Chapter 2

Preparing for Smooth Implementation
of the Long-Term Care Insurance System

Section 1.Smooth Implementation of the Long-Term Care Insurance System

(1) Conditions surrounding the care for the elderly

After the war the average life expectancy in Japan has been extended remarkably with the improved environment for living and the advancement of medicine. In 1997 the average life expectancy reached 77.19 years for men and 83.82 years for women, and Japan became a longest-lived society in the world.

On the other hand, the rapid increase of elderly people who require long-term care for bedridden condition or dementia is projected along with the progress of aging society. Considering this situation, families providing long-term care are bearing heavy burden physically and psychologically, and that is causing the "care-worn" to the families and destroying the relationship among family members.

Figure 2-1-1. Future Projection of Elderly People in the Condition of Bedridden, Dementia and Physically Weak

(2) Aim of the establishment of the long-term care insurance system

The long-term care insurance system was established while the long-term care for the elderly was becoming a serious issue. It is intended to provide social support to long-term care for the elderly and to enable elderly people to maintain their human dignity through the end of their lives by carrying on self-sufficient living in the condition in which they require long-term care.

The long-term care insurance system was established for the following purposes:

1 To provide stable fund for bearing the increasing expenditure through the collaboration of the entire society by designing the social insurance system in a way that the relation between the benefit and burden are easy to understand.

2 To create a user-oriented system in which necessary services are received through an unified comprehensive procedure by reorganizing the current inconvenient system in which welfare services and medical care services require different procedure for receiving services.

(3) Overview of the long-term care insurance system

1 Insurer

Municipality, which is the closest administrative unit to people, is the insurer of the long-term care insurance system, and it has multi-layered support from the national government, prefecture, medical care insurers, etc.

2 Scope of insured people

Insured people are citizens of age 40 or older, and they are divided into two categories, primary insured who are age 65 or older and secondary insured who are subscribers of medical insurance and age 40 or older to age under 65. Among the insured people, primary insured are eligible for services when their condition requires support always (condition of requiring long-term care) or for some daily activities for living (condition of requiring support). On the other hand, the secondary insured will be eligible for receiving services when their condition requires long-term care or support due to presenium dementia or due to a disease caused by aging such as cerebrovascular disease (selected 15 diseases of specific diseases).

3 Procedure and the contents of the insurance benefits

In order to receive the benefit of long-term care insurance, the insured person needs to be certified for being in the condition requiring the services such as bedridden and dementia (certification for long-term care need or for support). The insured person, his/her family, or the support provider requested to provide long-term care applies to the municipality, and the municipality investigates the physical and mental condition of the insured. The Certification Committee for Long-Term Care Need of the municipality will evaluate the investigation result and opinions of the family physician, and then according to the evaluation outcome, the municipality makes the decision on whether or not the insured should be certified as requiring long-term care or support.

When the insured is certified as requiring long-term care, the municipality will provide various services for both in-home and in-facility care, and the insured certified as requiring support will receive various in-home services to prevent the condition from worsening and requiring long-term care.

4 Burden on the user

To ensure impartiality between service users and non-users, in principle the users are required to bear 10% of the service cost for long-term care.

Residents of an institution are required to bear a portion of food cost that is about the equivalent of the food cost for average households and also to bear daily living expense.

However, in case of the elderly with low income, the maximum amount of burden is set by issuing service fee for long-term care (when the burden on the service user reaches a high value, a ceiling value is set for co-payment.) and by reducing the standard meal charge (portion of meal service cost that is about the equivalent to the food cost in an average household.).

5 Insurance premium

In order to ease the burden on the people with low income, each municipality sets a fixed premium for primary insured in accordance with the income level of the insured. In case of insured who are receiving the annual value of \180,000 or more benefits from the Old-Age Basic Pension, etc., a special collection (so-called deductible) will be applied to their pension, and for other insured people the municipality collects the premium individually.

In case of secondary insured people, the premium is calculated based on the calculation standard of the medical insurance system that they subscribe, and the amount will be collected with the general medical insurance premium by adding the portion of the long-term care insurance.

Figure 2-1-2. Certification of Long-Term Care Need and the Procedure for Using Services

6 Structure of fund source

In case of the long-term care insurance, a half of the expenditure is borne by the premium payment of the insured and the other half is borne with public fund to ensure stable supply of fund required for the payment of benefits. By referencing various existing systems, the breakdown of the public fund is fixed for 2:1:1 for the national government, prefecture and local municipality (25%, 12.5% and 12.5% of the total expenditure on the benefit respectably.).

Within 25% of the national fund, 5% is reserved to make adjustment of the financial gaps among municipalities because of the differences in the ratio of subscribers in their advanced elderly age, their abilities to bear the burden, etc.

Figure 2-1-3. Overview of the Long-Term Care Insurance System

2. Smooth Implementation of the Long-Term Care Insurance System

The long-term care insurance system is scheduled to commence in April 2000, and the central government, prefectures and municipalities are working together to prepare for smooth implementation of the system in various aspects.

(1) Development of the infrastructure for long-term care services

As we develop the system to provide long-term care services, it is critically important to ensure that services are sufficient to meet demand and to avoid a situation where "insurance is available but not the service."

To prepare proper services, we must focus on the achievement of the goals set in the New Ten-Year Strategy to Promote Health Care and Welfare for the Elderly (The New Gold Plan). After the introduction of the long-term care insurance system, business plan for the long-term care insurance will be created based on the understanding of actual conditions of people requiring care in individual municipalities and projecting the required volume of long-term care services for the future, and also necessary support will be prepared at the national level.

(2) Implementation of certification for long-term care need

In order to receive services from the long-term care insurance, the insured must be certified as being in the condition requiring services due to bedridden or dementia (certification for long-term care need or support need), and for the stable operation of the long-term care insurance system, an impartial and fair process is required for the certification.

To achieve that goal, the following guidelines are prepared:

1 Use the same standard nationwide, and implement the evaluation using the computer assessment as a draft.

2 Create a manual for the examination method and implement training to examiners.

3 Create a manual for the evaluation judgement for the certification committee for long-term care need, and implement training to committee members.

4 Share information widely throughout the nation to avoid inconsistency among municipalities.

Since fiscal 1996, some trial programs have been implemented for the certification for long-term care need, and in fiscal 1998 the trial was conducted for all municipalities. Based on the result of these programs, the standard for certification for long-term care need was revised as necessary and then proclaimed.

(3) Establishment of cabinet orders and ministerial ordinances

For the smooth progress of the preparation efforts in prefectures and municipalities, the Long-Term Care Insurance Law Enforcement Order and the cabinet orders on the calculations of National Treasure's cost sharing for the long-term care insurance were established in December 1998, and in March 1999 ministerial ordinances and notifications were formulated to stipulate the criteria for selecting service providers, etc.

For the notification to stipulate service fees for long-term care in fiscal 2000 budget, we will propel the effort while properly offering necessary information to prefectures and municipalities.

(4) Support for municipalities financially and in the implementation system

The long-term care insurance system is structured with municipalities to be the insurer and the national government, prefectures, medical care insurers, etc. to provide multi-layers of support, so that the municipalities can receive various support to prevent excessive burden of administrative work or financial needs.

The following support is facilitated in the system:

1 The national government will issue a half of cost for the new administrative work such as certification of long-term care need.

2 The Financial Stability Fund (The fund is borne by the national government, prefectures and premiums paid by the primary insured. Each shares 1/3) is placed in prefectures, and the fund or loan will be issued to supplement the unexpected increase of expenditures on benefit payment or lower payment rate of insurance premiums.

3 Prefectures support the coordination among municipalities for joint establishment of the Certification Committee for Long-Term Care Need with multiple municipalities.

To provide financial and implementation system-wise support to municipalities for their smooth preparation work, \19.1 billion was budgeted for fiscal 1999 for various preparation cost for municipalities including the certification work for long-term care need, which will commence in October 1999, and \0.5 billion for the preparation cost for prefectures to conduct training to examiners and committee members for the certification for long-term care need, etc.

(5) Preparation efforts for the implementation at municipalities and prefectures

Prior to the implementation of the public long-term care insurance system, individual municipalities and prefectures will formulate municipal business plan for the long-term care insurance and prefectural support plan for the long-term care insurance in accordance with the basic guidelines provided by the national government.

The business plan for the long-term care insurance is to determine the goals for the services provided by the long-term care insurance of individual municipalities so that the necessary services are available to the insured, and in order for municipalities to achieve their goals, prefectures formulate support plans for the long-term care insurance to determine the necessary items to support in order to succeed the smooth delivery of insurance benefits for the operation and coordination of the admission capacities of care facilities in each wide area (areas determined by each prefecture).

In addition, each municipality will determine the insurance premiums for primary insured people within the responsible area based on the projected service volume in the municipal business plan for the long-term care insurance.

(6) Support for trans-regional efforts

Trans-regional approaches to administrative work for long-term care insurance are expected to bring the following benefits:

1 Conducting the certification work for long-term care need in a wider area will ensure greater objectivity and impartiality in the evaluation, and it will become easier to secure doctors and nurses to be the members of the certification committee. Thus, efficient processing of the administrative work for certification for long-term care can be achieved.

2 Through the development of the service infrastructure in a wider area, better balanced service infrastructure can be developed.

3 The foundation for the insurance finance will be stabilized and the premium rates of the adjacent municipalities can be leveled.

Because of these potential benefits, the national government budgeted \1.5 billion for the system cost for trans-regional cooperation in fiscal 1999 to support the trans-regional efforts.

Table 2-1-4. Preparation Schedule for the Implementation of the Long-Term Care Insurance System

(7) Training of long-term care support specialists (care managers)

For the training of long-term care support specialists (care managers) in fiscal 1998, about 90,000 people who passed the written examinations before attending practical training had just completed the practical training in each prefecture, and the training in fiscal 1999 is scheduled to begin with the written examination on July 25.