Health care system in Japan

This article is about the Health care system in Japan. For the general health issues see Health in Japan

Total health spending per capita, in US dollars adjusted for purchasing power parity of Japan compared to other first world nations.

The health care system in Japan provides healthcare services, including screening examinations, prenatal care and infectious disease control, with the patient accepting responsibility for 30% of these costs while the government pays the remaining 70%. Payment for personal medical services is offered by a universal health care insurance system that provides relative equality of access, with fees set by a government committee. All residents of Japan are required by the law to have health insurance coverage. People without insurance from employers can participate in a national health insurance programme, administered by local governments. Patients are free to select physicians or facilities of their choice and cannot be denied coverage. Hospitals, by law, must be run as non-profit and be managed by physicians. For-profit corporations are not allowed to own or operate hospitals. Clinics must be owned and operated by physicians.

Japan's system is now being revamped by the current Prime Minister Shinzo Abe^[1] as popularized by Abenomics.

Medical fees are strictly regulated by the government to keep them affordable. Depending on the family income and the age of the insured, patients are responsible for paying 10%, 20%, or 30% of medical fees, with the government paying the remaining fee.^[2] Also, monthly thresholds are set for each household, again depending on income and age, and medical fees exceeding the threshold are waived or reimbursed by the government.

Uninsured patients are responsible for paying 100% of their medical fees, but fees are waived for low-income households receiving a government subsidy. Fees are also waived for homeless people brought to the hospital by ambulance.

Cost

In 2008, Japan spent about 8.5% of the nation's gross domestic product (GDP), or US$2,873 per capita, on health, ranking 20th among Organisation for Economic Co-operation and Development (OECD) countries. That amount was less than the average of 9.6% across OECD countries in 2009, and about half as much as that in the United States.^[4] In 2013 expenditure was $479 billion, 10.3% of GDP - about the midpoint of OECD countries.^[5]

The government has well controlled cost over decades by using the nationally uniform fee schedule for reimbursement. The government is also able to reduce fees when the economy stagnates.^[6] In the 1980s, health care spending was rapidly increasing as was the case with many industrialized nations. While some countries like the U.S. allowed costs to rise, Japan tightly regulated the health industry to rein in costs.^[7] Fees for all health care services are set every two years by negotiations between the health ministry and physicians. The negotiations determine the fee for every medical procedure and medication, and fees are identical across the country. If physicians attempt to game the system by ordering more procedures to generate income, the government may lower the fees for those procedures at the next round of fee setting.^[8] This was the case when the fee for an MRI was lowered by 35% in 2002 by the government.^[8] Thus, as of 2009, in the U.S. an MRI of the neck region could cost $1,500, but in Japan it cost US$98.^[9] Japan has had "catastrophic coverage" since 1973. Once a patient's monthly copayment reaches a cap, no further copayment is required.^[10] The threshold for the monthly copayment amount is tiered into three levels according to income and age.^[6][11]

Provision

Practising physicians per capita from 1960 to 2008

People in Japan have the longest life expectancy at birth of those in any country in the world. Life expectancy at birth was 83 years in 2009 (male 79.6 years, female 86.4 years).^[4] This was achieved in a fairly short time through a rapid reduction in mortality rates secondary to communicable diseases from the 1950s to the early 1960s, followed by a large reduction in stroke mortality rates after the mid-60s.^[12]

In 2008 the number of acute care beds per 1000 total population was 8.1, which was higher than in other OECD countries such as the U.S. (2.7).^[4] Comparisons based on this number may be difficult to make, however, since 34% of patients were admitted to hospitals for longer than 30 days even in beds that were classified as acute care.^[13] Staffing per bed is very low. There are four times more MRI scanners per head, and six times the number of CT scanners, compared with the average European provision. The average patient visits a doctor 13 times a year - more than double the average for OECD countries.^[14]

In 2008 per 1000 population, the number of practicing physicians was 2.2, which was almost the same as that in U.S. (2.4), and the number of practicing nurses was 9.5, which was a little lower than that in U.S. (10.8), and almost the same as that in UK (9.5) or in Canada (9.2).^[4] Physicians and nurses are licensed for life with no requirement for license renewal, continuing medical or nursing education, and no peer or utilization review.^[15] OECD data lists specialists and generalists together for Japan^[4] because these two are not officially differentiated. Traditionally, physicians have been trained to become subspecialists,^[16] but once they have completed their training, only a few have continued to practice as subspecialists. The rest have left the large hospitals to practice in small community hospitals or open their own clinics without any formal retraining as general practitioners.^[6] The first general practitioner course was established in Saga Medical University in 1978.

Quality

Japanese outcomes for high level medical treatment is generally competitive with that of the US. A comparison of two reports in the New England Journal of Medicine by MacDonald et al.^[17] and Sakuramoto et al.^[18] suggest that outcomes for gastro-esophageal cancer is better in Japan than the US in both patients treated with surgery alone and surgery followed by chemotherapy. Japan excels in the five-year survival rates of colon cancer, lung cancer, pancreatic cancer and liver cancer based on the comparison of a report by the American Association of Oncology and another report by the Japan Foundation for the Promotion of Cancer research.^[19] The same comparison shows that the US excels in the five-year survival of rectal cancer, breast cancer, prostate cancer and malignant lymphoma. Surgical outcomes tend to be better in Japan for most cancers while overall survival tend to be longer in the US due to the more aggressive use of chemotherapy in late stage cancers. A comparison of the data from United States Renal Data System (USRDS) 2009 and Japan Renology Society 2009 shows that the annual mortality of patients undergoing dialysis in Japan is 13% compared to 22.4% in the US. Five-year survival of patients under dialysis is 59.9% in Japan and 38% in the US.

In an article titled "Does Japanese Coronary Artery Bypass Grafting Qualify as a Global Leader?"^[20] Masami Ochi of Nippon Medical School points out that Japanese coronary bypass surgeries surpass those of other countries in multiple criteria. According to the International Association of Heart and Lung Transplantation, the five-year survival of heart transplant recipients around the world who had their heart transplants between 1992 and 2009 was 71.9% (ISHLT 2011.6) while the five-year survival of Japanese heart transplant recipients is 96.2% according to a report by Osaka University.^[21] However, only 120 heart transplants have been performed domestically by 2011 due to a lack of donors.

The 47 local government prefectures have some responsibility for overseeing the quality of health care, but there is no systematic collection of treatment or outcome data. They oversee annual hospital inspections. The Japan Council for Quality Health Care accredits about 25% of hospitals.^[22]

Access

Japanese Super Ambulance, Tokyo Fire Department

In Japan, services are provided either through regional/national public hospitals or through private hospitals/clinics, and patients have universal access to any facility, though hospitals tend to charge more to those patients without a referral. As above, costs in Japan tends to be quite low compared to those in other developed countries, but utilization rates are much higher. Most one doctor clinics do not require reservations and same day appointments are the rule rather than the exception. Japanese patients favor medical technology such as CT scans and MRIs, and they receive MRIs at a per capita rate 8 times higher than the British and twice as high as Americans.^[8] In most cases, CT scans, MRIs and many other tests do not require waiting periods. Japan has about three times as many hospitals per capita as the US^[23] and, on average, Japanese people visit the hospital more than four times as often as the average American.^[23] Due to large numbers of people visiting hospitals for relatively minor problems, shortage of medical resources can be an issue in some regions. The problem has become a wide concern in Japan, particularly in Tokyo. A report has shown that more than 14,000 emergency patients were rejected at least three times by hospitals in Japan before getting treatment. A government survey for 2007, which got a lot of attention when it was released in 2009, cited several such incidents in the Tokyo area, including the case of an elderly man who was turned away by 14 hospitals before dying 90 minutes after being finally admitted,^[24] and that of a pregnant woman complaining of a severe headache being refused admission to seven Tokyo hospitals and later dying of an undiagnosed brain hemorrhage after giving birth.^[25] The so-called "tarai mawashi" (ambulances being rejected by multiple hospitals before an emergency patient is admitted) has been attributed to several factors such as medical imbursements set so low that hospitals need to maintain very high occupancy rates in order to stay solvent, hospital stays being cheaper for the patient than low cost hotels, the shortage of specialist doctors and low risk patients with minimal need for treatment flooding the system.

Interior of standard ambulance

Insurance

Health insurance is, in principle, mandatory for residents of Japan, but there is no penalty for the 10% of individuals who choose not to comply, making it optional in practice.^[26][27] There are a total of eight health insurance systems in Japan,^[28] with around 3,500 health insurers. According to Mark Britnell, it is widely recognised that there are too many small insurers.^[29] They can be divided into two categories, Employees' Health Insurance (健康保険, Kenkō-Hoken) and National Health Insurance (国民健康保険, Kokumin-Kenkō-Hoken). Employees’ Health Insurance is broken down into the following systems:^[28]

• Union Managed Health Insurance
• Government Managed Health Insurance
• Seaman’s Insurance
• National Public Workers Mutual Aid Association Insurance
• Local Public Workers Mutual Aid Association Insurance
• Private School Teachers’ and Employees’ Mutual Aid Association Insurance

National Health Insurance is generally reserved for self-employed people and students, and social insurance is normally for corporate employees. National Health Insurance has two categories:^[28]

• National Health Insurance for each city, town or village
• National Health Insurance Union

Public health insurance covers most citizens/residents and the system pays 70% or more of medical and prescription drug costs with the remainder being covered by the patient (upper limits apply).^[30] The monthly insurance premium is paid per household and scaled to annual income. Supplementary private health insurance is available only to cover the co-payments or non-covered costs and has a fixed payment per days in hospital or per surgery performed, rather than per actual expenditure.^[31][32]

There is a separate system of insurance (Kaigo Hoken) for long term care, run by the municipal governments. People over 40 have contributions of around 2% of their income.^[29]

History

National Cancer Center Hospital in the Tsukiji district of Tokyo.

The beginning of the Japanese Health care system happened in 1927 when the first Employee Health Insurance plan was created.^[33]

In 1961, Japan achieved universal health insurance coverage, and almost everyone became insured. However, the copayment rates differed greatly. While those who enrolled in Employees' Health Insurance needed to pay only a nominal amount at the first physician visit, their dependents and those who enrolled in National Health Insurance had to pay 50% of the fee schedule price for all services and medications. From 1961 to 1982, the copayment rate was gradually lowered to 30%.^[34]

Since 1983, all elderly persons have been covered by government-sponsored insurance.^[35]

In the late 1980s, government and professional circles were considering changing the system so that primary, secondary, and tertiary levels of care would be clearly distinguished within each geographical region. Further, facilities would be designated by level of care and referrals would be required to obtain more complex care. Policy makers and administrators also recognised the need to unify the various insurance systems and to control costs.

By the early 1990s, there were more than 1,000 mental hospitals, 8,700 general hospitals, and 1,000 comprehensive hospitals with a total capacity of 1.5 million beds. Hospitals provided both out-patient and in-patient care. In addition, 79,000 clinics offered primarily out-patient services, and there were 48,000 dental clinics. Most physicians and hospitals sold medication directly to patients, but there were 36,000 pharmacies where patients could purchase synthetic or herbal medication.

National health expenditures rose from about 1 trillion yen in 1965 to nearly 20 trillion yen in 1989, or from slightly more than 5% to more than 6% of Japan's national income. The system has been troubled with excessive paperwork, assembly-line care for out-patients (few facilities made appointments), over medication, and abuse of the system because of apparent low out-of-pocket expenses to patients.

Another problem has been an uneven distribution of health personnel, with rural areas favored over cities.^[36]

In the early 1990s, there were nearly 191,400 physicians, 66,800 dentists, and 333,000 nurses, plus more than 200,000 people licensed to practice massage, acupuncture, moxibustion, and other East Asian therapeutic methods.

See also

• Aging of Japan
• Erwin Bälz—a foreign government advisor and cofounder of modern medicine in Japan
• Birth in Japan
• Health care compared—tabular comparisons with the U.S., Canada, and other countries not shown above
• Public health centres in Japan
• Social welfare in Japan
• Timeline of healthcare in Japan

Bibliography

Notes

References