For the first time, Japan is trying to hold down the number of bedridden elderly people kept alive, sometimes for years, by feeding tubes.
The government is planning to cut payouts on insertions in new patients and encourage home care. About 260,000 elderly live on feeding tubes nationwide. Faced with a heavy public debt burden, the government is trying to curtail growth of a ¥38.5 trillion annual health bill by releasing patients from hospitals sooner.
The Health, Labor and Welfare Ministry also plans to boost reimbursements to institutions that check swallowing ability and encourage rehabilitation to help the bedridden eat naturally. The changes, effective April 1, mark the first time Japan has cut government reimbursements for the practice.
“Eating is one of the most important human dignities and the country is moving forward to protect it,” said Kazuhiro Nagao, a doctor and deputy director of the Japan Society for Dying with Dignity.
The use of feeding tubes at the end of life, which isn’t standard practice in the Western world, is common in Japan, the world’s fastest aging society. They often prolong the lives of terminally ill or dementia-plagued elderly and the ministry says almost a quarter of people nourished via feeding tubes were given one without an evaluation.
The government reimburses about ¥100,700 per feeding tube surgery, including the cost for the kit and 45 minutes of work by three doctors, according to Gaihoren, a group of surgical societies that assesses reimbursements for surgeries.
More than 90 percent of the patients estimated to be fed in this manner are bedridden, according to a survey by the national hospital association. They are, on average, 81 years old and nourished by tube for 2.3 years.
Most of the elderly who are put on feeding tubes are never taken off them. While almost a quarter of those fed via tube had the potential to eat by mouth again, only about 2 percent of them did so and had the tube removed, according to a study funded by the health ministry.
Japan’s shrinking labor force means there are fewer taxpayers to pay for government-funded care of dependent seniors. A quarter of Japanese are over the age of 65 now and by 2060 about 40 percent will fall into that demographic, according to National Institute of Population and Social Security Research.
Cash reimbursed to hospitals from the national health insurance program for inserting the tubes will be cut 40 percent to ¥60,700 as of April, while ¥25,000 will be added if a swallowing evaluation is done before the insertion, the health ministry said.
Rehab per session will be doubled to ¥3,700 for hospitals “with an outcome of 35 percent recovery or higher.” The price paid back to stop the feeding and stitch up the incision will rise 17 percent to ¥140,400. Hospitals performing 50 surgeries a year or more will face a further 20 percent cut in payouts for each new feeding-tube case “if they don’t evaluate all cases and the recovery is lower than 35 percent” from April next year.
Recuperation hospitals will be encouraged to speed up rehab to help discharge patients from hospitals quicker, said Yukihiko Ikebata, vice chairman of Japan Association of Medical and Care Facilities, which represents recuperation hospitals.
The new rules recommend a guideline used for stroke patients to assess swallowing ability with feeding tube cases. That includes practices such as checking throat muscles by having a patient swallow food coated with an imaging agent and see how it travels using X-rays or endoscopes.
The rules require patients, many of them suffering from advanced dementia, to travel to a clinic or a hospital from nursing homes for rehab and could be stressful and risky for them, said Hidehiro Ozeki, chairman of research committee at Japanese Council of Senior Citizens Welfare Service, which represents nursing homes for terminal seniors.
Some remain skeptical that the practice to insert a tube, which is so ingrained in medical and nursing culture, will slow anytime soon. The new rules won’t lower the number of new cases as most hospital have less than 50 cases and won’t see the additional 20 percent cut, said Tatsuro Ishizaki, a researcher at Tokyo Metropolitan Institute of Gerontology.
There still needs to be a broad discussion on how to cope with end of life care in an aging society medically, ethically and economically to change the overall situation, said Yoshihiro Takayama, infectious disease specialist at Okinawa Prefectural Chubu Hospital.
While Kanao Tsuji, director of Suidobashi Higashiguchi Clinic in Tokyo, expects the new rules to reduce the number of new cases, he says that feeding the elderly orally will put pressure on homes as the process and preparation can take around 90 minutes.
The elderly will still benefit from better care as doctors will try to strike a better balance between extending life and improving its quality, said Ichiro Fujishima, director of Hamamatsu City Rehabilitation Hospital and chairman of the Society of Swallowing and Dysphagia of Japan.
“A focus on swallowing evaluation and rehab will encourage doctors to think more about balancing the two and will help patients to be discharged from facilities,” he said.