Kobayashi Y, Reich M R
Department of Public Health, Teikyo University School of Medicine, Tokyo, Japan.
Soc Sci Med. 1993 Aug;37(3):343-53. doi: 10.1016/0277-9536(93)90265-6.
This paper examines the financing of elderly health care in Japan for medical institutions, nursing homes, and at home. The analysis demonstrates that the conventional figures for elderly health expenditures in Japan systematically underestimate the real costs by excluding the costs of uninsured services, nursing homes, and home health care. The paper estimates these costs and shows that they add about 10% to the conventional figure for elderly health care costs in Japan. This inquiry also shows how government policy for health care financing shaped distinctive Japanese patterns of elderly care provision. The financing system provided a hidden subsidy--through national health insurance coverage of long-term hospitalization--that encouraged high institutionalization rates of elderly in medical facilities. Public financing for long-term elderly hospitalization, however, has not been matched by government attention to quality of care, resulting in serious quality problems and reflecting a social trade-off between cost and quality. Also, until recently the financing system rarely reimbursed home health care, thereby creating strong disincentives to the development of formal home health care services. This analysis has important implications for reforms now being considered by the Japanese government in the financing and provision of health care for the elderly, especially the limitations of relying on reimbursement price policy. The reforms could have unintended negative consequences for equity, efficiency, and quality of care.
本文考察了日本医疗机构、养老院及居家养老的老年人医疗保健资金筹集情况。分析表明，日本老年人医疗保健支出的传统数据系统性地低估了实际成本，因为这些数据未将未参保服务、养老院及居家医疗保健的成本计算在内。本文估算了这些成本，并表明它们使日本老年人医疗保健成本的传统数据增加了约10%。该研究还展示了政府的医疗保健筹资政策如何塑造了日本独特的老年人护理模式。筹资体系通过国民健康保险对长期住院治疗的覆盖提供了隐性补贴，这使得老年人在医疗机构的住院率居高不下。然而，政府对老年人长期住院治疗的公共筹资并未与其对护理质量的关注相匹配，导致了严重的质量问题，反映出成本与质量之间的社会权衡。此外，直到最近，筹资体系很少为居家医疗保健报销费用，从而严重阻碍了正规居家医疗保健服务的发展。该分析对于日本政府目前在老年人医疗保健筹资与提供方面所考虑的改革具有重要意义，尤其是依赖报销价格政策的局限性。这些改革可能会对公平性、效率和护理质量产生意想不到的负面影响。
