Launch of a National Mandatory Chronic Disease Prevention Program in Japan

Abstract

Japan introduced the National Mandatory Chronic Disease Prevention Program in April 2008, based on the new health reform law enacted in 2006. All payors (insurers) in the public health insurance system, which covers the entire population of 128 million, are required by law to implement the program.

In Japan, payors are financed by health insurance premiums and government-subsidized public funds. However, Japan is facing an unprecedented rate of aging of its population, the national medical care expenditures have recently been increasing faster than the economic growth rate, and, furthermore, public finance in Japan fell into crisis in the late 1990s. As a result, the sustainability of the universal healthcare coverage has been the major item on the agenda in fiscal and economic policy discussions.

In 2000, The Japanese Ministry of Health, Labour and Welfare (MHLW) launched a policy known as “National Health Promotion in the 21st Century,” based on the premise that an improvement in lifestyle would result in a reduction of disease cases through the reduction of modifiable disease risk factors. The new law required the MHLW and local governments to draw up plans for the rationalization of medical expenditures. The National Chronic Disease Prevention Program is one of the main features. The sense of crisis and the intent to reduce the future chronic disease burden combined to drive the development of this large-scale project.

The National Chronic Disease Prevention Program is a huge undertaking that focuses on lifestyle-related disease and metabolic syndrome. The population and diseases targeted by the program are people aged 40-74 years, and lifestyle-related diseases such as type 2 diabetes mellitus. The health insurance program assesses the risk of the identified population using data predominantly from their annual health checkups (the checkup is a legal requirement so is commonly carried out in Japan, regardless of region or occupation). Members are then stratified according to a risk-assessment algorithm. The National Chronic Disease Prevention Program uses the metabolic syndrome criteria released in 2005 by eight Japanese academic societies, which were developed through review of both Japanese and international medical literature. The algorithm stratifies individuals, focusing on abdominal circumference, a number of risk factors, and age. Those at highest risk are assigned to one of two intervention categories: ‘motivational support’ or ‘active support.’ However, individuals already receiving medication for one of the risk factors are excluded from the intervention, since they are presumed to already be under the care of a physician. Payors assess programs at three levels: plan, annual program, and individual levels. Each payor is required to implement a quality-improvement program based on the plan, do, check, act (PDCA) concept.

This ambitious project remains controversial among researchers and has been described as “social experimentation.” However, it is hoped that the project will provide not only Japan but also other countries with lessons in the future.