3rd International Jerusalem Conference on Health Policy The Control of Chronic Disease in the 21st C

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3rd 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

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Rationale 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

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What 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?

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Caveats 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.

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Caveats 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!

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Prevention 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

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Rationale 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

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Relationship of the three sectors (Historical)
Curative medicine
Prevention
Social services
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Relationship of the three sectors (Present)
Long-term care (LTC)
Curative medicine
Social services
Prevention
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Advantages 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

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The 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

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Before 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

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Overall 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

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Overall 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

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Flow 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
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How 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

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How 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)

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What 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)

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Measures 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

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LTCI 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

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Accommodating 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?

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My 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

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Philosophical 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?

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Quality of Life Dimensions
Social
Physical
Mental
?Health-related Quality of Life
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Measurement 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?

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Quality-adjusted life year
Compression of morbidity with prevention
Natural course of decline
1.0
Quality of life
???
With prevention
Without prevention
0
????
Time ?
Death ? ?
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Discussion 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?

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Conclusion

• 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)