and lesbian seniors and their families from across Canada in accessing a broad range of health and social services in the community, and to examine the role of health care and social service organizations in shaping access and service delivery. DESIGN AND METHODS: This study used a qualitative exploratory design based on focus group interviews. Perspectives of older gay men and lesbians and their families involved in organizations addressing these issues, as well as professionals from both gay and lesbian health organizations and mainstream elder care organizations were sought. RESULTS: Specific reference was made to the impact of discrimination on the health and access to health services of these populations. Issues relating to invisibility, historic and current barriers to care, and the nature of service options are identified. IMPLICATIONS: Recommendations for change are highlighted, including those related to best practice programs and policies in the long-term care sector.     

Community options bring change to long-term care in Australia

Who stands to gain from Australia’s 10-year campaign to reform long-term care? The government seeking to contain costs? People trying to live at home despite their disabilities? The entire system of providing social services? Or all three?     

Conference for Seniors Citizens to Promote Self-Care Strategies

The U.S. Department of Health and Human Services (1990) stated in its publication "Health People 2000: Full Report" that preventable risk factors can be reduced by changes in health related behaviors, and these behaviors can be influenced by early health care intervention. "Senior Conference-Target Heatlh '93" offered a specific program for African-American Senior Citizens to promote independent living and self-care strategies while fostering participation in the management of their own health. One hundred thirty seven African-American seniors attended this conference. The topics presented included self-care for chronic diseases, health promotion activities, and availability of community resources. The conference approach used adult learning principles and brought health professionals, health services, and community leaders to the seniors for improving their health related knowledge and communication skills.     

End of Life Care for Older Russian Immigrants - Perspectives of Russian Immigrants and Hospice Staff

This pilot study examined immigrant Russian seniors and adult children’s views on end-of-life care, and hospice staff members’ experiences providing care to diverse immigrant clients, in areas of North Carolina with a high proportion of immigrants. Data were collected through individual in-depth interviews with informants, including Russian immigrant seniors, Russian adult children, and hospice staff, and analyzed by qualitative techniques. Findings indicate that there is little awareness of end-of-life care options among the Russian immigrant community in North Carolina. End-of-life care is rarely discussed within the family of first generation Russian immigrants but second-generation families are more open to doing so. First generation immigrant Russian seniors in our study do not seem to want any specialized end-of-life care often due to lack of awareness, and prefer family care. Second generation seniors’ attitudes are more accepting of this type of care. Hospice staff serve all those who seek care, receive training to serve diverse clients, and prioritize professional policies. There is sometimes potential for a gap between hospice policies regarding care and immigrant families’ expectations for care. Results suggest a great need for community outreach to immigrant groups to raise awareness of end-of-life care, including advance directives and hospice care and the role of interpreters in health care settings.     

"Lost to follow-up": the public health goals of accountable care

The Affordable Care Act made admirable strides toward the "triple aim" of reducing health care costs, increasing health care quality, and improving the health of the community at large. A key element of reform is the accountable care organization (ACO), which restructures health care delivery such that networks of providers are held responsible for a group of patients they serve. The recently announced Medicare ACO program lays the foundation for 2 of its 3 major goals by allowing ACOs to share in any cost savings, provided they meet quality criteria. Yet it seems that the public health goals of accountable care-arguably the most important of the 3-have been left behind. To better address public health goals, we propose a novel method for quality reporting within ACOs: introducing an "expanded denominator" that attributes patients to a health system if they have ever been seen within the system. An expanded denominator would ensure that ACOs are held accountable not only for patients already engaged in primary care but also for patients with fragmented care and high-risk community members not receiving adequate care. Ultimately, payment reform in Medicare, and potentially Medicaid, must support this new approach to quality measurement for it to have lasting ramifications.