How Has The National Policy To Prevent The Metabolic Syndrome Been Developed In The Japanese Ministr

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How Has The National Policy To Prevent The
Metabolic Syndrome Been Developed In The Japanese
Ministry Of Health?-To Facilitate The Healthier
Longevity Society- At ECOSAC Regional
Ministerial Meetingon Financing Strategies for
Health Care16-18 March 2009Colombo, Sri Lanka

• Kiyotaka SEGAMI, M.D., Ph.D.
• Executive Board-Director
• Welfare and Medical Service Agency
• The former Ministers counsel in health
• segami-k_at_umin.ac.jp
• segami200819_at_wam.go.jp

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Medical Concerns Better Health
Aging Population Issues
Social Concerns -Better QOL
Business Concerns -Finding Chances
Financial Concerns -Containment of --
Sustainability in Policy
Feeling Not Unhappy, Not in Poverty among Citizen
28 Sept 06/ Segami, K
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Depiction of Medical Expenditure Growth
Increase of medical Expenditure
Increase of Medical Expenditure of the elderly is
a Major Factor
Aging of the population Per Capita Medical
Expenditure of the Elderly 1.5 ratio of elderly
to non-elderly
Analysis of factors
Increase of Outpatient Medical Expenditure per
Patient
Increase of Inpatient Medical Expenditure per
Patient
Large number of Beds (Long Average LOS)
Prevalence of Lifestyle-related Disease in
Outpatient
Low Home Care Rate
Increase of Patients with Life Style-Related
Disease due to Visceral Obesity / Adipose Tissue
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Japanese Trial in Various Methods of Controlling
Medical Expenditure
ltAcutegt
ltChronicgt
Promotion of Terminal Care at Home
Conversion of Long-term in-patients to Nursing
Care
Functional Specialization and Referral System
According to Acute Phase, Rehab Phase, Nursing
Care Phase and Home Care Phase of illness
Inpatient Medical Expenditure
Referral System at Discharge
Containment of Medical Expenditure Growth

Promotion of Home Care
Decrease of Average Length of Stay
Improvement of Residence Other than Home
Reduce Admission Rate by Preventing the
occurrence of Severe Diseases
Prevention of Lifestyle-Related Diseases (Medical
Check-ups and Health Advice by Insurers etc.)
Outpatient Medical Expenditure
Reduce the incidence of diseases
Home Visit for Patients with patients with
duplicate care and Frequent Outpatient Visit
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Control of Medical Expenditures involving All
Stakeholders

Effective Health Care


Achieving Early Discharge, Reduction of he Number
of Beds
Reduce Prevalence Rate of Life-style Related
Disease
Containment of Health Care Expenditures
Providers

Creating Incentives for Patients to Pass Away at
Home or Nursing Facilities by Improving Home Care
Implementing Health Checkup and

Health Education to Prevent Life-style Related
Disease
Shorten average Length of Stay (LOS)
Insurers

Review of the universal fee schedule
to produce effective health care
National Government

Budgetary steps for Prefectures to
guide healthcare providers

Planning implementing plan for Medical
Expenditures Control, and Health Promotion
Planning, Health Care Planning, Long-term Care
Insurance Planning
Prefectures
Steps for Promoting Effective Health Care

Guidance of Municipalities
Promotion Education of prevention of
life-style related disease

Municipalities

Enhancing the provision of nursing care as a
foundation of home care

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Development of Stages of Life-style Related
Diseases and Medical Care Expenditure in 2004
Physical Inactivity
Unhealthy Diet
Smoking accelerates all stages of development and
more damages
Visceral Obesity 50 / Male 40yrs 20 / Female
Sleep Apnea
Metabolic Syndrome
Hypertension 5,939,000 patients receive medical
care Medical Exp 8 Billion USD
Diabetes 2,284,000 p Med Exp12 B USD (7,400,000
Suspected 8,800,000 Possible)
Amputation from Diabetic Neuropathy Ann.
Registry 3,000
Vision Loss from Diabetic Retinopathy Ann. R.
3,000
Diabetic Nephropathy
Arteriosclerosis
(For Reference) Malignant Neoplasm 1,280,000
p Annual Death 305,000 Med Exp 21.4 B USD
Hemodialysis from Renal Failure 230,000 p Annual
Incr 14,000 Med Exp 3.4 B USD
Cerebrovascular D. 1,374,000 p Annual Death
130,000 Annual Occur 234,000 Med Exp 17 B USD
Ischemic H. D. 911,000 p Annual Death
72,000 Med Exp 6.8 B USD
47.2 B USD
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Medical Concerns on Hypertension
Financial Concerns
Genetic Factor
(30-50 influence)
Numbers of Patients and Latent ones
Salt Intake Physical Inactivity Mental
Stress Visceral Obesity
Insulin Resistance RAS Activity SNS Activity Salt
Sensitivity
Cost of Medical Care
Medical Expenditure in Future
Hypertension
Life Style Modification
Drugs
Cardiovascular/Renal Complications
PREVENTION Public Health Approach
Kamide K, et al. Jp Heat J 2004
Status of the sight-lost after retinal hemorrhage
Number and Status of Renal Failure and the
Dialyzed
Status of the paralyzed after stroke
Social Concerns
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Status Quo Hypertension in Japan

• Receivers of medical services
• 5,939,000 are under the medical care due to
  Hypertension. (2004)
• 9.2 of total receivers
• Medical Expenditure for Hypertension
• 946 BJY (8,085 MUSD) in 2004
• 19.9 for Inpatient, 80.1 for Outpatient
• 7.8 of Total Medical Expenditure (12,106 BJY)
• Latent Patients estimated
• Patients are estimated 31,000,000
• persons at risk are also estimated 20,000,000
• Hypertension is not only the medical issue, but
  also the national financial one

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Health adjusted Life Expectancy and Years Lost
of Life Expectancy due to Hypertension
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Life Table Analysis of Hypertension in Female
Japanese
Years of Life Lost from Hypertension is 569,237
person-years at 65yrs of female. In other words,
the differences of life expectancies are 3.8
years from 22.5 years at age 65. (From Life Table
and Vital Statistics in 2000)
By Segami, K 2006
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Total measures of controlling Visceral Obesity
and Diabetes and other Risk Factors will cause
suppressing the Medical Expenditure for the
Elderly
Output Suppressing increment of ME for the
Elderly
Risk Factors for Onset (Preventable)
Medical expenditure per Capita
Health Promotion
Suppressing Aggravation of Dis.
Threshold of onset
Suppressing Onset of Dis.
Aging
(Preventive measures are effective for
suppressing the Medical Expenditure of Diabetes,
which will cause the complication after 25 yrs to
70 of patients.)
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Depiction of Medical Expenditure Growth Necessity
of Systematic Measures
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Schematic Image of Medical Coordination (in case
of stroke)
Subacute/ Recovery Phase
Acute Illness
Community Emergency Care Services
Rehab Function (Recovery Phase) Use of Longterm
Care insurance (if necessary)
Care Function (Including Rehab)
Living at Nursing Facility (Care house, Nursing
home etc.)
(Transfer Coordination)
(Referral Coordination)
(Referral Coordination)
(Discharge Coordination)
(Discharge Coordination)
(Discharge Coordination)
Discharge

Primary Care Function (Clinic, Hospital etc.)
Onset of Disease
Discharge
Discharge
Discharge
Home Care (Continuity care)Management, Education
Living at Home
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The theoretical understanding of the visceral
obesity as the starting point of most of those
diseases Countermeasures toward the more
effective prevention of these diseases
Diabetes, Hyper-lipidemia
Insulin Resistance
Left Ventricular Dysfunction
Am J Cardiol 64, 369, 1989
Metabolism 36, 54, 1987
Diabetes Care 19, 287, 1996
Bio-active Mediators from Adipose Tissue
Visceral Obesity
Hypertension
Sleep Apnea
Coronary Diseases
Hypertension 16, 484, 1990 Hypertension 27,
125, 1996
Atherosclerosis 107, 239, 1994 Int J Obesity 21,
580, 1997
J Int Med 241, 11, 1997
All by Prof. Matsuzawa Y. et al With
complimentary regards
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Prevention of Onset and Progression of
Lifestyle-Related Diseases
?High blood glucose, High blood pressure,
Hyperlipidemia do not progress separately.
These are like The tips of a single
iceberg. ?Medication (ex. Hypoglycemic agent)
merely reduces the size of one tip of the
iceberg. ?It is necessary to reduce the size of
whole iceberg by improving life style,
such as adherence to physical exercise and
improved diet.
Visceral fat
Malfunction of Metabolism
Improvement of Life Style
Adherence to Exercise Improved Diet Quitting
Smoking
Improved Diet
Adherence to physical exercise
Reducing caloric intake, Balanced Nutrition
Increase of energy consumption, Cardiovascular
activity
One medication merely reduces the size of one tip
of iceberg. It does not cure the whole disease.
Activation of Metabolism / Reduction of visceral
fat (Good Hormone? , Bad Hormone? )
Continuation
Appropriate blood sugar, pressure, lipid
Smaller Iceberg!
Reduction in weight and waist circumference
Feeling of Well Being
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Comprehensive Implementation of Medical
Expenditure Control 1. Ensuring a Balance
between rising health care costs and the public
financial burden
Rising Health Care Costs
Moderation in Health Care Cost in the
mid-and-long term (Decrease the number of
metabolic syndrome patients, at-risk group,
decrease the Average Length of Stay etc.)
Incremental Effects
Evaluate from an economic perspective
Ensuring consistency with the New Health
Promotion Plan, new Health Care Planning
Ensuring Secure and Reliable Health System
Review of the coverage policies of public health
insurance etc. (Short-term Policies)
Evaluate from both perspective
Moderating Public Burden
Present a clear estimate of medical spending in
the future including mid- long-term prospects
for about 5 years

Use as a way to examine the rising health care
costs
Examine the effectiveness of the control policies
by comparing the estimated and actual costs
after a certain period of time
Future review of policies
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Comprehensive Implementation of Medical
Expenditure Control 2. Promoting Plans for
Medical Expenditures Control

• The national government and prefectures must work
  together in
• Promulgating systematic measures to control
  medical expenditures, including of long-term
  hospitalization those regarding lifestyle-related
  disease prevention and those for rectifying the
  problem.
• (2) Taking steps to support plan implementation.
  Formulating such plans in a manner consistent
  with health promotion plans and long-term care
  insurance will ensure coordination between policy
  actions.
• (3) Conducting examinations to verify that the
  plan is being implemented.

Excerpt from Outline of Health Care Reform
Policy
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For Longevity and Healthier Life

• Death is inevitable, but a life of protracted
  ill-health is not.
• A half but most, in future, of cardiovascular
  diseases do/will not result in sudden death.
• Rather, they are likely to cause people to become
  progressively ill and debilitated, especially if
  their illness is not managed correctly.
• Prevention and control of Cardiovascular disease
  helps people to keep longer and healthier lives.

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The speaker appreciates your kind
attention. See you soon.
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Something else

• Lest of all, just for your sight.

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Status Quo Cardiovascular diseases in Japan

• Background of policy-making toward the prevention
  of the metabolic syndrome

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Population, Birth, and Death in Japan
In 2006 Population127,720 T Over 65 yrs 26,400
T (20.7)
Death est. 1,600 T
2030
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Increment of Cardiovascular Deaths
CVD StrokeInpatient310T?Outpatient850T Mal
NeoplasmInpatient140T?Outpatient110T
CVD Stroke 303,000 and 28 of total deaths in
2005
15.9 12.3 30.1 41.8
15.5 12.5 31.1 40.8
15.3 13.8 30.7
40.2
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Annual Incident Rate of Cardiovascular Diseases
Annual Incident rate of the first physician
visits (per 100,000)
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1 year after Cerebrovascular Events
To be decreased in future
Death 48,511(20.7)
Annual Occurrence 234,352 (100)
Alive 185,841(79.3)
Institutionalized 13,195(5.6)
Bed-bound at Home 17,469(7.4)
Home help needed 30,850(13.2)
Independent(Partially) 67,460(28.8)
To be increased
Recovery 57,053(24.3)
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Outline of Health Care Reform Policy(Government
and Ruling Parties Council on Health Care Reform
(December 1st, 2005)

• ltContentsgt
• ? Guiding Principles for the Reform
• 1. Ensuring safe and reliable healthcare while
  emphasizing prevention
• 2. Comprehensive Implementation of Cost
  Containment
• 3. Creating a new health insurance system
  accounting for the aging of society
• ? Ensuring safe and reliable healthcare while
  emphasizing prevention
• 1. Ensuring safe and reliable healthcare
• 2. Emphasizing prevention
• ? Comprehensive Implementation of Cost
  Containment
• ? Creating a new health insurance system
  accounting for the aging of society
• ? Reviewing the universal fee-schedule etc.
• ? Reform timing

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?. Ensuring safe and reliable healthcare
while emphasizing prevention

• Basic structure
• ? - 1. Policy Outline
• Ensuring Safe and Reliable Healthcare
• ? (1) Establishing a new structure capable
  of providing safe,
• secure and high-quality health
  care upon the consumers perspective
• ? - 2. of the Policy Outline
• Prevention as a centerpiece
• ? (2) Establishing a new structure focused on
  prevention of
• lifestyle-related diseases

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• Establishing a new structure capable of providing
  safe, secure and
• high-quality health care upon the
  consumers perspective

Assistance in healthcare decision-making by
providing healthcare information
Provision of unfragmented healthcare by promoting
specialization and coordinating provision of
healthcare services
Regional coordinated critical pathways A
treatment plan up until a patient goes home after
being treated in an acute-care hospital and then
a rehabilitation hospital. Information-sharing
between the patient and his or her medical
institution leads to the provision of efficient
and high-quality healthcare as well as the
patient's peace of mind
Improved quality of life (QOL) for patients
through well-developed home healthcare services
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(Budget)
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Status Quo Diabetes in Japan

• Background of policy-making toward the prevention
  of the metabolic syndrome

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Prevalence of Diabetes in Japan
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Correlation between Physician Visits for Diabetes
and Mortality from Renal Failure (Correlation
Coefficient 0.721)
Mortality Rate from Renal Failure (per 100,000
capita)
Incident Rate of the first Physician Visits from
Diabetes (per 100,000 capita)
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Correlation between Physician Visits for Diabetes
and Mortality from Pneumonia (Correlation
Coefficient 0.638)
Mortality Rate from Pneumonia (per 100,000 capita)
Incident Rate of the first Physician Visits from
Diabetes (per 100,000 capita)
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Status Quo Hypertension in Japan

• Background of policy-making toward the prevention
  of the metabolic syndrome

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Status Quo Hypertension in Japan

• Receivers of medical services
• 5,939,000 are under the medical care due to
  Hypertension. (2004)
• 9.2 of total Patients.
• Medical Expenditure, burden of cardiovascular
  diseases
• 946,000,000,000JY (8,085 MUSD) in 2004 for
  Hypertension
• 187,9 BJP for Inpatient
• 758,1 BJP for Outpatient
• 7.8 of Total Medical Expenditure (12,105,600 MJY)

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Correlation between Physician Visits for
Hypertension and Mortality from Renal Failure
(Correlation Coefficient 0.753)
Mortality Rate of from Renal Failure (per 100,000
capita)
Incident Rate of the first Physician Visits by
Hypertension (per 100,000 capita)
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Correlation between Physician Visits for
Hypertension and Mortality from Cerebral Infarct
(Correlation Coefficient 0.653)
Mortality Rate from Cerebral Infarct (per
100,000 capita)
Incident Rate of the first Physician Visits by
Hypertension (per 100,000 capita)
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Correlation between Physician Visits for
Hypertension And Decreases of Mortality in 5
years (1997-2002) from Cerebral Hemorrhage and
other minor Cerebral D. (Correlation
Coefficient -0.327 )
Decrease of Mortality in 5 years (1997-2002)
from Cerebral Hemorrhage
Incidence of the first Physician Visits for
Hypertension
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Correlation among these diseases
Background of policy-making toward the prevention
of the metabolic syndrome

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The prevention from the starting point as the
most appropriate countermeasure Countermeasures
toward the more effective prevention of these
diseases

• To prevent Visceral Obesity, Risk Factor Control
  by individual behavior changes
• Spread of Integrated and Consistent Health
  Promotion by Insurers and Regional Officials
  (Significant is to increase their motivation.)
• Complete and Efficient Medical Check ups (Based
  on evidence from mega cohort study.)
• Individual Health Advice for High-Risk Groups (By
  well-trained Health Personnel.)
• 1,325M USD to be allocated in 2007

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What can we do as the population approach?

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From the desk plan to the social movement

• The dawn of the national policy on Metabolic
  syndrome Group
• Stepping in to the academic round-table
  conference on making the Japanese version of
  diagnostic standard of metabolic syndrome
• The achievement of agreement among the high
  officials in the Ministry of Health on what-to-do
• Involvement of the stakeholders
• Discussions on the Ministerial Council
• The appropriation to the budget compilation of
  the National Government and exploitation
• To the deliberations on Congress

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The dawn of the national policy on Metabolic
syndrome Group

• The characteristics of the Japanese version of
  metabolic syndrome Abdominal perimeterMale
  85cm, Female 90cm
• (From the employee based cohort study with MRI,
  only accomplished in Japan)