[Long-term care insurance eligibility in Japan for patients having home oxygen therapy]

In Japan, long-term care insurance (LTCI) for the elderly has been available since April 2000. Eligibility levels for LTCI for patients with home oxygen therapy (HOT) was investigated for two periods during a 20-month interval between April 2000 and December 2001. During these periods, we hosted a seminar on respiratory care, taking the form of a special report on the daily life of HOT patients. This report was submitted to an expert committee in order to inform the members of the committee about the characteristics of HOT patients. Of 76 HOT patients who had utilized visiting-nurse services, 58 applied for an assessment for LTCI eligibility. The levels determined were less than those expected by the patients' doctors (Categories: Not fulfilling the criteria, seven cases; Rejected, 13 cases; Assistance-required, six cases; Care-required, level 1, 14 cases; Care-required, level 2, 10 cases; Care-required, level 3, three cases; Care-required, level 4, three cases; and Care-required, level 5, two cases). As many as six of the 27 patients who used home mechanical ventilation were rejected. There were also patients who were forced to stop the care services that they had been receiving. Forty patients, including eight who applied for a re-assessment, were finally assigned to a Care-required category. The home-help service was the most frequently utilized (35.0%). Day services, short stay, and the visiting-bathing service, which are commonly used for patients with cerebral apoplexy sequela, were not needed nearly as much (5.0%, 2.5%, 2.5%, respectively). The eligibility levels at the second point of evaluation were higher than those at the first point in 37.5% of the patients, and equal in 58.3%. In the 39 new-applicant patients at the second point of evaluation, the ratio of Care-required patients was significantly increased (62.7% to 72.2%, p < 0.05). The eligibility level is primarily decided by computer using a score derived from a form that contains 73 questions about the physical condition of the applicant. However, this information is inadequate for a precise assessment of the impairment of the HOT patients. The final decision on a patient is made by an expert committee, based on both the primary result and the report of the doctor in charge of that patient. It may be effective to inform the members involved in the final decision about the characteristics or special needs resulting from the disease that necessitates HOT. However, we believe that it may be more important to find a way to increase the validity of the primary judging. We would argue that a method for proper assessment of HOT patients should be designed.