Japan's practice of combining medical care insurance and long-term care insurance has made it more convenient for the elderly to seek medical services and also eased the pressure of senior care. A systematic analysis of Japan's experience, which is quite relevant to China, can help us establish a new-type of relationship among governments, nursing facilities and medical institutions.

China has conducted trial programs combining medical services and senior care in several provinces and cities. Achievements have been made, but problems also emerged during the course of the trials.

First, the lack of standards for specific assessments. The Guiding Opinions on the Combination of Medical Care and Services for Senior Citizens does not contain clearcut standards for assessing the physical condition of senior citizens and corresponding provision of care, while nursing institutions categorize the elderly into three groups of able to self-care, semiable and non-able. The level of disability is not taken into account, so non-differentiated care is provided.

Second, lack of clear provisions on the payment of nursing fees. The regions carrying out the trial programs do not mention the issue of who and how to pay for the combined medical and senior services in their execution plans. In some cases, the fees for nursing care are reimbursed through normal medical care insurance. But this approach clearly adds to the burden on medical care insurance.

Third, the issue of bed provision. It is required in the 13th Five-Year Plan (2016-20) that the ratio of nursing beds in facilities providing integrated medical and senior care shall be no less than 30 percent. However, the provision of beds in these facilities is rather out of balance. In remote nursing homes with low-level services, a considerable number of beds are vacant; but in public ones and some inexpensive senior care institutions with quality services, beds are in high demand and it may take a long time to get one.

Japan's approach to integrating medical services and senior care is different from that of China. Japan introduced its Long-Term Care Insurance (LTCI) in 2000, separating long-term care from medical services. Clear-cut standards were introduced to separate the two, with the medical service responsible for treating diseases and longterm care focusing on improving the lives of the elderly.

Japan makes clear provisions on the contribution and reimbursement of LTCI, including specific stipulations on policy holders, insurance charge, contribution to the premium, types of service, procedure for providing services and reimbursements. The contribution made by the high-income group is three times that of the low-income group. For the premium, the Japanese central government contributes 25 percent, the prefectures (circuits, metropolis) and municipalities (cities, towns and villages) 12.5 percent each, and policy holders the remaining 50 percent. Home care, community care, institutional services and supporting services are provided to the insured. When care is provided, policy holders pay only 10 percent of the cost, and the remaining 90 percent is reimbursed through the LTCI.

The LTCI was improved in 2012 with the establishment of integrated regional systems for long-term care and the sharing of medical and nursing information, ensuring that senior citizens can better benefit from the integrated system of medical, nursing and home care and that relevant information is put into efficient use.

Even so, there are still some problems with the LTCI. First, the assessment process is quite subjective and arbitrary, which may lead to unfairness. Second, although the Ministry of Health, Labor and Welfare makes the general insurance standards, these unified standards are not fair and sound considering the different levels of aging in different regions. Third, the huge financial burden. With the increasing number of service users, the cost incurred is increasing dramatically. When the LTCI was first set up in 2000, average monthly premium per capita was 2,911 Japanese yen ($26), but this figure increased to 5,869 in 2018.

Taking into account Japan's experience and China's problems, I believe that China should formulate detailed regulations to define the scope of insured medical services and the scope of insured nursing care, make a clear division between the two, conduct specific assessments of senior citizens' physical conditions and the services of medical institutions, nursing facilities and home care providers.

In addition, China needs an integrated system of medical and nursing care, with integrated management covering every stage from medical treatment, rehabilitation to recovery. Doctors should pay visits to the elderly and facilitated rehab services should be offered to the aged based on their physical conditions and needs in order to boost the efficiency of limited medical and nursing resources.

Private capital should be encouraged to get involved in nursing care, and the provision of services provided by private sources should also be promoted. Governments should be responsible for collecting the premium and accreditation and investigation committees shall be established to make long-and middle-term care insurance plans to monitor the quality of services provided and to ensure fair and healthy competition. Medical services should be extended to communities and households; comprehensive care centers and day-care centers could be built based on community service and internet platforms to offer professional and convenient home care services to elderly residents, such as nursing, bathing, rehab exercises and home visit services, as well as adaptation of homes.

Last, China needs to strengthen the system of talent management, encourage institutions of higher education to offer senior care related programs and better manage existing occupational qualifications to ensure that a practitioner can start practice only after he or she is licensed.

The author is researcher with the Division of Industry at China Center for International Economic Exchanges.

The author contributed this article to China Watch exclusively. The views expressed do not necessarily reflect those of China Watch.

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