Professional News
Japan's Health Care Universal, but M.D.s Cite Flaws
Psychiatric News
Volume 43 Number 18 page 10-10

A young Japanese career woman, "Masako," married her fiancé, "Naoki," on May 19. She wore a tiara and a white wedding dress, and her eyes sparkled with excitement.

Masako—not her real name—had good reason to be joyful. In addition to marrying a successful young professional, she could look forward to spending many years with him since the Japanese have one of the longest life expectancies in the world.

Longevity among the people of Japan is historically due, in part, to a healthy lifestyle and genetics. But these days it also might be attributed to the high-quality medical care offered in Japan and to access to that care by everyone through a universal health insurance system.

Japan's universal health insurance system has been in place since 1961. It covers the entire population—that is, everyone must enroll in it, and everyone must contribute financially to it depending on their income and assets.

The system can be divided into three parts—employee health insurance, National Health Insurance, and a national health insurance plan for the elderly.

Employee health insurance covers people who work for companies, the government, or private schools. Premiums are based on an employee's monthly salary. The average contribution is about 4 percent of the salary, with the employee paying half and the employer paying half. Those covered must make copayments for inpatient and outpatient medical care. Copayments may also be required for prescription drugs. Costs are shared by the patients up to a certain ceiling, after which they receive full coverage.

National Health Insurance covers those who are self-employed (say, physicians in private practice) and those not employed. The premiums are based on income and assets. Similar to employee health insurance, individuals share costs up to a certain ceiling, after which they receive full coverage.

The health insurance program for the elderly is funded by contributions from employee health insurance, National Health Insurance, and the government.

Japan's universal health insurance system essentially pays for health care in Japan since private health insurance is rarely used there. Moreover, the amount of money the system reimburses doctors and other health care providers is tightly controlled by the Japanese Health Ministry down to the smallest detail. Every two years, the ministry and Japan's health care industry (which includes physicians) negotiate a fixed price for every procedure and every drug.

Japan's universal health insurance system has a number of benefits.

One is "access to high-quality treatment at a low individual cost for all Japanese citizens," Masanori Nagamine, M.D., told Psychiatric News. Nagamine is a Japanese psychiatrist affiliated with the National Defense Medical College near Tokyo.

Another benefit, Nagamine said, is that "patients are able to select the hospitals or doctors they want to visit. They are not restricted by their insurance company. They do not need to see a general practitioner first."

Nor does Japan's universal health insurance system discriminate against psychiatric patients, Tsuyoshi Akiyama, M.D., a clinical professor of neuropsychiatry at Tokyo University, reported. It covers psychiatric treatment provided not just in hospitals or by private-practice psychiatrists, but in group homes (which are developing slowly) and in community mental health clinics (which are starting to emerge).

In fact, Japan's universal health insurance system includes special provisions to make sure that the severely mentally ill who are also poor have access to psychiatric care, Hiroto Ito, Ph.D., told Psychiatric News. Ito is director of the Department of Social Psychiatry at Japan's National Institute of Mental Health in Tokyo. Under these provisions, Ito explained, patients who are both severely mentally ill and poor do not have to pay any health insurance premiums, and when they receive treatment, they have to pay only very small copays.

Furthermore, if psychiatric patients are poor, the Japanese government provides them with cost-of-living subsidies, Fumiko Hoeft, M.D., Ph.D., said in an interview. Hoeft is a Japanese psychiatrist now affiliated with Stanford University in California. Indeed, "When I worked as a psychiatrist in Japan," she said, "sometimes hospitalized psychiatric patients wanted to treat me to lunch out of their subsidies."


However, Japan's universal health insurance system also has some disadvantages.

"We don't have enough time to see patients," Nagamine said.

"Since affordable medical care is available to everyone, the Japanese often visit doctors," Hoeft noted. "As a result, waiting times can be long. It is a problem not just for psychiatric patients but for all patients."

Hoeft also pointed out, "Due to the government's policy, psychiatric hospitals want to get patients who have been living there a long time to move into the community, but patients are often reluctant to do so since they then have to spend their government subsidies on an apartment, food, and so on."

"Doctors' fees are similar regardless of how much experience doctors have and regardless of the quality of the care they provide," Ito reported. "The system should focus on outcomes and processes of care."FIG1


Although clinical psychologists in Japan provide good psychotherapy, Akiyama said, they are not reimbursed by the universal health insurance system. Therefore patients who want therapy from psychologists have to pay for it out of pocket.

But probably the biggest disadvantage—at least from the physicians' point of view—is that the universal health insurance system does not reimburse them well for their services. "We have to work long hours for little payment," Nagamine said. "That is the major thing that I don't like about Japan's universal health insurance system."

Akiyama concurred: "The Japanese system does not pay appropriate fees for good-quality treatment or care. For example, a psychiatrist is paid less than $30 for a psychiatric interview."

The low pay grates on Japanese psychiatrists even more for the reason that some other medical specialties in Japan receive better reimbursement, Takuya Kojima, M.D., Ph.D., reported on the homepage of the Japanese Society of Psychiatry and Neurology in April. Kojima is chair of the society's board of directors.

The larger challenge, however, Hoeft pointed out, is that the Japanese population is aging rapidly. As a result, health care costs in Japan are soaring, and at the same time there are not enough young Japanese to work and pay taxes and thus keep Japan's universal health insurance system solvent. So the Japanese Health Ministry is looking for ways to reduce medical costs—say, by reducing reimbursement to physicians.

The Japanese Health Ministry is also asking other members of Japanese society besides physicians to help keep the universal health insurance system solvent. For example, "the government reimburses psychiatric hospitals better for patients' care if the patients remain in the hospital for a shorter rather than a longer time," Hoeft said. "And if you go to the hospital, you pay 30 percent of the cost yourself as copay. Ten years ago, it used to be 10 percent."

All told, the pros and cons of the Japanese health insurance system might help Americans decide where they want to take their own health insurance system, especially now that health insurance reform is a hot presidential-election issue.

"Personally I believe that the United States should adopt some sort of standardized health insurance," Akiyama proposed. "I guess your country cannot leave the situation as is where a substantial percentage of the population cannot receive standard-level medical care."

"Japan's universal health insurance system is very conservative," Ito said. "That is, it makes changes very slowly." As a result, it is able to monitor the impact of changes and to take their impact into consideration before it makes still more changes. The United States might want to do the same if it decides to revamp its health insurance system, he suggested.

"If you have health insurance in the United States and go to a hospital, you don't have to pay anything there, but later you get all these bills, which are really complicated," Hoeft pointed out." Sometimes you can't tell whether you are double-charged or not. It is also confusing when a statement says, 'This is a bill' or 'This is not a bill,' and then you double pay, and then you have to get reimbursed for the double payment. And it is also unnerving that unpaid bills go to a debt collector right away!

"But in Japan, you don't have to go through any of these hassles. You pay any copay you owe when you leave the hospital, and that is the end of it. Thus, I suggest that Americans might want to adopt this aspect of the Japanese health insurance system." ▪

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