Delivering appropriate care for the aged

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

Abstract

In July 2006, the Health Care Reform Act passed Parliament. It stipulates the establishment of a new scheme for fundng health care for the aged. Moreover, a consultation paper on how appropriate health care for the aged should look like has been under discussion. On the basis of this paper, a modified payment system will be developed that is to follow certain principles such as dignity and safety and that is to promote forms of care such as home and palliative care.

Purpose of health policy or idea

The Health Care Reform Act 2006 stipulates that the existing scheme for funding health care for the elderly is to be replaced by a newly established public insurance, thereby following the framework set by the Cabinet in 2003. Under the present system, people aged 75 and older must be enrolled either in Employment Health Insurance or in National Health Insurance and pay contributions to their insurers. But, for the purpose of sharing financial burdens, pooled funds - coming from both insurers and local and national governments - pay for health care for the elderly. Although there are no deductibles to meet, the elderly pay 10 percent coinsurance.

Although the scheme for pooling funds has worked well since the1980s, the rapidly aging population lead to the need for a new health insurance for the aged under which contributions and co-payments will increase, but disproportionally according to income and currently enrolled insurance. Since an insurer will be established in a prefecture, sizes of pooled funds will become larger. Management is also expected to become more efficient and accountable in terms of both financing and provision.

A new payment system is to be used under the new insurance for achieving appropriate health care for the elderly. A consultation paper is under discussion which sets out life, dignity, and safety of the aged as principles for care and it stipulates comprehensive assessment, home care, palliative care, and integrated care as critical areas to be addressed. Although the above mentioned principles are quite abstract, this paper has facilitated the public dabate on appropriate care for the aged and may lead to a consensus on how appropriate care for the elderly should look like. The new system which probably will include financial incentives for putting these principles into practice is being developed at the moment. It is to be introduced in April 2008.

Main points

Main objectives

The Health Care Reform Act 2006 stipulates that the existing scheme for funding health care is to be replaced by a new one from 2008 on, following the framework set by the Cabinet in 2003.

A modified payment system is to be used under the new scheme. A consultation paper has been under discussion which sets life, dignity, and safety of the aged as principles for care and stipulates comprehensive assessment, home care, palliative care, and integrated care as critical areas that should be addressed. Based on the principles and the health care areas mentioned in the paper, a new payment system will be developed. 

Type of incentives

Financial and non-financial incentives will likely be introduced.

Groups affected

Providers, aged persons and their caregivers, health and social care professionals

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

The development of this policy, ie. the development of a new payment system that is based on principles such as dignity and safety and that is to promote forms of care such as home and palliative care, is still underway. The fact that the consultation paper explicitly describes the principles for delivering health care for the aged will be very important, though the principles are controversial. The principles are important in the sense that health care resources should be allocated according to them. A new payment system that is based on these principles is to be deveoped in the next months.

Political and economic background

Political pressure to contain health care costs has been quite strong because of a huge cumulative debt. Moreover the population has aged rapidly, which may lead to an increase in national health expenditures.

In Japan, the proportion of the population aged 75 and over increased from 4.84 percent in 1990 to 7.10 percent in 2000. According to projections this share will rise to 10 percent in 2010 and 15 percent in 2020. In 2008 approximately thirteen million people will be 75 or over. In FY 2005, 28.8 pecent of national health expenditure was spent on health care for those aged 75 and over (This figure does not include expenditure through the long-term care insurance).

Next to the economic and demographic developments, controversial ethical issues also have been emerging that triggered the discussion about how appropriate care for the aged should look like and the need for a new health insurance system for the aged. One of the most critical issues is what care should be provided to the dying elderly, and where and how. Despite its importance, there has been litte consensus on the issue. However, considering the fact that approximately 80 percent of deaths take place in medical facilities, efforts for building consensus on the issue among health and long-term care professionals, policy makers, government officials, bioethists and those concerned are urgently needed.

Purpose and process analysis

Current Process Stages

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

Origins of health policy idea

Since the 1980s principles of health care for the aged have been continuously debated. It is a new development, though, that neither health professionals nor bioethist but the Government itself makes efforts to establish principles of health care for the aged. However, the 2006 Health Care Reform Act and the consultation paper are based on discussions on health care and aging that have taken place during the last two decades.

Initiators of idea/main actors

• Government

• Payers

• Others

Approach of idea

The approach of the idea is described as:
renewed: In other countries, this type of principles have been established by governments.

Innovation or pilot project

Else - The consultation process started in clinical terms rather than in economic terms.

Stakeholder positions

The above mentioned consultation paper was developed by the "Ad hoc committee for health care for those aged 75 and over" under the Social Security Council. The committee was composed of a health economist, four physicians, one of whom is a board member of the Japan Medical Association (JMA), a home care nurse, and three persons concerned with advocating consumers interests. Officials from the Ministry of Health, Labour, and Welfare have been secretary to the committee. The committee aims specifically at deliberating appropriate health care for the elderly as a preparation for creating a new payment system under the new insurance.

With regard to the development of abstract principles that are to underlie health care for the elderly, health professions have been supportive. Most of them have been against current "cost containment policies", which are foreseen in the Health Care Refom Act. Practical implications for how health care for the aged should look like have been proposed by some health professionals. For example, the Japanese Nursing Association has argued that visiting nursing care should be further developed to put the principles proposed by the paper into practice.

There has been little discussion on a concrete payment system for health care for the elderly. One exception is a proposition by the All-Japan Federation of National Health Insurance Organizations in 2006. It proposed the introduction of a patient registration scheme and gate-keeping into the health care system for the elderly in order to make health care provision more efficient. Financial authorities have emphasized the need for increased efficiency and containing costs, but have not expressed their opinion on the principles of health care.

The positions of stakeholders will depend on the draft payment system that will be developed by officials at the Ministry of Health, Labour, and Welfare and released in the autumn of 2007 at the committee.

Actors and positions

Government
Ministry of Health, Labour, and Welfare	very supportive		strongly opposed
Ministry of Finance	very supportive		strongly opposed
Council on Economic and Fiscal Policy	very supportive		strongly opposed
Payers
All-Japan Federation of National Health Insurance Organizations	very supportive		strongly opposed
Professional Organizations
Japan Medical Association	very supportive		strongly opposed
Japanese Nursing Association	very supportive		strongly opposed

Influences in policy making and legislation

The development of a new payment system has been stipulated in the Health Care Reform Act 2006. The current process is an implementation of the act. The policy seems explicitly concerned with controversial issues such as dignity, home care and palliative care.

Actors and influence

Government
Ministry of Health, Labour, and Welfare	very strong		none
Ministry of Finance	very strong		none
Council on Economic and Fiscal Policy	very strong		none
Payers
All-Japan Federation of National Health Insurance Organizations	very strong		none
Professional Organizations
Japan Medical Association	very strong		none
Japanese Nursing Association	very strong		none

Positions and Influences at a glance

Adoption and implementation

Academic health professionals, health economists, and consumers have been involved in developing the consultation paper. Insurers and associations of health professions had opportunities to express their opinions. Governement officials have kept some distance from the development.

Monitoring and evaluation

The policy displays a rather broad view on how health care for the aged should be delivered. Thus this view will be reviewed when detailed policies will be evaluated, though the timing is not stated.

Review mechanisms

n/a

Expected outcome

The consultation paper sets out how health care for the aged, ie. for people 75 and over, should look like with regard to services provided and quality. In-depth analysis on the issues will be crtically important for overall policy making in the field of health care. However, a problem is that it is difficult to distinct those 75 and over from those less than 75 in terms of health care needs. In this sense, a payment system should be very carefully developed according to the principles and considerations on health care for the aged.

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

In the sense that this policy sets the principles of delivering health care for the aged, its impact on quality of  care is potentially fundamental. Its impact on equity and efficiency will depend on a payment system that will be developed on this policy.

References

Sources of Information

Ad Hoc Committee on Health Care for the Aged, Social Security Council (2007): Health care for the elderly aged 75 and over: principles and challenges.

Author/s and/or contributors to this survey

Matsuda, Ryozo

Suggested citation for this online article

Matsuda, Ryozo: "Delivering appropriate care for the aged". Health Policy Monitor, March 2007. Available at http://www.hpm.org/survey/jp/a9/2