- Email: [email protected]
Pitfalls of new long-term care insurance in Japan
CORRESPONDENCE
Pitfalls of new long-term care insurance in Japan Sir—Yumiko Arai (May 26, p 1713)1 insists that Japan’s new long-term care insurance serves elderly people well.1 In July, the Ministry of Health and Welfare of Japan reported that medical costs for 2000 were 2·1% less than those for 1999. Thus, the new insurance has lowered the medical cost for elderly people.2 However, the families of disabled elderly and handicapped people still struggle against chronic diseases. A survey from Sendai, north Japan, showed that 25% of elderly people and their families who used the long-term care insurance service do not understand or are not concerned with it. Only 32% of the consumers were satisfied with the insurance. Most of the frail elderly people and their families felt that the cost of the service is high and the coverage is difficult to understand. Thus, the benefits and duties of long-term care in elderly and younger people need to be clarified. Many private or institutional shortterm care facilities have been built in Japan in response to the new insurance. However, to balance out these costs, patients who have grade 3·5 disability (0 is lowest, 5 is highest) need to be treated. The grade of disability does not always reflect the patients’ disorders or the caregivers’ difficulties.3,4 For example, handicapped patients without dementia, who cannot move by themselves can be classified as grade 4–5. More energetic and physically healthy elderly patients with dementia under supervision of caregivers are graded as 2–3. Surprisingly, in some instances, bedridden patients who cannot change position by themselves can be graded as 3. The short-term-care facilities are likely to select the grade 4–5 patients. Furthermore, because of economic reasons, short-term-care facilities sometimes accept these healthier patients for longer than 3 months. The original concept of long-term care insurance in Japan was to support home care, but the short-term care facilities may weaken this Japanese tradition. Some families in urban areas are enthusiastic about the service. Satisfaction with the service is low in central Tokyo, where the Japanese tradition is very weak. A descriptive analysis of existing policies and consumer practices raises the question of whether recent incremental reforms will lead to future solutions for the major constituents most affected by their implementation.5 The revised
1016
long-term care insurance system is urgently needed to support frail individuals and their families. *Shinji Teramoto, Takeo Ishii, Takeshi Matsuse *Department of Internal Medicine, Sanno Hospital, International University of Health and Welfare, Tokyo 107-0052, Japan; and Yokohama City University Medical Center, Yokohama (e-mail: [email protected]) 1 2
3
4
5
Arai Y. Japan’s new long-term care insurance. Lancet 2001; 357: 1713. Willis DA. Long-term care: a substantive factor in financial planning. J Indiana Dent Assoc 2000; 79: 22–23. Shimada C, Iwashita K. Care networks of visiting nurse agencies before the long-term care insurance act. Nippon Koshu Eisei Zasshi 2001; 48: 304–13. Masuda Y, Kuzuya M, Uemura K, et al. The effect of public long-term care insurance plan on care management and care planning in Japanese geriatric hospitals. Arch Gerontol Geriatr 2001; 32: 167–77. Rivers PA, McCleary KJ, Glover SH. Longterm care financing: are current methods enough? J Health Hum Serv Adm 2000; 22: 472–94.
Absence of viral transmission in injecting drug users in Russia Sir—In the past 10 years, the abuse of drugs has became a major publichealth issue in the former Soviet Union republics. The estimated number of drug users in Russia is up to 3–4 million, most of whom are injecting drug users aged 14–30 years. This epidemic has caused a striking rise in the number of parenterally transmitted infections. At least 100 000 cases of HIV-1 infection had been identified in Russia by March 2001, more than 90% of which were associated with injected-drug use. Moreover, 70–90% of injecting drug users in Russia are infected with hepatitis C virus (HCV). A similar situation now exists in the Ukraine, Belarus, Moldova, Kazakhstan, and other countries in this area. Much genetic variation exists in HIV-1 and HCV, and the variants diverge greatly from those in western Europe. HIV-1 genetic subtype B variants are widespread among injecting drug users in all western European and North American countries.1 However, three highly homogeneous HIV-1 variants, one belonging to subtype A, another to subtype B, and the third being a gagA/envB recombinant have been identified in injecting drug users in Russia.2 Unlike western Europe, HIV-1 subtype A variants dominate in Russia, where the estimated
proportion of HIV-1 infections caused by genetic subtype A has reached 93%. In addition, the genetic subtype B variants found among injecting drug users in the former Soviet Union had characteristic genetic mutations distinguishing them from the western European variants. The Russian subtype B strains clustered together genetically, and were separate from all other HIV-1 strains in injecting drug users worldwide.3 Similarly, HCV genomes are highly diverse. HCV genetic subtypes 3a and 1a dominate among young injecting drug users in western Europe, whereas subtype 1b is rare in individuals younger than 20 years presumed to have been infected through drug use.4 By contrast, HCV genetic subtypes 1b and 3a are the most prevalent among injecting drug users in Russia. They were seen in 96 (39·5%) of 243 and in 84 (34·6%) of 243 clinical samples derived from the Russian injecting drug users aged 14–30 years, respectively. At the same time subtype 1a was only reported in ten (4·1%) of 243 cases. Finally, up to 13% of injecting drug users in western Europe are infected with the human T-cell leukaemia virus type II,5 whereas this virus is not present at all in this risk group in Russia. These data show that contacts between injecting drug users from western Europe and Russia are still limited. One population of transmitted viruses is characteristic for western Europe and the other for most of the former Soviet republics. Intensity of exchange with contaminated equipment among injecting drug users is, of course, not the main indicator of developing cultural relations between countries. However, based on these results, we may conclude that the relationships between the two parts of Europe are much less pronounced than within the European Union or between the former Soviet Union republics; the cultural iron curtain is still to fall. We thank G P Taylor (Imperial College School of Medicine, St Mary’s Hospital, London, UK), L M Selimova and E V Kazennova (D I Ivanovsky Institute of Virology, Moscow, Russia) for helpful discussions.
*Aleksei F Bobkov, Evgeny I Samokhvalov, Dmitry K Lvov, Marina R Bobkova, Vadim V Pokrovsky, Jonathan N Weber *D I Ivanovsky Institute of Virology, Moscow 123098, Russia; Russan Federal AIDS centre, Moscow, Russia; and Imperial College School of Medicine, St Mary’s Hospital, London, UK 1
Expert Group of the Joint United Nations Programme on HIV/AIDS. Implications of HIV variability for transmission: scientific
THE LANCET • Vol 358 • September 22, 2001
For personal use. Only reproduce with permission from The Lancet Publishing Group.
Pitfalls of new long-term care insurance in Japan Sir—Yumiko Arai (May 26, p 1713)1 insists that Japan’s new long-term care insurance serves elderly people well.1 In July, the Ministry of Health and Welfare of Japan reported that medical costs for 2000 were 2·1% less than those for 1999. Thus, the new insurance has lowered the medical cost for elderly people.2 However, the families of disabled elderly and handicapped people still struggle against chronic diseases. A survey from Sendai, north Japan, showed that 25% of elderly people and their families who used the long-term care insurance service do not understand or are not concerned with it. Only 32% of the consumers were satisfied with the insurance. Most of the frail elderly people and their families felt that the cost of the service is high and the coverage is difficult to understand. Thus, the benefits and duties of long-term care in elderly and younger people need to be clarified. Many private or institutional shortterm care facilities have been built in Japan in response to the new insurance. However, to balance out these costs, patients who have grade 3·5 disability (0 is lowest, 5 is highest) need to be treated. The grade of disability does not always reflect the patients’ disorders or the caregivers’ difficulties.3,4 For example, handicapped patients without dementia, who cannot move by themselves can be classified as grade 4–5. More energetic and physically healthy elderly patients with dementia under supervision of caregivers are graded as 2–3. Surprisingly, in some instances, bedridden patients who cannot change position by themselves can be graded as 3. The short-term-care facilities are likely to select the grade 4–5 patients. Furthermore, because of economic reasons, short-term-care facilities sometimes accept these healthier patients for longer than 3 months. The original concept of long-term care insurance in Japan was to support home care, but the short-term care facilities may weaken this Japanese tradition. Some families in urban areas are enthusiastic about the service. Satisfaction with the service is low in central Tokyo, where the Japanese tradition is very weak. A descriptive analysis of existing policies and consumer practices raises the question of whether recent incremental reforms will lead to future solutions for the major constituents most affected by their implementation.5 The revised
1016
long-term care insurance system is urgently needed to support frail individuals and their families. *Shinji Teramoto, Takeo Ishii, Takeshi Matsuse *Department of Internal Medicine, Sanno Hospital, International University of Health and Welfare, Tokyo 107-0052, Japan; and Yokohama City University Medical Center, Yokohama (e-mail: [email protected]) 1 2
3
4
5
Arai Y. Japan’s new long-term care insurance. Lancet 2001; 357: 1713. Willis DA. Long-term care: a substantive factor in financial planning. J Indiana Dent Assoc 2000; 79: 22–23. Shimada C, Iwashita K. Care networks of visiting nurse agencies before the long-term care insurance act. Nippon Koshu Eisei Zasshi 2001; 48: 304–13. Masuda Y, Kuzuya M, Uemura K, et al. The effect of public long-term care insurance plan on care management and care planning in Japanese geriatric hospitals. Arch Gerontol Geriatr 2001; 32: 167–77. Rivers PA, McCleary KJ, Glover SH. Longterm care financing: are current methods enough? J Health Hum Serv Adm 2000; 22: 472–94.
Absence of viral transmission in injecting drug users in Russia Sir—In the past 10 years, the abuse of drugs has became a major publichealth issue in the former Soviet Union republics. The estimated number of drug users in Russia is up to 3–4 million, most of whom are injecting drug users aged 14–30 years. This epidemic has caused a striking rise in the number of parenterally transmitted infections. At least 100 000 cases of HIV-1 infection had been identified in Russia by March 2001, more than 90% of which were associated with injected-drug use. Moreover, 70–90% of injecting drug users in Russia are infected with hepatitis C virus (HCV). A similar situation now exists in the Ukraine, Belarus, Moldova, Kazakhstan, and other countries in this area. Much genetic variation exists in HIV-1 and HCV, and the variants diverge greatly from those in western Europe. HIV-1 genetic subtype B variants are widespread among injecting drug users in all western European and North American countries.1 However, three highly homogeneous HIV-1 variants, one belonging to subtype A, another to subtype B, and the third being a gagA/envB recombinant have been identified in injecting drug users in Russia.2 Unlike western Europe, HIV-1 subtype A variants dominate in Russia, where the estimated
proportion of HIV-1 infections caused by genetic subtype A has reached 93%. In addition, the genetic subtype B variants found among injecting drug users in the former Soviet Union had characteristic genetic mutations distinguishing them from the western European variants. The Russian subtype B strains clustered together genetically, and were separate from all other HIV-1 strains in injecting drug users worldwide.3 Similarly, HCV genomes are highly diverse. HCV genetic subtypes 3a and 1a dominate among young injecting drug users in western Europe, whereas subtype 1b is rare in individuals younger than 20 years presumed to have been infected through drug use.4 By contrast, HCV genetic subtypes 1b and 3a are the most prevalent among injecting drug users in Russia. They were seen in 96 (39·5%) of 243 and in 84 (34·6%) of 243 clinical samples derived from the Russian injecting drug users aged 14–30 years, respectively. At the same time subtype 1a was only reported in ten (4·1%) of 243 cases. Finally, up to 13% of injecting drug users in western Europe are infected with the human T-cell leukaemia virus type II,5 whereas this virus is not present at all in this risk group in Russia. These data show that contacts between injecting drug users from western Europe and Russia are still limited. One population of transmitted viruses is characteristic for western Europe and the other for most of the former Soviet republics. Intensity of exchange with contaminated equipment among injecting drug users is, of course, not the main indicator of developing cultural relations between countries. However, based on these results, we may conclude that the relationships between the two parts of Europe are much less pronounced than within the European Union or between the former Soviet Union republics; the cultural iron curtain is still to fall. We thank G P Taylor (Imperial College School of Medicine, St Mary’s Hospital, London, UK), L M Selimova and E V Kazennova (D I Ivanovsky Institute of Virology, Moscow, Russia) for helpful discussions.
*Aleksei F Bobkov, Evgeny I Samokhvalov, Dmitry K Lvov, Marina R Bobkova, Vadim V Pokrovsky, Jonathan N Weber *D I Ivanovsky Institute of Virology, Moscow 123098, Russia; Russan Federal AIDS centre, Moscow, Russia; and Imperial College School of Medicine, St Mary’s Hospital, London, UK 1
Expert Group of the Joint United Nations Programme on HIV/AIDS. Implications of HIV variability for transmission: scientific
THE LANCET • Vol 358 • September 22, 2001
For personal use. Only reproduce with permission from The Lancet Publishing Group.