An introductory presentation of Japan's elderly care policy including the launch of the Long-Term Care Insurance (LTCI) scheme and Community-Based Integrated Care System (CBICS).

1. From the country with
the highest ageing rate
MPH Candidate, Class of 2017
Emory University Rollins School of Public Health
Taketo Tanaka, MD

2. Japan’s ageing rate is projected to be highest in the world!!!
38.8% in 2025
25.8% in 2015
Ageing rate
> 65 y/o (% of total)

3. Japanese older adults lives 10 years
with illness or disabilities
Male FemaleAge Age
10 years difference
10 years difference
Healthy life
expectancy
Actual life
expectancy

4. https://s-media-cache-ak0.pinimg.com/736x/25/78/f3/2578f34febd23818fd92ef5aee47acc0.jpg

5. http://www.who.int/ageing/events/world-report-2015-launch/populations-are-getting-older-full.gif?ua=1

6. Three eras of Japan’s elderly care
pre LTCI
• 1963~
LTCI
• 2000~
CBICS
• 2015~
LTCI: Long-Term Care Insurance
CBICS: Community-Based Integrated Care System

7. Era of pre LTCI
• Elderly Welfare Act legislated in 1963
• District government responsible to provide care
• Expensive and insufficient
• “Social (prolonged) hospitalization”
• Cheaper and safer to “live” in hospital
• Highest hospital beds per population in OECD
• Relied on care by “Yome” (daughter-in-law)
LTCI: Long-Term Care Insurance

8. 3 key concepts of LTCI
• Separation of elderly care from medical service
• Pressure to decline length of hospital stay
• “Socialization” of elderly care
• Reduce burden of “Yome” to care her parents-in-law
• More “Yome” can equitably work
• Introduced market mechanism
• Private institutions allowed to provide services
• Rich can purchase services uncovered by LTCI
LTCI: Long-Term Care Insurance
Yome: Daughter-in-law in Japanese

9. Structure of LTCI (1/2)
• Finance
• General government budget : 50%
• Premium : 50%
• Deducted from payroll of people older than 40
• 55 USD per month per person (2016)
• Co-payment rate
• 10% of service fee
• Beneficiary
• Part 1 : 65 years old or older
• Part 2: From 40 to 64 years old with specific conditions
• Terminal stage cancer
• Neurological disorders (e.g. amyotrophic lateral sclerosis)
• Other

10. Structure of LTCI (2/2)
• Benefit package
• Home-based care
• E.g. care worker visit, nurse visit, adult daycare
• Facility-based care
• E.g. nursing home, respite care
• NO cash benefits
• Limitation in service use by care dependency level
• Accreditation
• Standards of facility
• Guideline for human workforce
• Accredited care worker
• Accredited care manager

11. How to utilize LTCI scheme
(More) disease,
disability
(Re)application
Evaluate care
dependency
level
Acknowledge care
dependency level
Build care plan
Use services
Planned and
monitored by
accredited care
manager
Assessment from
physicians and
district government
7 levels indicate limitation
of service amount
To district government

12. Issues remained after LTCI
• Fragmentation of care
• Healthcare providers vs. care workers
• Bounce back of frail patients
• Fiscal instability of LTCI scheme
• More beneficiary, more expenditure
• Less premium payer
• Huge amount of national debt

13. 29.1 32 39.8 50.5 60.1 67.4
5.9
52.7 55.1 57.5 60.4 66.2 69.2 77.3
4.5
52.1 62.9 66.2 65.4 66.9 71.2 77.1
65.5
4 0.1 0
55.1 70.9
89.1
107
125.2 133.2 138.7 87.6 76.9 78.8 85.2 91 97
105.2
39.4
49
57.1
64.1
59.5
61.4
65.1
75.6 80.6 82.3 85.4
90.1
95.2
99.3
31.7
35.8
39.4
43.1
49.2
52.7
56 65.2 71.1 73.8 71.3
70
72.4
74.7
33.9
36.5
39.4
42.4
47.9
49.7
52.5 54.7 57.9
59 63
64.1
67
69.6
29
34.1
38.1
41.4
45.5
46.5
46.5 48.9
50
51.5
56.4
59.3
60.9
61.2
H12.4末 H13.4末 H14.4末 H15.4末 H16.4末 H17.4末 H18.4末 H19.4末 H20.4末 H21.4末 H22.4末 H23.4末 H24.4末 H25.4末
要支援 要支援１ 要支援２ 経過的 要介護１
要介護２ 要介護３ 要介護４ 要介護５
（Unit: 10,000 people）
（出典：介護保険事業状況報告）
２１８
２５８
３０３
３４９
３８７
４１１
４３５
４４１ ４５５
４８７
４６９
５０８
５３３
５６４
5.6 million people are acknowledged
as being care dependent in 2016
↑ care dependency level
20162000

14. 4,371
4,357
4,344 4,250
4,175
4,112
3,941 3,680 3,324
3,077 2,896
2,761 2,596
1,303
1,412 1,529
1,749
1,733
1,479
1,407 1,495 1,645
1,600
1,383
1,225
1,128
678
870 1,037
1,135 1,242
1,442
1,432 1,231 1,186
1,272
1,407
1,366
1,187
224
294
383
511 637 736
846 1,015
1,037
985
977
1,035
1,149
6,575
6,933
7,293
7,645
7,787 7,769 7,626
7,421
7,192
6,933
6,664
6,387
6,060
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
678
870
1,037
1,135
1,242
1,442
1,432
1,231
1,186
1,272
1,407
1,366
1,187
224
294
383
511
637
736 846
1,015
1,037
985
977 1,035
1,149
901
1,164
1,419
1,646
1,879
2,179
2,278 2,245 2,223 2,257
2,385 2,401
2,336
0
500
1,000
1,500
2,000
2,500
3,000
Old-olds will increase,
whose prevalence of care
dependency is high
Premium payers, people
aged 40~, will decrease
75~85 y/o
85 y/o~
40~64 y/o
65~74 y/o
75~84 y/o
85 y/o~
（資料）将来推計は、国立社会保障・人口問題研究所「日本の将来推計人口」（平成24年1月推計）出生中位（死亡中位）推計
実績は、総務省統計局「国勢調査」（国籍・年齢不詳人口を按分補正した人口）
（10,000 people） （10,000 people）

15. 100 billion USD spent annually
only for LTCI scheme
６．９
兆円
６．７
兆円
（注）2000～2013年度は実績、2014～2016年度は当初予算（案）である。
○ 総費用
2000年度 2001年度 2002年度 2003年度 2004年度 2005年度 2006年度 2007年度 2008年度 2009年度 2010年度 2011年度 2012年度 2013年度 2014年度 2015年度 2016年度
５．７
兆円
３．６
兆円
４．６
兆円
５．２
兆円
６．２
兆円
６．４
兆円
６．４
兆円
(12年度) (13年度) (14年度) (15年度) (16年度) (17年度) (18年度) (19年度) (20年度) (21年度) (22年度) (23年度) (24年度) （25年度） （26年度） (27年度) (28年度)
７．４
兆円
○ 65歳以上が支払う保険料 〔 全国平均 ( 月額・加重平均 ) 〕
８．２
兆円７．８
兆円
介護保険の総費用（※）は、年々増加
※介護保険に係る事務コストや人件費などは含まない（地方交付税により措置されている）。
８．８
兆円
介護費用と保険料 推移
９．２
兆円
１０．０
兆円
１０．１
兆円
１０．４
兆円
Cumulative expenditure of LTCI
(Currency: JPY)

16. The cost for social security is
projected to increase
社会保障給付は、高齢化により今後も急激な増加が見込まれます。団塊の世代全員が75歳以上とな
る2025年に向かって、特に医療・介護分野の給付は、財源調達のベースとなるGDPの伸びを大きく上
回って増加していきます。団塊の世代が75歳以上となる前の2020年代初めまでに、受益と負担の均衡
が取れた社会保障制度を構築していく必要があります。
（出典）厚生労働省「社会保障に係る費用の将来推計の改定について（平成24年３月）」
（注）（ ）内の％表示はＧＤＰ比。
年金
５３．８兆円
（１１．２％）
医療
３５．１兆円
（７．３％）
介護８．４兆円（１．８％）
子ども子育て４．８兆円（１．０％）
その他７．４兆円（１．５％）
年金
６０．４兆円
（９．９％）
医療
５４．０兆円
（８．９％）
介護１９．８兆円（３．２％）
子ども子育て５．６兆円（０．９％）
その他９．０兆円（１．５％）
年金
１．１２倍
医療
１．５４倍
介護
２．３４倍
１０９．５兆円
（２２．８％）
１４８.９兆円
（２４．４％）
社会保障に係る費用
１．３６倍
ＧＤＰ ４７９．６兆円
2012年度
ＧＤＰ ６１０．６兆円
2025年度ＧＤＰ １．２７倍
10．将来の社会保障給付費
Medicine
530 billion
Medicine
340 billion
LTC 190 billion
LTC 80 billion
Pension
590 billion
Pension
530 billion
Medicine
X 1.54 times
LTC
X 2.34 times
Unit: USD
Pension
X 1.12 times

17. Japan’s total health expenditure
(% GDP) is now 3rd largest in OECD図 4 新基準による保健医療支出の対 GDP 比（諸外国新基準 2014 年度、日本新基準 2014 年
度） 16.6
11.4
11.4
11.2
11.1
11.0
10.9
10.6
10.4
10.3
10.1
10.0
9.9
9.5
9.4
9.3
9.1
9.1
9.1
9.0
9.0
8.9
8.5
8.3
7.7
7.7
7.6
7.2
7.1
7.0
6.4
6.3
6.1
5.8
5.5
5.1
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
20.0
UnitedStates
Switzerland
日本
Sweden
France
Germany
Netherlands
Denmark
Belgium
Austria
Ireland
Canada
UnitedKingdom
Finland
NewZealand
Norway
Spain
OECD
Italy
Australia
Portugal
Iceland
Slovenia
Greece
Chile
CzechRepublic
Israel
Hungary
Korea
SlovakRepublic
Poland
Luxembourg
Estonia
Mexico
Latvia
Turkey
(%)
[出典] OECD Health Statistics 2016 (OECD.Stat) および医療経済研究機構による推計
（注）United States，Turkey は旧基準による推計、New Zealand，Australia は OECD による推計

18. http://www.economist.com/news/finance-and-economics/21677648-despite-shinzo-abes-best-efforts-japans-economic-future-
will-be-leap
Japan’s debt is twice as much as
national GDP

19. 5 concepts of CBICS
• Clinical integration
• Interprofessional work/education
• Deinstitutionalization
• From facility to home/assisted living residence
• Decentralization
• From prefectural to district government
• Prevention of care dependency
• Prevention of service dependency
• Reconstruction of self-help group/community
CBICS: Community-Based Integrated Care System

20. ３０’
2013
Current preventive
services by LTCI
Total cost
District government
responsible for Action
Plan to prevent care
dependency
Strengthen prevention of
care dependency
CBICS is expected to reduce the
annual growth of LTCI expenditure
to 3-4% per year.
Strengthen prevention of
service dependency.
Encourage self-help
ProjectedcostwithoutCBICS
Projectedcost
withCBICS
CBICS is expected to reduce the
expansion of long-term care cost
2018
2015

21. What is clinical integration?
A case study…
http://kompas.hosp.keio.ac.jp/file/000323_01.jpg

22. Lessons learned
• Elderly care is always financial burden
• Maintain and reconstruct self-help group
• Separate, but not fragment

23. Reference
• Japan Ministry of Finance. (2014, December 25). Report of Japan’s Fiscal Condition. Japan
Ministry of Finance. Retrieved from
http://www.mof.go.jp/budget/fiscal_condition/related_data/201509/201509_2.pdf
• Japan Ministry of Health, Labor and Welfare. (2015). The current situation and prospective role
of the Long-Term Care Insurance in Japan. Tokyo. Retrieved from
www.mhlw.go.jp/seisakunitsuite/bunya/hukushi_kaigo/kaigo.../gaiyo/.../hoken.pdf
• Mitsutake, N. (2016, August 4). Japan’s health expenditure according to the System of Health
Accounts 2011. Institute for Health Economics and Policy. Retrieved from
www.ihep.jp/news/popup.php?dl=763
• Shibuya, K., Hashimoto, H., Ikegami, N., Nishi, A., Tanimoto, T., Miyata, H., … Reich, M. R. (2011).
Future of Japan’s system of good health at low cost with equity: beyond universal coverage. The
Lancet, 378(9798), 1265–1273. http://doi.org/10.1016/S0140-6736(11)61098-2
• Tamiya, N., Noguchi, H., Nishi, A., Reich, M. R., Ikegami, N., Hashimoto, H., … Campbell, J. C.
(2011). Population ageing and wellbeing: Lessons from Japan’s long-term care insurance policy.
The Lancet, 378(9797), 1183–1192. http://doi.org/10.1016/S0140-6736(11)61176-8
• Tanaka, S., Ikebata, Y., Iwamura, M., Kawagoe, S., Takahashi, H., Tsutsui, T., … Matsuda, S. (2014,
March). Final Report: the research to estblish Community-Based Integrated Care System in Japan.
Mitsubishi UFJ Research and Consulting Co., Ltd. Retrieved from
http://www.murc.jp/uploads/2014/05/koukai_140513_c8.pdf
• World Health Organization. (2015). World Report on Ageing and Health. Generva. Retrieved from
http://who.int/ageing/events/world-report-2015-launch/en/