As the number of older persons in need of long-term care services increase, community based services continue to hold the be the predominant position among elderly care services in developed countries. Japan is the most rapidly aging country in the world. In 2010, the proportion of those aged 65 and over in the total population was 22.7%
]. It is estimated that it will reach 40.5% by 2055, with 1 in 2.5 people being 65
years old and over
]. Because of rising medical expenses caused by these dramatic changes in demographics, the Japanese government developed a policy to substitute long hospital stay with a community-based service. In 2000, a long term care insurance (LTCI) that aimed at providing long term care for the elderly population by integrating health services and social services was introduced in Japan
Under the LTCI, persons certified by the municipal government as in need of care or support will receive benefits in the form of the following services. Long-term care benefits consist of mainly two services: community-based services and facility services. The two main types of community-based services are (1) health services: home-visit nursing services (VNS), home-visit rehabilitation services, and management guidance for in-home care and (2) social services: home-help services, home-bath services, and rental service for assistive devices. These services have a fixed fee determined by the central government (see Table
). Each insured individual pays 10% of the eligible charges for services as a co-payment. In order to receive services from the LTCI insured person need to obtain and apply for certification of needed long-term care. The degree for long-term care requirement is classified into six care-needs levels. The maximum payment is fixed by each level. With the increasing number of elderly persons and because of the health policy, the home care needs of the frail elderly persons are increasing in Japan. Home health services by a physician are covered exclusively by the health insurance instead of by the LTCI. However, the VNS, one of the home health services, is covered mainly by the LTCI. Except for some cases (terminally ill patients with cancer, patients with incurable disease, acute exacerbation of disabling conditions, or individuals under 40), the VNS users are covered by the LTCI and not by health insurance. The Japanese Health, Labour, and Welfare Ministry reported that approximately 80% of the VNS users were insured by the LTCI in 2008.
Community-based services and fees for each service in April 2000 (Unit: Japanese Yen)
The number of persons using the VNS under the LTCI was 458,300 in the FY2010. That is only 10.9% of the total community-based services users covered by the LTCI. The total number of the community-based services users has increased about 1.9-fold since the FY2001. However, the number of persons using the VNS increased at a lower rate (1.3-fold) compared to the social services, such as home-help services (1.8-fold) and day care services (2.2-fold)
]. The difference between the VNS and social services is that the VNS provides health services under medical doctor’s guidance. Pursuant to progressive population aging, national health services expenditures have been increasing
]. The number of outpatients also has been increasing with age
]. However, the number of the VNS users has hardly changed since the introduction of the LTCI system. We are concerned that the use of the VNS covered by the LTCI is limited due to systemic reasons. We hypothesize that the reasons for the lower use of the VNS under the LTCI include the following:
First, the care management system of the LTCI might contribute to the low use of the VNS. In order to use the services under the LTCI, the insured person needs to prepare a long-term care service plan (care plan), which is a combination of several types of services, depending on one’s need for care or support. The care plan is established by the care managers of care management agencies. After the care plan is created, the care management agency contracts with service providers on behalf of the insured person. A study showed that the care plans prepared by care managers of medical corporations mostly consist of a combination of health services and social services, but the great majority of care plans prepared by care managers of non-medical corporations utilize a combination of social services only
]. These reports suggest that the use of the VNS may be related to the corporation type of the care management agency. However, so far, there is no further research examining this relation.
Second, the VNS fees are highest for community-based services covered by the LTCI (see Table
). Service users are requested to pay 10% co-payment, except for the few who receive public livelihood assistance. For the low income elderly population, this 10% co-payment is a heavy burden. As a result, clients and their families, regardless of their actual needs, may choose more affordable services such as home-help services that cost less than the VNS under the LTCI
]. The relation between the VNS and income level has not been reported previously.
Ten years after the establishment of the LTCI, the Japanese government promotes the VNS in preparation for the super-aging society and the high rate of elderly mortality. The VNS is the centerpiece of the health insurance reform or the long-term care insurance system. Therefore, it is important to identify the factors related to the use of the VNS through empirical studies. However, there are only a few empirical studies investigating the factors associated with VNS use in Japan. One study reported that VNS users authorized to receive the VNS by care managers had higher rates of medical treatment and severe dementia levels compared to non-users
]. Another study reported that LTCI clients with higher care needs used the VNS more
]. However, these previous studies did not investigate the influence of service provisions under the LTCI on the VNS use.
In other countries, many studies have found significant relations between elderly persons’ use of home health services, and their physical characteristics (e.g., functional status), household characteristics (e.g., income level), ethnicity, and geographic location
]. Although these results were almost concordant, they included all the services and not only the VNS. Moreover, the LTCI make the community-based services provision quite unique in Japan; generally service use is arranged by a care-manager, and services use is restricted by the maximum payment. Therefore, we selected corporation type of care management agency, care-needs levels, and income as the main variables focusing on the Japanese LTCI system.
The aim of our study was to investigate the predictors of the VNS use covered by the Japanese LTCI using the claim data and surveys conducted on the insurers of the LCTI in six Japanese rural towns. We combined important enabling factors related to the LTCI system, such as the organization type of the care management agency, income level, care-needs level, and family caregiver’s situation
], with predisposing factors in this study. Our results could contribute toward meeting the needs for the VNS use better.