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Promoting end-of-life care outside hospitals

Partner Institute: 
Kinugasa Research Institute, Ritsumeikan University, Kyoto
Survey no: 
(12) 2008
Taro Tomizuka and Ryozo Matsuda
Health Policy Issues: 
System Organisation/ Integration, Remuneration / Payment, Responsiveness
Reform formerly reported in: 
Delivering appropriate care for the aged
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no yes yes yes no no
Featured in half-yearly report: Health Policy Developments 12


The Government has been promoting end-of-life care at home or at nursing homes, rather than at hospitals, which is expected to increase patients' choices of places to get care. In 2006, a special fee schedule for clinics registered for providing planned home care was introduced, which highly values care in communities. In addition, in 2007, the Government issued a guideline on processes of decision-making in end-of-life care, and fosters awareness of choices where to die.

Purpose of health policy or idea

The Government has been promoting end-of-life care outside hospitals. Especially, the patient's home and nursing homes have been valued as preferred choices of places for this care. This policy is expected to make the healthcare system more responsive to individuals' needs and wishes and to decrease the length of hospital stays.

The Government reported that the existing healthcare system has not successfully provided end-of-life care according to the preferences of people in terms of place of death. The number of deaths a year in Japan reached 1.1 million in 2007. Most people in Japan reported that they wanted to spend their end of life at home. For example, in a research study by the MHLW, 'Investigation into end-of-life care', 63% of respondents said that they would like to stay at home even in the case of being terminally ill. Other surveys conducted in the last decades showed similar results. Nevertheless, the rate of deaths at home has been decreasing over the last fifty years. In 2007, the rate of deaths at home was 12.3% whereas 85.3% died in hospitals (National Statistics Bureau 2007).

On the other hand, the policy is along the lines of a preceding policy, which aims to reduce the length of hospital stays. OECD Health Data 2007 illustrated that the average length of hospital stay in Japan - 19.8 days - was the longest in all OECD countries. The OECD average is 6.3 days. Although the difference may reflect differences in services provided at hospitals, the Government concluded that there is scope for more efficient utilization of hospital beds. A 2005 policy paper named 'The outline of reform of health care system' mentioned that the long hospital stays in Japan mainly resulted from a delay of discharges from hospitals due to the lack of coordination of care between hospitals and the community and the lack of resources to support care in the community. Moreover, the longer length of hospital stays was supposed to have contributed to the growth of health care expenditure. Therefore, the government wanted to reduce the length of hospital stays by promoting care in communities so as to reduce inefficiencies and thus also healthcare costs.

Main points

Main objectives

This policy appears to spread over different acts and policy papers. However, the main objective is to reinforce the healthcare system's capacity to provide end-of-life care outside hospitals by:

  • increasing the number of clinics that provide home care for terminally ill patients (In Japan, all doctors, even those providing only home care have to belong to a clinic by law. The medical fee is reimbursed to clinics, not to doctors.);
  • increasing the number of nursing homes which accept terminally ill patients to the end;
  • increasing the amount of care available at home and nursing homes;
  • supporting patients in their decision about end-of-life care, including treatments and the place where to receive care, and their communication with physicians;
  • promoting better coordination of care among hospitals, clinics and other health care professionals in communities through prefectures.

The Government expanded the concept of 'home care' to include the care at nursing homes, called 'another home care'. Then the reimbursement schemes for home care were developed to cover both home care and care at nursing home.

The instruments for implementing this policy were:

  • To establish a registration system for clinics, called 'home care support clinics', on the condition that the clinics provide 24 hours home care and coordination of care with local hospitals
  • To set higher reimbursement rates for home care provided by registered home care support clinics
  • To extend medical insurance coverage to care at nursing homes
  • To implement a new fee schedule that remunerates providers for setting up an agreement of care with elderly terminally ill patients
  • To issue a guideline for supporting decisions on end-of-life care by terminally ill patients and their families
  • To extend long-term insurance coverage to care for cancer patients

The guideline for supporting decision-making of end-of-life care by terminally ill patients and their families was firstly issued by the MHLW in 2007. Then, it was refined by the "committee of the process of the decision of end-of-life care". The guideline emphasised patient-centered choice in end-of-life care based on enough information and guidance by a team of health care professionals.

Type of incentives


  • Clinics can receive higher reimbursement fees for the provision of end-of-life care at home or in nursing homes after registration. Moreover, clinics can get additional payments when they provide information of end-of-life care to an old patient with a terminal illness and his/her families, and set up a written agreement on end-of-life care for them. The extra payments for informing patients and setting up a written agreement have been suspended in the meanwhile due to criticism from patients and their families. Patients feared that setting up a written agreement on end-of-life care would be an incentive for providers to deliver less curative services.
  • Hospitals can receive additional payments when they refer patients to home care in collaboration with the registered home care support clinics and/or health care professionals in the community.


  • To publicly report the rates of deaths taking place at home in each prefecture might promote the development of a structured local healthcare system that is capable of providing end-of-life care outside hospitals, particularly by promoting coordination of care among hospitals, clinics and other healthcare professionals in communities.
  • A guideline to support decision-making in end-of-life care by terminally ill patients and their families, as mentioned above, has been published in 2007.

Groups affected

Patients who are terminally ill, their families, clinics, hospitals, nursing homes, health care resources in the community such as care workers, prefectures

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Characteristics of this policy

Degree of Innovation traditional rather innovative innovative
Degree of Controversy consensual neutral highly controversial
Structural or Systemic Impact marginal neutral fundamental
Public Visibility very low high very high
Transferability strongly system-dependent strongly system-dependent system-neutral

It is innovative that the policy sets targets in such a potentially controversial policy area. But controversies apparently exist in the policy measures, rather than in its general direction.

This policy will improve the visibility of choices of places for end-of-life care. However, while the policy excessively focused on increasing choice for patients and their families, it is less clear in outlining how the burden of providing end-of-life care at home after the choice can be reduced or how family members can be supported in this process.

Political and economic background

In the light of long-term fiscal instability, consistent political pressure to contain healthcare costs has been quite strong. One of the causes of increasing healthcare cost is supposed to be the rapid growth of the elderly population, a group that is likely to need additional medical care, support by others and hospitalization. In FY 2006, 29.2 percent of national health expenditure was spent on health care for those aged 75 and older, which was around 9.6 trillion yen.

Moreover, as mentioned in the (9) 2007 report, controversial issues, such as what kind of care should be provided to the dying elderly, where and how, have been emerging in political discussions. However, consensus on the issue appeared hardly achievable.

Change based on an overall national health policy statement

The Health Care Reform Act (2006) based on The outline of reform of health care system (2005)

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no yes yes yes no no

Origins of health policy idea

In 2001, the MHLW published a document, named 'Health care provision in the 21st century', which illustrated a vision for the future of the Japanese healthcare system for the first time. This document discussed end-of-life care in terms of patients' quality of life. It suggested that healthcare services for dying people should be provided at the place where they want to spend their end of life, preferably at the place they had been living. In order to achieve this aim, the document recommended to develop home care, end-of-life care at nursing homes and resources in the community as well as to foster patients' awareness of choices of treatment in end-of-life care and choices of places where to die.

Initiators of idea/main actors

  • Government
  • Scientific Community

Approach of idea

The approach of the idea is described as:
amended: The reform was based on partial amendments of the Medical Care Law.

Stakeholder positions

Based on the policy document 'Health care provision in the 21st century' published in 2001, the MHLW issued a couple of policy papers, named 'Fundamentals of the reform of health care provision' (2002) and 'Visions of the reform of health care provision' (2003). These papers underlined the importance of 'patient-centeredness' and 'high quality and efficient healthcare provision', which might be directed by patient choice. End-of-life care in the community was stated as a part of patient preferences. This fundamental direction, ie. promoting end-of-life care in the community, prevailed and influenced the formulation of the cabinet paper 'The outline of reform of health care system'(2005).

The Japan Medical Association issued a policy paper strongly supporting the cabinet paper.

Actors and positions

Description of actors and their positions
Ministry of Health, Labour and Welfarevery supportivevery supportive strongly opposed
The Cabinetvery supportivevery supportive strongly opposed
Scientific Community
Japan Medical Associationvery supportivesupportive strongly opposed
Nursesvery supportivesupportive strongly opposed
Care workersvery supportiveneutral strongly opposed

Influences in policy making and legislation

The 2006 Health Care Reform Act was successfully legislated in terms of end-of-life care in the community, preferably at home and in nursing homes.

Legislative outcome


Actors and influence

Description of actors and their influence

Ministry of Health, Labour and Welfarevery strongvery strong none
The Cabinetvery strongvery strong none
Scientific Community
Japan Medical Associationvery strongneutral none
Nursesvery strongneutral none
Care workersvery strongneutral none
Ministry of Health, Labour and Welfare, The CabinetJapan Medical Association, NursesCare workers

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

Despite a complicated registration process for home care support clinics and difficulties to establish 24 hour home care services, around 10,600 clinics were successfully registered as 'home care support clinics' at the end of October 2008. One of the major difficulties is that almost all clinics in Japan are single-handed. Group practices and polyclinics are not so popular. Therefore, in order to provide 24 hour home care, clinics have to collaborate with other clinics and hospitals. This process is not so easy, and it is especially difficult to find other clinics providing the same level of home care in geographically small areas. One newspaper reported that around 30% of 'home care support clinics' had not provided end-of-life care in the community at all. In addition, inequality in the number of 'home care support clinics' among prefectures was reported in the newspaper.

On the other hand, introduction of additional payments for providing information on end-of-life care to elderly terminally ill patients and their families and making a written agreement on end-of-life care was suspended due to strong opposition by the elderly and the media. This payment was planned to be introduced with the inception of the new insurance scheme for the elderly aged 75 and older, named 'Health Insurance for the Old-Old' implemented in April 2008 (see HPM report (12)2008). It was suspended because the elderly and the media feared that such agreements would be an incentive to restrict curative care for the elderly.

Monitoring and evaluation

Each prefecture will report achievements in the form of changes in the rate of deaths taking place at home in the near future. However, the monitoring period has not been stated yet.

Review mechanisms

Mid-term review or evaluation

Dimensions of evaluation


Results of evaluation


Expected outcome


1. Decreasing the length of stay in hospitals
Explicit coordination of care and meeting terminally ill patients' needs to stay at home will result in shorter hospital stays.

2. Increasing the number of deaths taking place outside hospitals
Providing end-of-life care more often at home and in nursing homes will meet patients' needs and result in an increase of the number of deaths taking place outside hospitals.


1. Cost-shifting from insurance covered care to informal care by family members
Policies to support family-carers financially and non-financially are not included in this reform. The burden on family-carers might be reduced to some extent by using home care services provided by home care nurses and home care by doctors, but the effect might be partial. A large amount of labour in caring for patients at home will still have to be provided by family members.

Opportunity costs of family carers and costs of unpaid work by family carers have not been estimated but might be huge, and non-medical costs (ie. costs for food, clothes, and other supplies) are imposed on the family whereas out-of-pocket medical costs remain capped. This policy might force patients and families into poverty due to the cost of end-of-life care at home or in nursing homes.

2. Excessive promotion to stay at home even in vulnerable states
To achieve the target rate of deaths taking place at home, hospitals might be encouraged to force patient off the facilities.

3. Shortage of skilled healthcare professionals for end-of-life care in the community
No formal training for providing end-of-life care has existed and quality control of healthcare professionals providing end-of-life care has not existed as well. Therefore, the level of skills largely depends on the individual effort of healthcare workers. Due to the high demand for skilled professionals, there might be a shortage of skilled healthcare professionals for end-of-life care.

Impact of this policy

Quality of Health Care Services marginal rather marginal fundamental
Level of Equity system less equitable neutral system more equitable
Cost Efficiency very low neutral very high

Since the policy was mainly concerned with incentives for providers, it may have little actual impact on patients' and their families' behavior to choose end-of-life care at home.
National targets may increase equity in delivering home end-of-life care, but it's too early to foresee possible impacts on equity because it will highly depend on other policy measures concerned with the health workforce and carers.
Also, it is difficult to foresee possible impacts on efficiency which shall be empirically evaluated in various cases.


Sources of Information

  1. Ministry of Health, Labour and Welfare (2008). Investigation into end-of-life care.
  2. The Cabinet, Committee of health care reform; Liberal Democratic Party (2005). The outline of reform of health care system.
  3. The Health Care Reform Act, 2006
  4. The National Cancer Act, 2006
  5. Ministry of Health, Labour and Welfare (2001). Health care provision in 21st century.
  6. The committee of the process of the decision of end-of-life care (2007). The guideline for supporting decision of end-of-life care by terminally ill patients and their families.
  7. Yomiuri Shinbun, 27th October 2007

Reform formerly reported in

Delivering appropriate care for the aged
Process Stages: Policy Paper, Idea

Author/s and/or contributors to this survey

Taro Tomizuka and Ryozo Matsuda

Taro Tomizuka is a visiting research fellow at the Institute of Human Sciences, Ritsumeikan University. 

Ryozo Matsuda is a professor in community health and health policy at the College of Social Sciences and a member of board for the Institute of Human Sciences, Ritsumeikan Univerisity.

Suggested citation for this online article

Tomizuka, Taro and Ryozo Matsuda. "Promoting end-of-life care outside hospitals". Health Policy Monitor, October 2008. Available at