Mental Health Care Reforms in Asia: The Regional Health Care Strategic Plan: The Growing Impact of Mental Disorders in Japan

The Regional Health Care Strategic Plan is expected to promote better coordination between inpatient and community care for people with mental disorders. Local programs are developing evidence-based approaches to community-based treatment programs for people with mental disorders. Alternatives to hospital care include evidence-based outreach services, such as assertive community treatment (ACT) programs, early intervention programs, and day treatment services. ACT has been shown to be a cost-effective alternative to long-term inpatient care (11), and some ACT programs have begun to take root in Japan (5). ACT focuses primarily on people with severe and persistent mental illness. Currently, ACT services are available in limited areas in Japan; some psychiatric clinics provide outreach services with psychiatrists, nurses, and psychiatric social workers. ACT programs will be expanded beyond the few areas where they have been launched, with the aim of preventing hospital readmission. Day programs have been reimbursed in Japan since 1974. The total per-day reimbursement for participation in a day program and outpatient care is equivalent to the cost per day of long-stay inpatient care. This reimbursement scheme has helped newly admitted psychiatric patients use community services after hospital discharge. Housing for people with mental disorders, including group homes, is gradually increasing, despite the limited national budget for such programs. These community services must be backed up by acute inpatient services.

One new effort seeks to expand the use of patient-initiated discharge plans that include crisis resolution. On discharge to the community, the patient and multidisciplinary staff jointly develop an individualized plan. It includes a crisis plan that addresses how the patient should respond to the crisis and seek help when his or her condition is not stable. Because the patient’s needs and preference are reflected in the plan, better compliance is expected.

Early recognition and diagnosis of mental disorders increases the likelihood of successful treatment, which highlights the need for education, training, and support for primary care physicians. The goal is to create a system that facilitates patients’ entry into specialized care—a system in which community health services and family physicians refer patients with significant mental health needs to psychiatrists and specialty mental health providers connect patients with other types of medical needs to general medical services and those with human service needs to social services.

Under a 2012 initiative of the National Center of Neurology and Psychiatry in Japan, national specialized care and research centers (cancer, cardiovascular disease, global health and medicine, child care, geriatric care, and neurology and psychiatry) launched collaborative care programs focused on depression diagnosis and treatment to integrate mental health care with general medical care. Scientific and practical collaboration with professionals treating general medical illnesses contributes to a better understanding of mental health among health care providers.

Implementation of plans for the four other diseases with priority status has encountered several problems. Prefectures were interested in being perceived as successful, which created an incentive to propose the minimum targets allowed. As a result, the plan-do-check-act cycle has not worked well. For mental disorders, the fifth priority disease, indicators are being used to reinforce the plan-do-check-act cycle. However, local governments do not have experience in developing regional mental health plans, and the initiative will tax their technical capacity. Regional differences in the quality and implementation of the action plans are therefore expected. Although some variation is appropriate, the goal is to minimize variation, and each prefecture will need to develop indicators specific to its health care system.

Financial incentives to focus on acute care and to promote community services do not lead directly to fewer psychiatric beds because private psychiatric hospitals have added community programs to conventional institutional care. Each prefecture’s plan must address the appropriate number of psychiatric emergency beds and acute care beds; however, the closure or reduction of chronic care units remains open for discussion.

Finally, concerns have been raised about the capacity of the community service systems to respond to the vastly increasing needs of the population requiring mental health care. Sustainable funding of community care systems is always a challenge. Good community care, although cost-effective, requires significant investments. Funds for developing community services can be expected from the savings achieved by reducing inpatient care, but such conversion is often not easily realized. Currently, ACT is reimbursed not as ACT per se but as a combination of home care and visiting physician and nursing services. In some cases, this may result in implementing models that do not adhere to what has been shown to work. To promote these intensive and complex services, a payment system is needed that makes providing these services viable in community-based programs. Payment policy in this area is controversial.