HEALTH SYSTEMIN FOCUS

JAPANReporters: Lustre,Ceferino

Salisi, JamesMembers: Sabularce, Joey Motos, Jeffrey

de Guzman,Angelo Dubrico, Gretchen

Profile of JAPAN

• 3rd largest economy in the world (recently surpassed by China)

• constitutional monarchy with a parliamentary government

• 47 perfectures

• Japan has a healthcare system characterized by universal health insurance coverage, as all Japanese citizens belong to one of the country’s health insurance systems.

• hybrid system funded by job-based insurance premiums and taxes -- is universal and mandatory, and consumes about 8 percent of the nation's gross domestic product

BISMARCKIAN Model

• State-mandated social insurance, started by Bismarck in

1883, 1st Chancellor in Germany• Covers all or most citizens

through employer and employee payments to insurance , while providing care through public &

private providersfound in Germany, Japan, Belgium,

France, Netherlands

DEMOGRAPHIC Characteristics and Health Status of the

Japanese People

Demographic Characteristics

• As of May 2010: population 127, 360, 000

Male: 62, 010, 000Females : 65, 340, 000

Distribution by Age group

• The average life expectancy remains among the highest in the world.

• In 2009: 86.44 years - women79.59 years – men

In 2008, the crude birth rate was 8.7 per 1000 persons and the crude death rate was 9.1 per 1000 persons

NATALITY

8.6 per 1,000

19.6 per

1,000

Yearly comparison of live birth rates by age group of mother

GENERAL MORTALITY

General Mortality

• death rates had gradually declined since 1957, recording the lowest rate of 6.0 in 1979 and 1982.

• deaths have demonstrated an upward trend, and death rates have been growing, reflecting the aging of the population

Trends in deaths and death rates, 1955-2006

8.5 per 1,000

General Mortality

• Due to a highly-technological, competition-oriented society, the stress levels felt by all age groups are rising.

• The number of suicides in Japan surpassed the 30,000 mark for the first time in 1998 and has since remained in the range of 30,000 per year, registering at 30,649 in 2009.

• The number of suicides was particularly high for men in their 20s, 30s and 40s.

273

143

INFANT MORTALITY

Trends in infant deaths and infant death rates, 1955-2006

Causes of infant deaths

Causes of Infant Deaths

• 30% congenital malformations

• 13.8% respiratory and cardiovascular diseases

FETAL MORTALITY

Trends in foetal deaths and fetal death rates, 1955-2006

Health Service Delivery

(Organization and Administration)

Four Primary Mechanisms:• Public health centers – prevention and

maintenance, • Physician offices – solo-practice

physician in smaller communities• Clinics – in large communities,

in-/outpatient care offered • Hospitals – more than 20 beds

and contain higher level of technology

Public Health System

• 411 Public health centers by perfectures– doctor, dentist, pharmacist, veterinarian, X-ray specialist,

nurse, dietician– Regulatory (licensing, sanitation)

• 2,692 Municipal health centers– Community health promotion– General services

• The four subsystems are not always closely coordinated and continually

compete for resources. • Traditional medicine is extensively

practiced and herbal medicines are widely sold.

Organizational Structure

Health Insurance System

• There is universal coverage of the population by statutory health insurance

• Three insurance schemes:– SMHI , for employees of large companies and

their dependents– GMHI, for employees of small to medium-sized

corporations and their dependents– NHI, for the self-employed

• Public-administered financing through numerous schemes,

• Delivery is highly fragmented/decentralized,

• Private hospitals dominate the hospital system,• Hospitals operate as a closed system,• There is freedom to choose providers,• There is no gate-keeper system,

• Payment system is fee-for- service under a national uniform price schedule,

• There is long waiting time but short consultation time,

• Expenditure on drugs comprises a high share of total health expenditure,

• There is no complete separation of drug prescribing and dispensing,

Utilization of Health Facilities

• Overutilization– 14 consults per person per yr (vs 4 consults in US, 2003)– 13.8 days ave. stay in acute beds in hospital (vs. 5.6 US,2006)– Overprescribing of diagnostic tests (doctors own equipment)

Source: The Challenge of Reforming Japan’s Health System. McKinsey &Company Nov 2008

Responsiveness and Client Satisfaction

• Long waiting time– 50% of the time > 30 mins

• Short care time spent with physician

-13.5 % < 3 mins, 54% 3-9 mins

Source: 2010 Japan Ministry of Health data

Financial Risk Protection

• Overall Health spending– 14% in out of pocket expenditures

HUMAN HEALTH RESOURCE

James Salisi

Pharmacists

• Only secondary role versus physicians in dispensing medications

Nurses

• 980 nurses per 100,000 (2008 data), improved from 821 in 2000

• Nurses in Japan have similar situations as in other OECD nations—lack of autonomy, low salaries, lack of professional recognition, MDs in teaching positions

• Public health nurses have most advanced training• Clinical nurses• Nurse midwives• Assistant nurses

• Four levels of nursing:– Public health nurse: graduate program, provide home

health, pediatric check-ups, industrial health– Clinical nurse: 3 yrs beyond high school, 80% in hospital,

15% in clinics– Nurse Midwives: Critical role in prenatal care and

delivery, clinical training & practicum, 50% hospital based, 33% own practice

• Assistant nurse: 2 year vocational program, like LPN in US (Tracey Lynn Koehlmoos, PhD, MHA,Lecture 13, HSCI 609 Comparative International)

Physicians

• Decline in number especially in pediatrics and obstetrics– 222 per 100,000 in 2008 (very low for OECD, since average is 300

per 100,000)

• No academic differentiation between specialist and generalists

• Most clinics and small hospitals are owned and operated by private physicians

• However, the trend is now away from private FFS practice toward more prestigious, salaried hospital-based practice (Tracey Lynn Koehlmoos, PhD, MHA, Lecture 13, HSCI 609 Comparative Internation)

• Physicians as businessmen• Physicians as pharmacists• Physicians as policy makers• No emphasis on informed consent or full

disclosure

Midlevel and other Health Professionals

• Allied medical professions have been slow to develop

• Midwives, health admin, mental health counselling, psychotherapy,

• Medical technology• Emergency medical services• Long term care

HEALTH FINANCING

• Universal insurance (all employers offer coverage for employees and dependents, 1995) –started 1961

• National insurance program supplements for those not fully employed

• Health Insurance Law of 1922• New Medical Service Law 1948

• Health costs are lowered by:– limiting prices for pharmaceuticals and

discouraging high-cost services

• Promoting an appropriate combination of the fee-for-service reimbursement system (medical fees are paid for each medical act)and fixed payment system (a fixed amount of fee is paid regardless of individual medical act), and encouraging appropriate divisionof roles and collaboration between hospitals and clinics.

• Health and welfare services for disabled and senior citizens

• The proportion of Japan's social security expenditure to national income registered 24.4 percent. (70% elderly cost) – SHJ 2010

Distribution of health spending

• 49.2% insurance• 36.4% taxes• 14.4% out of pocket

• 1/3 of spending for elderly

Source: Japan:Health Systems Review,vol. 11, No.5, World Health Organization, 2009

Health Spending

• 6.6% of GDP (Gross Domestic Product), among the lowest in OECD countries, from a low of 2.6% of GDP in 1956, yet GDP growth is stagnating

• $ 2,600 per capita in 2005

Health Facilities

• 80% of hospitals and 94% of clinics(20 beds) are privately owned

Health Regulation and Governance

Health Regulation and Governance

The New Medical Service Law (1948)basis for development and regulation of healthcare

facilitiesMedical Care Council recommends and coordinates

hospital services and clinics

• Health Promotion Law (2002) – importance of an environment conducive to healthier lifestyles as

strategy for the ageing society

• Universal Insurance coverageCoverage for all citizens including nonemployed in

1961

1. Medical Care Acthuman and capital resources are regulated

2. Health Insurance Actfinancing is regulated

Regulation at central government level

• Supervision and regulation of health care providers (hospitals and clinics)regarding health insurance

• Pharmaceutical manufacturing and imports• supervises the pharmaceutical industry over

manufacturing, clinical trials and post-marketing surveillance

Regulation at prefecture level

• The Medical Care Act delegates regulation of health care providers (hospitals, clinics, pharmacies and health care homes) to the prefecture governments.

• stand in the forefront of activities and responsibilities

• health insurance reimbursement and health service management

Regulation and governance of the purchasing process

• Contracts for the insurance system with providers are made between the government and individual providers, and there is little room for the discretion of the insurers

• the government possesses sole purchasing power over health insurance practices

Regulating quality of care

• Medical Care Act sets the minimal standards of health care based on structural indicators such as health personnel and hospital facilities, the violation of which may result in criminal charges

Key Challenges to Japan’s Health System

Challenges to Japan’s Health Sector

• Aging Population• Differential Insurance Benefits• Inadequate Coordination between Public and

Private Health Care• Obsolete physicians• Health worker shortage• Duplication and Overlap of Providers• Inadequate Incentive Structure• Insufficient Attention to Modern Management

Aging Population

• Japan has the world's oldest population¹– by 2050, 40 percent will be 65 or older– Treatment will be more expensive for anticipated case

mix– Demand for medical care will triple in the next 25

years

¹Harden B. Health Care in Japan: Low-Cost, for Now: Aging Population could Strain System. The Washington Post. September 9, 2009.

Differential Insurance Benefits

• Basic benefits are universal• Special benefits vary widely

– Extras services are covered by private insurers– Costs are not effectively controlled²– Access to health care becomes a problem

²McKinsey. The Challenge of Reforming Japan’s Health System

Inadequate Coordination between Public and Private Health Care

• Little formal cooperation and coordination between the private health care system and locally based public health care system – Physicians as entrepreneurs

• Unmitigated development of private health care providers

Obsolete Physicians

• No continuing medical education for physicians – Head Surgeon of Tokyo Medical University lost 3 out

of 20 patients he performed a heart valve operation on; he was not trained to do heart valve surgeries

• No academic differentiation between general practitioners and specialists

Health Worker Shortage

• Physicians aggregate in lucrative fields like dermatology and ophthalmology and avoid surgery because of its stressful nature

• Not enough surgeons, obstetricians, and nurses, anesthesiologists, emergency room physicians– Low pay, long hours, stressful job

Duplication and Overlap of Providers

• Hospitals experience a “crowding-out” effect– Space for emergency care and serious medical conditions

are taken by routine treatment³• No gatekeeper for medical care or hospital stay

• Japan has three times as many hospitals as the US per capita

3Harden B. Health Care in Japan: Low-Cost, for Now: Aging Population could Strain System. The Washington Post. September 9, 2009.

Inadequate Incentive Structure

• Does not encourage careful practice because services are rewarded regardless of quality or the skills of provider– Physicians are revered, their decisions are rarely

questioned

Insufficient Attention to Modern Management

• Relative lack of hospital administration– Lack formal systems to evaluate quality and

appropriateness of care• Overutilization of unnecessary medical procedures

– Physicians with no administration training continue to dominate decision making

HEALTH CARE REFORMS

Outline of ReformsYear REFORMS

1922 Health insurance law(private sector)

1938 Ministry of Health & Welfare established

National Health Insurance Law

1948 Medical Service Law, Public Health Center Act, Act on Nurses & Midwives

1961 Universal Health Insurance completed

1982 Health Services for the Elderly Act

1985 Revision of Medical Care Act

1989 10 year Plan for Elderly (Gold Plan)

2002 Health Promotion Act or Healthy Japan 21

2006 Structural Health Care Reform Act,

2008 Elderly Health Care Security Act

Medical Service Law

• 1948– Post war period– Medical facilities destroyed, shortage of

Personnel– Formalized the system, allowing physicians to

open own practice or clinics– Together w/ Act on Medical Practitioners, Nurses

and Midwives

National Health Insurance

• National Health Insurance Act in 1938– Included the farmers, self-employed– Low coverage since voluntary participation– Approximately 30 million still uninsured

Source: Growth of Economy and Accomplishment of Universal Medical Insurance and Pension Programs: 1955-1964, Japan Ministry of Health website

Universal Health Insurance

• Completed in 1961– Required all citizens to be insured– Increased subsidies to 30% from the national to

municipal government

Separation of prescribing & dispensing

• Stipulated in 1874 Medical Actbut not implemented

• 1980s• Advocacy for implementation

• 1990s– 54% drugs dispensed by pharmacists

Health Services for the Elderly Act

• 1982– Financial redistribution mechanism for elderly

insured– insurers with higher than national average

enrolment will contribute less and vice versa

Gold Plan

• 1989– 10 year Strategic Plan for Health & Welfare

Services for the Elderly– Each municipality then had own Health &

Welfare Plan– However, heavily relied on taxes for financing

the plan

Healthy Japan 21

• 2000– Addressed the increasing # of lifestyle-related

diseases– Influenced by the Healthy People 2000 of US,

where smoking is declining– National Health Promotion in the 21st century– Community level involvement

Healthy Japan 21

• 2000

– 9 areas (smoking, alcohol , nutrition, exercise, leisure, circulatory, diabetes, cancer)

Health Care Reform Package

• 2002– For 1st time in Japan history,

Health expenditures decreasedue to price reduction in

medical fee (2.7%), thus*decrease in overall health

spending by 0.7%

Source: “Japan and Massachussetts: a Comparison of Universal Health Care Systems”

Structural Health Care Reform Act

• 2006– Addressed problems in inequality in elderly

enrolment– Effectively separated the insurance of 75 yrs old

from other insurances

Elderly Health Care Security Act• 10% co-insurance for

old-old above 75 yrs• 30%co-insurance for young- old,65-75 yrs

TELEMEDICINE and COMMUNITY Health Centers

• addressed lack of physicians in rural areas– Manned by nurses– Use of Information technology

2 year Mandatory Internship in General Medicine

• 2006– Addressed the “stagnation” of Japanese doctors– Mandatory before practice of medicine– General residency (focus medical and surgical

areas)

Japanese Residency Matching Program

• 2003– Addressed the “stagnation” of Japanese doctors– Similar to US, where a doctor is matched to the

appropriate training hospital

Recent Innovations

• Toyono town in Osaka Perfecture– Telephone consultations– Primary care services in emergency rooms– 80% drop in # children treated in emergency

rooms

Remaining Issues

• Lack of monitoring in reimbursements of insurance

• Lack of assessment mechanism of cost effectiveness of medical interventions

• Lack of incentives for personnel for results (more incentives if more patients)

• Lack of accreditation of physicians

THANK YOU and Have a Good Day!