developments in long-term care insurance in japan olivia s ... · developments in long-term care...

Developments in Long-Term Care Insurance in Japan

Olivia S. Mitchell, John Piggott, and Satoshi Shimizutani

Research Paper 08/2007


Olivia S. Mitchell, John Piggott, and Satoshi Shimizutani*

April 2007

*Mitchell is the International Foundation of Employee Benefit Plans Professor of Insurance and Risk Management; Executive Director of the Pension Research Council, and Director of the Boettner Center at the Wharton School, University of Pennsylvania; and a Research Associate of the NBER. Piggott is Professor of Economics and Director of the Centre for Pensions and Superannuation, University of New South Wales. Shimizutani is an Associate Professor of Economics at Institute of Economic Research, Hitotsubashi University. Funding for this research was provided by the Economic and Social Research Institute, the Pension Research Council, the Boettner Center at the Wharton School of the University of Pennsylvania, the Australian Research Council and Hitotsubashi University. We thank Noriko Inakura and Takeshi Yamaguchi for their excellent research assistance. Without implicating them, we acknowledge helpful assistance and suggestions from seminar participants at the ESRI, Cabinet Office, Government of Japan, Tokyo in March 2007. The authors retain full responsibility for all views contained herein. © 2007 Mitchell, Piggott, and Shimizutani.

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Abstract As the Japanese long-term care (LTC) system was implemented only recently, there is little information available on the determinants of entitlement and utilization. This paper seeks to disentangle some of the patterns using the most up-to-date data. We find that the demand for LTC in Japan – particularly home care – is growing rapidly, as elderly consumers find subsidized LTC care preferable to and more available than hospitalization. At the same time, regional disparities in care persist and are likely to grow. KEYWORDS: health insurance, nursing home, aging, elderly care, hospital, disability, means-testing Olivia S. Mitchell (corresponding author) 3641 Locust Walk, 304 CPC Department of Insurance & Risk Management Wharton School, University of Pennsylvania Philadelphia PA 19104-6218 [email protected] John Piggott School of Economics University of New South Wales Sydney 2052, Australia [email protected] Satoshi Shimizutani Associate Professor, Institute of Economic Research, Hitotsubashi University, 2-1 Naka, Kunitachi-shi, Tokyo Japan 189-8603 [email protected]

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Olivia S. Mitchell, John Piggott, and Satoshi Shimizutani

Demographers and policymakers have observed the striking fact that the Japanese nation is

aging very quickly; today about one-fifth of the population is age 65 or older, or roughly double

the US rate. Notwithstanding its overall effectiveness and low cost, the Japanese healthcare

system is under stress, as a result of rising numbers of long-lived older persons (here defined as age

65+) who using more medical care overall and particularly long-term care. For instance, healthcare

costs of persons 65+ were five times the average in Japan in 2000; furthermore the bulk (90%) of

the growth in healthcare costs in recent years can be attributable to population aging (Yashiro et al.,

2006). Some 3% of the 65+ in Japan currently reside in nursing homes, and this fraction is

projected to rise dramatically over the next two decades (Ikegami and Yamada, 1996). It would

appear that as the number of elderly rises, they may experience relatively high levels of

hospitalization and incur expensive medical care at the end of life.

Our paper contributes to research on this topic by evaluating recent changes in the Japanese

LTC delivery model and updating the statistical model introduced in Mitchell, Piggott, and

Shimizutani (2006). In what follows, first we briefly describe the Japanese long-term care system

drawing on existing studies and adding updates from recent policy developments. Next, we present

our new estimates and offer an interpretation of findings. Finally we discuss possible policy

implications.

A Brief Overview of Japan’s Old-Age Care System1

The Japanese healthcare system relies on mandated universal medical coverage tied to

participants’ jobs or regions of residence.2 For employees, municipalities and firms must offer

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mandatory healthcare coverage financed by premiums levied on household heads (in the case of

the community-based plans), or shared half by employers and half by employees (for

company-based plans; the self employed pay the full premium). The special position of older

persons (age 65+)3 has been summarized by Mitchell et al. (2006) and others (e.g. Campbell and

Ikegami, 2000). In the main, medical services for the older population are provided via a national

mandatory plan known as the Citizens’ Health Insurance (CHI) program which provides

hospitalization and medical services to the elderly. The Japanese healthcare system has

experienced several reforms over the years, and a time line of key policy changes appears in Table

1. Many authorities have praised Japan’s relatively low health care expenditures, compared to

international developed nation standards (c.f. Ikegami and Campbell, 1999), said to result from

strict government control over medical services and pharmaceuticals, fixed reimbursement

systems for hospital services, and a low “intensity” level of care per patient (Yoshiro et al., 2006).

Table 1 here

In addition, persons over the age of 40 are included in a national long-term care insurance

(LTCI) program also mandated by the national government. Under this scheme, the central

authorities set the prices of nursing home beds, adult day-care centers, and home health aid

providers. They also play important roles in setting eligibility standards and determining who is

entitled for care. Specifically older persons needing benefits under the current Japanese LTC

program can avail themselves of both in-home services (at-home care) and services at facilities

(institutional care).4 Eligibility for care is set based on a local or prefectural-level committee’s

lengthy assessment of all applicants’ medical and physical status (Ikegami, 2003). This

committee categorizes applicants into one of six health care level groupings, and then benefits are

attached to that grouping.5 Applicants are assigned a case manager who provides a care plan; the

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applicant’s status is then re-evaluated every six months. (Medical care is not included in the LTC

menu; rather that is delivered separately by the applicant’s doctor.) LTC services range from

in-home services (e.g. home visits, day treatment), to short-stays at residential facilities, to

long-term custodial and health facilities.

Financing of the LTC system is pay-as-you-go, relying on social insurance premiums,

general tax revenue, and user fees. About half of the LTC system is financed by earmarked

premiums from workers over age 50 and retirees; the remainder is split between the central

government and local government entities (JMHLW, 2002). Worker and retiree premiums vary

geographically, and the payments also depend on income (those with low incomes pay relatively

less). Users of the LTC system also bear out of pocket costs via a 10% co-insurance on each

service used, up to a cap which can vary with income; they also pay meal charges while in a

residential facility.6

An interesting feature of the Japanese approach to LTC is its relatively high degree of

reliance on local or decentralized decisionmaking regarding service use. Though the central

government sets prices and types for LTC services and determines the number of units of care per

pre-set level of “care need,” each municipality (and there are now around 2,000) establishes

insurance premiums, and “care managers” are assigned to determine what types of care a certified

person is eligible for. In addition, there is room for each municipality to control how many people

to serve with LTC via a unified certification process; local governments also must approve

providers of LTC insurance (only nonprofits can provide institutional care) The idea is that

providers will compete locally for patients along several dimensions including quality of care, but

not prices ; this is more likely for non-hospital entities including home care providers which

include for-profit and not-for-profit firms, as well as local government service organizations.

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There is substantial geographic diversity across Japan in terms of the where older persons

are located. Figure 1 depicts dependency ratios, or the number of people age 65+ as a percent of

the population, from North to South by prefecture, in 2001 and again in 2005, the most recent year

for which we have data. Overall, in just four years the older population grew 10 percent, with some

experiencing a rise in the fraction of people over 65 by up to 25%.

Figure 1 here

Both the geographic differentials and the large changes over what is a rather short period

are again apparent in Figure 2, which depicts the entitlement rate for long-term care by prefecture.

We define this as the number of people age 65+ which have been deemed to be entitled to LTC, as

a percent of the population of that age. In the earlier year, 2001, the average entitlement rate was

13%, but only four years later, this had risen by more than one third, to 17.3%.

Figure 2 here

A breakdown of the overall data into patterns of institutional versus in-home care is useful,

as it soon becomes clear that the overall picture conceals substantial changes in patterns of care.

Figure 3 tracks regional patterns in the number of persons age 65+ entitled to institutional care, and

here we see that overall, the percentage change was small, on the order of 5% between the four

years. By contrast, home-health care utilization grew by almost half (47%). Such patterns no doubt

played a key role in the reform enacted in Spring 2006, under which elderly benefits from the

Long-term Care Insurance system were reduced so as to slow the national rate of growth of costs

(Ogawa et al., 2007). Figure indicates how the mix of capacity is changing over time: in just four

years, the number of hospital beds per thousand persons age 65+ fell by 15% on average, whereas

the beds dedicated to LTC rose by almost 8%. This marks a substantial change in the way care

facilities are being allocated to the elderly in Japan.

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Figures 3 and 4 here

Model and Estimates

Our earlier work on the Japanese LTC system analyzed available data on the links between

elderly entitlement rates and utilization rates of LTC beds and demographic as well as economic

variables (Mitchell et al., 2006). That analysis relied on two years’ of regional data for FY 2001

and FY 2002, to evaluate whether there were demographic and economic factors that could be

sensibly linked to the observed patterns. Now we have gathered three additional years of data (FY

2003-FY 2005) to expand our sample size from 94 observations in the earlier work, to 235 here (47

prefectures for 5 years). Summary statistics appear in Table 2.

Table 2 here

Our approach relates several key factors to the observed LTC entitlement rates as well as

institutional-care and home-care utilization rates by the elderly. Table 3 offers three models for

each dependent variable. Model 1 includes as regressors the area’s population density, the percent

of the population over the age of 75, average household earnings, and health care employees’ pay.

Population density proxies for urbanity; in cities, older people are hypothesized to be less likely to

have offspring readily accessible to care for them. The fraction 75+ is included to test whether

LTC entitlement and utilization rates are responsive to demographic concentrations of older

persons. We include healthworkers’ pay to indicate whether utilization is responsive to salary

levels of caregivers, and average household earnings controls on ability to pay which varies both

cross sectionally and in the time series. Model 2 adds two capacity variables, namely the number

of LTC and hospital beds per older (65+) person, to assess whether utilization responds to capacity.

If there is no response, this may be because beds are quantity-rationed. Model 3 includes all the

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foregoing factors and also adds year controls, to assess robustness of results. In order to address

the fact that prefectures have different size populations, we employ the Weighted Least Squared

(WLS) method to perform the regressions.

Table 3 here

The estimates for Model 1 are reasonable, as in our previous work, but in some cases the

effects are much larger than before. For instance, population density has a more positive and

statistically significant effect than our earlier findings on overall entitlement rates and on

home-care utilization (the effect on institutional care is not substantially different). This suggests a

widening discrepancy in LTC usage between urban and rural areas over the period. Similarly, an

older population (age 75+) was previously positive and significant on LTC entitlement rates and

utilization rates. In the extended dataset, our results are stronger than before, particularly for

entitlement and home care utilization rates, where the coefficients increased substantially. For

reasons mentioned below, this is not the case for institutional care use. Moving on to healthcare

workers pay levels, the coefficients are negative and significant as before, mainly for entitlement

patterns and home care use. This sensitivity of LTC patient usage is probably a result of the

coinsurance structure of the LTC insurance system. Average household earnings in the region are

not statistically significant in most models (unfortunately we have no data on average earnings for

elderly persons alone.)

Model 2 includes bed availability for institutional and non-hospital care. It is interesting

that bed availability for institutional care enters the entitlement and utilization rate equations

positively. Nevertheless the coefficients are small, perhaps because there is excess demand from

consumers so that supply determines usage rates. This is especially the case for institutional care

utilization where availability accounts for most of the variation. Model 3 adds year dummies to

Deleted: each

Deleted: s

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Model 2; it is clear that entitlement and home care usage are rising over time. This may be due to

consumers learning about the new system, whereas they had information about the preexisting

hospitals providing institutional care.

Overall, we believe that the most notable change in results has to do with the large increase

in the coefficient on the proportion of the population 75+. Evidently this group is demanding and

obtaining higher levels of LTC services over time, controlling for other factors. It is also worth

noting that large regional disparities in age structure across the nation pose challenges for the

“centralized” approach to LTC under the Japanese system. Local government reluctance to boost

hospital capacity for institutional care is likely to instead direct increasing numbers of newly

entitled elderly to home care use. Whether this will ensure adequate treatment is unclear in the

Japanese context; however the US literature on this topic indicates that home care is not a

particularly effective substitute for nursing home care (Garber, 1996).

Conclusions and Discussion

The US and other developed – and aging – nations look with interest at how Japan is

coping with a high and rising demand for long term care for its large and growing older population.

The Japanese approach to LTC model is a complex tax-and-transfer scheme, supported by

mandatory but means-tested premiums levied on workers and retirees by local governments, as

well as general tax revenue from central and local governments and out of pocket payments by

beneficiaries. LTC eligibility is determined by local boards appointed by municipalities, but fees

for benefits are set at the national level. As the Japanese system has been in place just a few years,

there is yet little information available with which to study the determinants of entitlement and

utilization. This paper seeks to disentangle some of the patterns using the most up to date data.

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Compared to our earlier work which covered only two years, our extended data show some

interesting patterns. In just a few years, LTC entitlement rates have risen substantially – by as

much as one third, from 13% to 17.3% of the 65+ population. Utilization rates have also risen,

mainly in the home health care area, where usage rose almost 50% (versus only 5% for

institutional care use). Indeed, the number of hospital beds per thousand persons age 65+ fell by

15% on average, whereas the beds dedicated to LTC rose by almost 8%. This marks a substantial

change in the way care facilities are being allocated to the elderly in Japan.

Our regression results imply that the demand for LTC in Japan will grow, as elderly

consumers find subsidized LTC care preferable, and more available, than hospitalization.

Noguchi and Shimizutani (2002a) has noted that at-home care is becoming increasingly attractive

to older persons compared to welfare institutional care, particularly when an older person has no

family members with whom he or she can live. Our results also indicate that regional and

urban/rural disparities in entitlement and utilization patterns will continue, so that the adjustment

scheme proposed to smooth over these regional differences (with 5% of total revenue) may not

resolve inequality in treatment across prefectures. As noted by Shimizutani and Inakura (2007),

local governments now face tighter fiscal budgets, and they are clamping down on both

entitlement and LTC care utilization. And Fukui and Iwamoto (2006) state that “until FY 2100,

the scheme maintains a higher contribution rate in order to accumulate sufficient funds….the sum

of the contribution rates with regard to health insurance and long-term care insurance increases

from 5 percent of the total earnings to 12.47 percent of the same.” The implied 63% increase in the

tax burden under the current scheme – one which is already strained – suggests that more

fundamental reforms may be needed to keep the system afloat.

One approach may be to spur the market for privately-provided LTC insurance, insofar as

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older persons can muster sufficient income/assets to buy the coverage. In other work (Mitchell

and Piggott 2004) we have suggested a role for reverse mortgages in Japan in this regard, as a

means of financing services and provide care for the nation’s growing elderly population.

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Table 1. Historical Developments in Japan’s Healthcare System Year Policy or program development

1961 Universal coverage of medical services established

1973 Free medical care services provided to those aged 70 and over

1981 Contribution to the cost sharing of medical expenses increased; Policy of fee exemption for high-cost medical services introduced

1983 Free medical services for those age 70 and over abolished, and elderly patients required to make monthly contributions of 400 yen (equivalent to US$2 based on the 1983 exchange rate) per month for outpatient care and 300 yen per day for inpatient care; Law on Health Service System for the Elderly (those aged 70 and over) established

1984 10% co-payment for non-elderly introduced

1986 Elderly contributions increased: For outpatients, from 400 to 800 yen per month For inpatients, from 300 to 400 yen per day

1987 Law on the Health Services Facilities of the Elderly enforced

1990 10-year Gold Plan implemented


1995 Elderly outpatients’ contributions increased from 1000 yen to 1010 yen per month


1997 Co-payment for non elderly raised from 10% to 20%

Elderly contributions increased: For outpatients, from 1020 yen per month to 500 yen per visit For inpatients, from 710 to 1000 yen per day

1998 Elderly inpatients’ contributions increased to 1100 yen per day

1999 Elderly contributions increased: For outpatients, from 500 to 530 yen per visit For inpatients, from 1100 to 1200 yen per day

2000 Long-term Care Insurance made effective;

Contributions for the elderly abolished and payment limits set (3000 yen per month for outpatients, 37 200 yen per month for inpatients)

2002 10% co-payment required of elderly patients; 20% co-payment required of those with higher income

2003 Co-payment for non-elderly increased from 20% to 30%

Diagnosis Procedure Combination introduced at 82 specially designated hospitals

2006 Co-payment for elderly increased from 10% to 20% Source: Ogawa, Mason, Matsukura and Nemoto (2007)

Formatted

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Table 2: Sample Statistics for Empirical Analysis of LTC Entitlement Rates, Institutional Utilization Rates, and Home Care Utilization Rates for the 65+ in Japan

Mean Median S.D Min Max Dependent Variables

ENTL_TOT/(ELD65*1000) (%) 15.49 15.50 2.50 9.47 21.57

UHM_TOT/(ELD65*1000) (%) 8.99 8.95 1.69 4.96 13.23

UINSL_TOT/(ELD65*1000) (%) 3.26 3.36 0.61 2.04 4.89

Independent Variables

AREA (Km2) 7805.71 5804.46 11595.38 1861.76 83454.08

DEN ('000 Persons/Km2) 0.66 0.28 1.14 0.07 5.98

ELD65/POP_TOT (%) 20.77 21.25 2.93 13.54 27.09

ELD75/POP_TOT (%) 9.43 9.58 1.86 5.09 14.15

Health Care Sector Pay ( M Yen/year) 4.36 4.42 0.38 3.38 5.22

Average Household Earnings (M Yen/year) 4.43 4.39 0.56 3.36 6.19

BDLTC_TOT/ELD65 (# beds/ '000 Persons ELD65) 33.59 34.38 6.23 20.87 51.07

BDNET_HSP/ELD65 (# beds/ '000 Persons ELD65) 54.75 53.74 8.24 38.54 81.79 Source: See Data Appendix.

16

Table 3: Multivariate (WLS) Regression Results for LTC Entitlement and Utilization Rates: Extended Models

VariablesFY2001-FY2002

Coef. Coef. Coef. Coef. Coef. Coef. Coef. Coef. Coef.Population Density 0.0068 0.0015 *** 0.0057 0.0013 *** 0.0039 0.0009 *** 0.0040 0.0010 *** 0.0011 0.0004 ** 0.0005 0.0001 ***

Percent 75+ 0.5030 0.1370 *** 0.2976 0.1257 ** 0.3216 0.0860 *** 0.2190 0.0966 ** 0.1336 0.0385 *** 0.0535 0.0073 ***

Health Care Sector Pay -0.0160 0.0063 ** -0.0096 0.0051 * -0.0078 0.0040 * -0.0067 0.0039 * -0.0026 0.0018 0.0005 0.0003

Average HH Earnings -0.0116 0.0058 ** 0.0010 0.0049 -0.0051 0.0036 -0.0018 0.0038 -0.0056 0.0016 *** 0.0000 0.0003

LTC Bed Availability 0.0022 0.0004 *** 0.0008 0.0003 *** 0.0009 0.0000 ***

Hospital Bed Availability 0.0000 0.0002 -0.0002 0.0002 0.0000 0.0000 *

Constant 0.2125 0.0347 *** 0.0748 0.0365 ** 0.1041 0.0218 *** 0.0762 0.0280 *** 0.0562 0.0097 *** -0.0075 0.0021 ***

R2 0.4323 0.6474 0.352 0.3983 0.576 0.9886FY2001-FY2005

Coef. Coef. Coef. Coef. Coef. Coef. Coef. Coef. Coef.Population Density 0.0078 0.0011 *** 0.0083 0.0010 *** 0.0043 0.0008 *** 0.0047 0.0008 *** 0.0056 0.0008 *** 0.0027 0.0006 *** 0.0007 0.0002 *** 0.0004 0.0000 *** 0.0005 0.0000 ***

Percent 75+ 0.7510 0.0949 *** 0.3619 0.0976 *** 0.3484 0.0689 *** 0.5237 0.0660 *** 0.2728 0.0726 *** 0.2577 0.0524 *** 0.1227 0.0186 *** 0.0496 0.0046 *** 0.0524 0.0043 ***

Health Care Sector Pay -0.0230 0.0052 *** -0.0181 0.0046 *** -0.0095 0.0033 *** -0.0152 0.0036 *** -0.0154 0.0035 *** -0.0091 0.0025 *** -0.0028 0.0010 *** 0.0005 0.0002 ** 0.0004 0.0002 *

Average HH Earnings -0.0058 0.0045 0.0032 0.0041 0.0056 0.0029 * 0.0001 0.0031 0.0019 0.0031 0.0035 0.0022 -0.0044 0.0009 *** 0.0001 0.0002 0.0001 0.0002

LTC Bed Availability 0.0031 0.0003 *** 0.0018 0.0003 *** 0.0015 0.0003 *** 0.0006 0.0002 *** 0.0009 0.0000 *** 0.0009 0.0000 ***

Hospital Bed Availability -0.0006 0.0002 *** 0.0007 0.0001 *** -0.0006 0.0001 *** 0.0003 0.0001 *** 0.0001 0.0000 *** 0.0000 0.0000 ***

FY 2002 dummy 0.0154 0.0024 *** 0.0109 0.0018 *** 0.0000 0.0001

FY 2003 dummy 0.0290 0.0026 *** 0.0202 0.0020 *** 0.0000 0.0002

FY 2004 dummy 0.0373 0.0028 *** 0.0267 0.0021 *** -0.0001 0.0002

FY 2005 dummy 0.0410 0.0029 *** 0.0303 0.0022 *** -0.0008 0.0002 ***

Constant 0.2074 0.0269 *** 0.1123 0.0309 *** 0.0145 0.0226 0.1049 0.0187 *** 0.1053 0.0230 *** 0.0350 0.0172 ** 0.0518 0.0053 *** -0.0088 0.0015 *** -0.0080 0.0014 ***

R2 0.4621 0.5987 0.8030 0.4056 0.4913 0.7394 0.6213 0.9837 0.9859

Home Care Utilization Rate Institutional Care Utilization Rate

Std. Err.

Std. Err. Std. Err. Std. Err. Std. Err. Std. Err. Std. Err. Std. Err. Std. Err. Std. Err.

Std. Err. Std. Err. Std. Err. Std. Err. Std. Err. Std. Err. Std. Err. Std. Err.

Entitlement Rate

Source: Authors’ computations. The estimation method is WLS. Note: *** significant at 1% level; **significant at 5% level, * significant at 10% level.

17

Figure 1. Dependency Ratios by Region in Japan: 2001 (thin line) and 2005 (with triangles) (Population 65+/Total Population)

10%

20%

30%

Hokk

aido

Aom

ori

Iwat

eM

iyagi

Akita

Yam

agat

aFu

kush

ima

Ibar

agi

Toch

igiGu

mm

aSa

itam

aCh

ibaTo

kyo

Kana

gawa

Niiga

taTo

yam

aIs

hikaw

aFu

kui

Yam

anas

hiNa

gano Gifu

Shizu

oka

Aich

iM

ieSh

igaKy

oto

Osak

aHy

ogo

Nara

Wak

ayam

aTo

ttori

Shim

ane

Okay

ama

Hiro

shim

aYa

mag

uchi

Toku

shim

aKa

gawa

Ehim

eKo

chi

Fuku

oka

Saga

Naga

saki

Kum

amot

oOi

taM

iyaza

kiKa

gosh

ima

Okina

wa

Source: Authors’ calculations using data provided by Japan’s Ministry of Health, Labor and Welfare; All Japan National HI Organization; and Statistics Bureau of Japan.

Tohoku Kanto Chubu Kinki Chugoku Shikoku Kyusyu

18

Figure 2. Long Term Care (LTC) Entitlement Rates by Region in Japan: 2001 (thin line) and 2005 (with triangles) (Number entitled/Population 65+)

0%

5%

10%

15%

20%

25%

Hok

kaid

oAo

mor

iIw

ate

Miy

agi

Akita

Yam

agat

aFu

kush

ima

Ibar

agi

Toch

igi

Gum

ma

Saita

ma

Chi

baTo

kyo

Kana

gaw

aN

iigat

aTo

yam

aIs

hika

wa

Fuku

iYa

man

ashi

Nag

ano

Gifu

Shiz

uoka

Aich

iM

ieSh

iga

Kyot

oO

saka

Hyo

goN

ara

Wak

ayam

aTo

ttori

Shim

ane

Oka

yam

aH

irosh

ima

Yam

aguc

hiTo

kush

ima

Kaga

wa

Ehim

eKo

chi

Fuku

oka

Saga

Nag

asak

iKu

mam

oto

Oita

Miy

azak

iKa

gosh

ima

Oki

naw

a

Source: See Figure 1.


19

Figure 3. Entitlement Rates to Institutional and Home Care by Region in Japan: 2001 (thin line) and 2005 (line with triangles) (Number entitled to Care/Population 65+) A. Institutional Care Entitlement Rates: 2001 and 2005

0%

1%

2%

3%

4%

5%

Hok

kaido

Aom

ori

Iwat

e

Miyag

i

Akita

Yam

agat

aFu

kush

ima

Ibar

agi

Toch

igi

Gum

ma

Saita

ma

Chiba

Toky

o

Kana

gawa

Niig

ata

Toya

ma

Ishika

wa

Fuku

i

Yam

anas

hiNag

ano

Gifu

Shizuo

ka

Aich

i

Mie

Shiga

Kyot

o

Osa

ka

Hyo

goNar

a

Wak

ayam

a

Totto

ri

Shim

ane

Oka

yam

a

Hiro

shim

a

Yam

aguc

hi

Toku

shim

aKa

gawa

Ehim

e

Koch

i

Fuku

oka

Saga

Nag

asak

i

Kum

amot

o

Oita

Miyaz

aki

Kago

shim

a

Okina

wa

B. Home Care Entitlement Rates: 2001 and 2005

0%

2%

4%

6%

8%

10%

12%

14%

Hok

kaid

oAo

mor

iIw

ate

Miy

agi

Aki

taYa

mag

ata

Fuku

shim

aIb

arag

iTo

chig

iG

umm

aSa

itam

aC

hiba

Toky

oKa

naga

wa

Niig

ata

Toya

ma

Ishi

kaw

aFu

kui

Yam

anas

hiN

agan

oG

ifuSh

izuo

kaA

ichi

Mie

Shig

aK

yoto

Osa

kaH

yogo

Nar

aW

akay

ama

Totto

riSh

iman

eO

kaya

ma

Hiro

shim

aYa

mag

uchi

Toku

shim

aKa

gaw

aEh

ime

Koc

hiFu

kuok

aSa

gaN

agas

aki

Kum

amot

oO

itaM

iyaz

aki

Kago

shim

Oki

naw

a


20

Figure 4. LTC and Hospital Bed Capacity by Region in Japan: 2005 Lines with triangles, 2001 thin lines. (# Beds/000 Population 65+)

0

20

40

60

80

100

Hok

kaid

oAo

mor

iIw

ate

Miy

agi

Akita

Yam

agat

aFu

kush

ima

Ibar

agi

Toch

igi

Gum

ma

Saita

ma

Chi

baTo

kyo

Kana

gaw

aN

iigat

aTo

yam

aIs

hika

wa

Fuku

iYa

man

ashi

Nag

ano

Gifu

Shiz

uoka

Aich

iM

ieSh

iga

Kyot

oO

saka

Hyo

goN

ara

Wak

ayam

aTo

ttori

Shim

ane

Oka

yam

aH

irosh

ima

Yam

aguc

hiTo

kush

ima

Kaga

wa

Ehim

eKo

chi

Fuku

oka

Saga

Nag

asak

iKu

mam

oto

Oita

Miy

azak

iKa

gosh

ima

Oki

naw

a

ltc_bed_ava01 non_ltc_bed01 ltc_bed_ava05 non_ltc_bed05



Data Appendix Variable name Variable Definition Unit Comment Data Source

entl_tot /(eld65*1000) Entitlement Rate All-Japan Federation of National Health Insurance Organization http://www.kokuho.or.jpNote: Data in October

uhm_tot/(eld65*1000) Home Care Utilization Rate "

uinst_tot/ (eld65*1000) Instit Care Utilization Rate "

entl_tot Total entitled persons Persons "

uhm_tot Total at-home care users Persons "

uinst_tot Total institutional care users Persons "

eld65 Population 65+ 000 PersonsJapan Statistics Bureau : http://www.stat.go.jp/data/jinsui/2.htm#01Note: Projected population for 2001-2004 National popolation Census for 2005

den Population density 000 person / Km2 pop_tot / area2 "

pop_tot Total population Thousand "

area2 Area of prefectures Km2 Geographical Survey Institute : http://www.gsi.go.jp/KOKUJYOHO/MENCHO/200510/ichiran.htm

ratio_eld75 eld75 / pop_tot Percent 75+ Japan Statistics Bureau http://www.stat.go.jp/data/jinsui/2.htm#01

eld75 Population age 75+ Thousand persons "

wg_wgt1Weighted annual total income of health care service (included bonus)

Million yen See -->

Basic Survey on Wage Structure by JMHLW http://wwwdbtk.mhlw.go.jp/toukei/kouhyo/indexkr_4_8_4.html with calculation, WG_WGT1=([(WGAS_RA*12+WGAS_SP)*NUMAS+(WGST_RA*12+WGST_SP)*NUMST)]/(NUMAS+NUMST))/1000

wgst_ra Monthly wage of staff nurse Thousand Yen "

wgst_sp Bonus of staff nurse " "

numstf Sample size of staff nurse Ten persons "

wgas_ra Monthly wage of assistant nurse Thousand Yen "

wgas_sp Bonus of assistant nurse " "

numas Sample size of assistant nurse Ten persons "

wgm_tott1 (wgm_totr * 12 + wgm_tott ) / 1000

Average annual total income of total industires (include bonus)

Million yen "

wgm_totr Average monthly wage of total industries Thousand Yen "

wgm_tott Average bonus of total industires Thousand Yen "

ltc_bed_ava bdltc_tot / eld65 LTC Bed Availability bdltc_tot / eld65

bdltc_tot Total bed number in LTC institutions Bed number

non_ltc_bed bdnet_hsp / eld65

Non-LTC Hospital Bed Availability bdnet_hsp / eld65

Survey on Medical Institution by Ministry of Health,Labor and Welfare :http://www.mhlw.go.jp/toukei/saikin/hw/iryosd/04/toukei.html

bdnet_hsp Bed number for non-LTC Bed number bd_hsptl - bd_hsltc "

bd_hsptl Total bed number in medical institution Bed number "

bd_hsltc Bed number in medical institution for LTC " "

Survey on LTC Institutions by Ministry of Health,Labor and Welfare :http://www.mhlw.go.jp/toukei/saikin/

1 This section draws on Mitchell et al. (2006). 2 For a review of the Japanese LTC system before the introduction of the public system see Campbell and Ikegami (1998); Yashiro et al. (1996 and 2006). 3 As noted in Mitchell et al (2006), Japanese firms are being required to extend the retirement age to 65 gradually by FY2014. 4 Unless otherwise indicated, this discussion is adapted from Mitchell et al. (2006), JMHLW (2003b,c) and Campbell and Ikegami (2000). 5 These groups range from the least demanding “Support Required” (the consumer can live independently but requires assistance for Instrumental Activities of Daily Livings (IADLs)); to five increasingly disabled levels of “Care Required” for help in basic Activities of Daily Living (ADLs). 6 The copays are complicated, as noted in Mitchell et al (2006). For instance an old-age welfare pension recipient faces an out-of-pocket limit of ¥15,000/month; someone exempt from municipal tax faces a limit of ¥24,600/month; and a regular taxpayer has a limit of ¥37,200/month.

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