Introduction by the editor: In this issue of Psychiatric Services, we are pleased to launch a new column, Mental Health Care Reforms in Asia, which joins columns on mental health reforms in Europe and in Latin America. Reforms are emerging in Asia as well, and the journal plans to stay abreast of developments and report them to our readers. In this column, Dr. Ito and his colleagues describe a new mental health planning process in Japan. In April 2013 mental disorders were identified as a priority disease for attention of policy and program development in Japan. This is an unprecedented opportunity to reform the mental health service system and mental health policies in the rapidly aging island nation with a surfeit of hospital beds and a limited outpatient sector.
In Japan, a key challenge is to rebalance the provision of mental health care from institutions to the community. This column provides an overview of a new strategic plan in Japan to guide policy and address challenges in reallocating mental health resources while maintaining free access to medical services. Japan’s universal health insurance system has successfully promoted good health at a reasonable cost for the Japanese population (1,2). However, in the 50 years since universal coverage was instituted in 1961, new challenges have emerged. In Japan, physicians can open clinics and practice in any location they choose, and there are no limits on utilization of inpatient care. Although this arrangement allows for a great deal of freedom, it also means that no organization or profession has responsibility for the care of a defined population. There are thus few incentives to consider all the needs of patients and to view care from a longitudinal perspective. At the same time, health care spending is rising in Japan as the mean age of the population increases. Currently, persons over age 65 account for 23% of the Japanese population (3), compared with about 13% of the U.S. population. These trends have driven an important political impulse to reallocate resources to attenuate the impacts of both rising health care spending and the aging population.
Mental disorders have a growing impact on the health of the Japanese people and impose an increasing burden on the health care delivery and financing systems. The number of patients with mental disorders who are treated by physicians now exceeds the number of patients with diabetes (4). In most Asian countries, inpatient care has been the treatment of choice for people with mental disorders (5), in contrast to many nations in the Organization for Economic Cooperation and Development. In Japan, there are 2.7 psychiatric beds per 1,000 persons, with private nonprofit organizations accounting for 91% of these beds (6). In 2010 the average length of a psychiatric inpatient stay was 301 days (6); 18% of psychiatric beds were occupied by patients who stayed less than three months, 15% by patients who stayed from three months to one year, and 67% by those who stayed for more than one year (7). Spending for psychiatric inpatient care was estimated at 1,459 billion yen (US$16 billion), which represents 10.4% of all spending on inpatient care for all conditions (US$1=JPN¥90) (8). A shift from hospital- to community-based care is increasingly necessary in Japan.
In April 2013, mental disorders were designated as a priority disease for national medical services in Japan, the fifth priority after cancer, stroke, acute myocardial infarction, and diabetes. The Japanese government announced a new national initiative, the Regional Health Care Strategic Plan. Beginning in 2013, all prefectures in Japan will, for the first time, be required to assess local mental health care needs and develop necessary service components. The plan requires local governments to determine the availability of mental health services and identify actions to address local needs, allocate resources, and evaluate the progress.
The government released the national guidelines for the Regional Health Care Strategic Plan to all prefectures in March 2012. The national guidelines build on the Basic Policy for Mental Health and Welfare Reforms of 2004 (the Basic Policy) (9), which established a mechanism to encourage a shift from hospital to community care. The Basic Policy was revised in 2009 (10), with four new principles designed to significantly reduce the number of inpatients and prevent new episodes of long stays in psychiatric hospitals. First, mental health care should be differentiated according to the focus of provider efforts on emergency, acute, or chronic care. More personnel and economic incentives should be given to providers of emergency and acute care. The Basic Policy requires that acute care providers must increase the intensity of their services and their expansion of community-based services. Second, government should assist providers in improving the quality of mental health care. Third, social support services should be expanded in the community. Fourth, public education about mental illness and treatment is needed, and the voice of service users should play a stronger role in policy making.
Individual prefectures will be expected to create plans for mental health services and to implement and evaluate services according to the national guidelines. This represents a rare opportunity for each prefecture to incorporate into health service planning its priorities for serving its population. This change is significant because regional control of services in Japan is not the usual arrangement. The goals of the Regional Health Care Strategic Plan are to alter the balance between institutional and community-based care for patients with severe and persistent mental disorders (for example, schizophrenia); integrate care for general medical and mental health conditions (for example, depression); and support greater independence for people with mental disorders, including older adults with behavioral and psychological health problems (for example, dementia). Each prefecture will set up a committee to develop a plan and monitor progress. The level of authority given to these committees is an issue that will be decided as implementation evolves.
Each plan must specify community action plans that target specific conditions, mainly schizophrenia, depression, and dementia. Several principles of the Regional Health Care Strategic Plan must be addressed. The Basic Policy must lead to a comprehensive community-based system. The system should provide access to general medical and nursing care as well as social services and employment support services. Hospitals must ensure appropriate staffing and emphasize discharge support through collaboration with other community service providers. Patients and their families should be informed of services available in the community.
Each prefecture must assess its needs and develop a strategic plan for prevention, access to services, treatment, recovery, rehabilitation (inpatient and outpatient), emergency psychiatric care, and complications resulting from general medical illnesses. Each prefecture will use quantified performance targets for the development and implementation of strategic plans, including the suicide rate, length of hospital stay, rate of readmission within three months, and rates of health center consultation, day treatment use, nursing service visits, and emergency care.
The Regional Health Care Strategic Plan is expected to promote better coordination between inpatient and community care for people with mental disorders. Local programs are developing evidence-based approaches to community-based treatment programs for people with mental disorders. Alternatives to hospital care include evidence-based outreach services, such as assertive community treatment (ACT) programs, early intervention programs, and day treatment services. ACT has been shown to be a cost-effective alternative to long-term inpatient care (11), and some ACT programs have begun to take root in Japan (5). ACT focuses primarily on people with severe and persistent mental illness. Currently, ACT services are available in limited areas in Japan; some psychiatric clinics provide outreach services with psychiatrists, nurses, and psychiatric social workers. ACT programs will be expanded beyond the few areas where they have been launched, with the aim of preventing hospital readmission. Day programs have been reimbursed in Japan since 1974. The total per-day reimbursement for participation in a day program and outpatient care is equivalent to the cost per day of long-stay inpatient care. This reimbursement scheme has helped newly admitted psychiatric patients use community services after hospital discharge. Housing for people with mental disorders, including group homes, is gradually increasing, despite the limited national budget for such programs. These community services must be backed up by acute inpatient services.
One new effort seeks to expand the use of patient-initiated discharge plans that include crisis resolution. On discharge to the community, the patient and multidisciplinary staff jointly develop an individualized plan. It includes a crisis plan that addresses how the patient should respond to the crisis and seek help when his or her condition is not stable. Because the patient’s needs and preference are reflected in the plan, better compliance is expected.
Early recognition and diagnosis of mental disorders increases the likelihood of successful treatment, which highlights the need for education, training, and support for primary care physicians. The goal is to create a system that facilitates patients’ entry into specialized care—a system in which community health services and family physicians refer patients with significant mental health needs to psychiatrists and specialty mental health providers connect patients with other types of medical needs to general medical services and those with human service needs to social services.
Under a 2012 initiative of the National Center of Neurology and Psychiatry in Japan, national specialized care and research centers (cancer, cardiovascular disease, global health and medicine, child care, geriatric care, and neurology and psychiatry) launched collaborative care programs focused on depression diagnosis and treatment to integrate mental health care with general medical care. Scientific and practical collaboration with professionals treating general medical illnesses contributes to a better understanding of mental health among health care providers.
Implementation of plans for the four other diseases with priority status has encountered several problems. Prefectures were interested in being perceived as successful, which created an incentive to propose the minimum targets allowed. As a result, the plan-do-check-act cycle has not worked well. For mental disorders, the fifth priority disease, indicators are being used to reinforce the plan-do-check-act cycle. However, local governments do not have experience in developing regional mental health plans, and the initiative will tax their technical capacity. Regional differences in the quality and implementation of the action plans are therefore expected. Although some variation is appropriate, the goal is to minimize variation, and each prefecture will need to develop indicators specific to its health care system.
Financial incentives to focus on acute care and to promote community services do not lead directly to fewer psychiatric beds because private psychiatric hospitals have added community programs to conventional institutional care. Each prefecture’s plan must address the appropriate number of psychiatric emergency beds and acute care beds; however, the closure or reduction of chronic care units remains open for discussion.
Finally, concerns have been raised about the capacity of the community service systems to respond to the vastly increasing needs of the population requiring mental health care. Sustainable funding of community care systems is always a challenge. Good community care, although cost-effective, requires significant investments. Funds for developing community services can be expected from the savings achieved by reducing inpatient care, but such conversion is often not easily realized. Currently, ACT is reimbursed not as ACT per se but as a combination of home care and visiting physician and nursing services. In some cases, this may result in implementing models that do not adhere to what has been shown to work. To promote these intensive and complex services, a payment system is needed that makes providing these services viable in community-based programs. Payment policy in this area is controversial.
In line with the increasing prioritization of treatment for and prevention of mental disorders in Japan, development and implementation of the Regional Health Care Strategic Plan will be mandatory in the prefectures. The government has made it a priority to shift care from hospitals to communities closer to patients’ homes. The balance between institutional and community care is delicate, but it is the key to success. By implementing deinstitutionalization gradually, Japan will have the advantage of continuing to learn from the experiences of other countries.