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It’s almost become routine for Yoshiko Nakamura to wake up at 2 a.m. to a phone call from a desperate elderly person who has no one else to turn to.

Care manager Yoshiko Nakamura answers a call at her office in Tokyo’s Ota Ward.

“The TV is blaring,” one senile caller cried, prompting the care worker in Tokyo’s Ota Ward to dredge through her memory for the layout of her client’s room.

“There’s a plug right behind you,” she remembers. “Why don’t you disconnect the power?”

While handling these calls and other daily problems are not in Nakamura’s job description, she and other care managers in the public nursing-care insurance system have been urged to play a larger role since the system was introduced a year ago.

Under the old scheme, nursing-care services were usually provided free-of-charge as part of public welfare programs. The new system allows eligible seniors to choose service providers from the private or public sectors, a system that is financed by taxes and from premiums paid by those aged 40 and over.

Understandably, most elderly are in a poor position to select appropriate service providers and the services that best suit their needs.

Care managers, who must pass a prefectural government-set exam and complete 32 hours of training, are usually hired by service providers to assess the care services that elderly clients need. They also serve as a conduit between users and service providers.

Some have expressed concern that the relatively lax criteria for qualification as a care manager may lead to substandard service. While several years “relevant” work experience is required before taking the exam, the definition of “relevant” is very broad — from acupuncturists to doctors.

While care managers are described as key to the system, Nakamura and her peers believe the reality is far from the ideal painted by the system’s architects. They say the incessant phone calls and other demands on their time place them under too much pressure for too little remuneration.

“Maybe we are a bit too old-fashioned,” said Nakamura, referring to the voluntary efforts they make for their clients. “Because basically, our job is to make a care plan.”

The Health, Labor and Welfare Ministry has said one care manager can care for up to 50 clients. The care managers, however, disagree.

They complain that “peripheral work” takes too much time and energy, making it impossible to adequately consult with clients and ensure the best service menu is provided and properly carried out.

In addition to endless paperwork and phone calls, care managers must also submit a monthly service report on the services provided — extremely time-consuming work.

“We don’t have enough time to sit face to face with clients — that’s been the frustration in the past year,” said one care manager in Tokyo.

And the pay is further compounding the care managers’ problems, making it difficult for them to keep their operations afloat.

The monthly fee for each care plan is about 7,000 yen per client, with no additional fee even when clients change the plan during the month.

If a care manager takes 50 cases a month, that person will make 350,000 yen. Out of that must come all costs, including administration, telephone and transport. “There is absolutely no financial merit,” Nakamura said.

These conditions are making it increasingly difficult to find care managers willing to accept demanding clients who change service providers frequently, and many have quit.

Nakamura said such cases are often referred to her office.

“We cannot turn (clients) down when they say they were rejected at seven places,” she said. “Our operation owes a lot to the goodwill of each staff member.”

Care workers’ woes

On the front line of nursing care, care workers fare no better under the new system, with many saying their working conditions have deteriorated.

In addition to their unstable employment status — most are part-time and paid by the hour — their efforts are now less appreciated by the elderly, many of whom treat them as mere housemaids.

“(All care workers) I have met across the country have told me nothing good has happened since the start of the system,” said Noriko Tanaka, secretary general of Tokyo Care Union, a labor organization for care workers.

She said that under the old system, welfare authorities decided the kind of care that should be provided and care workers knew exactly what was expected.

But the new system, which emphasizes “user-oriented services,” provides neither care recipients nor providers with a clear picture of what is expected, she said.

Consequently, care workers are often asked to do things that obviously fall out of their jurisdiction, such as washing cars, walking dogs and cooking.

There was even a case in which a care recipient asked for a worker to be replaced because “her predecessor was a better cook.”

After a spate of such incidents nationwide, the Health Ministry issued guidelines and distributed pamphlets to the elderly listing household chores not deemed to affect daily life and not covered by insurance, such as weeding and general cleaning.

But care workers often find it difficult to reject what they see as selfish demands from the elderly, citing the heightened consumer awareness of care recipients who pay premiums and 10 percent of the service fees.

“Under the old system, I felt that care workers were helping the elderly. But under the new system, I always feel pressure that users will replace us if we turn down their requests,” a female worker in her 40s said in a union questionnaire.

And care workers say they face the same problem of inadequate pay that the managers face.

A survey by the union shows most workers are not paid for transport, compiling reports, attending business meetings or any time between calls on different clients.

The workers also contend the hourly rates they receive of around 1,129 yen for household chores and 1,658 yen for nursing care are insufficient. Around 66 percent of the workers earn less than 100,000 yen a month.

“There is a growing fear that the system will collapse eventually,” said union lawyer Mami Nakano, citing the survey result. “High-quality services cannot be ensured when workers are made to sacrifice themselves.”

The set price for household chores and nursing-care services has also been called discriminatory against the former.

Care workers generally offer both types of service and provide either based on users’ requests.

The system sets standard fees to be paid to service providers at 4,020 yen per hour for nursing care and at 1,530 yen for household chores.

Critics say the price discrepancy, which was set by the designers of the system, reflect disrespect for household chores — a very male-oriented way of thinking.

Atsuko Yasuoka, a care manager who also heads a service provider in Nishi-Tokyo, said that while household chores are looked down upon by the public, they are often more demanding because workers have to adapt to each household’s way of doing things.

By comparison, nursing care has a relatively established approach applicable to most people, she said.

“People don’t understand that (the elderly are ignorant of the way nursing-care services should be provided), but everyone is the master of their household and an expert at household chores in their own homes.”

Managers call the shots

The services an elderly person can receive vary according to the level of care they require, which is determined by a care manager. Those deemed to be in need of the highest level of care can use home services worth up to about 360,000 yen a month, while the lowest is set at 62,000 yen.

The difference in coverage provided has had one negative effect, however, in that it has generated incentives for cash-strapped nursing facilities to focus on patients requiring higher levels of care, according to Hiromitsu Makise, director of a nursing home in Tokyo’s Meguro Ward.

The coverage difference between the lowest and the highest levels of care amounts to about 600,000 yen annually.

Under the old system, public nursing facilities received public money based on the number of residents regardless of the residents’ conditions.

Perversely, those deemed to need lower levels of care are often more difficult customers. A mobile person suffering from dementia, for example, can cause more stress for workers than a bed-ridden patient.

Nursing homes are consequently tempted to avoid serving senile elderly because caring for them is not as lucrative. The problem has been compounded by the scarcity of beds in nursing homes, which allows the facilities to pick and choose clients, Makise said.

As of last March 31, there were 302 nursing homes in Tokyo with 27,325 beds and 9,664 people on waiting lists.

Competition goal fades

The rationale given by the Health Ministry for the privatization of the nursing-care system was that competition would improve service.

It presented a rosy picture of the nursing-care business, projecting a 4.3 trillion yen market in fiscal 2000, with the possibility of growth to 21 trillion yen by fiscal 2025.

These positive sentiments triggered something of a gold rush in the market, with private businesses developing nationwide operations to serve the lucrative market.

But the reality since the system’s introduction in April has been bleak, with many service providers cutting back their operations.

Comsn Inc., a major Tokyo-based provider, has often been cited as a warning to others of what can happen when a business aims too high.

The company conducted a 5 billion yen advertising campaign and had opened around 900 service outlets nationwide by April, peaking at 1,200 soon after.

But the service provider closed or merged 480 stations just two months later after it incurred monthly losses of 3.5 billion yen. It now has 300 outlets and is incurring monthly losses of around 300 million yen.

Yet, Masahiro Origuchi, chairman of its parent company The Goodwill Group Inc., said that setting up hundreds of outlets nationwide was an experiment to identify the locations that would be lucrative. He said those areas could not be identified until after the system had kicked off.

“I still believe the nursing care market is highly profitable, (and will) keep growing in the next 50 years. I’m confident that service quality will improve through market competition,” Origuchi said.

But others, particularly care workers, remain doubtful that a profit-driven system will lead to better services.

A 48-year-old care manager, who asked not to be named, decided to leave a Comsn outlet in Tokyo earlier this month to join a nonprofit service provider. She said she did not have the time under a profit-driven company to provide newly recruited care workers with enough training.

While she intends to make money eventually, her desire to help people cannot be realized at the moment in a private company. Only NPOs provide that opportunity, with the small salary an inescapable downside, she said.

“There are many things not covered by insurance under the system,” she said. “It is wrong to put the financial burden on service providers. The system should be redesigned immediately.”

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