Declining Quality of the Healthcare System in Japan - Suggestions from Ireland

Rene Duignan (JIC Study Group, Aoyama Gakuin University, and Health Policy Institute, Japan)

The opinions expressed are purely the author's and do not represent the views of any of his employers.

The declining quality of the healthcare system in Japan is sadly evident from a glance through recent headlines; (a) People dying in ambulances after being turned away by multiple hospitals, (b) The tragic Hepatitis C cases, (c) The plight of "cancer refugees" denied life-saving treatment/medicine, (d) Dreadful crimes committed by mentally-ill people somehow missed or ignored by the mental health system. From personal experience, we endure unreasonably long waiting times, short pressurized doctor consultations and are inevitably prescribed large volumes of medicine. (According to McKinsey research, intriguingly drug dispensing in Japan is 2.3 times higher than the US per disease burden. Japan also has both 3 times as many hospitals and 3 times as many beds per capita as the US. Hospital stays average 24 days in Japan compared to 10 days in Germany and 5 days in the US. However Japanese healthcare labor levels are 29% lower than in the US, implying less time with doctors and less nurses per patient.) The Japan macro picture shows rural hospitals closing with private equity funds beginning to circle overhead. Income inequality is widening and obviously the aging population loads ever heavier burden on health services. Meanwhile, the government and opposition indulge in short-term political bickering, apparently relishing the novelty of a "two-party system". In the background is a policy quagmire with a staggering national debt at 170% of GDP.

Public opinion surveys on health highlight three basic problems; (1) Shortage of doctors, (2) Lack of a "balanced billing" system, (3) Weak patient advocacy voice. However, these same surveys show fierce public resistance to higher taxes or to the acceptance of more "out of pocket" burden. Yet health spending per person in Japan is considerably lower than in other countries including Ireland, which has half the amount of over-65s. In Japan 80% of medical costs are still funded by the government despite the spiraling budget deficit. For cost containment, latest technology and pharmaceuticals are simply not affordable or to be encouraged. The private sector remains under-developed due to heavy regulations, such as those that prevent "balanced billing" meaning that people lose all health insurance coverage if they opt for a single non-insured treatment in their overall package. This appears a cruel "winner-take-all" system with no middle ground. Maintaining medical service equality is the moral defense but the moral expense is to exclude large sections of the rapidly expanding lower middle class from the treatment they require. In Ireland, private healthcare services are booming, private hospitals are even being built within the grounds of public hospitals. World class treatment is available at fair prices due to economies of scale, service-provider competition and higher efficiency levels.

Three brief comparisons with my own country as regards funding. (a) In Ireland, value-added tax is 21%, in Japan the 5% consumption tax has become a political minefield with neither party willing to commit electoral suicide to make the necessary hike. (b) In Ireland, a pack of 20 cigarettes with "sin" tax included costs 1,200 yen while in Japan, the same pack costs just 300 yen. In Europe, it is often a case of "government against big tobacco" but in Japan, big tobacco is the government due to its 50% shareholding of Japan Tobacco (JT). Could this be a conflict of interest for the government on both the healthcare and fiscal levels? (c) In Ireland, a visit to your doctor costs a flat fee of 12,000 yen so you only tend to visit when you are quite sick. In Japan, as the visit is around 200 yen, from an economic viewpoint, people will file into already congested waiting rooms with minor ailments like a common cold.

While immigration is a dreadfully complicated topic in Japan, "entertainers" visa are easy to attain for Filipinos, yet nurse visa's are most certainly not. In Ireland, 60% of new nurse registrations in 2005 and 2006 came from the Philippines and India. By all accounts, these nurses are providing the Irish nation with excellent service. Deregulation has even seen the birth of small 1-stop doctor's consultation booths in shopping centers, often staffed by doctors from India, the Middle East and Europe, many of whom had actually studied medicine in Ireland.

The incubation and support of patient advocacy groups in Japan is a low-cost option to create "patient voice" pressure to improve in service quality and basic efficiency. In Ireland, doctors, nurses, administrators and patients often join together to loudly voice their dissatisfaction in the media or at protest rallies, realizing that they are highly inter-dependant stakeholders. In Japan, organizations like the Japan Medical Association and MHLW bureaucrats are dominant and don't like dissent, forming with the LDP the Iron Triangle of health policy. Patient advocacy groups appear weak, isolated and unprofessional compared to international standards due to a basic lack of infrastructure to support and develop them. It is often left to non-profit organizations like the Health Policy Institute Japan a) to incubate, educate and help institutionalize such motivated collections of concerned citizens. b) to bring doctors, bureaucrats and patients together, as equals, to discuss urgent shared problems and c) to educate young doctors on wider issues such as health policy down to patient human interaction, to avoid recent cases of patients being told they have terminal cancer on the telephone.

By attempting to create a better balance between private and public sectors, healthcare could become a highly productive service sector contributing to consumption and GDP growth rather than being a huge fiscal burden. By allowing the private sector to grow, treatment will become more outcome-oriented, transparency and quality will rise, perhaps reducing the distorted incentives to over-prescribe medicine or keep hospital bed occupancy rates artificially high. Doctors and hospitals will be judged and ranked on their performance and non-medical experts will enter the industry to help boost operational efficiency. The aging population would be allowed to unlock some of their massive saving to invest in their most important asset, their health.

What level of crisis in the sad decline of healthcare in Japan will act as the trigger to force the political, social and structural changes that could perhaps one day save our lives and those of our children? Hospitals rejected 24,089 emergency patients in 2007. One "patient" recently died in an ambulance driving forlornly around Tokyo after being refused emergency treatment by 10 hospitals, although in great pain, was she still conscious enough to able to hear all of those "gomennasai" phone calls above the sirens?

(A shorter version of this article appeared in the Mainichi Shimbun on March 10, 2008.)