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

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).

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

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

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.

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. 

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).

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

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 & medicine, 3(4), 196–202. https://doi.org/10.35772/ghm.2020.01118

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

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

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

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

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

As of February 5, 2021, there have been 399,048 confirmed COVID-19 infections in Japan, and 6,135 deaths attributed to COVID-19, according to the World Health Organisation, corresponding to 4.851 COVID-19 attributed deaths per 100,000 population. Japan is among other Asian countries reporting lower infection fatality rates than other parts of the World (Source: https://ageingasia.org/wp-content/uploads/2020/12/COVID_LTC_Report-Final-20-November-2020.pdf). Most of the early attention on Japan was focused on the Diamond Princess cruise ship: people on board started a 2-week quarantine on February 5, 2020 (Source: https://pubmed.ncbi.nlm.nih.gov/32183930/).

There is no publicly available official data on the numbers of people who use or provide care who have had COVID-19 infections or whose deaths are attributed to COVID-19. It was reported that 14% of all COVID-19 was the result of infections in care homes in early May 2020.

There is limited data on long-term COVID-19 in Japan as yet but growing interest in it and how it should be managed (Source: https://www.japantimes.co.jp/news/2021/02/07/national/covid-aftereffects-long-lasting/).

Applications for LTC (both community and facility based) through the national insurance scheme decreased by more than 20% across many cities compared to the previous years due to concerns regarding infection from care assessment workers (Source: https://ageingasia.org/wp-content/uploads/2020/12/COVID_LTC_Report-Final-20-November-2020.pdf). At least 909 LTC services (858 are day-care and 51 are home-visit services) have temporarily suspended operations as of April 20, 2020, due to the risk of infection (Source: https://onlinelibrary.wiley.com/doi/full/10.1002/jgf2.366). It is not clear if the impact of those closures has been assessed. It is also not clear how home care has been affected.

Closure of day care and community services risks having significant impact on wellbeing (Source: https://onlinelibrary.wiley.com/doi/full/10.1002/jgf2.366 ). There is research into the impact of restrictions on the general population but so far none found on the LTC population.

There is limited information. One article points to challenges in the use of technology/remote consultations with older population, plus financial pressures on care providers.

Most of the early attention on Japan was focused on the Diamond Princess cruise ship: people on board started a 2 week quarantine on February 5, 2020 (Source: https://pubmed.ncbi.nlm.nih.gov/32183930/).

A published article gives an account of the different measures implemented in Japan during the COVID-19 pandemic.

Japan responded more immediately to the threat of COVID-19 in LTCFs in comparison with Western countries. This has been attributed to cultural respect for older adults, and existing high standards of hygiene and infection control as a result of frequent TB outbreaks (Source: https://ageingasia.org/wp-content/uploads/2020/12/COVID_LTC_Report-Final-20-November-2020.pdf). On January 29, 2020, LTCFs were contacted by the national ministry in charge and told to put in place infection control measures. On February 13, they were contacted again. On February 24, measures stepped up with restricted visits and more stringent infection control (at this point, there were only 141 confirmed cases in Japan). National lockdown started on March 14, but, by then, LTCFs had been in lockdown for 3 weeks already. (Source: https://pubmed.ncbi.nlm.nih.gov/32183930/). There are hierarchically organised government agencies whose sole missions are elderly care (at the top of the hierarchy is the Bureau of Health and Welfare for the Elderly in the MHLW). Local governments have specific departments that liaise with this Bureau. Well-established channels of communication within the sector may also have been beneficial (Source: https://programs.wcfia.harvard.edu/files/us-japan/files/margarita_estevez-abe_covid19_and_japanese_ltcfs.pdf).

A national taskforce (Advisory Committee on the Basic Action Policy on Coronavirus) was established, including experts from the Ministry of Health, Labour & Welfare (that oversees long term care) (Source: https://www.universityworldnews.com/post.php?story=20200703123239310). However, it’s not clear to what extent the taskforce focused on long-term care.

It is unclear what measures have been put in place for data and information sharing within LTC during the COVID-19 pandemic. Japan has not adopted electronic record sharing on a large scale and most records remain paper-based and mostly shared by fax (Source: https://www.healthaffairs.org/do/10.1377/hblog20200721.404992/full/).

Some of the supplementary budget provided by the government in response to the COVID-19 pandemic was for the construction of a ‘data-sharing system among hospitals, municipalities and national ministries’ to support the government with monitoring the number of people with COVID-19 infections (Source: https://ltccovid.org/wp-content/uploads/2021/03/ltccovid-Country-Report-Japan_Final-27-February-2021.pdf).

New legislation has been brought in nationally to manage the pandemic, but when it was released, LTCFs had already responded using well-established infection control protocols (Source: https://programs.wcfia.harvard.edu/files/us-japan/files/margarita_estevez-abe_covid19_and_japanese_ltcfs.pdf).

A recent study by the OECD, published in October 2021, reported that during the first wave of the Covid-19 pandemic, Japan not only prolonged LTC foreign workers’ contracts and visas, but it also offered them special rewards. Moreover, Japan assisted LTC workers’ mental well-being while providing them free services for psychological support.

Source:

Rocard, E., P. Sillitti and A. Llena-Nozal (2021), “COVID-19 in long-term care: Impact, policy responses and challenges”, OECD Health Working Papers, No. 131, OECD Publishing, Paris, https://doi.org/10.1787/b966f837-en.

Early in the response, local LTCI officials had triggered well-established infection control measures put in place and regularly used for outbreaks of TB & influenza. A disease prevention manual was published; stricter hygiene practices put in place; and staff and visitor health screening and limited resident visitation (https://programs.wcfia.harvard.edu/files/us-japan/files/margarita_estevez-abe_covid19_and_japanese_ltcfs.pdf; https://ageingasia.org/wp-content/uploads/2020/12/COVID_LTC_Report-Final-20-November-2020.pdf).

LTCFs used well-established infection control procedures and swiftly isolated affected residents and suspended visits and social events (as they are used to do in the case of influenza/TB outbreaks). Mask-wearing was also already common practice in the event of these outbreaks. Data suggests most cases were contained with few large outbreaks within facilities (https://programs.wcfia.harvard.edu/files/us-japan/files/margarita_estevez-abe_covid19_and_japanese_ltcfs.pdf).

Facilities implemented well-established policies to restrict visits, as used in times of influenza or TB outbreaks. These policies were triggered swiftly (https://programs.wcfia.harvard.edu/files/us-japan/files/margarita_estevez-abe_covid19_and_japanese_ltcfs.pdf).

Japan did not pursue a policy of mass testing, instead focusing on the 3Cs (closed space, crowded places, close contacts (https://www.mhlw.go.jp/content/3CS.pdf) and pursuing rigorous retrospective tracing) (https://thediplomat.com/2020/06/japans-pragmatic-approach-to-covid-19-testing/).

There are some reports of shortages of PPE (https://onlinelibrary.wiley.com/doi/full/10.1002/jgf2.366; https://programs.wcfia.harvard.edu/files/us-japan/files/margarita_estevez-abe_covid19_and_japanese_ltcfs.pdf).

A study of the implementation of infection control measures in a nursing home in rural Japan includes a description of the use of Information and Communication Technology (ICT) using a system called Mame-net established by the local government. This system enabled the nursing home to share information regarding the health condition of the residents with the local clinic, and, if there were immediate concerns, there was direct phone communication between the care home staff and the clinic. The system is also used to share information about the residents’ condition with their family members (Ochta et al., 2021).

References

Ohta R, Ryu Y, Sano C. (2021) Effects of Implementation of Infection Control Measures against COVID-19 on the Condition of Japanese Rural Nursing Homes. International Journal of Environmental Research and Public Health. 18(11):5805. https://doi.org/10.3390/ijerph18115805

Japan has been relatively slow to roll out vaccines. Vaccination started in April 2021 for all people aged 65 and over, followed by care home staff from June but it faces issues with high levels of vaccine hesitancy (https://www.theguardian.com/world/2021/jan/28/japan-faces-olympian-task-slow-start-covid-vaccinations). Japan also faces logistical difficulties in roll out of the Pfizer vaccine in that it lacks sufficient syringes to deliver it (https://www.theguardian.com/world/2021/feb/10/japan-pfizer-vaccine-doses-wrong-syringes). There do not appear to be plans to prioritise people who live in care homes.

Japan has offered payments to all citizens as part of their economic stimulus packages, which may help offset some of the economic burden of care (AHWIN, 2020 in https://ageingasia.org/wp-content/uploads/2020/12/COVID_LTC_Report-Final-20-November-2020.pdf).