Kiyotaka SEGAMI, M.D., Ph.D. Executive Board-Director Welfare and Medical Service Agency

1. How Has The National Policy To Prevent The Metabolic Syndrome Been Developed In The Japanese Ministry Of Health?-To Facilitate The Healthier Longevity Society-At ECOSAC Regional Ministerial Meetingon Financing Strategies for Health Care16-18 March 2009Colombo, Sri Lanka Kiyotaka SEGAMI, M.D., Ph.D. Executive Board-Director Welfare and Medical Service Agency The former Minister’s counsel in health segami-k@umin.ac.jp segami200819@wam.go.jp

2. Other Concerns Other Concerns Other Concerns Other Concerns Medical Concerns –Better Health Aging Population Issues Social Concerns -Better QOL Business Concerns -Finding Chances Financial Concerns -Containment of -- Sustainability in Policy Feeling Not Unhappy, Not in Poverty among Citizen 28 Sept 06/ Segami, K

3. Large Variation of Per Capita Medical Expenditure for the elderly （Average \750,000, Highest：\900,000, Lowest：\600,000） Depiction of Medical Expenditure Growth Increase of medical Expenditure Increase of Medical Expenditure of the elderly is a Major Factor Aging of the population Per Capita Medical Expenditure of the Elderly 1.5 ratio of elderly to non-elderly Analysis of factors Increase of Inpatient Medical Expenditure per Patient Increase of Outpatient Medical Expenditure per Patient Large number of Beds (Long Average LOS） Prevalence of Lifestyle-related Disease in Outpatient Low Home Care Rate Increase of Patients with Life Style-Related Disease due to Visceral Obesity / Adipose Tissue

4. Japanese Trial in Various Methods of Controlling Medical Expenditure ＜Chronic＞ ＜Acute＞ Promotion of Terminal Care at Home Conversion of Long-term in-patients to Nursing Care Functional Specialization and Referral System According to Acute Phase, Rehab Phase, Nursing Care Phase and Home Care Phase of illness Inpatient Medical Expenditure Referral System at Discharge Containment of Medical Expenditure Growth ＋ Promotion of Home Care Decrease of Average Length of Stay Improvement of Residence Other than Home Reduce Admission Rate by Preventing the occurrence of Severe Diseases Prevention of Lifestyle-Related Diseases （Medical Check-ups and Health Advice by Insurers etc.） Outpatient Medical Expenditure Reduce the incidence of diseases Home Visit for Patients with patients with duplicate care and Frequent Outpatient Visit

5. Effort to Improve Lifestyle Patient (Insured) Appropriate Physician Visit Control of Medical Expenditures involving All Stakeholders ・ Effective Health Care ・ ・ Achieving Early Discharge, Reduction of he Number of Beds Reduce Prevalence Rate of Life-style Related Disease Containment of Health Care Expenditures Providers ・ Creating Incentives for Patients to Pass Away at Home or Nursing Facilities by Improving Home Care Implementing Health Checkup and ・ Health Education to Prevent Life-style Related Disease Shorten average Length of Stay (LOS) Insurers ・ Review of the universal fee schedule to produce effective health care National Government ・ Budgetary steps for Prefectures to guide healthcare providers ・ Planning & implementing plan for Medical Expenditures Control, and Health Promotion Planning, Health Care Planning, Long-term Care Insurance Planning Prefectures Steps for Promoting Effective Health Care ・ Guidance of Municipalities Promotion & Education of prevention of life-style related disease ・ Municipalities ・ Enhancing the provision of nursing care as a foundation of home care

6. Development of Stages of Life-style Related Diseases and Medical Care Expenditure in 2004 Physical Inactivity Unhealthy Diet Smoking accelerates all stages of development and more damages Visceral Obesity 50% / Male 40yrs+ 20% / Female Sleep Apnea Metabolic Syndrome Hypertension 5,939,000 patients receive medical care Medical Exp: 8 Billion USD Diabetes 2,284,000 p Med Exp:12 B USD (7,400,000 Suspected + 8,800,000 Possible) Amputation from Diabetic Neuropathy Ann. Registry: 3,000 Vision Loss from Diabetic Retinopathy Ann. R.: 3,000 Diabetic Nephropathy Arteriosclerosis (For Reference) Malignant Neoplasm 1,280,000 p Annual Death: 305,000 Med Exp: 21.4 B USD Hemodialysis from Renal Failure 230,000 p Annual Incr: 14,000 Med Exp: 3.4 B USD Cerebrovascular D. 1,374,000 p Annual Death: 130,000 Annual Occur: 234,000 Med Exp: 17 B USD Ischemic H. D. 911,000 p Annual Death: 72,000 Med Exp: 6.8 B USD 47.2 B USD

7. Medical Concerns on Hypertension Financial Concerns Genetic Factor (30-50% influence) Numbers of Patients and Latent ones Salt Intake Physical Inactivity Mental Stress Visceral Obesity Insulin Resistance RAS Activity SNS Activity Salt Sensitivity Cost of Medical Care Medical Expenditure in Future Hypertension Life Style Modification Drugs Cardiovascular/Renal Complications PREVENTION Public Health Approach Kamide K, et al. Jp Heat J 2004 Status of the sight-lost after retinal hemorrhage Number and Status of Renal Failure and the Dialyzed Status of the paralyzed after stroke Social Concerns

8. Status Quo: Hypertension in Japan • Receivers of medical services • 5,939,000 are under the medical care due to Hypertension. (2004) • 9.2% of total “receivers” • Medical Expenditure for Hypertension • 946 BJY (=8,085 MUSD) in 2004 • 19.9% for Inpatient, 80.1% for Outpatient • 7.8% of Total Medical Expenditure (12,106 BJY) • Latent Patients estimated • Patients are estimated 31,000,000 • persons at risk are also estimated 20,000,000 • Hypertension is not only the medical issue, but also the national financial one

9. Male ０ yrs ６５ yrs ７５ yrs ８５ yrs Life Expectancy in 1995 77.7 17.6 10.7 5.8 Health Adjusted LE Hypertension 68.3 16.2 9.4 4.7 Years Lost of Life Expectancy 9.4 1.3 1.3 1.1 Female ０ yrs ６５ yrs ７５ yrs ８５ yrs Life Expectancy in 1995 84.6 22.5 14.2 7.7 Health Adjusted LE Hypertension 77.1 18.7 12.1 7.6 Years Lost of Life Expectancy 7.5 3.8 2.1 0.1 Segami, K(2006) Health adjusted Life Expectancy and Years Lost of Life Expectancy due to Hypertension

10. Life Table Analysis of Hypertension in Female Japanese Years of Life Lost from Hypertension is 569,237 person-years at 65yrs of female. In other words, the differences of life expectancies are 3.8 years from 22.5 years at age 65. (From Life Table and Vital Statistics in 2000) By Segami, K 2006

11. Total measures of controlling Visceral Obesity and Diabetes and other Risk Factors will cause suppressing the Medical Expenditure for the Elderly Output: Suppressing increment of ME for the Elderly Risk Factors for Onset (Preventable) Medical expenditure per Capita Health Promotion Suppressing Aggravation of Dis. Threshold of onset Suppressing Onset of Dis. Aging （Preventive measures are effective for suppressing the Medical Expenditure of Diabetes, which will cause the complication after 25 yrs to 70% of patients.)

12. Countermeasures to Suppress Life Style Related Diseases Functional Specialization and Referral System of Medical Facility ①Spread of Integrated and Consistent Health Promotion by Insurers and Regional Officials (Significant is to increase their motivation.) ②Complete and Efficient Medical Check ups (Based on evidence from mega cohort study.) ③Individual Health Advice for High-Risk Groups (By well-trained Health Personnel.) Acute Stage Rehabilitation Chronic Stage Home Care referral Nursing Care System Respect for Local Daily Activity of the elderly Systemic Approach to change Mechanism of delivery of Health Services 1,325M USD to be allocated in 2007 Depiction of Medical Expenditure Growth Necessity of Systematic Measures

13. Schematic Image of Medical Coordination (in case of stroke) [Acute Illness] [Subacute/ Recovery Phase] Community Emergency Care Services Rehab Function (Recovery Phase) Use of Longterm Care insurance (if necessary) Care Function (Including Rehab) Living at Nursing Facility (Care house, Nursing home etc.) (Transfer Coordination) (Referral Coordination) (Referral Coordination) (Discharge Coordination) (Discharge Coordination) (Discharge Coordination) Discharge Primary Care Function (Clinic, Hospital etc.) Discharge Discharge Onset of Disease Discharge Home Care （Continuity care）Management, Education Living at Home

14. The theoretical understanding of the visceral obesity as the starting point of most of those diseasesCountermeasures toward the more effective prevention of these diseases Insulin Resistance Diabetes, Hyper-lipidemia Left Ventricular Dysfunction Am J Cardiol 64, 369, 1989 Metabolism 36, 54, 1987 Diabetes Care 19, 287, 1996 Bio-active Mediators from Adipose Tissue Visceral Obesity Hypertension Coronary Diseases Sleep Apnea Hypertension 16, 484, 1990 Hypertension 27, 125, 1996 Atherosclerosis 107, 239, 1994 Int J Obesity 21, 580, 1997 J Int Med 241, 11, 1997 All by Prof. Matsuzawa Y. et al With complimentary regards

15. High Blood sugar High Blood Lipid High Blood Pressure 1.Exercise 2. Diet 3.Non-Smoking Drug is last resort Prevention of Onset and Progression of Lifestyle-Related Diseases ○High blood glucose, High blood pressure, Hyperlipidemia do not progress separately. These are like ”The tips of a single iceberg”. ○Medication (ex. Hypoglycemic agent) merely reduces the size of ”one tip of the iceberg”. ○It is necessary to reduce the size of “whole iceberg” by improving life style, such as adherence to physical exercise and improved diet. Visceral fat Malfunction of Metabolism Improvement of Life Style ・Adherence to Exercise ・Improved Diet ・Quitting Smoking Adherence to physical exercise Improved Diet Reducing caloric intake, Balanced Nutrition Increase of energy consumption, Cardiovascular activity One medication merely reduces the size of one tip of iceberg. It does not cure the whole disease. Activation of Metabolism / Reduction of visceral fat （Good Hormone↑ , Bad Hormone↓ ） Continuation Appropriate blood sugar, pressure, lipid Smaller Iceberg! Reduction in weight and waist circumference Feeling of Well Being

16. Comprehensive Implementation of Medical Expenditure Control1. Ensuring a Balance between rising health care costs and the public financial burden Rising Health Care Costs Moderation in Health Care Cost in the mid-and-long term (Decrease the number of metabolic syndrome patients, at-risk group, decrease the Average Length of Stay etc.) Incremental Effects Evaluate from an economic perspective Ensuring consistency with the New Health Promotion Plan, new Health Care Planning Ensuring Secure and Reliable Health System Review of the coverage policies of public health insurance etc. (Short-term Policies） Evaluate from both perspective Moderating Public Burden Present a clear estimate of medical spending in the future including mid-& long-term prospects for about5 years ＝ Use as a way to examine the rising health care costs Examine the effectiveness of the control policies by comparing the estimated and actual costs after a certain period of time Future review of policies

17. Comprehensive Implementation of Medical Expenditure Control2. Promoting Plans for Medical Expenditures Control • The national government and prefectures must work together in; • Promulgating systematic measures to control medical expenditures, including of long-term hospitalization those regarding lifestyle-related disease prevention and those for rectifying the problem. • (2) Taking steps to support plan implementation. Formulating such plans in a manner consistent with health promotion plans and long-term care insurance will ensure coordination between policy actions. • (3) Conducting examinations to verify that the plan is being implemented. * Excerpt from Outline of Health Care Reform Policy

18. For Longevity and Healthier Life • Death is inevitable, but a life of protracted ill-health is not. • A half but most, in future, of cardiovascular diseases do/will not result in sudden death. • Rather, they are likely to cause people to become progressively ill and debilitated, especially if their illness is not managed correctly. • Prevention and control of Cardiovascular disease helps people to keep longer and healthier lives.

19. The speaker appreciates your kind attention. See you soon.

20. Something else • Lest of all, just for your sight….

21. Status Quo: Cardiovascular diseases in Japan Background of policy-making toward the prevention of the metabolic syndrome

22. Population, Birth, and Death in Japan In 2006 Population127,720 T Over 65 yrs 26,400 T (20.7%) Death est. 1,600 T 2030

23. Increment of Cardiovascular Deaths CVD + Stroke: 303,000 and 28% of total deaths in 2005 CVD + Stroke：Inpatient310T、Outpatient850T Mal Neoplasm：Inpatient140T、Outpatient110T 15.9% 12.3% 30.1% 41.8% 15.5% 12.5% 31.1% 40.8% 15.3% 13.8% 30.7% 40.2%

24. Annual Incident Rate of Cardiovascular Diseases Annual Incident rate of the first physician visits (per 100,000)

25. 1 year after Cerebrovascular Events To be decreased in future Death 48,511（20.7％） Annual Occurrence 234,352 (100%) Alive 185,841（79.3％） Institutionalized 13,195（5.6％） Bed-bound at Home 17,469（7.4％） Home help needed 30,850（13.2％） Independent（Partially） 67,460（28.8％） To be increased Recovery 57,053（24.3％）

26. Outline of Health Care Reform Policy（Government and Ruling Parties Council on Health Care Reform (December 1st, 2005) <Contents> ⅠGuiding Principles for the Reform 1. Ensuring safe and reliable healthcare while emphasizing prevention 2. Comprehensive Implementation of Cost Containment 3. Creating a new health insurance system accounting for the aging of society ⅡEnsuring safe and reliable healthcare while emphasizing prevention 1. Ensuring safe and reliable healthcare 2. Emphasizing prevention ⅢComprehensive Implementation of Cost Containment ⅣCreating a new health insurance system accounting for the aging of society ⅤReviewing the universal fee-schedule etc. ⅥReform timing

27. Ⅱ. Ensuring safe and reliable healthcare while emphasizing prevention Basic structure Ⅱ - 1. Policy Outline “Ensuring Safe and Reliable Healthcare” → (1) Establishing a new structure capable of providing safe, secure and high-quality health care upon the consumers’ perspective Ⅱ - 2. of the Policy Outline “Prevention as a centerpiece” → (2) Establishing a new structure focused on prevention of lifestyle-related diseases

28. - Enabling people to receive safe and high-quality healthcare - - Enabling people to recover quickly and return home - Enabling people to obtain sufficient healthcare information - - Information collection and release by prefectures --> Instituting a structure under which a medical institution can register its available healthcare service offerings with the prefecture, which then disseminates such information in an easy-to-understand way. - Clearly presenting to residents and patients at the regional level, in the form of a health care planning, the healthcare services which are available, as well as the details of inter-institution coordination. - Widening the range of information advertised. - Establishing a system of regional healthcare coordination for respective fields of healthcare, such as stroke, cancer and pediatric emergency care, by reconsidering the health care planning. - Providing, within a system of regionally coordinated healthcare, unfragmented healthcare through the wider application of networked critical pathways. Ensuring appropriate healthcare provision even takes into account a patient’s care after discharge or transfer. • Establishing a new structure capable of providing safe, secure and • high-quality health care upon the consumers’ perspective Assistance in healthcare decision-making by providing healthcare information Provision of unfragmented healthcare by promoting specialization and coordinating provision of healthcare services * Regional coordinated critical pathways A treatment plan up until a patient goes home after being treated in an acute-care hospital and then a rehabilitation hospital. Information-sharing between the patient and his or her medical institution leads to the provision of efficient and high-quality healthcare as well as the patient's peace of mind Improved quality of life (QOL) for patients through well-developed home healthcare services

29. Forecast of Medical Expenditure (Estimate based on reform plan, January 2006) FY2006 FY2010 FY2015 FY2025 31.2 (trillion) 37 (trillion) 48 (trillion) Projection after reform 27.5 (trillion) % of National Income 7.3% 7.4% ～ 7.7% 8.0% ～ 8.5% 8.8% ～ 9.7% % of GDP 5.4% 5.4% ～ 5.6% 5.8% ～ 6.1% 6.4% ～ 7.0% 33.2 (trillion) 40 (trillion) 56 (trillion) Without Reform (status quo) 28.5 (trillion) % of National Income 7.6% 7.9% ～ 8.2% 8.7% ～ 9.2% 10.3% ～ 11.4% % of GDP 5.5% 5.8% ～ 5.9% 6.3% ～ 6.6% 7.5% ～ 8.2% National Income 375.6 (trillion) 403 ～ 420 (trillion) 432 ～ 461 (trillion) 492 ～ 540 (trillion) GDP 513.9 (trillion) 558 ～ 576 (trillion) 601 ～ 634 (trillion) 684 ～ 742 (trillion) (Assumption of the estimate) 1. “Without Reform” refers to the projected expenditures under the current health insurance law with an unrevised universal fee schedule. The increase of Medical Expenditure per capita is extrapolated from past data (2.1% for people below 70 and 3.2% for people above 70) 2. “After Reform” refers to the Budget in 2006 and when the revision of health insurance law etc. and the revision of the universal fee schedule are implemented 3. Nominal Economic Growth used in the calculation of National Income and GDP is based on two cases,“Basic Case” and “Risk Case”. Both cases are using the same assumption of “Reform and Prospect 2005 (Draft)” (until 2011) and “Recalculation for Pension Finance 2004” (from 2012) Changes in Nominal Economic Growth 2006 2007 2008 2009 2010 2011 2012～ Basic Case 2.0% 2.5% 2.9% 3.1% 3.1% 3.2% 1.6% Risk Case 2.0% 1.9% 2.1% 2.2% 2.1% 2.2% 1.3% (Budget)

30. Status Quo: Diabetes in Japan Background of policy-making toward the prevention of the metabolic syndrome

31. 40 Diabetes Suspected Diabetes Diagnosed Diabetes Suspected Diabetes Diagnosed Male 35 Female 30 Prevalence Rate 25 20 15 10 5 0 20〜29 30〜39 40〜49 50〜59 60〜69 70〜 Age 2002 Diabetes Survey by Ministry of Health Prevalence of Diabetes in Japan

32. Correlation between Physician Visits for Diabetes and Mortality from Renal Failure (Correlation Coefficient: 0.721) Mortality Rate from Renal Failure (per 100,000 capita) Incident Rate of the first Physician Visits from Diabetes (per 100,000 capita)

33. Correlation between Physician Visits for Diabetes and Mortality from Pneumonia (Correlation Coefficient: 0.638) Mortality Rate from Pneumonia (per 100,000 capita) Incident Rate of the first Physician Visits from Diabetes (per 100,000 capita)

34. Status Quo: Hypertension in Japan Background of policy-making toward the prevention of the metabolic syndrome

35. Status Quo: Hypertension in Japan • Receivers of medical services • 5,939,000 are under the medical care due to Hypertension. (2004) • 9.2% of total “Patients”. • Medical Expenditure, burden of cardiovascular diseases • 946,000,000,000JY (=8,085 MUSD) in 2004 for Hypertension • 187,9 BJP for Inpatient • 758,1 BJP for Outpatient • 7.8% of Total Medical Expenditure (12,105,600 MJY)

36. Correlation between Physician Visits for Hypertension and Mortality from Renal Failure (Correlation Coefficient: 0.753) Mortality Rate of from Renal Failure (per 100,000 capita) Incident Rate of the first Physician Visits by Hypertension (per 100,000 capita)

37. Correlation between Physician Visits for Hypertension and Mortality from Cerebral Infarct (Correlation Coefficient: 0.653) Mortality Rate from Cerebral Infarct (per 100,000 capita) Incident Rate of the first Physician Visits by Hypertension (per 100,000 capita)

38. Correlation between Physician Visits for Hypertension And Decreases of Mortality in 5 years (1997-2002) from Cerebral Hemorrhage and other minor Cerebral D. (Correlation Coefficient: -0.327 ) Decrease of Mortality in 5 years (1997-2002) from Cerebral Hemorrhage Incidence of the first Physician Visits for Hypertension

39. Correlation among these diseases Background of policy-making toward the prevention of the metabolic syndrome

40. The prevention from the starting point as the most appropriate countermeasureCountermeasures toward the more effective prevention of these diseases • To prevent Visceral Obesity, Risk Factor Control by individual behavior changes; • Spread of Integrated and Consistent Health Promotion by Insurers and Regional Officials (Significant is to increase their motivation.) • Complete and Efficient Medical Check ups (Based on evidence from mega cohort study.) • Individual Health Advice for High-Risk Groups (By well-trained Health Personnel.) • 1,325M USD to be allocated in 2007

41. What can we do as the population approach?

42. From the desk plan to the social movement The dawn of the national policy on Metabolic syndrome Group • Stepping in to the academic round-table conference on making the Japanese version of diagnostic standard of metabolic syndrome • The achievement of agreement among the high officials in the Ministry of Health on what-to-do • Involvement of the stakeholders • Discussions on the Ministerial Council • The appropriation to the budget compilation of the National Government and exploitation • To the deliberations on Congress

43. The dawn of the national policy on Metabolic syndrome Group • The characteristics of the Japanese version of metabolic syndrome: Abdominal perimeterMale: 85cm, Female: 90cm (From the employee based cohort study with MRI, only accomplished in Japan)