Understanding Japan’s Elderly Care Dilemma
Japan’s Healthcare Efficiency: A Closer Look
In Japan, outpatient services often face criticism for their inefficiency. A consistent pattern emerges among the elderly; even when their health conditions have stabilized, they persist in making frequent clinic visits.
International Comparisons: Putting Japan in Perspective
The survey revealed that over 90% of the elderly in Japan, the U.S., Germany, and Sweden consider themselves either ‘healthy’ or ‘not very healthy but not sick,’ demonstrating little variation in self-assessed health.
A detailed 2020 survey by Japan’s Cabinet Office shed light on the frequency of medical service usage among the elderly in different countries. The survey revealed that over 90% of the elderly in Japan, the U.S., Germany, and Sweden consider themselves either ‘healthy’ or ‘not very healthy but not sick,’ demonstrating little variation in self-assessed health. However, a striking difference emerged in the frequency of clinic visits. In Japan, about 60% of the elderly visit hospitals or clinics more than once a month. This rate is considerably higher than in the U.S. (about 20%), Germany (about 30%), and Sweden (about 8%), highlighting a unique aspect of Japan’s healthcare culture.
The Price of Privatization: Japan’s Medical Landscape
In Japan, the majority of hospitals and clinics operate privately, relying on their own revenue rather than state subsidies. This often pressures them to continue diagnosing and treating, sometimes even when dealing with age-related conditions that might not require constant medical attention. As a result, there’s a tendency to perform unnecessary tests and treatments to maximize billing. This practice has led to a deep-rooted culture where visiting clinics frequently is seen as normal, especially among the elderly who often view regular visits as a routine part of life. Consequently, clinics, driven by the need to see more patients for increased profitability, find themselves in a cycle of encouraging these excessive visits. This not only perpetuates an unusual culture of frequent consultations but also strains the system, affecting the quality of care provided.
Cultural Shifts and Systemic Changes
The Origins of a Unique Culture
This unique culture of elderly medical care can largely be attributed to the system introduced in 1973. It was a scheme made possible by Japan’s rapid economic growth, a temporary luxury that provided free medical care to those over 70 years old.
The Dream and Reality of Free Medical Care
The system of free medical care, which seems like a dream for the elderly, has led to the flourishing of a peculiar culture in elderly medical care. No matter how many times they visit the clinic or how expensive the tests are, it’s all free, leading many elderly people to frequent clinics for reassurance and to see their doctor’s face. This provision of free care, initially seen as a benefit of Japan’s rapid economic growth, has unexpectedly contributed to a culture of dependency and overuse.
Socialization of Clinics: Beyond Medical Needs
Many elderly people engage in social conversations with peers from their neighborhood during their clinic visits, turning these clinics into social gathering places — a phenomenon referred to as ‘the socialization of medical clinics.’ Additionally, doctors, knowing that patients will visit frequently even for minor ailments, have adopted this as a practice, making such clinics popular. This situation has led to prevalent ‘over-testing’ in clinics equipped with expensive diagnostic equipment, which continue to perform unnecessary tests. In addition, the issue of ‘over-medication’ is widespread across various clinics, with many prescribing more medication than necessary, contributing to a culture of excessive medical dependency. Furthermore, the practice of ‘social hospitalization,’ where patients are admitted even when they could be treated at home or with regular visits, has become common, further illustrating how the healthcare system has evolved beyond just medical needs.
The System Behind Unrestricted Access
Why has such unrestricted medical care for the elderly emerged? The answer lies in Japan’s adoption of a ‘social insurance system,’ allowing medical institutions to open freely and citizens to choose their medical providers without restrictions. All of Japanese citizens are enrolled in medical insurance, with the premiums serving as the primary source of funding for healthcare. This system is not unique to Japan but is also adopted by other countries such as Germany and France. In Japan, individuals are free to visit any hospital or clinic they prefer, and there’s no problem with consulting multiple medical institutions. If one is not satisfied with a particular clinic, they can easily switch to another. While having to pay for medical services can act as a deterrent to some extent, what happens when it’s free? Essentially, as long as time allows, individuals can access medical services without any limitations.
Comparing International Healthcare Models
It’s helpful to compare with the United Kingdom, known for its free healthcare system. The UK employs a ‘nationalized system’ where healthcare services are provided almost for free to the general populace, funded by taxes. In this system, healthcare institutions are generally public. Other countries with similar systems include Sweden, Canada, and New Zealand. However, there are restrictions on consultations. In the UK, for example, patients are limited to consulting at the clinic where they are registered. If they go directly to a clinic or hospital where they are not registered, they won’t be accepted. If advanced medical care is needed, patients can be referred by their registered doctor to a national hospital for treatment.
Consequences of Free and Unlimited Access: Shaping Elderly Healthcare
In summary, the combination of ‘free’ and ‘unlimited consultations’ has given rise to an unrestrained culture of elderly visits. This trend was further exacerbated by the predominance of private clinics, which, driven by the need to maintain profitability without state subsidies, often encouraged frequent visits and unnecessary treatments. Subsequently, due to the strain on medical funding, the system of free healthcare for the elderly was abolished within a decade. However, for some time afterward, the cost of elderly medical care remained low, which, coupled with the practices of these private clinics, allowed the peculiar culture of elderly healthcare to take root and persist.
The Transition from Free to Fee: Consequences and Adaptations
Currently, the co-payment rate is 30% for those under 70 years old, 20% for those between 70 to 74 and for pre-school children, and 10% for those over 75 (with the same income as active workers paying 30%). Due to this, the frequency of elderly people casually visiting clinics and hospitals has decreased compared to before. However, the frequency of visits is still largely left to the discretion of the doctors, leading to a division between clinics that encourage frequent visits and those that do not. Moreover, some restrictions have been introduced in terms of medical fees to limit the frequency of tests, reducing the prevalence of excessive testing. Yet, unnecessary tests continue unabated. Within the rules of medical compensation, it’s still possible to induce visits and tests even when they aren’t necessary. In today’s Japan, the freedom to seek medical care is preserved, meaning the only deterrent for consultations is the cost. Looking at it differently, this creates a disparity where people with higher incomes face fewer restrictions on consultations, while those with lower incomes are more constrained, leading to an inequity in access to medical care.
Towards a Sustainable Model: Policy and Reform
Standardizing Care: The Push for Efficiency
What then could be the solutions to the challenges mentioned here? Changing the ‘social insurance system’ isn’t simple, so let’s consider what can be done while maintaining this system. As a reference, there’s the reform of the hospital payment system in Japan. In terms of hospital treatments, standardization has been promoted, and since 2003 the Diagnosis Procedure Combination (DPC) system has been introduced. This system consists of a comprehensive evaluation based on a fixed daily point determined by the Ministry of Health, Labour and Welfare, depending on the patient’s condition and treatment, as well as the conventional fee-for-service part (for surgeries, gastroscopies, rehabilitation, etc.). While not a complete standardization, this system has been effective in reducing unnecessary long-term hospital stays.
In Japan, the costs of inpatient and outpatient medical care are almost equal, but standardization has not progressed as much in outpatient care, leaving a great deal of discretion to the doctors. Going forward, there is a need to advance standardization in outpatient care, which accounts for most of the outpatient medical expenses. This is necessary not only to reduce wasteful medical expenses but also to improve the quality of medical care. In the case of hospitalization, there are limitations such as the number of beds, but for outpatient care, there are no such limits on the number of patients, which can lead to an increase in unnecessary visits. This, in turn, can exceed the capacity of the doctors and medical staff, necessitating shorter examination and consultation times per patient. Consequently, this creates a risk where serious patients who need more time and intensive care might receive inadequate attention.
Drawing from the successes and lessons of standardizing inpatient care, it’s time to extend these principles to outpatient services.
Integrating Scientific Analysis in Compensation Systems
Initially, when calculating physicians’ fees and expenses, it’s crucial to adopt the following scientific perspectives: standardize the frequency of consultations, tests, and treatments for each disease. This ensures consistency and fairness in medical practices. Establish a mechanism to calculate and reflect the standard costs of diagnosis and treatment in compensation, varying by region and period. This approach aims to adapt to economic changes and regional differences, ensuring that medical compensation remains fair and appropriate over time and across locations.
Aligning Incentives with Health Outcomes
Building on a foundation of scientific analysis, ideally, medical compensation should be based on the outcomes, such as rewarding the successful treatment of acute illnesses, an approach not yet fully realized. For chronic conditions like diabetes and hypertension, which typically don’t ‘cure’ in the traditional sense, compensation would instead be calculated as a management fee to cover the ongoing management and monitoring required, rather than an outcome-based payment for a cure. As a physician, what I desire is the addition of outcome-based compensation for curing illnesses. The current system does not offer such rewards. In an extreme case, the system is more profitable for medical institutions if patients continue to visit for ongoing consultations and tests without being cured. Or, even if the patient has recovered and no longer needs medical care, the system might encourage regular visits ‘just in case.’ The true aim of medical care is to cure diseases and restore health.
Adapting to New Realities: The Future of Healthcare in Japan
Embracing Change: Adapting to New Patient Expectations
With the changing times and the introduction of medical fees for the elderly, there seems to be a gradual shift in people’s attitudes towards healthcare. The number of visits made simply for social interaction has decreased, and more people prefer to minimize their clinic visits. Experience with online consultations has grown, and for some illnesses, an increasing number of people are beginning to consider online care as a sufficient option. While still not the majority view, this once rare opinion is gradually gaining acceptance and is seen as a viable alternative by a growing segment of the population. Especially, the COVID-19 pandemic has significantly altered the perception and approach towards medical consultations among the elderly and those with mild conditions.
Revolutionizing Healthcare: Towards an Integrated Approach
Once again, I believe there’s a need to fundamentally evolve the structure of the medical compensation payment system. This should be done by respecting the current lifestyles and thought processes of people, and by incorporating scientific analytical methods. Efforts are required to overhaul the system from its roots to make it more in line with contemporary needs and expectations.