Reorganization of regular health check-ups

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

Public health insurers will be responsible for providing regular health check-ups and, if necessary, behavioural services. Although the health check-ups and behavioural services to be provided will be specified by the government, health insurers are expected to take on more active roles in promoting health in order to prolong healthy life as well as contain health care costs.

Purpose of health policy or idea

According to the Health Care Reform Act 2006, public health insurers will be responsible for providing health check-ups, specified by the Ministry of Health, Labour, and Welfare, to beneficiaries aged 40 and over from April 2008. An insurer must develop and publish a five-year plan of implementing specified health check-ups and behavioural interventions.

This policy is intended to promote healthy behaviour among people and mitigate the increase of health expenditures.

Main points

Main objectives

The objectives of the policy are to promote healthy behaviour among people by:

1. achieving a more efficient and focused provision of personal preventive services;
2. making public insurers more actively promote healthy behaviours; and
3. co-ordinating health promoting services and activities by prefectural governments.

Also, promotion of healthy behaviour is expected to mitigate the increase of health care expenditures.

Type of incentives

One financial incentive for insurers is that they can obtain discount according to their accomplishment of promoting healthy behaviours. The government will develop guidelines as a non-financial incentive. Another might be publishing performance data of each insurer.

Groups affected

Municipalities, public health insurers, preventive health service providers

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

Innovation - innovative, because transferring the responsibility from local government to public health insurers is quite new, though there was a history of transfer of responsibilities a long time ago.

Controversy - controversial in the following sense: this policy might make coordination between personal preventive services such as health check-ups and programs targeted to the general population such as mass education; that cancer screening is excluded from the transferred responsibility of public insurers may decrease efficiency.

Systemic Impact - fundamental, this policy firstly has introduced non-financial objectives for public health insurers and may change their behaviours.

Visibility - low, the media and public attention had focused rather on reform of health care for the aged.

Transferability - system-dependent as to transfer of the responsibility because it depends on existing allocation of responsibilities. However it can be transferred in the sense that purchasers can be made responsible for specified preventive health services as well as curative health services.

Political and economic background

This policy was developed between 2003 and 2005 when the ruling parties were still strong in the Diet with the Koizumi Administration. The government had to decrease the amount of accumulated deficit and declared to contain costs by reforming health care changing its basic policies for economic and fiscal operation and implementing structural reform. Meanwhile, the government had a general policy to prolong the length of healthy life.

The government has promoted decentralization by increasing revenues of local governments from tax with reduction of subsidies and promoting mergers of municipalities. The administrative reform has been intended to increase efficient management of local governments with sufficient capacities.

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

Before the enforcement of the act, the responsibility for check-ups had been dispersed among local governments, insurers, and employees without effective coordination mechanisms. This dispersion had been regarded as causing inefficiency and making policy implementation difficult. Also, there have been little financial incentives for those responsible. Considering that obesity and diabetes are projected to be big issues in the near future, it became necessary to establish a more consolidated mechanism with effective coordination of health check-ups and psycho-educational services in order to promote healthy behaviours However, among those responsible, local governments (municipalities), which are responsible for providing health check-ups for their residents over 40 and over, have failed to increase take-up rates of health check-ups. On the other hand, public health insurers have been supposed to develop their active roles in controlling health expenditures, which health check-ups and related services may lead to. In this situation, consolidated responsibility of public health insurers on delivering preventive services, especially behavioural preventive services, has emerged as a policy option in the process of larger health care reform.

Initiators of idea/main actors

• Government

• Providers

• Payers

• Scientific Community

Approach of idea

The approach of the idea is described as:
new:

Stakeholder positions

In October 2004 a committee of the Health Sciences Council, which is a standing advisory committee in charge of promoting health sciences and public health, started to discuss policy options of delivering health check-ups and health promoting services, considering existing problems and the on-going administrative reform. Soon the committee paid attention to the fact that dependents of employed people and self-employed people took less health check-ups than employed people. The discussion mainly focused on health check-ups concerning diabetes, thus cancer screenings were not discussed.

The committee discussed ways of increasing access to health check-ups and behavioural health services as well as clarifying responsibilities for providing those services. In September 2005, just before the MHLW published its plan for health care reform, the committee finally published an interim report (though a final report has not been published), which formally laid down the lines of putting more responsibilities in the hands of the public insurer, although the details of these responsibilities were not proposed there. Meanwhile, another small committee organized by the MHLW specifically in charge of discussing issues related to health check-ups and health promotion emphasized the necessity of introducing incentives for taking or providing health checkups, evidence-based practices, and competition between providers.

Finally in its plan for health care reform in October 2005, the MHLW clearly proposed that public health insurers should be responsible for providing health check-ups and related personal behavioural services.

Since this policy has little public visibility among big changes introduced by the health care reform, there was little serious argument on it. Japanese Medical Association critisized the policy as intended for cost cost containment.

Actors and positions

Government
Ministry of Health, Labour and Welfare	very supportive		strongly opposed
Providers
Japan Medical Association	very supportive		strongly opposed
Payers
National Federation of Health Insurance Societies	very supportive		strongly opposed
All-Japan Federation of National Health Insurance Organizations	very supportive		strongly opposed
Scientific Community
Epidemiologists	very supportive		strongly opposed

Influences in policy making and legislation

The policy was included in the Health Care Reform Bill 2006, which was submitted by Cabinet in February 2005 to the Diet. The Diet passed the bill without amendment. However, the Upper House adopted a resolution of requesting the Government to make efforts to build capacities, particularly human resources such as public health nurses and nutritionists, for implementing health check-ups and behavioural services.

Legislative outcome

success

Actors and influence

Government
Ministry of Health, Labour and Welfare	very strong		none
Providers
Japan Medical Association	very strong		none
Payers
National Federation of Health Insurance Societies	very strong		none
All-Japan Federation of National Health Insurance Organizations	very strong		none
Scientific Community
Epidemiologists	very strong		none

Positions and Influences at a glance

Adoption and implementation

By law, from April 2008, all public health insurers will be responsible for providing health check-ups and behavioural health services to the insured aged 40 and over in the following organizational and financial structures:

1. The MHLW determines principles on the method of health check-ups and behavioural services as well as process and outcome targets;
2. A public health insurer must develop and publish a five-year plan of business on health check-ups and behavioural services every five years, which shall include the method of health check-ups and behavioural services as well as process and outcome targets;
3. Starting in 2013 public health insurers can retain or lose funds according to their achievement of the targets above mentioned;
4. Each insurer or municipality of Citizen Health Insurance will get subsidies from the national government and the affiliated prefecture for providing health check-ups and personal behavioural services;
5. The Government can subsidize health insurers of Society-Managed Health Insurance and Government-Managed Health Insurance; and
6. Each prefecture will be expected to promote concerted actions of public health insurers, municipalities, providers, and other related entities.

Details on the implementation of the law have been developed by committees under the MHLW.

Expected outcome

Since the responsibilities of public health insurers will be made clear, their actions will probably be strengthened and improved, which would hopefully result in an increase of utilization of health check-ups. Furthermore information gathered by health insurers can be analyzed whether collectively or separately which hopefully will lead to an improvement of health check-ups.

However, whether individualistic services will actually promote healthy behaviour or not, and lead to cost containment at the macro level is controversial.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

Quality - fundamental, the government will develop more detailed guidelines for health check-ups and behavioural health services and monitor performances of public health insurers, which may enable improvement of the quality of services delivered.

Equity - more equitable, public health insurers may take more efforts to increase utilization of the services by the insured, particularly unemployed women who have used these services least frequently.

Efficiency - neutral, it is difficult to estimate impact on efficiency because of a lack of data and robust methodology, though cost-efficiency is generally expected to improve.

References

Sources of Information

Committee of Community Health Promotion, Health Science Council. Future Directions of Health Promotion: Interim report. Japan 2005.

Japanese Ministry of Health, Labor and Welfare. Health Care Reform: A consultation paper. 2005.

Author/s and/or contributors to this survey

Ryozo Matsuda

Ryozo Matsuda is professor in community health and health policy at the College of Social Sciences, Ritsumeikan Univerisity. This report was written when he was a visiting fellow at LSE Health, London School of Economics and Political Science.

Suggested citation for this online article

Ryozo Matsuda: "Reorganization of regular health check-ups". Health Policy Monitor, October 2007. Available at http://www.hpm.org/survey/jp/a10/4