Title: 3rd International Jerusalem Conference on Health Policy The Control of Chronic Disease in the 21st C
13rd International Jerusalem Conference on Health
PolicyThe Control of Chronic Disease in the 21st
Century Integrating primary, secondary, and
tertiary preventionMerging of Primary and
Tertiary Prevention in the Aging Society-The
Case of Japan-
- Naoki Ikegami, MD, MA, PhD
- Dept. of Health Policy Management
- Keio University School of Medicine
- ikegami_at_sc.itc.keio.ac.jp
2Rationale for preventing chronic diseases
- Chronic diseases Diseases due to aging and life
style, not infection - Focus in Japan is now on the metabolic syndrome
Diabetes, hypertension, hyperlipidemia - Aging cannot be avoided ? So life styles must be
improved - Focus should be on primary prevention
- Prevention should be better than treatment
because the typical patient will - Once diagnosed, will remain a patient till death
- Once symptoms manifest, will have acute
exacerbations and progressive decline - ? Admitted on a stretcher, discharged on a
wheelchair
3What is prevention?
- Promotion and counseling towards healthier life
styles - Is this prevention or is this missionary work?
- Treating patients without any symptoms diagnosed
as having metabolic syndrome - Goal is to reduce risk of renal failure, heart
disease, stroke etc. - Is this prevention or is this treatment?
- Treating patients to reduce the risk of decline
or exacerbation - Is this prevention or is this treatment?
- Encourage frail people to be more self-reliant
- Is this prevention (tertiary) or is this social
care? - Is improvement only possible if there are PTs and
OTs?
4Caveats in prevention programs (1)
- Goal Early detection ? Improve life style by
counseling more exercise, better dietary habits ?
Reduce risk for renal failure, heart disease,
stroke etc. ? Contain costs - Each phase must succeed in order to achieve the
ultimate goal! - But, dont just stand there, do something! ?
Japan has introduced mandatory annual screening
for metabolic syndrome to all aged 40 - Evaluation of effectiveness
- Ultimate outcome is compression of morbidity
- But then, follow-up period will be 40 years!
- Reliance on secondary indicators from relative
risk analysis - Lead-time effect of screening
- Early detection prolongs the period from
detection to death - Costs may not decrease, but could increase due to
aggressive treatment of hypertension etc.
5Caveats in prevention programs (2)
- Taking drugs is easier than changing life styles
- R D, promotion of drugs which are better and
more expensive - How effective is primary prevention?
- How intrusive should governments and insurers be
in encouraging healthier life style? - How should compliance be monitored? Penalties
imposed? - Cost-effectiveness and priorities
- More effective if focused on serious cases
- Systolic blood pressure threshold of 160, not 130
- But, then the goal of early prevention will not
be achieved - Shorten period of frailty ? Ultimate goal Sudden
death? - But, for cardiologists, that would be a failure!
6Prevention for the elderly population
- Positive aspects
- More aware of their progressive frailty ? More
incentive to change life styles - More freedom to change life styles Less
constrained by work, family obligations - More tangible and quicker feedback if life style
is changed - Quit smoking for those with emphysema
- More contact with physicians etc. ? More
opportunities to provide appropriate counseling - Negative aspects
- Elderly may be more set to their present life
style
7Rationale of public LTC insurance
- Fact Aging of society leads to a shift from
informal care to formal services ? Aging of
family care-provider - Belief Frail elders are entitled to optimize
their quality of life - Assumption Younger generation are prepared to
pay taxes and/or premiums to achieve these
societal goals - Policy goal Incorporate and coordinate services
to meet needs of frail elders and their care
givers - Curative medicine, social services and prevention
must be coordinated in long-term care
8Relationship of the three sectors (Historical)
Curative medicine
Prevention
Social services
9Relationship of the three sectors (Present)
Long-term care (LTC)
Curative medicine
Social services
Prevention
10Advantages of public LTC insurance
- Health insurance
- Benefits become medicalized
- Egalitarian standards Topping-up not allowed
- Expensive professional staff has dominant role
- Patients find it difficult to exercise choice
- LTC insurance
- Benefits are a combination of health and social
care - Decent level of care Topping-up allowed
- Low-wage staff has dominant role
- Clients find it easier to exercise choice
11The situation in Japan
- Japan has the highest ratio of the elderly in the
world - Proportion of 65 in general population
- 7 in 1970, 20 in 2006, 27 in 2020
- Increasing at the rate of 1 every two years
- Proportion of healthcare costs spent by 65
- Already 50 in 2006? Will compose 2/3 in 2020
- Health care IS caring for the elderly (except for
pediatricians and obstetricians, 4/5 of patients
will be elderly) - Aging of population accounts for a 2 annual
increase in health expenditures - Public LTC insurance implemented in the year 2000
12Before implementation of LTCI
- Health care open-ended entitlement
- Increasing use of hospitals for LTC hospitals
have become de facto nursing homes - ?Growing problem since health care became free
for elders in 1973 - Social services budget limited, means-tested
- Ad hoc, unfair decisions made by local welfare
offices ? Growing problem since the increases in
resources from 1989 (Gold Plan) - Both sectors had been expanding rapidly prior to
the implementation of the LTCI ? Need to
rationalize
13Overall design (1)
- Transferring health and social services to the
LTCI - From health visiting nursesPT services, day
care, Health facilities for elders (HFE), some
LTC hospitals - From social home-helpers, day care, nursing
homes, loan of wheelchairs, home improvement
(putting in slopes, rails) etc. - Population covered 65 and 40-64 with age
related disability (Alzheimers, stroke, diabetes
etc) - Management municipalities or coalition of
municipalities - Premium levels set locally according to estimated
expenditures
14Overall design (2)
- Financing Half by taxes, half by premiums
- Premiums from 65 Deducted from pensions, 1/6 of
total - Premiums from 40-64 Deducted from wages, 1/3 of
total - Pooled at national level and redistributed to
municipalities adjusting for differences in their
age and income levels - Generous levels of entitlement
- Home care 7 levels from US 400 to 3,000 per
month - Clients may, in principle, freely choose their
provider agency, purchase services and spend up
till this amount - Institutional care Full coverage except for some
hotel costs - 10 co-payment applied to both (decreased if of
low income) - Entitlement levels based on assessment of ADL
etc. - Irrespective of income level or amount of family
support
15Flow chart for receiving LTCI services
? Process of assessing eligibility levels by
municipalities ? Process of drawing care
plans by care manager agencies ? Delivery of
services by LTCI provider agencies
16How LTCI should have been designedMy views from
the ivory tower
- Arrive at a consensus on the level of
governments responsibility - Fiscal sustainability How much people are
willing to pay, taking into consideration the
future expansion in need due to aging - The degree to which resources should be
prioritized to those most in need - Design eligibility criteria for triaging elders
based on above using assessment items that have
been tested for reliability and validity - Survey the prevalence of those who would be
eligible - Adjust eligibility criteria based on survey
results
17How LTCI actually was designed
- Entitlements difficult to cut back
- Those who had been receiving services prior to
the implementation must be allowed to continue to
do so - Low income elders living alone were receiving
social services - Couldnt be so frail if they are able to live
alone - Some municipalities had been generous in
provision - Eligibility criteria designed so that almost all
who applied would be evaluated as being eligible - Only 2 of those who applied were certified as
ineligible (but still major concern to government)
18What happened after implementation
- LTCI has become popular and accepted
- Greater than expected annual increases in
expenditures - Estimated rate of 4 4.3 (00)?5.5 billion Yen
(05) - Actual rate of 11 3.7 (00)? 6.7 billion Yen
(05) - Percentage of 65 eligible Planned to be 12
became 16 (05) - Greater than expected increase in those eligible
- Especially for the lighter levels 2.2 times
increase (compared with 1.6 times for heaviest)
19Measures taken by the government
- Difficult to make eligibility criteria stricter
- ? Solution Limit benefits to preventive
services for the two lightest levels - Making a virtue of a de facto reduction in
benefits - Rationale Providing IADL support by home-helper
has made elders more dependent ? Benefits
restricted to prevention - Preventive services are more in line with LTCIs
goal To allow elders to maintain their
independence - Fiscal advantages of preventive services
- Fewer would apply for such services than for IADL
support - Service provision is, in principle, restricted to
3 months - Unit cost of preventive services is less than
that of regular
20LTCI preventive services
- Provided in adult day care centers
- Mild exercise training pedaling on machines etc.
- Main component of prevention services
- Nutrition counseling more nutritious diet
- Oral health training oral hygiene, mastication,
swallowing - Services supervised by the new municipal
Community Comprehensive Care Centers - Clients have less freedom to choose provider
agency - Target population
- All those in the original lightest level
- Those in the 2nd from lightest who have been
screened as being appropriate for prevention (not
suffer from Alzheimers etc.) - Goal Decrease the projected number of those
frail and eligible by 10 in 10 years by
preventing decline
21Accommodating current clients
- New preventive program has been gradually rolled
in from April, 2006 - Current beneficiaries will continue to receive
present services until reassessed - Up to one year before reassessment
- Some are likely to have declined (fortunately?)
when reassessed - Even if there is no decline, and therefore only
eligible for preventive services, they can still
demand IADL support services (home-helpers) - But, home-helpers must involve the client in
home-making! - Example Asking the client to cut vegetables
while she cooks - This may be effective, but how to monitor?
22My rationale for LTCI preventive services
- Person aged 65 in Japan has about 20 more years
of life on average - Screening for medical conditions alone would not
be sufficient - Most, if not all, would have some chronic
diseases - Medication is the 2nd choice, life style changes
the 1st - LTCI provides more opportunities for changing
life styles than health insurance - LTC is focused on every day life support and care
23Philosophical doubts
- How much encouragement, cohesion, financial
incentives, disincentives, penalty should be
given to frail elders? At risk elders? Healthy
elders? Or non-elders? - Who is happier? The couch-potato, or the jogger?
- The elder watching TV all day, or walking on a
tread-mill in the day care center? - Who has better quality of life? ? The jogger
- Why? ? Quality of life measured is health-related
quality of life - Is obsession on health, healthy?
24Quality of Life Dimensions
Social
Physical
Mental
?Health-related Quality of Life
25Measurement issues
- Quality of life is multi-dimensional, but to
allocate resources and prioritize, must be
collapsed into one dimension - Collapse into utilities or value sets
- 1 Perfect health 0 Death
- Measure both the length and quality of life
- Quality-adjusted life years
- Are these measurements really valid?
- Quality of life must be self-assessed
- People with dementia would not be able to respond
- Discontinuity in measurement scales Validity?
26Quality-adjusted life year
Compression of morbidity with prevention
Natural course of decline
1.0
Quality of life
???
With prevention
Without prevention
0
????
Time ?
Death ? ?
27Discussion points
- 1) Can preventive services targeted at frail
elders reverse or delay dependency? - 2) To what extent should government programs try
to change the individuals life style? - 3) Should IADL support service be part of
benefits? If so, to whom? - 4) What is right balance in public expenditures
between light care and heavy care? - 5) How much should governments spend on LTCI?
28Conclusion
- Whether preventive services will compress
morbidity or frailty will be difficult to measure - Success stories of sedentary life styles being
improved by services, leading to an improvement
in the quality of life - Failure stories of elders being denied the
home-helper who had made a real difference in
their lives - However, LTC is variety of ongoing health and
social services for individuals needing
assistance on a continuing basis (IOM, 1986) - LTC is part of life ? Tertiary prevention (rehab)
must be merged with primary prevention (life
style)