Issues of medical treatment in Japan
The characteristics of medical care in Japan are not only the universal health insurance system, but also the free access system that allows patients to freely choose where to go. The freedom to choose where to go is considered to be a big advantage for patients. On the other hand, however, we consider that it also has problems such as the concentration of patients in hospitals that have an acute treatment environment.
The figure below is a graph of the “2017 Patient Survey Overview” published by the Ministry of Health, Labor and Welfare in 2017.
The pie chart shows that the ratio of general clinics tends to be higher than that of hospitals, but looking at the trends by age group, there is also a marked tendency for infant and elderly patients to attend general clinics. It can be inferred that this reflects the cases of regularly attending clinics including the acquisition of pre-existing drugs. In any case, when you feel something wrong with your physical condition but cannot determine the cause, you may often choose a hospital that offers general medical care.
The flood of patients in the hospital increases the waiting time at the outpatient department as well as the burden on the doctor who receives them. In addition, situations such as “waiting time of 3 hours, medical treatment of 3 minutes” will naturally come.
In many countries overseas is divided into primary care for the purpose of initial medical examination and secondary care for the purpose of treatment. Clinics are in charge of the primary care, and patients who are judged to need treatment at the hospital receive the secondary care at the hospital. Therefore, doctors in general clinics have the role of comprehensive diagnostician and are said to have an extremely high position in the medical community.
Many general clinics are referred to as “Home Doctor” and many families have the specific one. In other words, it has a lot of information related to health such as family’s medical history and medication history, and when something unusual occurs, it is possible to make appropriate decisions promptly. This is also the point that is greatly different from the “family doctor” in Japan.
The position of doctors in charge of primary care is high, but this also means that a strong relationship of trust has been established between hospital doctors and home doctors. When a patient is brought to a hospital that is in charge of secondary care, it appears that the doctor at the hospital assigns importance to the first visit to the home doctor and does not perform any duplicate inspection. In Finland, which has a similar idea, for example, I heard that when a medical condition of patients undergoing cardiac catheterization is identified from the medical record information sent, catheterization is performed one after another like an assembly line. Consequently, it seems that much more treatment results have been accumulated than in Japan.
Enhancing primary care brings enormous benefits to patients as well. Needless to say, the appropriate treatment should be obtained promptly, but even if the name of the disease is unclear, it is most important that the home doctor makes the optimal diagnosis. Even if you have a headache, there are many causes. It is often the case that you cannot decide for yourself whether you should go to internal medicine or neurosurgery. I think there are many cases where the destination of the visit cannot be specified and the patient goes to a hospital with various clinical departments because doctors in general clinics also have various signs such as internal medicine, gastroenterology, and surgery. After all, it is also often experienced that patients are taken to various departments and undergo various inspections. Many of these situations, like in other countries, can be prevented by having a specialist general practitioner nearby, which allows early treatment before the disease progresses and reduces the risk of being too late, I think.
Another issue of medical treatment in Japan is that the division of roles between medical care and long-term care is extremely unclear. A report by Japan Medical Association Research Institute also points out this, “Although there are slightly more beds in Japan worldwide, there are few facilities where elderly people live for a long time, and beds are taking the place of facilities.”
In the 7th insured long-term care service plans in April 2018, the new legislation of the care aid medical home has abolished the conventional long-term care beds, and those who need long-term care are to be transferred to care aid medical homes by March 2024. It is said that the number of care aid medical homes will be 515 (32,634 beds) at the end of June 2020, and it seems that local governments with undeveloped care aid medical homes are gone.
A breakdown of the facilities that were converted to care aid medical homes, however, shows that the number of conversions from the conventional long-term care beds is the largest and, in terms of the number of beds, while the ratio of conventional long-term nursing beds is overwhelming, it seems that there are too few newly opened facilities.
The compensation standard at the care aid medical home is being considered by the Social Security Council and Medical Care Benefit Expenses Subcommittee. But, from the perspective of proper operation of the facility, I also feel concerned about the financial burden on the local government because nursing-care benefits seem
s to be transferred from the long-term nursing of the conventional medical insurance to the nursing-care insurance.
Japan’s medical system has many issues and problems that have become apparent due to the current COVID-19 pandemic, but I feel that the root of which is the problems of the current medical fee system. The conventional medical fee system has been entrusted to the “fee-for-service system”, where points are set for each medical service unit. In other words, the structure is that a fixed score is counted as a medical fee according to certain medical services.
On the other hand, as a structure seen in the Nordic countries, there is a “capitation payment” proportional to medical power. In other words, the structure is that the number of patients held by a medical institution is predicted in advance from the population, etc., and that is distributed to the medical institution as a reward. The lower the incidence of injury and disease (= the medical practice itself decreases), the higher the profitability can be expected.
In the United States, a system called “Diagnosis Related Groups / Prospective Payment System (DRG / PPS)” has been introduced since 1983. This is a method of classifying diseases by diagnosis group (DRG) and paying a fixed amount of medical fees for each diagnosis group (PPS). It is said that such a method makes it possible to manage medical resources suitable for the condition and manage medical performance appropriately.
Similar to DRG, Japan’s DPC (Diagnosis Procedure Combination), also incorporates the concept of comprehensive evaluation by diagnosis group. However, instead of using bundled payment for all medical fees, it is used in combination with the fee-for-service system. The reason is that it is difficult to comprehensively classify and standardize because it is necessary to apply a wide variety of medical technologies according to the medical condition of each individual patient. In other words, the method is that the basic medical costs are bundled as a hospital fee, and the costs for individual treatments are paid as a doctor fee.
In this way, there are various ways of thinking and methods in the medical fee system, but the most important thing for patients, their families, and society is whether the best medical care is provided under proper resource management. For that purpose, it is also important to strengthen the check function for hospitals like those introduced above and I think it is essential to make efforts to reduce acts such as checking for duplicate and unnecessary tests and medication by cooperating between medical institutions to handle medical data.
We have experienced the unprecedented crisis of the COVID-19 pandemic and been confronted by the unexpected weakness of the medical system against it. Therefore, I think now is the time to radically rethink medical care from the perspective of the rights and obligations imposed on ourselves as social beings.
Translation responsibility: Fumihiro Adachi