COVID-19 and the Long-Term Care system in Japan

Structural characteristics of the LTC system, impact of the pandemic, measures adopted and new reforms

This country profile brings together information on the experience of the long-term care sector (focusing on people who use and provide care) during the COVID-19 pandemic in Japan from a living international report on COVID-19 Long-Term Care. It also provides links to research projects on COVID-19 and long-term care, to key reports, and lists key experts on the impacts of COVID-19 on the long-term care sector in Japan.

Experts on COVID-19 and long-term care in Japan that have contributed to this report:

Margarita Estevez-Abe, Ide Hiroo, Natasha CurryNina HemmingsAdelina Comas-Herrera

Living report: COVID-19 and the Long-Term Care system in Japan

PART 1 – Long-Term Care System characteristics and preparedness
  • 1.00. Brief overview of the Long-Term Care system

    Most of Japan’s LTC services are covered by the mandatory long-term care insurance (LTCI) introduced in 2000. Japan’s LTCI—which is administered by municipal governments—is operated independently of the medical insurance system and subsidizes non-medical benefits-in-kind including residential (long-term and short-term) day care services and home care services, as well as the cost of home adjustments to enable older citizens to live in their homes safely. When an insured person requires services, the municipal government evaluates and determines the level of care to be covered by LTCI. Insured persons then contract any service provider of choice within the municipality and pay a 10% co-payment. The remaining 90% of the service cost is reimbursed directly to the service providers by the municipal LTCI (Estévez-Abe and Ide 2021a).

    The Japanese publicly-funded LTC system consists of residential and non-residential care sectors. The Japanese LTCI subsidizes day care services and home care services in addition to residential care services.  Unlike many European countries, the Japanese LTC system does not offer cash benefits to people in need of care (Estévez-Abe and Ide, 2021b).  Families do not receive any compensation for providing care and support to their relatives and there is almost no reliance on informal paid care by natives or migrants (Estévez-Abe and Caponio 2022).

    Residential LTC facilities are broadly divided into quasi-public facilities and for-profit facilities. The LTCI subsidizes the cost of care provided in all quasi-public facilities and a sub-section of for-profit facilities (Estévez-Abe and Ide 2021a, 2021b). The quasi-public facilities include: (i) Special nursing homes; (ii) Long-term care health facilities; (iii) LTC medical facilities; (iv) Sanatorium medical facilities; (v) Social welfare facilities for older citizens. The first category of facilities provides non-medical nursing care for older people who require highest level of LTC. The second category are facilities that provide nursing care to older people who are undergoing rehabilitation with the goal of returning home. Although the official goal is that patients do not stay in these facilities for more than 3 months, many of them stay for more than 6 months. The third and fourth categories are hospitals for elderly patients requiring nursing care in addition to medical care. (The third category will be phased out and integrated into the fourth type.) The fifth category are residential social welfare facilities for older people who find it difficult to live at home due to non-age-related disabilities, lack of economic means and/or family support. Traditionally, the non-profit sector has dominated this particular LTC sector because of the quasi-public nature of the services.

    The LTCI only subsidizes the cost of care provided in for-profit facilities that are specifically licensed by municipal governments (Estévez-Abe and Ide 2021a). In light of its rapidly aging population, the Japanese government is giving financial incentives to for-profit eldercare facilities to convert to proper nursing homes (Aramaki 2020).

    Using the data presented in Estévez-Abe and Ide (2021a) and the population data from the Japanese government (Stat.go.jp)  we can estimate that there were roughly 26 LTC beds for every 1,000 people aged 65 and older in 2017 when we adopt the narrowest definition of LTCF—that is, excluding the second and third categories mentioned earlier (OECD estimates it to be 24.1, see OECD 2019 Figure11.26).  When we include all five categories of LTCFs, the number of beds increases to 38. When we further include the number of beds in for-profit eldercare homes not licensed to provide nursing care, the number goes up to 57.

    In Japan, the non-residential care sector is significantly bigger than the residential sector. In 2014, 7.8% of those aged 65 or older used day care in Japan. According to Maeda (2020), 4 million older persons used day care facilities in 2019. This roughly translates to 11% of the population aged 65 and older.

    References:

    Aramaki, Seiya. 2020. “The content of the latest revision of fee schedule for for-profit nursing homes.” https://kaigo.jp/column/entry/497/ accessed on March 16, 2022.

    Estévez-Abe M and Hiroo I (2021a) “COVID-19 and Long-Term Care Policy for Older People in Japan,” Journal of Aging & Social Policy, 33:4-5, 444-458, DOI: 10.1080/08959420.2021.1924342

    Estévez-Abe, Margarita and Hiroo Ide. (2021b). ““COVID-19 and Japan’s Long-Term Care System.” LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, February 27, 2021. Retrieved from: ltccovid.org

    Maeda K. Outbreaks of COVID?19 infection in aged care facilities in Japan. Geriatr. Gerontol. Int. 2020;20:1241–1242. 10.1111/ggi.14050. https://onlinelibrary.wiley.com/doi/10.1111/ggi.14050

    OECD. 2019. Health at a Glance 2019. Paris: OECD.

    Statistics 65: http://www.stat.go.jp/data/jinsui/2017np/index.html

  • 1.01. Population size and ageing context

    Japan has one of the largest populations of older adults in the world. In 2020, 28.4% of the population was over the age of 65 (source: https://www.stat.go.jp/english/data/handbook/pdf/2020all.pdf#page=23).

  • 1.02. Long-Term Care system governance

    Accountability for the system is clear: a national framework of revenue raising, eligibility & benefits sits alongside clear roles for municipalities as insurers for over 65s and market shapers with some powers to influence provision (Curry et al. 2018).

    While the municipal governments are the administrators of the LTCI, LTCI is a nationally regulated system. The menu of services and pricing is set by the Ministry of Health, Labour and Welfare (MHLW) and hence is standardized across the country. Furthermore, the MHLW sets the rules over who can operate as service providers and imposes specific requirements on the provision of services such as minimum levels of accommodation, care worker/resident ratio, the number of medical and trained care staff, nutritionists and physical therapists. The MHLW also requires municipal and prefectural governments to update their long-term care service plans every three years (Estévez-Abe and Ide 2021a).

    References:

    Curry, N., Castle-Clarke, S. Hemmings, N. (2018). ‘What can England learn from the long-term care system in Japan?’ Nuffield Trust Research Report. Retrieved from: https://www.nuffieldtrust.org.uk/research/what-can-england-learn-from-the-long-term-care-system-in-japan

    Estévez-Abe, Margarita & Hiroo Ide (2021a) “COVID-19 and Long-Term Care Policy for Older People in Japan,” Journal of Aging & Social Policy, 33:4-5, 444-458, DOI: 10.1080/08959420.2021.1924342

  • 1.03. Long-term care financing arrangements and coverage

    Japan has a relatively well-funded system, based on mix of tax, social insurance and individual co-payments. Revenue raising mechanisms are flexible to allow for extra top ups in difficult times. However, the system is under financial pressure due to the fast rise in need as a result of rapid ageing. Its generosity has been reduced over time over affordability concerns (Curry et al. 2018)

    On being assessed as needing care by the municipal government, which administers Long-Term Care Insurance system (LTCI), service users are assigned a monthly in-kind budget to spend on care according to their level of need. A care manager meets with the service user to determine the actual menu of services needed. Service users pay a co-payment on accessing services which ranges from 10% for most people to 30% for most affluent. Co-payments are capped at fixed monthly level on a sliding scale according to income. People can opt to buy more care beyond assigned level at 100% cost, but care packages are thought to be generous and few people top up beyond their allocated budget. As mentioned earlier, the re-imbursement for care services from the LTCI does not cover room or board.

    Funding for the LTCI systems is raised as follows: 50% is from mandatory insurance contributions from all residents aged 40 and older and the rest is from general taxation, 25% from the national government and 12.5% each from the prefectural and municipal governments. The insurance rates are set by each municipality on the basis of the insured resident’s income levels (Estévez-Abe and Ide 2021b).

    References:

    Estévez-Abe, M., Hiroo Ide. (2021). “COVID-19 and Japan’s Long-Term Care System.” LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, February 27, 2021. Retrieved from: ltccovid.org

    Curry, N., Castle-Clarke, S. Hemmings, N. (2018). ‘What can England learn from the long-term care system in Japan?’ Nuffield Trust Research Report. Retrieved from: https://www.nuffieldtrust.org.uk/research/what-can-england-learn-from-the-long-term-care-system-in-japan

  • 1.04. Approach to care provision, including sector of ownership

    The 2000 LTC insurance reforms sought to create a competitive and mixed market of provision. Today, the Japanese LTC market consists of a mixture of public, quasi-public and for-profit service providers. Although the non-profit sector has long dominated Japan’s LTC sector, the overall picture has changed due to the growth of the for-profit sector in recent years.

    Non-profit providers dominated the residential LTC market because of regulatory restrictions. Aside from public sector providers, only two types of private non-profit organizations—social welfare corporations and medical corporations—were allowed to provide residential LTC services (Estévez-Abe and Ide 2021a). Because local governments are the licensing agents of social welfare corporations, the government and private non-profit actors work in tandem to plan and provide nursing services within the jurisdiction (ibid.).  In other words, these two non-profit organizations fulfilled quasi-public roles within the Japanese LTC sector.

    The government has encouraged the growth of for-profit nursing homes by introducing favourable reforms since 2006.[1] It should be noted that there are two types of for-profit eldercare facilities—one provides nursing care but the other one doesn’t. The growth of the for-profit LTC sector has increased the range of choices for users.

    As for the market for day care and home care services, for-profit providers have always dominated.  It is important to note here that non-profit providers such as social welfare corporations are allowed to operate for-profit services. Many social welfare corporations, which operate non-profit quasi-public residential LTC facilities, operate as for-profit providers of day care and home care services.

    Providers are reimbursed by the LTCI according to a national fee schedule although municipalities have some freedoms to adjust it to suit local needs (Curry et al. 2018).

    References:

    Curry, N., Castle-Clarke, S. Hemmings, N. (2018). ‘What can England learn from the long-term care system in Japan?’ Nuffield Trust Research Report. Retrieved from: https://www.nuffieldtrust.org.uk/research/what-can-england-learn-from-the-long-term-care-system-in-japan

    Estévez-Abe, Margarita & Hiroo Ide (2021a) “COVID-19 and Long-Term Care Policy for Older People in Japan,” Journal of Aging & Social Policy, 33:4-5, 444-458, DOI: 10.1080/08959420.2021.1924342

    [1] Undated document created by the Ministry of Health, Labour and Welfare. https://www.mhlw.go.jp/file/06-Seisakujouhou-12600000-Seisakutoukatsukan/0000038009_1.pdf  accessed on March 16, 2022.

     

     

     

     

  • 1.06. Care coordination

    LTC services include some nursing, so much of what we would count as healthcare comes under LTC. Individuals are assigned a care manager on becoming eligible for care and, if the person is in hospital, they facilitate discharge. At a national level, the LTC and health systems are reviewed together every 6 years – this is where provider rates and regulations are reviewed (Curry et al. 2018). Japan has an ambition to create integrated care communities but these are wider than health and care and include community services and voluntary organisations too (Morikawa, 2014). Individuals assessed and deemed to have care needs are assigned a care manager who helps people to navigate the system (Tamiya et al. 2011).

    References:

    Curry, N., Castle-Clarke, S. Hemmings, N. (2018). ‘What can England learn from the long-term care system in Japan?’ Nuffield Trust Research Report. Retrieved from: https://www.nuffieldtrust.org.uk/research/what-can-england-learn-from-the-long-term-care-system-in-japan

    Morikawa, M. (2014). ‘Towards community-based integrated care: trends and issues in Japan’s long-term care policy’. International Journal of Integrated Care. Retrieved from: Japan’s long-term care policy (ijic.org)

    Tamiya et al. (2011). Population ageing and wellbeing: lessons from Japan’s long-term care insurance policy. Lancet. doi: 10.1016/S0140-6736(11)61176-8

  • 1.07. Information and monitoring systems 

    As almost all people in need of care go through the municipality-funded needs assessment process to qualify for care, there is good data available on numbers of service users that is used to inform policy and reviews of care benefits by Ministry of Health, Labour & Welfare. It’s not clear whether the data is used for evaluation (source: https://www.mhlw.go.jp/english/policy/care-welfare/care-welfare-elderly/dl/ltcisj_e.pdf).

  • 1.08. Care home infrastructure

    The majority of nursing care facilities are run by non-profit social welfare or medical institutions (for profit organisations are restricted from entering the care market for the individuals with high needs). The rest of the market operates with a mixed market of provision, ownership types and sizes. For-profit assisted living facilities tend to cater to the more independent and hence less vulnerable population. They cannot provide LTC services unless they are specially licensed by the respective prefectural governments to do so, even if they have a licence, such facilities have to contract external licensed LTC service providers if the residents need nursing care. Providers are paid according to a national fee schedule, so they compete on quality and convenience, not price.  All providers must be licenced by the prefectural government (Estevez-Abe et al. 2021; covid19_and_japanese_ltcfs.pdf (harvard.edu).

    References:

    Margarita Estévez-Abe and Hiroo Ide. (2021). “COVID-19 and Japan’s Long-Term Care System.” LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, February 27, 2021. Retrieved from: ltccovid.org

     

  • 1.09. Community-based care infrastructure

    Japanese formal LTC relies heavily on day care and homecare services. In 2014, 7.8% of those 65 or older used day care in Japan. In 2019, in absolute numbers there were 1,077,609 users of day care services and 971,432 users of home care services. Many day care service providers also accommodate overnight stays.

    With the revision on Japan’s long-term care insurance law, current ageing health policies have shifted to a more population centric approach. Group activities called “Kayoi-no-ba” have been valued in Japan as a disability prevention initiative. The Kihon Checklist – a 25-item questionnaire – has been broadly used by health experts and researchers to assess frailty in Japan. However, a new 15-item questionnaire has been newly developed to identify frailty and other health-related problems in older people of 75 years and above. This will enable the provision of necessary support to frail individuals at any healthcare facility in local communities (Estevez-Abe, 2021; Kojima et al. 2021).

    References:

    Estévez-Abe, M., Hiroo Ide. (2021). “COVID-19 and Japan’s Long-Term Care System.” LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, February 27, 2021. Retrieved from: ltccovid.org

    Kojima, M., Satake, S., Osawa, A., & Arai, H. (2021). Management of frailty under COVID-19 pandemic in Japan. Global health & medicine3(4), 196–202. https://doi.org/10.35772/ghm.2020.01118

  • 1.10. Workforce conditions: pay, employment conditions, qualification levels, shortages

    In 2017 there were 5.9 formal LTC workers per 100 older adult population. It is estimated that by 2025 Japan will have a shortage of 380,000 LTC workers.  The country experiences severe and widespread staff shortages and high staff turnover which stem from a number of factors, including: a combination of high requirements for qualifications and low pay compared to other sectors (e.g. retail); low status; very low immigration (Curry et al, 2018; https://ageingasia.org/).

    Care workers are required to hold a qualification earned by sitting a formal examination at worker’s own expense. Providers are required to observe strictly-enforced rules around staff to service user ratios (Ikegami, 2007).

    Japan has sponsored basic training programmes for both new students and experienced workers willing to return to work after a long break. These initiatives led to an increase in the number of LTC workers of around 20% between 2011 and 2015. The country also provides scholarships for nurses specialising in geriatric care. Japan has workplace counselling services to promote prevention of accidents and burnout (OECD 2020. Who Cares? Attracting and Retaining Care Workers for the Elderly).

    References:

    Curry, N., Castle-Clarke, S. Hemmings, N. (2018). ‘What can England learn from the long-term care system in Japan?’ Nuffield Trust Research Report. Retrieved from: https://www.nuffieldtrust.org.uk/research/what-can-england-learn-from-the-long-term-care-system-in-japan

    Ikegami, N. (2007). ‘Rationale, Design and Sustainability of Long-Term Care Insurance in Japan – In Retrospect’ Social Policy and Society 6(03):423 – 434
  • 1.11. Role of unpaid carers and policies to support them

    The extent to which the system relies on unpaid care is unclear. The recent reforms were successful in largely shifting the responsibility of caring from families to the state by offering in-kind benefits to those in need. However, there are no cash benefits for people with needs, hence there is no option to use cash benefits to pay for care to relatives or friends. Although in-kind benefits are generous, but may not cover all needs. Moreover, there is also a 10% co-payment on accessing care, therefore poorer people may need to avoid using formal care and rely on unpaid carers instead (Curry et al. 2018).

    References: 

    Curry, N., Castle-Clarke, S. Hemmings, N. (2018). ‘What can England learn from the long-term care system in Japan?’ Nuffield Trust Research Report. Retrieved from: https://www.nuffieldtrust.org.uk/research/what-can-england-learn-from-the-long-term-care-system-in-japan

  • 1.12. Personalisation, user voice, choice and satisfaction

    Once an individual is found to have needs, they are assigned a notional budget to spend on care. In theory, they can choose between competing providers, assisted by a care manager. However the care managers are mostly employed by providers. There are safeguards in place to prevent them referring all their clients to one providers but they are weak and do not fully address the conflict of interest (Curry et al. 2018).

    References:

    Curry, N., Castle-Clarke, S. Hemmings, N. (2018). ‘What can England learn from the long-term care system in Japan?’ Nuffield Trust Research Report. Retrieved from: https://www.nuffieldtrust.org.uk/research/what-can-england-learn-from-the-long-term-care-system-in-japan

  • 1.13. Equity and Long-Term Care

    A national framework for eligibility and benefits based on need only, creates consistency. Co-payment operates on a sliding scale according to income. Monthly cap on co-payments protects against high costs (Curry et al. 2018).

    References:

    Curry, N., Castle-Clarke, S. Hemmings, N. (2018). ‘What can England learn from the long-term care system in Japan?’ Nuffield Trust Research Report. Retrieved from: https://www.nuffieldtrust.org.uk/research/what-can-england-learn-from-the-long-term-care-system-in-japan

  • 1.14. Pandemic preparedness of the Long-term care sector

    Japan had well-established routine protocols of prevention and control in Long-Term Care Facilities (LTCFs). Each LTCF has a mandatory infection control committee which meets regularly. Practices such as isolating residents in LTCFs suspected to have a contagious infection, such as flu, were already in place before the COVID-19 pandemic. As soon as threat level was raised (as it would be for new TB outbreak or flu), LTCFs responded rapidly, as they were already familiar with protocols to isolate residents.

    At the beginning of the pandemic in 2020 many LTCFs were in full or semi-lockdown already due to seasonal flu-outbreaks in January and February, this may have inadvertently helped protect care homes from COVID-19 outbreaks (Estevez-Abe and Ide, 2021)

    References:

    Estévez-Abe M. and Ide H. (2021). “COVID-19 and Japan’s Long-Term Care System.” LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, February 27, 2021. Retrieved from: ltccovid.org

     

PART 2 – Impacts of the COVID-19 pandemic on people who use and provide Long Term Care
PART 3 -Measures adopted to minimise the impact of the COVID-19 pandemic on people who use and provide Long-Term Care
PART 4 – Reforms to strengthen Long-Term Care systems and to improve preparedness for future pandemics and other emergencies

Printable version of this country profile:

https://ltccovid.org/country/japan/

To cite this report:

Estevez-Abe M., Ide H., Curry N., Hemmings N. and Comas-Herrera A. (2023) COVID-19 and the Long-Term Care system in Japan. In: Comas-Herrera A., Marczak J., Byrd W., Lorenz-Dant K., (editors) International living report on COVID-19 and Long-Term Care users and providers: context, impacts, measures and lessons learnt. LTCcovid, Care Policy and Evaluation Centre, London School of Economics and Political Science. Available at: https://ltccovid.org/country-questions/


Most recent LTCcovid report for Japan (February 2021):

https://ltccovid.org/wp-content/uploads/2021/03/ltccovid-Country-Report-Japan_Final-27-February-2021.pdf

Acknowledgement and disclaimer

This report has been initially developed by the team working on the Social Care COVID Recovery and Resilience project and questions will be added to and validated by LTCCovid contributors who are experts on Long-Term Care in their respective countries. This study is funded by the National Institute for Health and Care Research (NIHR) Policy Research Programme (NIHR202333). The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.