International Journal for Quality in Health Care 14:295-303 (2002)
© 2002 International Society for Quality in Health Care
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Use of home health services covered by new public long-term care insurance in Japan: impact of the presence and kinship of family caregivers
Department of Hygiene and Public Health, Teikyo University School of Medicine, Itabashi, Tokyo, Japan
Objective. In April 2000, the system for caring for the elderly in Japan was changed drastically with the launch of new long-term care insurance. Unlike the previous system, the maximum monthly amount of insured services is now decided solely by an applicant’s physical condition, regardless of family support. We investigated whether the presence and kinship of a family caregiver still affect service use under the new system.
Design. A cross-sectional, mailed, self-administered questionnaire survey and analysis using multiple logistic regression.
Setting. One month after the introduction of long-term care insurance in Japan.
Participants. The main family caregivers of 237 applicants for long-term care insurance with a caregiver and 33 applicants without a caregiver, living in the community in one city.
Outcome measures. The applicants’ sex, age, and eligible care level, existence of a family caregiver, family caregiver’s sex, age, and kinship, and service use for each service covered by long-term care insurance.
Results. Caregiver factors significantly affected use of the main services. The most popular service, nursing-home daycare, was utilized most when a wife was caring for her husband. As the level of care increased, this service was utilized less. Home help, the second most popular service, was most utilized when a wife was caring for her husband or when there was no caregiver.
Conclusion. The use of major services may be decided more by the needs of caregivers than by the care level of the applicant. To successfully implement the new system, consideration of the caregiver situation should be included in policy making.
Keywords: family caregiver, home health care, insurance, public long-term care, service use
In most industrialized countries with rapidly aging populations, the question of how to provide care for the growing number of disabled elderly has become a major issue for the elderly, their families, and for policy makers. While the proportion of elderly people aged 65 years or over is 12.7% in the US (1998) and 15.8% in Germany (1997), in 2000 it was already 17.5% in Japan [1], where the proportion is increasing at the fastest rate in the world. To tackle the anticipated explosion in demand for long-term care services and the financial burden entailed in paying for them, a prospective payment system (PPS) for home health care covered by Medicare was started in the US on 1 October 2000 [2,3]. Germany put a long-term care insurance (LTCI) plan into effect in 1995 [4,5], and Japan drastically changed its old system into an LTCI following styled on that of Germany on 1 April 2000 [6]. Although it is modeled after the German LTCI, the Japanese LTCI differs in several important aspects. After much debate, it was decided that the Japanese LTCI would not provide a cash benefit [6]. In the German LTCI system, non-professionals who provide more than 14 hours of home nursing care per week have their contributions to statutory pension insurance and accident insurance paid [4,5]. These measures were adopted to encourage families to provide care, which occurs more often in Germany than in the US [4]. The Japanese LTCI covers some medical care that is not included in the German system, such as visiting nurses, rehabilitation, and hospital beds providing long-term care. There is a monthly limit to the use of this medical care under LTCI. This aspect may be similar to the PPS for home health care covered by Medicare in the US.
Until recently, Japanese society had a reputation for providing traditional family care for the elderly. In 1995, 32% of Japanese elderly were living with a married son, a decrease from 41% in 1980. Yet the percentage is still much higher than in other countries; it was 1.1% in the US and 2.4% in Germany in 1995 [7]. Daughters-in-law (34%) are the typical caregivers for bedridden or frail older persons [8]. If they were to become ill and be bedridden for one month, 43% of Japanese elderly would prefer to be cared for while living with their children. This is four times the rate reported for other countries [7].
In such a traditional situation, welfare services for the elderly in Japan, including nursing homes and home care, were formerly means tested, and not usually available to anyone who could be cared for by their family [6]. The administrative apparatus for deciding eligibility and providing services was the old placement system (sochi-sei), derived from public assistance, which consisted mainly of financial assistance to needy elderly. Consequently, medical care services were inadequately used by those elderly who were not eligible for welfare services.
In the new program, everyone aged 40 and older with an income must pay LTCI premiums, and all older persons with a disability are eligible to receive benefits, regardless of income or family situation. The program covers 90% of the cost of institutional or community-based care (formal services only). There are six levels of care need under LTCI. A government computer program classifies each applicant into one of six levels, or rejects applicants, after analyzing on-site assessments based solely on the physical and mental status. The lowest level, called ‘assistance required’, is intended for preventive services (care level 0); the other five levels are called ‘care required’, and range from the lowest (care level 1) to the most severe (care level 5) needs. Each level of eligibility entitles the applicant to services worth an explicitly defined monetary amount, and the family situation is not investigated in the process of deciding eligibility. No systematic data are available to assess the family caregiver’s situation.
The new LTCI is a radical change for Japan, from traditional family-based care toward the socialization of care of the elderly, and the integration of medical care and welfare services. This radical change is reflected in the complete shift of eligibility criteria for service use from a care-giving situation to physical condition alone. However, in a society with a tradition of family care, there has been criticism that the new system totally neglects the family situation. It is therefore important to assess the new system to determine whether the family caregiving situation still has an impact on service use.
The utilization of formal services in the home and their relationship with informal services has been a focus of research in the US, and many studies have been published [9–22]. However, few studies have been conducted in Japan, either of LTCI or of the old system. One study qualitatively analyzed the process of formal service use by caregivers [23]. Two small quantitative studies reported that the use of home care services under the old welfare system was related to the caregiver’s age and to patient’s mental and physical function [24], and that use of a community rehabilitation program under the old health care system was related to the situation of the family caregiver [25].
Our study examined the actual utilization of each service under the new LTCI through a questionnaire survey conducted in a Japanese city. We focused on the effect of family caregivers’ situation in the new LTCI by examining the existence and kinship of a family caregiver and the impact this had on service use, after considering the effects of care level, by comparing users and non-users for each service. To our knowledge, this is the first study to investigate service utilization under the new LTCI in Japan. Moreover, there have been few analyses of different kinds of services in the same population in Japan or elsewhere.
Materials and methods
The survey was conducted in a city located 100 km west of Tokyo, Japan. Its population on 1 April 2000 was 55 000, and the proportion of elderly (aged >65 years) was 16.3%. This proportion is similar to the average for Japan (17.2%). Based on a survey conducted in 1998 [26], 711 elderly people (aged >65 years) in need of some assistance were living in the community, and the main caregivers for the elderly were their daughter-in-law (31.1%), wife (19.4%), husband (7.9%), daughter (7.7%), or son (4.6%); 23.6% of the elderly had no family caregiver.
A mailed, self-administered, questionnaire survey was conducted between 9 and 31 May 2000, 1 month after the introduction of LTCI. The initial study population included all the applicants for LTCI in the city (n = 685) on May 1. Since the purpose of this study was to analyze community-based services, we excluded 88 applicants who were living in institutions (nursing homes). Thus, the study subjects consisted of 597 applicants living in the community. The applicant list was obtained from the local government, which was the insurer. The family caregiver who was most responsible for the care of the elderly person was asked to answer the questionnaire, and the applicants were asked to answer themselves if there was no family caregiver. The questionnaire was returned anonymously, using an attached stamped, addressed envelope. The main questions asked were the applicant’s sex, age, and eligible care level (0–5), the caregiver’s sex, age, and relationship to the applicant, and service use (used or not, for each of the 10 community-based services provided under LTCI) for all applicants, including users and non-users. In the analyses of the caregiver’s relationship to the applicant, we used dyads of caregiver and applicant as a variable. In our experience with Japanese home care, the care-giving condition seems to differ according to these dyads, and dyads are a good way to avoid interaction in the caregiver/applicant relationship. In the analyses, dyads that applied to <10% of applicants were categorized into ‘others’ to make the statistics stable. In the majority of other dyads, the applicant was the father (60% of ‘others’).
The community-based services covered by LTCI include three components [6]: (i) services derived from former welfare services, such as home help with care giving or housekeeping, bath services, and the loan of devices like wheelchairs; (ii) services derived from former health insurance benefits, such as visiting nurses, rehabilitation at home, and ‘medical management’ (supervision of a medical plan by a physician is covered in the LTCI; however, the fee for physicians’ visits are still covered by health insurance); and (iii) services that are available from both sectors, such as nursing home daycare and temporary ‘respite’ stays in an institution. Adult daycare provided in an intermediate care facility, formerly a health service, includes rehabilitation programs and medical supervision (health daycare). In contrast, nursing-home daycare provided in a nursing home, formerly a welfare service, does not include rehabilitation or medical supervision (nursing-home daycare). Similarly, there are respite stays provided by intermediate care facilities (health respite stay) and respite stays provided by nursing homes (nursing-home respite stay). Services formerly provided as health services are more expensive than services formerly provided as welfare services. Additionally, a service for home remodeling, formerly provided by welfare services, is included in the LTCI; however, we did not ask about this service, because it is usually a one-time service, used after discharge from hospital, and is not included in the monthly coverage limit.
Statistical analysis
In order to examine the relation between service use and care level, and the characteristics of applicants and caregivers, a univariate logistic analysis was carried out for each service. The strengths of relations were explained using the crude odds ratio (OR) and 95% confidence interval (95% CI). A stepwise multiple logistic regression analysis was used to evaluate the effect of the various factors on the use of each service, with care level and dyads of caregiver/applicant relationships treated as fixed variables, and the multiple adjusted OR and 95% CI were obtained. The inclusion and exclusion criteria for the stepwise regression were both 20% [27] in order to include more variables in the final model, allowing some protection against confounders. The Hosmer–Lemeshow test was used for the goodness-of-fit test statistic of the model. The 95% CIs were based on the likelihood test statistics. All the analyses were computed using PC-SAS [28].
Results
The response rate was 54%; 323 out of 597 questionnaires were returned. Fifty-three applicants living in institutional settings (intermediate care facility = 47, nursing home = 5, and hospital = 1) at the time of the survey were excluded; ultimately, 270 subjects were used for the analysis. The characteristics and service use of the subjects with caregivers are shown in Table 1. Subjects with and without a caregiver were analyzed separately, since their characteristics differed. The most frequent care level for applicants with a caregiver was care level 2 (23%), followed by care level 1 (20%). Twenty-two per cent of applicants with a caregiver did not use any service. Nearly half of the users (44%) used only one service. The most popular service was nursing-home daycare, used by 34% of applicants with a caregiver.
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For the 33 applicants without a caregiver (Table 2), the care levels were distributed from 0 to 3. The most popular service for the applicants without a caregiver was home help, used by 52%. They did not use the home bath service, nursing-home respite stay, rehabilitation at home, or ‘medical management’ at all; 15% of them did not use any service; and no one used more than four services.
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For further analysis, we re-classified the six care levels into three care levels (care levels 0–2, 3–4, and 5, in the analyses of the subjects with a caregiver, or care levels 0, 1, and 2–3 in the analyses of the subjects without a caregiver), according to their distribution, and analyzed the six services used by >10% of applicants (nursing-home daycare, home help, visiting nurse, home bath service, loan of devices, and nursing-home respite stay). Except for visiting nurse, these services were formerly welfare services.
The summary statistics, the crude ORs for each variable and 95% CI by service for the subjects with a caregiver are shown in Table 3. The care level significantly affected use of all of the services; only nursing-home daycare use was inversely affected by care level. The caregiver’s characteristics were significantly related to use of home bath services and respite stay. Although we analyzed the entire data set (including the 33 subjects without a caregiver) in the same way in order to examine the effect of the existence of a caregiver, we show only the result of the multivariate analysis, because the comparisons between those with and without caregivers were underpowered.
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The multivariate adjusted ORs and 95% CI for the covariates are shown in Tables 4 and 5. The effect of the existence of a family caregiver on the use of each service was only significant for home help. The multivariate adjusted results for home help use are shown in Table 4. Home help was used more when the applicant had no family caregiver (OR 5.2, 95% CI 2.21–12.59), and no other factors were significant.
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In the multivariate analyses of the subjects with a caregiver (Table 5), the most popular service, nursing-home daycare, was utilized less as the care level increased, while the reverse was true for use of all of the other services. This service was most utilized when a wife was caring for her husband (OR 4.80, 95% CI 1.57–15.68 compared with ‘others’) and when the caregiver was female. Home help, the second most popular service, was utilized most when a wife was caring for her husband (OR 3.84, 95% CI 1.02–16.85). Its use was also related to care level, but it was utilized less when a daughter-in-law was caring for her mother-in-law (OR 0.23, 95% CI 0.06–0.94), a son was caring for his mother (OR 0.18, 95% CI 0.04–0.87), or the applicant was male (OR 0.13, 95% CI 0.03–0.59). The use of home bath service and loan of devices was related to higher care levels, and to older applicants.
Discussion
Even under the new system, in which the maximum service use is limited solely by physical condition, unlike in the previous system, caregiver factors still affect use of the main services: nursing-home daycare and home help. Care level positively affected the use of most of the services, as expected, but the effects for these main two services were negatively significant and non-significant, respectively.
In the analysis examining the effect of the existence of a caregiver, applicants without a caregiver used home help more often. The number of elderly living alone is currently increasing rapidly in Japan, and has more than doubled in the past 10 years [1]. Elderly people without a caregiver were the focus of the old welfare system, but their monthly service limitations are now the same as for elderly people with a caregiver. Basing the provision of services solely on physical condition may not answer their needs.
Previous studies have reported that disability [9,10,12–14,16,18] and age [10,12,17] are the two most important predictors of home care service use. Our study confirmed that disability, surrogated by care level, had a positive effect on the use of all the services, except nursing-home daycare. A positive effect of care level is expected, given an LTCI that is structured so that applicants with higher care levels can use more services. Rather, it should be noted that the presence or kinship of caregiver was the only factor promoting the use of nursing-home daycare and home help (in the analysis including applicants without caregivers), and that care level inversely affected nursing-home daycare use. The use of major services, namely former welfare services, may be decided more by the needs of caregivers than by the physical need of the applicant.
Nursing-home daycare and home help were the services used most frequently, and the proportion of users among all applicants was 35% and 25%, respectively. Considering the above, an adequate supply of service and promotion of the use of these two services is important in future LTCI planning, and family caregivers have an important effect on their use.
A wife caring for her husband frequently used nursing-home daycare and home help. The demand from wives for formal services may actually be higher than that from other caregivers, because wives are older. An older caregiver was also an eligibility criterion in the former system. Now, the monthly service limitations on those with old caregivers are the same as for others, which may result in their needs not being met. From another perspective, in Japan, the wife may play a role in ‘bridging’ [17] service use by searching for social resources more actively. Some studies in the US have shown a negative effect of spouse on formal service use [11,12], i.e. the elderly with a spouse used fewer formal services. The difference in these results may be explained by differences in the family structure between Japan and the US, and by the fact that formal services may be used as substitutes for informal care more in the US than in Japan. A recent study in the US [13] showed that in the late 1990s more elderly people with family caregivers started to use home care compared with the elderly without a caregiver. Further cross-cultural analyses of the roles of informal caregivers in various kinds of services are needed.
A daughter-in-law caring for her mother-in-law is the most frequent caregiver/applicant dyad in Japan [8], and, contrary to the findings for wives, they used home help less. There are two possible explanations for this: either daughters-in-law actually do not need home help, since they are usually younger, or there is some barrier that prevents use of this service. Some previous studies have stated that family care-giving obligations are still a Japanese social norm, and are compatible with a prejudicial attitude toward formal services [23,29]. Daughters-in-law, as the traditional caregivers in Japan, may be the most amenable to these obligations. Service use by daughters-in-law requires further study, because daughters-in-law may be at a disadvantage in the new Japanese LTCI system, in which they do not benefit as informal caregivers as they would in the German system, i.e. by receiving cash and social security benefits [6].
Caring burden [18], the characteristics of caregivers [10], and caregivers’ needs [19] are reported to be the main factors determining the use of formal home services in the US. Our study shows that the caregiver effect is still strong in the new system in Japan. Since Japanese society has a tradition of family care, the new system could be criticized for totally neglecting the family situation.
The new system may not meet the needs of some elderly people, especially applicants in lower care levels, who were eligible for some services under the previous welfare system that was based on the need of caregiver rather than physical need, but who cannot use these services under the new LTCI owing to the lower monthly limits. The 10% co-payment may limit the use of services, especially by users who previously enjoyed the services free or had lower costs based on income. In fact, a government comparison of service use before and after LTCI showed that service use decreased for 27% of the applicants in care level 0, a much higher proportion than that for the total population (17.7%) [30].
This study had some limitations. Firstly, it was conducted just 1 month after the inauguration of the LTCI, because of an urgent need for an analysis to use in policy making after the drastic change in the system. At that time, the elderly did not have to pay any insurance fees. Service use may change once the insurance fee becomes mandatory (payment of half the fee became mandatory in October 2000, and payment of the full fee became mandatory in October 2001), and may not yet be stable. A longitudinal survey is needed to examine the effect of the insurance fee.
Secondly, this cross-sectional study was conducted in a single city in Japan. Although the proportion of elderly in this city was similar to the Japanese average, the proportion ranges from 12 to 24% from prefecture to prefecture [1]. Furthermore, there may be large regional differences in care for the elderly in Japan, as there are in the US [32–34]. The concept of family care giving may also vary. The main reason that municipalities, rather than the national or prefectural governments, were given the role of insurer for the LTCI was the regional differences in the elderly population and their circumstances. Studies in the US have reported that some of the wide variation in home health utilization across the country is explained by differences in the supply of services [31–33]. Further studies investigating regional differences, including information on supply, are warranted.
Thirdly, our sample may be too small to compare users and non-users of services that were not very popular. In the case of home bath services and respite stay, there were no significant factors in the multivariate analyses. Owing to the small sample size, these results were not interpreted.
Finally, it should be noted that the ‘non-service user’ group in our comparison may be artificially enriched with elderly people who were using alternative services. Had it been possible, subjects who did not participate in LTCI would have been included, but these data were not available. However, government statistics report that 75% of the elderly with some disability applied for LTCI [34], and, as shown in Tables 1 and 2, 66% of those with a caregiver and 21% of those without a caregiver used only one service. Of the 237 subjects with a caregiver, the majority in the ‘non-service user’ group used no services at all. This limitation is not thought to have major implications for our results.
The results of this study suggest that the use of major services may be decided more by the needs of caregivers than by the care level of the applicant. Recently, the well-being of the family caregiver was reported to be a strong factor determining the home discharge of patients with cardiovascular disease in Japan [35]. To make LTCI equitable, a monthly limitation based solely on physical condition is a very important facet of LTCI, which is aimed at changing the management of care of the elderly from an individual issue into a societal issue. In planning an adequate supply of services and promoting their effective use, however, it is important that the insurers understand the role of the family caregiver, especially in the transition phase from the old system to the new.
In conclusion, for the successful implementation of the new system, consideration of the caregiver’s situation should be included in policy making.
Acknowledgements
The authors would like to thank the municipal government of Fuji-Yoshida City and the municipal Department of Nursing Care and National Health Insurance for their contribution to organizing this study, which was supported in part by a grant for Comprehensive Research on Ageing and Health (no. H12-036) provided by the Ministry of Health, Labour and Welfare, Japan.
Address reprint requests to Nanako Tamiya, Department of Hygiene and Public Health, Teikyo University School of Medicine, 2-11-1 Kaga Itabashi, Tokyo 173-8605, Japan. E-mail: ntamiya{at}med.teikyo-u.ac.jp 
Received for publication . Accepted for publication March 25, 2002.
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