Relationship of Health Services to Medical Expenses for the National Health Insurance and Certification Rate for Long-term Care Insurance Services in Municipalities

In many municipalities, implementation rates of health services mandated by the Health and Medical Service Law for the Elderly have not reached the national goal that was set at the start. This study aimed to evaluate the effects of health services using medical expenses for the National Health Insurance (NHI) and certification rate for long-term care insurance services in 99 municipalities in Gifu Prefecture as indices. Both indices were standardized by the age composition of the population. Among the health services, visit rates for health examinations or implementation rates for health education or health counseling correlated negatively with medical expenses for each insured person. The visit rate for gastric cancer screening correlated negatively with medical expenses for malignant neoplasms of the stomach. Implementation rates of health education or health counseling, or ratios of public health nurses correlated positively with certification rates for long-term support need and care need grade 1, and negatively with those for long-term care need grades 2, 3, and 4. The author concluded that medical expenses are reduced by the implementation of available health services, that early detection and prevention of aggravation of disease is essential for those who need long-term care services, and that health services must be reinforced with primary prevention.


INTRODUCTION
In Japan, the Health and Medical Service Law for the Elderly was enforced to cope with a shift from infectious to chronic diseases in 1983 1).Municipal governments issue health handbooks and provide health education, health counseling, health examinations, functional training, and home-visit guidance to residents aged 40 years and older based on health services required by law.Recently, the implementation rates of these health services have remained at a lower level than the national goal in many municipalities in Gifu Prefecture, although these services were expanded vigorously by municipal governments at the beginning.A review of available health services will be necessary to determine whether reinforcement is necessary.
In 2000, the "National Health Promotion Movement in the 21st Century (Healthy Japan 21)" was initiated to promote comprehensive health through a decrease in premature death and an extension of the period during which people can live without suffering dementia or being bedridden.The abovementioned health services were instituted as part of the plan to realize Healthy Japan 21 u.Simultaneously, following a sixmonth trial, the municipalities started a long-term care insurance system to provide social support for long-term care for the elderly and to enable them to maintain their dignity by keeping up their self-constituted lives.
The aim of health services in the municipalities is social support for individual health initiatives to enhance people's capacities for living2).In order to evaluate the effects of these services, the fullness of individual life must be used as an index.
This is difficult to measure, however, because of its subjectivity and, thus, it cannot be used as a factor to increase a budget for health services in the municipalities.The usual measurement of the effects of health services is the relationship to medical expense 38).In this study, the author analyzed the relationship of implementation rates of health services to medical expenses per person for National Health Insurance (NHI) and certification rate for long-term care insurance services for each resident.

MATERIALS AND METHODS
Gifu Prefecture is located in the center of Japan and comprises 99 municipalities: 14 cities, 55 towns and 30 villages.The prefecture had a population of 2.1 million in 1995 s) within an area of 10,595.75km2.The percentage of the population aged 65 years and older was 15.3%.

Data source
The data on health services used in this study were visit rates for health examinations 10), implementation rates of health education, health counseling, and home-visit guidance 11) in fiscal years 1995-9, and ratios of public health nurses at work per population of each municipality from 1996-2000.The ratios of hospital beds per population of each secondary emergency medical service area from 1996-2000, and ratios of physicians and dentists at work per population of each municipality and each secondary emergency medical service area in 1996 and 1998 11) were used for data on medical supplies.Population density from 1996-2000 and per capita income by municipality from 1994-8 12) were used as socioeconomic data.Medical expenses for NHI in the municipalities in May 1996-2000 13), and the number of persons certified for long-term care insurance services on May 31, 2000, in the municipalities 14) were used as indices of the effects of health services.
Health examinations include basic health examinations mandated by law, and gastric, uterine, lung, breast, and colorectal cancer screenings.These health examinations are provided for residents aged 40 years and older who are not offered such examinations at their workplaces or elsewhere.Of all residents in Gifu Prefecture aged 40 years and older, 33.4% were the subjects for basic health examinations from 1995-9.The implementation rates of health education, health counseling, and home-visit guidance were calculated as figures per subject for basic health examinations.
Medical expense per insured person was standardized for 5year age group by the indirect method using the total population of Gifu Prefecture as the standard.The ratio of the subjects of the NHI from 1996-2000 was 41.2% of all residents in Gifu Prefecture.Included in this study were malignant neoplasms of the stomach, uterus, trachea/bronchus/lung, breast, and large intestine; diabetes mellitus; circulatory, hypertensive, heart, and cerebrovascular diseases; medical outpatients, medical inpatients, medical total; and dental total.
In Japan, the conditions requiring long-term care insurance services are classified into long-term support need and care need grades 1-5.The certification rate per resident aged 65 years and older was also standardized for age groups 65-74 and 75+.

Statistical Analysis
The coefficient of variation (CV) for each index was calculated to examine the annual variation for 5 years in each municipality.Data correlations were calculated for all municipalities.Stepwise regression analyses (Fm = 4.000, Font = 3.996) were then conducted using the medical expense or the certification rate for long-term care services as the dependent variables, and the indices for health services, medical supplies and socioeconomic factors that correlated with each dependent variable as the independent variables.

RESULTS
The ratios of municipalities that reached the national goals of visit rates for health examinations (50% for basic health examinations and 30% for cancer screenings) were 63.6%, 37.4%, 12.1%, 46.5%, 24.2%, and 37.4% for basic health examinations, gastric, uterine, lung, breast, and colorectal cancer screenings, respectively.Fifteen municipalities did not conduct lung cancer screenings.Table 1 shows the characteristics of indices for health services and medical expenses.CVs for the visit rates for health examinations remain at stationary levels in many municipalities.Only the CV for medical expenses for malignant neoplasms exceeded 50.
Visit rates for 6 kinds of health examinations, and implementation rates of health education, health counseling, and home-visit guidance correlated positively with each other (Table 2).The ratio of public health nurses correlated positively with visit rates and especially with implementation rates.Population density and per capita income correlated negatively with visit rates for health examinations and the ratio of hospital beds in secondary emergency medical service area correlated positively (Table 3).The ratio of public health nurses correlated negatively with population density and the ratio of physicians and dentists correlated positively.
Regarding medical expenses, visit rates for health examinations, especially those for lung cancer screening, and implementation rates of health education correlated negatively with medical expenses for outpatients and the ratio of physicians correlated positively (Table 4).Implementation rates of health counseling correlated negatively with medical expenses for inpatients and the ratio of physicians correlated positively.The ratio of public health nurses correlated negatively with medical expenses for diabetes mellitus and the ratio of physicians correlated positively.The ratio of public health nurses and physicians correlated positively with medical expenses for hyperten-   Certification rates for long-term care insurance services were 3.0% for those from 65 to 74 years old and 19.6% for those 75 years and over.The implementation rate of health counseling correlated positively with the certification rate for long-term support need, and the ratio of public health nurses correlated positively with that for long-term care need grade 1 (Table 6).
The implementation rate of home-visit guidance correlated negatively with certification rates for long-term care need grades 2 and 3.The implementation rate of health counseling correlated negatively with the certification rate for long-term care need grade 4. The certification rate for long-term care need grade 4 correlated positively with medical expenses for cerebrovascular diseases (r = 0.37, p < 0.01).

DISCUSSION
The author used medical expenses for the NHI as an index because the subjects of the NHI aged 40 years and older are included in the subjects in the municipalities using health services mandated by the Health and Medical Service Law for the Elderly.The exact number of the latter subjects can be identified by a survey of entire households.Therefore, the visit rates for health examinations are often inaccurate in large municipalities.The CV indicates that annual fluctuations of many indices used in this study are not significant except for the medical expenses for each malignant neoplasm.Some municipalities have not conducted lung cancer screenings because there are questions about whether it is effective 15).However,  for long-term care insurance, which have not been calculated yet, also should be evaluated.Now, health promotion measures that emphasize primary prevention, such as "Healthy Japan 21," are being conducted.Primary prevention depends on individual initiatives.However, people sometimes receive health services through a sense of civic responsibility 16).Municipalities have to support residents by providing various kinds of health services.Medical expenses are reduced by the implementation of available health services and these health services are helpful in the early detection and prevention of aggravation of disease in patients who need long-term care services.These results provide an administrative factor for the reinforcement of health services as one of the targets in the community plan of Healthy Japan 21.The author conclude, therefore, that health services must be reinforced along with primary prevention.

Table 1 .
Characteristics of indices for health services and medical expenses.
* Monthly medical expense per insured person in May 1996 -2000 .

Table 2 .
Correlation between indices of health services in municipalities .

Table 3 .
Correlation between indices of health services, medical supplies and socioeconomicfactors in municipalities .

Table 4 .
Relationship of health services, medical supplies and socioeconomicfactors to medical expenses.
nant neoplasms of the uterus and the ratio of physicians correlated positively.The ratio of public health nurses correlated negatively with medical expenses for malignant neoplasms of the lung.Neither medical expenses for malignant neoplasms of the breast nor those of the large intestine showed a correlation with the indices used in this study.

Table 5 .
Relationship of health services, medical supplies and socioeconomicfactors to medical expenses for malignant neoplasms.

Table 6
need long-term care services in an effort to prevent aggravation of their health conditions.The relationship between the certification rate for serious long-term care needs and medical expenses for cerebrovascular diseases suggests that cerebrovascular disease is an important cause of serious long-term care needs.The relationship of health services to the expenses