Available online 6 October 2022

ABSTRACTObjectives

: This study aimed to examine the effect of increased cost sharing on long-term care (LTC) service utilization among home-dwelling older adults, using nationwide long-term care insurance (LTCI) claims data in Japan.

Methods

: In August 2015, the coinsurance rate for Japanese LTCI increased from 10% to 20% for higher-income beneficiaries. We analyzed 27,911,076 person-month observations between April 2015 and July 2016 from 1,983,163 home-dwelling older adults (aged ≥ 65 years). We employed a difference-in-differences approach to estimate the effect of the increased coinsurance rate on overall LTC service utilization and for each of the four main service subcategories. The control group comprised those whose coinsurance rates remained at 10%.

Results

: The treatment group, whose coinsurance rate increased, accounted for 9.6% of all participants. The raised coinsurance rate caused statistically significant reductions of 0.46% (95% confidence interval [CI]: 0.36%, 0.56%) and $25.7 (95% CI: $23.7, $27.8) in the percentage of utilization of LTC services and total monthly LTC expenditures per person, respectively. Service utilization decreased in each of the four service subcategories.

Conclusions

: The increased coinsurance rate resulted in statistically significant but small reductions in LTC service utilization overall and in each service type among higher-income home-dwelling beneficiaries. Requiring more cost sharing from higher-income individuals may alleviate the fiscal burden on LTC systems without serious reductions in service utilization.

Section snippetsINTRODUCTION

With age, the probability of needing long-term care (LTC) increases. Most developed countries provide public LTC coverage [1], because its need is unpredictable and it can be overwhelming for older adults’ disposable incomes [2]. In terms of public finance, LTC expenditures are projected to impose an increased burden on developed countries, owing to aging populations and the labor-intensiveness of the LTC sector [3]. Thus, developed countries face the pressing issue of balancing social

Setting

In Japan, all individuals aged ≥ 40 years, except those receiving public assistance, are insured under public LTCI. Older adults in need of care and those aged 40–64 years with age-related diseases are assessed for eligibility based on the degree of care needed. They are classified into one of eight stages according to their physical and cognitive functioning: those ineligible for benefits, support levels 1 (lowest need for care)–2, and care levels 1–5 (highest need for care) [18]. They qualify

RESULTS

Table 1 presents the descriptive statistics for the total observations stratified by treatment status. The treatment and control groups comprised 189,887 beneficiaries (9.6%) and 1,793,276 beneficiaries (90.4%), respectively (Panel A). Males constituted 78.8% and 29.6% of the treatment and control groups, respectively. Panel B demonstrates the service utilization dummy and expenditure for each service averaged at the person-month level during the pre-treatment period. In both groups, about 86%

DISCUSSION

This nationwide quasi-experimental study demonstrated that coinsurance rates increasing from 10% to 20% led to reduced LTC service utilization among higher-income home-dwelling beneficiaries across Japan. Service utilization decreased for each of the four main service subcategories. In subgroup analyses, total monthly LTC expenditures decreased regardless of sex or degree of care needed; however, the policy change had no significant effects on some outcome variables among female beneficiaries

CONCLUSIONS

In this study, we employed nationwide LTCI claims data from Japan and found that the increased coinsurance rate from 10% to 20% caused statistically significant but small decreases in LTC service utilization among higher-income home-dwelling beneficiaries. This reduction was also observed in analyses by the type of LTC service. Increasing cost sharing for higher-income individuals can be a policy option for developing the fiscal sustainability of LTC systems, although further studies should be

CRediT authorship contribution statement

Kazuaki Sano: Conceptualization, Methodology, Software, Validation, Formal analysis, Data curation, Writing – original draft, Visualization, Project administration. Atsushi Miyawaki: Methodology, Writing – review & editing, Visualization. Kazuhiro Abe: Software, Resources, Data curation, Writing – review & editing, Funding acquisition. Xueying Jin: Investigation, Writing – review & editing. Taeko Watanabe: Investigation, Writing – review & editing. Nanako Tamiya: Investigation, Writing – review

Declarations of Competing Interest

none

Acknowledgements

We would like to thank Editage (www.editage.com) for English language editing.

FUNDING

This study was supported by a grant-in-aid from the Japanese Ministry of Health, Labour, and Welfare; Health and Labour Sciences Research Grant, Japan; (H30-choju-ippan-007) and the Japan Society for the Promotion of Science (Grant number: JP19K24161). The funders had no role in the study design, analysis and interpretation of the data, preparation and review of the manuscript, and the decision to publish.

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