Long-Term Care Trends
Interview with Mr. Tatsuo Honda
Director, Department of Planning, National Institute of Population and Social Security Research, Japan / News Release
April 26, 2006
The pressing needs of Japan’s rapidly aging population have stimulated innovative reforms to the country’s long-term care system. Beginning in 1990 with the release of the Gold Plan – a Ten-Year Strategy for Health and Welfare for the Elderly – and most recently with the initiation of the Long-term Care Insurance System (LTCI) in 2000, Japan has formulated a comprehensive strategy for dealing with the long-term care needs of its older population.
The LTCI is a mandatory, public long-term care insurance system to which every citizen age 40+ contributes premiums. The system entitles people who require care as they age to choose from a range of services and providers. The services include home-based, community-based and institutional care options and are paid for by the government, but require a co-payment by the patient.
The AARP Global Aging Program recently spoke with Mr. Tatsuo Honda of Japan’s National Institute of Population and Social Security Research about the recent long-term care policy initiatives in Japan. Mr. Tatsuo Honda is an expert in the Japanese long-term care system and has worked in multiple capacities on long-term care policy at the national and local government levels.
GAP: In 2000, the Government passed long-term care reforms and created the mandatory Long-Term Care Insurance System. I understand that there was a wave of negative media attention toward the new system in the months leading up to and following the reforms.
What was the sentiment of the Japanese public toward the new system at the time of the reforms, and how has it changed since?
TH: There were various opinions within many groups about the implementation of the Long-Term Care Insurance System in Japan. Some opinions were negative, but many were optimistic. For example, thanks to the new system, social services will be improved to ease family burdens at home, and users will be able to have many more choices in long-term care services through the use of private-sector vitality.
Looking at the implementation status of Long-Term Care Insurance, the number of insured persons aged 65 and over has increased by approximately 3.4 million, up 16 percent, over a period of 4 years and 11 months. The number of persons certified in need of care increased approximately 1.9 million, up 87 percent, in the same period. The number of service users obviously increased. In particular, residential service users have increased approximately 1.49 million, up 153 percent, in a period of 4 years and 9 months. Meanwhile, institutional service users also increased approximately 0.25 million, up 49 percent, in the same period.
I believe that many Japanese have now accepted the important roles of the Long-Term Care Insurance System.
* Refer to “Outline of Long-term Care Insurance System”
GAP: Are there concerns about the long-term financial sustainability of the new system?
TH: Yes, there are. The most recent reform measures passed in the Diet in June 2005 had the following three basic goals:
- Sustainability
- Active Aging Society
- More comprehensive Social Security aiming at an efficient and effective Social Security System.
These three goals are mutually related. To sustain the scheme, the reform measures were implemented to increase the efficiency of the system and to provide more targeted benefits. More autonomy was given to the insurers, i.e., municipalities. Therefore, they can promote more optimal and appropriate services to their own communities. The second point was to establish an “Active Aging Society” by changing the system into a prevention-oriented one. Additional preventive services, such as exercise programs and nutrition counseling, were introduced for individuals requiring a lower level of support. The last point was to create more comprehensive Social Security. From this viewpoint, coordination of long-term care insurance with the public pension scheme was adjusted, such as, through additional charges for in-facility food and living costs to balance pocket expenses between at-home and in-facility cases. This reform also aims to establish a comprehensive health management system in cooperation with the health care system.
Regarding the current financial situation, total expenditure and total benefits paid have been increasing rapidly. For example, benefits expenditure has been increasing by over 10% a year. The total expenditure for long-term care insurance in FY 2000(actual) was 3.6 trillion yen and 6.8 trillion yen in FY 2005(budgeted). Financial sustainability is one of the most important issues regarding the future of the Long-Term Care Insurance System.
GAP: Because it costs substantially less to care for an individual through community-based and home-based care than through institutional care, the Japanese government has been encouraging more users of long-term care to seek community and home-based care options.
What has the government been doing through incentives, public awareness/education, and public policy to encourage greater use and expansion of community-based and home-based care services?
TH: In the Reform of 2005, the government implemented new community-based services provided by municipalities to support the lives of individuals requiring long-term care. Such support comprises four measures:
- The first creates services that are available only to residents of a city. The power to certify such services has been transferred to municipalities, and the services are available only to residents of the municipality.
- The second prepares the appropriate service infrastructure for an individual community. Each municipality determines the necessary goal itself to enable well-planned enhancements in areas where the service infrastructure is lagging; and, in other areas that are already far advanced, excessive enhancement should be avoided.
- The third creates a certified standard, and care fee schedules according to unique local situations.
- The fourth promotes a fair, unbiased, and transparent scheme. Many members including local residents, elderly, business managers, and welfare/health/medical workers are involved in the long-term care scheme.
In the 2005 reform, a Community-wide Care System was also implemented to improve service quality. The Community-wide Support Center plays a very important role by serving three main functions:
- comprehensive consultations
- prevention-focused care management
- comprehensive/continuous management
GAP: Have you seen a significant increase in the use of home-based and community-based care since the 2000 reforms? Are there any patterns or general characteristics among the types of patients who choose these care options, rather than institutional care (i.e. older/younger, sicker/healthier, family/no family, urban /rural)?
TH: As mentioned previously, we have seen a significant increase in the use of residential services since 2000. Taking into account the care level, there is a clear characteristic of users who choose residential services compared to users of institutional services.
Long-term Care Insurance in Japan has introduced the Care Level Certification System. Under this system, insured persons who apply for the benefit are classified into 7 categories: independent, level in need of support and care level 1 through 5. Somebody categorized as “level in need of support” requires the least support, while level 5 indicates the severest needs.
According to a survey on the benefits in FY2003 of the Ministry of Health, Labor and Welfare (MHLW), out of individuals categorized as “level in need of support” and level 1, 34 percent use residential services. On the other hand, for institutional services, a “level in need of support” and level 1 person’s share is 7.3 percent. A person less in need of care is more likely to use the residential scheme. In contrast, a level 4 and 5 person’s share of residential services is about 28.6 percent, while their share of institutional services it is about 62.1 percent. A person who is less independent is more likely to choose institutional services than residential services.
GAP: Many homes in Japan, particularly in affordable housing, can be very inaccessible for older people or people with disabilities, due to lack of elevators, narrow hallways, and deep bathtubs.
Given the push for home-based care, has there also been a push to make homes more accessible and affordable so that people can age comfortably in place?
TH: Yes, there has also been a push to make homes more accessible and affordable since 2000. The LTCI will provide people a once-in-a-lifetime subsidy of up to $1800.00 USD to be spent on home remodification. The person must pay a 10 percent co-pay, but can then take out up to the maximum amount for these purposes.
According to a survey of the MHLW, the insurance benefit for modifying housing, paid under the scheme of the Long-Term Care Insurance, has increased significantly. In FY2000, the total expenditure was 15,952,243 thousand yen, which increased to 40,959,616 thousand yen in FY2003, so the amount more than doubled, approximately 2.6 times, from the initial year.
This provision has been successful, and more Japanese people are taking advantage of this subsidy. But, some problems have been reported by the media. For example, some people misuse this benefit to enrich themselves and not necessarily to modify a home to make it more comfortable for the elderly. The business of modifying houses has been booming in recent years.
GAP: Given Japan’s aging workforce, low immigration rate and increasing demand for health and long-term care services, how concerned are policymakers of a looming shortage in long-term care and health care workers? What is being done to address this issue?
TH: So far in Japan, although the demand for care workers is increasing continuously, maintaining the quality of care workers is more important than quantity. In Japan, certificated care workers play the most important roles in this area.
According to a report by a government commission, The Training Curriculum for Welfare Specialists: An Ideal Certified Care Worker, the list of qualities required for certificated care workers is as follows:
- A wide range of education and excellent communication skills to build relationships based on trust with those in need of care;
- the ability to make an accurate assessment of the state of those in need of care, provide care services based on a good plan, and evaluate for oneself the results of services provided;
- the ability to respect the lives and the human rights of those in need of care, and provide care services in cooperation with them;
- the ability to cooperate and collaborate with other health care and welfare professionals in providing care services; and
- an eagerness toward self-improvement and training among juniors to deliver better quality of care services.
The following new measures were implemented in hopes of improving the quality of care workers as outlined in the report:
- An education curriculum was reviewed and revised to develop the qualities outlined.
- From the perspective of promoting the quality of certified care workers, full-time care instructors have been required since 2003 to improve both nursing care education and techniques. Instructors are required to take certified training courses consisting of basic subjects, basic specialized subjects, and specialized subjects. Trainees are required to take courses totaling more than 300 hours.
- The national examination for certified care workers was revised to encourage a standard curriculum at training facilities and secure educational consistency. Starting with the examination initiated in January 2002, the number of questions has been increased. Also, questions based on actual cases were introduced to identify the applicants’ abilities to develop care processes.
The MHLW is concerned about and is still seeking new policies and strategies for improving the quality of care workers.
GAP: Are there inequities in terms of availability and quality of long-term care services between rural and urban areas? If so, how are the inequities being addressed?
TH: It is very difficult to evaluate the quality of long-term care because there is not sufficient evidence about evaluating quality, which has a psychological aspect. So I would like to explain the gaps among different areas in terms of long-term care insurance benefits and the user ratios of the long-term care scheme in Japan.
In 2003, the municipality that had the highest long-term care insurance benefit paid average expenses of 35,653 yen per capita. On the other hand, the municipality that had the lowest benefits paid average expenses of 7,795 yen per capita in the same year. The main reason for this gap is a mismatch between the size of a municipality and its institutional services. In other words, if a relatively small municipality owns a good facility, and there are many users of the institutional services, the cost becomes extraordinarily high.
In February 2005, the national ratio of certified service users out of the total elderly population was 15.7%, but among prefectures the percentage ranged from 20.4% to 12.0%. The cause of this gap was the different situations of institutional services. For example, for the ratio of users of institutional services in February 2005, the highest prefecture recorded 4.5%, while the lowest one recorded 2.2%. Regarding the residential service-user’s ratio, the highest was 12.5% and the lowest was 7.1%. The positive relationship between the higher ratio of institutional services and higher benefit expenditure per capita is observed from the data.
GAP: Japan is one of the leaders in broadband technology, in terms of speed, access and affordability, and is far ahead of the U.S. in using ultra-high speed fiber optic connectivity. The speed and the affordability of broadband can enable the use of sophisticated assistive technologies that can help people age in place, such as real-time teleconferencing and networked monitoring devices that monitor vital signs or activity levels and alert people to take medications, alert caregivers of problems, etc.
Has Japan been using its broadband and technological advances to help people age in place?
TH:I personally appreciate that you speak well of Japanese broadband technology in terms of speed, access, and affordability.
Information communication technology has led to a meaningful life after retirement by expanding opportunities for the elderly. The basic idea of promoting information communication technology for them is based on the philosophy of universal design. At the same time, we also pay close attention to the needs of individuals despite age differences.
Among government bodies in Japan, the Ministry of Internal Affairs and Communications plays an important role in this area in co-operation with the other ministries including the Ministry of Health, Labor and Welfare.
GAP: Has the private sector seen this area as a market opportunity?
TH: Perhaps the private sector does. For example, some major mobile phone companies sell unique mobile phones for elderly users. Unlike many new mobile phones with various functions including Internet connection, they have the functions limited to making and receiving calls.
GAP: Could you point to any best practices in innovative products or initiatives that have emerged in Japan to help people age in place?
TH: To promote universal design, we will establish a standard and a guideline for information communication devices. And, we are going to establish functions in central and local governments, where ideas and means of information technology will spread throughout the nation. In addition, a variety of support for individuals in need will be provided through community services, etc.
GAP: Have Japanese policymakers been looking internationally for best practices and policies for addressing the challenges of an aging population? What can other countries learn from the Japanese example when addressing aging issues?
TH: Japanese policymakers pay close attention to practices and policies of other countries including the United States, Germany, France, Sweden, and the United Kingdom. There is a cordial partnership between the United States and Japan. The social security systems of Germany and France have the same financial revenue structure, the so-called Bismarck model, which is also the same structure as that of Japan. Sweden has one of the highest levels of public welfare in the world. After the Second World War, Japan was very much influenced by the Social Insurance and Allied Services report of Sir William Henry Beveridge, which was a government commissioned report proposing a “cradle to grave” social security system for the United Kingdom.
Japan now confronts an enormously changing population structure due to a rapidly aging population. The percentage of Japanese aged 65+ is projected to be 28.7 percent in 2025, increasing to 35.7 percent in 2050, while its Total Fertility Rate (TFR) has been declining. In 1950 the TFR was 3.65, in 1970 it was 2.13, in 1990 it was1.54, in 2000 it was 1.36, and in 2004 it was 1.29 – this decline is occurring faster than we projected. Given this situation, the Japanese government has been implementing various measures to tackle an aging population. The speed at which the population structure of Japan is changing is much more rapid than that of European countries and the United States. The various measures the Japanese government has implemented so far may have implications for other countries.
The views expressed in this interview are those of Tatsuo Honda and not those of AARP or the National Institute of Population and Social Security Research. All responsibilities for these answers go to Tatsuo Honda.
Biography
Mr. Tatsuo Honda currently serves as Director of the Department of Planning at the National Institute of Population and Social Security Research, a national policy research organization established by the Ministry of Health, Labour and Welfare to research and report on social, economic and demographic issues affecting Japan. Prior to serving in his current position, he served in a number of positions at the Ministry of Health, Labour and Welfare, including, Director of Facilities Planning for National Hospitals and Deputy Director of the Office of Preparation of Long-term Care Insurance. He also worked as Director of In-Home Services for the Elderly for Osaka Prefecture and earlier in his career he worked at Japan’s Consulate General in Sao Paulo Brazil.