1. Estimating Expenditure on Long-Term Care (LTC) in Japan SAKAMAKI, Hiroyuki, MBA Institute for Health Economics and policy (IHEP) Tokyo,Japan 10 th Oct, 2002, OECD Paris

2. IHEP 10 th Oct, 2002, OECD Paris Institute for Health Economics and Policy, Tokyo, Japan Presentation Outlines Estimates on Expenditure for LTC Estimation Processes and Issues until 1999 Public Long Term Care Insurance (LTCI) in 2000 Estimation Strategy after 2000

3. IHEP 10 th Oct, 2002, OECD Paris Institute for Health Economics and Policy, Tokyo, Japan Graying population in Japan Population ( ≧ 65yo) –4.16 M ( 4.9%) in 1950 –21.19M (16.7%) in 1999 –33.12M (27.4%) in 2025

4. IHEP 10 th Oct, 2002, OECD Paris Institute for Health Economics and Policy, Tokyo, Japan Expenditures including for long-term care in Japan until 1999 Expenditure on long-term in-patient nursing care (HC.3.1) -Expenditure for health service facilities for the elderly (HP.2.1) -Estimated expenditure for meal service for inpatients in hospitals for the elderly (HP.1.1) -Estimated expenditure for inpatient care in hospitals for the elderly (HP.1.1) Expenditure on long-term home health care (HC.3.3) -Expenditure for home-visit nursing care for the elderly (HP.1.1)

5. IHEP 10 th Oct, 2002, OECD Paris Institute for Health Economics and Policy, Tokyo, Japan Facility services providing LTC Long term care welfare facilities for the aged [ LTCW ] : special nursing home for the aged Long term care health facilities for the aged [LTCH]: facilities of health care services for the aged Long term care medical treatment facilities [LTCM]: medical treatment beds, beds for treatment of senile dementia, LTC strength building hospital.

6. IHEP 10 th Oct, 2002, OECD Paris Institute for Health Economics and Policy, Tokyo, Japan Expenditure for long-term care in Japan for 1999 Items of Health Data Estimate (Million Yen) % of THE Total expenditure on health (THE) 38,011,356- Total expenditure on long-term nursing in-patient care 2,908,1767.7% Total expenditure on long-term home health care 91,4000.2%

7. IHEP 10 th Oct, 2002, OECD Paris Institute for Health Economics and Policy, Tokyo, Japan Financing of long-term care in Japan for 1999 TotalPublicPrivate Expenditure on health 38,011,35629,669,720 (78.1%) 8,341,636 (21.9%) Expenditure on long-term in- patient nursing care 2,908,1762,549,317 (87.7%) 358,859 (12.3%) Expenditure on long-term home health care 91,40089,100 (97.5%) 2,300 (2.5%) (Million Yen)

8. Expenditures for long-term care by function of care and provider industry in Japan of 1999 (SHA table 2) HP.1.1 General Hosp. HP.2.1 Nursing care facilities Total HC.3 Services of long-term nursing care 2,057,493942,0832,999,576 HC.3.1 In-patient long-term nursing care 1,966,093942,0832,908,176 HC.3.2 Day cases of long-term nursing care 000 HC.3.3 Long-term nursing care: home care 91,4000 (Million Yen)

9. IHEP 10 th Oct, 2002, OECD Paris Institute for Health Economics and Policy, Tokyo, Japan Estimation process (1) Total expenditure on long-term nursing care (HC.3.1) = sum of following 3 items  Expenditure for health service facilities for the elderly(HP.2.1) ＝ National health expenditure for health facilities for the elderly (Public) + Fee for health facilities for the elderly (private)  Estimated expenditure for meal service for inpatients in hospitals for the elderly (HP.1.1) =National health expenditure for meal services during hospitalisation related to hospitals × Proportion of the number of working beds for the elderly to the total number of working beds  Estimated expenditure for inpatient care in hospitals for the elderly (HP.1.1) =National health expenditure for inpatient care in hospitals for the elderly × Estimated proportion of amount of inpatient care in hospitals for the elderly, on the basis of official statistics

10. IHEP 10 th Oct, 2002, OECD Paris Institute for Health Economics and Policy, Tokyo, Japan Estimation process (2) Total expenditure on long-term home health care (HC.3.3) = Expenditure for home-visit nursing care for the elderly (HP.1.1) Private expenditure on long-term home health care = total expenditure on long-term health care × patients’ payment about home-visit nursing care for the elderly. Public expenditure on long-term home health care = total expenditure on long-term health care － private expenditure on long-term health care

11. IHEP 10 th Oct, 2002, OECD Paris Institute for Health Economics and Policy, Tokyo, Japan Issues of estimation ● Date source necessary for estimates of expenditure items that conceptually exist are not available. This may cause underestimate. For example, expenditure for day cases of long-term nursing care (HC.3.2) ● Boundary of LTC Persons who need long-term care (NOT health services) were covered by the Medical Insurance due to insufficiency of the Long-term Insurance system before 2000. ● Introducing Long Term Care Insurance System (LTCI) in 2000 Consistency should be needed before/after introducing LTCI.

12. IHEP 10 th Oct, 2002, OECD Paris Institute for Health Economics and Policy, Tokyo, Japan Trend of National Medical Expenditure

13. IHEP 10 th Oct, 2002, OECD Paris Institute for Health Economics and Policy, Tokyo, Japan Before and after enforcement of LTCI Before After National medical expenditure Official statistics about LTCI No available data Total expenditure for long-term care, defined by SHA Data sources

14. IHEP 10 th Oct, 2002, OECD Paris Institute for Health Economics and Policy, Tokyo, Japan Public Long Term Care Insurance System (LTCI) ● Established in April 2000. ● Insurer: the municipalities ● Insured: people aged 40 and above ● Eligible: - People aged 65 or older in need of care or support - People aged from 40 to 64 who are participants of medical insurance, in need of care or support due to a disease caused by aging such as; presenile dementia or cerebrovascular disorders, etc

15. IHEP 10 th Oct, 2002, OECD Paris Institute for Health Economics and Policy, Tokyo, Japan Integration of Health and Welfare Welfare for the AgedMedical services for the Aged Under Health Insurance Long LoS Not equiped for LTC From gov. budget The municipalities driven Means tested Long term care insurance Social insurance April 2000 ～

16. Financing of LTCI ● 2001 budget 4,770 billion yen co-pays560 billion yen Provision4,210 billion yen Apart from co-payment of the users. The users pay 10% of the benefit amount. Public Expenditure (HF.1.1)

17. IHEP 10 th Oct, 2002, OECD Paris Institute for Health Economics and Policy, Tokyo, Japan Estimating Strategy for LTCI Discrimination b/w LTC and Healthcare services –by Providers –by Function of Services –by Degree of Need of LTC

18. IHEP 10 th Oct, 2002, OECD Paris Institute for Health Economics and Policy, Tokyo, Japan Facility services Long term care welfare facilities for the Aged [ LTCW ] (Special Nursing home for the Aged) NA Long term care health facilities for the Aged [LTCH] (Facilities of health care services for the aged) HP2.1HC3.1 Long term care medical treatment facilities [LTCM] Medical treatment beds Beds for treatment of senile dementia LTC strength building Hospital HP1.1HC1.1

19. IHEP 10 th Oct, 2002, OECD Paris Institute for Health Economics and Policy, Tokyo, Japan Benefits of LTCI Persons requiring long term care or support will receive benefits in the following services. - In-home services - Facility services

20. IHEP 10 th Oct, 2002, OECD Paris Institute for Health Economics and Policy, Tokyo, Japan In-home services Home- visit/ commuting care service Home-visit care (Home help service)HC 3.3 ? HP 3.6? Home-visit bathing servicesHC 3.3 ? HP 3.6? Home-visit nursingHC 3.3HP 3.6? Home-visit rehabilitationHC 3.3 ? HP 3.6? Commuting for care (Day services, at day care centres) HC 3.2 Commuting rehabilitation (Day care)HC 3.2 Welfare equipment rental serviceX Short-term stay service Short-term stay at a care facilityHC 3.2? Medical care service through a short-term stayHC 3.2? OthersDaily life care in communal living for the elderly with dimentia HC 3.2? Daily life care for residents in a special facilityHC 3.2? Management guidance for in-home careX Allowance for purchasing welfare equipmentX Allowance for modifying houseX

21. IHEP 10 th Oct, 2002, OECD Paris Institute for Health Economics and Policy, Tokyo, Japan Degree of Need of LTC Condition Yen /Month Needing AssistanceNot deemed LTC but needing assistance in everyday life 61,500 Needing LTC 1Needing some LTC165,800 Needing LTC 2Needing small degree of LTC194,800 Needing LTC 3Needing medium degree of LTC 267,500 Needing LTC 4Needing large degree of LTC306,000 Needing LTC 5Needing highest degree of LTC 358,000

22. IHEP 10 th Oct, 2002, OECD Paris Institute for Health Economics and Policy, Tokyo, Japan SHA application of LTC LTCM TBD LTCH LTCW Home care Need 5Need 4Need 3Need2Need1Assi. Increase of medical provision → Intensity of medical need → = Include in HHA

23. IHEP 10 th Oct, 2002, OECD Paris Institute for Health Economics and Policy, Tokyo, Japan Conclusion Pilot Study to estimate LTC will start beginning of 2003, when all relevant data will be published.

24. IHEP 10 th Oct, 2002, OECD Paris Institute for Health Economics and Policy, Tokyo, Japan Japan SHA Team Koki HAYAMIZU Tastuo IHARA Yoshiyuki OZAWA Hiroyuki SAKAMAKI Manabu YAMAZAKI