The United States’ method of financing long-term care services, as well as infection control practices and facilities’ average size have been key factors why U.S. nursing homes have experienced more than twice the rate of COVID-related deaths as Japan, researchers say.

Data revealed that 35% of coronavirus deaths in the U.S. have involved nursing homes personnel, while the figure has been just 14% in Japan. Harvard researchers compare the differences in the pandemic’s impact on US nursing homes to Japan’s in new insights published in JAMA.

They noted that the average monthly wage for Japan’s LTC workers is $2,718, while America’s is $2,203, nearly 19% less. Meanwhile, the number of beds per care worker is 2 in the U.S., but 1.5 in Japan (25% less).

The average size of a U.S. facility is 106 beds, while in Japan, it’s 69, another significant difference.

One of the starkest contrasts was revealed between infection control practices.

Japan’s long-term care insurance system requires nursing homes to convene infection control committees at least once every three months to prevent outbreaks of infectious diseases, according to the researchers. Data from 2019 shows that 99.7% of Japanese facilities had an infection control committee, and 94.2% held infection control training for staff.

In contrast, a May government report revealed that 82% of all surveyed nursing homes were cited for having an infection prevention and control deficiency in one or more years between 2013 and 2017. 

“Swift government action in Japan also contributed to the low number of COVID-19 cases among residents of nursing homes. On January 31, 2020, when only 12 cases were reported in the country, the Japanese government initially informed LTC agencies about how to respond to COVID-19. On February 24, the government ordered LTC facilities to be locked down,” they wrote. 

Another big difference between the two countries is that since 2000, the Japanese government has leveraged a universal long-term care insurance system, which is compulsory for citizens over 40 to contribute to. 

Japan also took more of a top-down approach to mobilizing a national response against COVID-19, and most of Japan’s LTC facilities are run by nonprofit organizations, compared to America having two-thirds be for-profits. On the other hand, the biggest payer of  LTC services in the U.S. is Medicaid, a government entitlement program for the poor.

“As medium- to long-term interventions, the experience from Japan suggests the need for the United States to shift toward smaller, unit-based facilities, with higher staff ratios, higher wages for care workers, more consistent enforcement and supervision of nursing home standards and guidelines, and flexible deployment of home- and community-based services under a comprehensive LTC system,” the researchers concluded.