Practical aspects of policy research using medical and long-term care insurance claims data

Abstract

In this article, we emphasize practical approaches to policy research using medical and long-term care insurance claims data in Japan. We aim to highlight the challenges faced when using claims data for policy-making and to clarify areas of concern when advancing such research. Specifically, we use a policy research initiative related to the promotion of coordination between home medical care and long-term care as a case study. Within this project, we discuss the challenges faced in developing effective evaluation metrics using claims data.

In our selected case study, we examined whether data on four key areas necessitating coordination between home medical care and long-term care in the daily lives of home care patients can be extracted from the linked medical and long-term care insurance claims database (Nara Prefecture KDB). These areas include daily medical and care support, admission and discharge support, emergency response, and end-of-life care. This examination includes defining these metrics on the claims. Recognizing that local governments primarily use the ‘Visualization System for Community-Based Integrated Care’ to gain quantitative insights into their initiatives, we also reviewed the precautions necessary when extracting data from this system. Furthermore, we conducted interviews to assess the initiatives of Municipality A, considered a leading authority on the promotion of coordination between home medical care and long-term care within the target prefecture.

The study results suggest the need to initially define metrics on the claims for most of the four key areas. Although the numbers of claims for home medical care retrievable from the Visualization System are based on extractions from the National Database of Health Insurance Claims and Specific Health Checkups of Japan, these definitions are not explicitly disclosed. Given that the values extracted from claims can vary based on the definitions of medical procedure codes, caution is necessary when municipalities individually extract and employ data from their available KDBs. Particularly when comparing between municipalities, there is a risk that the use of different definitions might result in the retrieval of unrelated data, resulting in invalid comparisons. It is necessary to ensure that the definitions of data extracted from the claims within the Visualization System are verifiable across municipalities. As the emphasis on using claims data in government administration increases, potentially gaining more recognition as evidence for shaping policies, the importance of aligning the promotion of claims use by the administration with policy research is likely to grow.