Supplementation

2015.12.17

Last week TV programs

• Why Japan introduced the universal coverage health insurance system?

1. For patients• Easy to access the doctors

2. For doctors• rescue the doctors from bankruptcy

Last week TV programs

• Japan Medical Association wants to keep the doctor’s independence.

1. Dr. Takemi’s “Professional Freedom”

2. Medical Care Facilities Finance Corporation since 1960

Last week TV programs

• Japan Medical Association opinion

• “Doctor’s distribution is a big issues. Naturally, this problems is to be solved by the doctor’s oneself. Some doctors go to depopulated area.””

• Wherever doctors open the clinics or hospitals, don’t interfere. It’s a doctor’s concerns.

Hospitals to 100 thousands people 1956

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MHLW, “Survey of Medical Institutions” various years

Hospitals to 100 thousands people 1968

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MHLW, “Survey of Medical Institutions” various years

In the beginning of the High Growth Era

Between 1950’s and 1960’s, many rural area’s young people rush into urban area to get a job.

• Hokkaido => Sapporo, Tokyo• Kanto => Tokyo• Tokai => Nagoya, Osaka, Tokyo• Kinki => Osaka• Shikoku => Osaka, Tokyo• Kyushu=> Fukuoka, Osaka, Tokyo

http://jpri.kyodo.co.jp/309/1964, March, 18thMass Employment

Last week TV programs

• People rushed into the big city, the doctors rushed into the big city too for getting the big demands.

• Comparing with the east and west Japan, west has much doctor’s than east. This relates to the Civil war in the end of 19c.

MHW(current MHLW)• The MHW thinks that the deliveries and demands of health

care is to be controlled under the MHW. Their idea is like U.K. system.

• The National Health Service in U.K. has a gate keeper for the examination. The gate keeper called General Practitioner assigns the patients to the hospitals or clinics in accordance with the health conditions of the patients.

• So, some patients go to the pharmacy with a GP’s prescription, some is to be hospitalized to get a surgery with a patient’s information of the letter of introduction.

MHLW(MHW) Plan

PrefecturalHospital City Hospital

Town Hospital

Village Clinic

Each of prefectures

Village Clinic

Village Clinic

Village Clinic

Village Clinic

City Hospital

Town Hospital

Letter of introduction

MHW vs. JMA• Sometime, the JMA’s committee had decided to boycott the

Health Insurance. (However, the boycott carried out only once in 1971.)

• In 1971, after the 10 years of introducing the universal public insurance system, Government Managed Insurance deficit was getting obviously more and more. MHW decided to reduce the health expenditure. What MHW introduced to reduce the health cost were using the monitoring system (auditing the insurance fee system), prohibiting to sell the medicine with the free drugs.

• The JMA repels the health care controlled by MHW and carried out a boycott.

MHA’s aim

• After the introducing the Universal Health Insurance, MHA’s aim was Reduction of the regional difference of the health care.

• The Free Self-Employed Practitioner System and Medical Care Facilities Finance Corporation made the distribution of the hospital and clinics distorted.

• MHA uncontrolled the arrangement of the doctors, so MHA used the Medical Service law which regulates the medical care institutions (hospitals, clinics, etc.).

MHA’s aim• MHW was going to reduce the regional difference of the doctor

placement by increasing doctors.• In those days, doctor’s ratio = 1.5/1,000, WHO recommend is

2.0 /1,000.

• 1973 　“ One-prefecture, one medical college” • It happened to coincide with the time when Prime Minister Kakuei

TANAKA proposed 'Nippon Retto Kaizo-Ron' (Plan for Remodeling the Japanese Archipelago; Building a New Japan) for promoting the development of land in Japan, and it seemed that the construction of these Shinkansen lines could progress smoothly.

MHLW’s aim

• The number of doctors were increasing, but many doctor went to the big city.

• After 1986, MHW policy of increasing the doctors is changed.

MHLW’s aim

Prof.

Assistant Prof.

Lecturer

Resident

Student

Goes to somewhere

Structure of Ikyoku

MHLW’s aim

• MHLW made the ceiling of the beds. • Made the large number of beds area’s beds

smaller, thus, the small number of beds area’s beds larger, MHLW thought.

• Before the revision of Medical Service Law enacted, the rampant increase in beds happened.– Often taking a way to ease the pain from a radical

reform is the feature of Japanese reform.

MHLW’s aim• From April 2004, a two-year clinical training system will be

introduced for medical school graduates.

• And yet, lectureship-based credit system in medical education called “Ikyoku” was in power, Ikyoku send the doctors to depopulated area.

• MHLW thinks that Ikyoku’ abilities are limited for the health care in the regional area graduates training. Thus, every residents have the right to choose the every training place.

• However, many young doctors select the big city’s hospital as the training place.

IKYOKU

Prof.

Assistant Prof.

Lecturer

Resident

Student

Once go to somewhere

Currently, come back!

Depopulated area’s doctor shortage problem still continue, it seems the problem get worse more than before.

MHLW’s aim

• The regional colleges which lost the residents calls back the doctors from a district hospitals.

• Thus, in the depopulated area, rural area have no doctor.

• MHW wish to go well, in the end, MHA fails to control the doctor.

Health Care Structure and Demand Side

Structure of Japan's Medical Insurance System

• Once one participate in one of the medical insurance system, he or she regularly pays premium tothe insurer, and receive insurance benefits when any insurance event takes place. There are twotypes of the insurance benefits: benefits in kind such as medical services that one receive atmedical institutions, and cash benefits provided by the insurer.

• Any medical institution is required to offer medical services, to the insured of any of the medicalinsurance system once it makes an application to and is accredited by the Directors of RegionalSocial Insurance Bureaus as an insurance medical facility. Through assessment and paymentorganizations, they send to the insurance entities bills for medical services that have beenprovided and the payment there of is made to medical institutions. The subscribers pay his or heramount of partial cost-sharing at the medical institution.

Insurer

Examination and paymentorganization

Insured of the medicalinsurance system

Insurance medical facilities

Directors of Regional Social Insurance Bureaus

Bills

Bills

Payment

Payment

Cash benefits

Benefits in kind(medical care)

Premium

Copayment

Applications/Written reports

Registration/Guidance

Feature of Health Care System

• The universal public insurance system– Workplace

• Employees of big company or small & middle company• National & Local government workers• Private school teachers & staffs

– Community• Self-employed, farmer, fishery etc.• Business association

– doctor, lawyer, special profession

– Late-stage medical care system for the elderly• 75years old and over

– financial adjustment

Feature of Health Care System

• Free Choice of Medical Care Institution– Basically, people can use any medical institution

on his/her own choice with health insurance card.– However, if you choice the hospital with more than

200 beds and with out the letter of introduction from clinic or small hospital, your fee for first medical examination is expensive. The fee for first medical examination depends on the hospital, now the amount of the fee is \5,000 – \10,000.

Feature of Health Care System

• Free Self-Employed Practitioner System– Any doctor or dentist can establish clinic by giving

a notice to the prefectural governor.– As for the hospital, it is complex.• The permission on the newly establish hospital is not

granted in the area that has already excessive number of beds.

– In either case, the advance adjustment with the regional doctor association.

Feature of Health Care System

• Fee-For-Service medical care– Fee-for-service (FFS) is a payment model a payment

of the actual cost of treatment.– In health care, it gives an incentive for physicians to

provide more treatments because payment is dependent on the quantity of care, rather than quality of care.

– In the Japanese health care system, FFS is mixed with a nationwide price setting mechanism to control costs.

Feature of Health Care System

• The system of Medical Treatment Fee Mark– It is a nationwide price setting mechanism, 1 mark

= \10. If you have a appendicitis and take a operation in standard (without a periappendicular abscess ), you are in be 9days and the cost is \230 thousands around 　 (the operation only \62,400). Of course, you have a medical insurance card, your cost is 30% of \70,000.

– 　

Fee for service

• Infectious disease–pneumonia–Tuberculosis

Model of medicine in acute phasetuberculosis, or some infection disease

antibiotics

In short, but in large

Many Old Japanese know that antibioticsmade the patient dramatically improved.→ Old Japanese like the drug, injection,And some medical examination.→ High Cost

Aging society

• Last week TV shows the doctors freely set up the hospitals or clinics by Medical Care Facilities Finance Corporation.

Number of Hospitals by number of beds

1993 1996 1999 2002 2005 2008 2011 2013 2014 0

1 000

2 000

3 000

4 000

5 000

6 000

7 000

8 000

9 000

10 000

2 487 2 458 2 435 2 399 2 344 2 288 2 190 2 168 2 147

　 900 床以上　 800 ～ 899　 700 ～ 799　 600 ～ 699　 500 ～ 599　 400 ～ 499　 300 ～ 399　 200 ～ 299　 150 ～ 199　 100 ～ 149　　 50 ～ 99

MHLW “Survey of Medical Institutions” 2014

Number of Hospitals by number of beds

1993 1996 1999 2002 2005 2008 2011 2013 20140

10

20

30

40

50

60

70

80

90

100 　 900 床以上　 800 ～ 899　 700 ～ 799　 600 ～ 699　 500 ～ 599　 400 ～ 499　 300 ～ 399　 200 ～ 299　 150 ～ 199　 100 ～ 149　　 50 ～ 99

MHLW “Survey of Medical Institutions” 2014

%

Aging society• Last week TV shows the doctors freely set up the hospitals

or clinics by Medical Care Facilities Finance Corporation.

• In the end, small there are small sized hospital in Japan.

• Owing to the capital shortage, small hospitals have no ability to make a delicate operation and high treatment.

• Small hospitals management problems occurred in the end of 1960’s.

The process of Free Health Care for Elderly

1960　 Sawauti Vil.; Iwate Pref. 65 and over age out-patient fee was free(benefit rate was 100% in NHI)1968　 Yokohama City 　For 80 and over age, NHI benefit rate raised 1969 Akita Pref. 　 For 80 and over age 80, The subsidy form prefecture for the out-of pocket excess

the a specific sum of money　　　　 Tokyo Met. For 70 and over age, no out of pocket system with income limits introduced1971　 When drawing up a 1972 budget, MHW decided to introduce the medical expenses supply

system for the elderly72.07 To execute the medical expenses supply system, the draft of Welfare Law for the Elderly was

passed unanimously* In those days, only two prefecture had no measures of reduction or charge-free elderly health cost

73.01 Implementation of the medical expenses supply system for the elderly with limit of incom– 70 and over age NHI insured, 70 and over age dependents of health insurance – age of 65 to 69 bedridden old person from (Oct. 1st) – the medical expenses supply system for the elderly covered only out-of pocket fee– municipalities implement the system, the cost allocation was 2/3 National Gov., 1/6 prefectures, 1/6

municipalities1983　 Abolition of the system by the implementation of health and welfare for the aged act

33出所） 吉原健二・和田勝『日本医療保険制度史（増補改訂版）』東洋経済新報社 , 2008. 等

Politics in those days…

• Equal balance between conservative and reformist– Some prefecture’s governor and some

municipalities Mayer are left wing– Liberals or left wings always push the social

security policy• c.f. In the old time, Republican and Democratic in USA,

the Conservative and Labour In UK– The conservatives take on an idea of the left wing

Three-way deadlock

• Politician– want to success in election– inducement of profit for the electorate

• Bureaucrat– policy making– cooperation of the politicians and the doctors

• JMA– own purpose, typically rising the fee mark of

medical activity

Rate of 65+ in total pop.

Policies and Schemes

1960sBeginning of Elderly Welfare

5.7%(1960)

1961: Universal Pension System1961: Universal Health Care1963: Elderly Welfare Law (start of Special Nursing

Home; SNH)1970sExpansion of Expenditure for Elderly healthcare

7.1%(1970)

1973: Free Health Care for Elderly

1980sHospitalization and Bedridden elderly Elderly issues recognized as Social Problem

9.1%(1980)

1982: Elderly Health Act1983: Partial Co-payment for Elderly1988: Municipalities to make health and welfare plans

for Elderly1989: Gold Plan (National Strategy to secure Elderly

services)1990sImplementation of Gold Plan

12.0%(1990)

1994: New Gold Plan1995: Aging Society Basic Law

2000sLong Term Care Insurance

17.3%(2000)

2000: Long Term Care Insurance 2006: Elderly Abuse Prevention Law

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Milestone Elderly Policies in Japan

The process of Free Health Care for Elderly

1960　 Sawauti Vil.; Iwate Pref. 65 and over age out-patient fee was free(benefit rate was 100% in NHI)1968　 Yokohama City 　For 80 and over age, NHI benefit rate raised 1969 Akita Pref. 　 For 80 and over age 80, The subsidy form prefecture for the out-of pocket excess

the a specific sum of money　　　　 Tokyo Met. For 70 and over age, no out of pocket system with income limits introduced1971　 When drawing up a 1972 budget, MHW decided to introduce the medical expenses supply

system for the elderly72.07 To execute the medical expenses supply system, the draft of Welfare Law for the Elderly was

passed unanimously* In those days, only two prefecture had no measures of reduction or charge-free elderly health cost

73.01 Implementation of the medical expenses supply system for the elderly with limit of incom– 70 and over age NHI insured, 70 and over age dependents of health insurance – age of 65 to 69 bedridden old person from (Oct. 1st) – the medical expenses supply system for the elderly covered only out-of pocket fee– municipalities implement the system, the cost allocation was 2/3 National Gov., 1/6 prefectures, 1/6

municipalities1983　 Abolition of the system by the implementation of health and welfare for the aged act

37出所） 吉原健二・和田勝『日本医療保険制度史（増補改訂版）』東洋経済新報社 , 2008. 等

Free Health Care for Elderly made the demands exploded

Rate of treatment accepter to 100 thousands

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1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

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2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000 197019731975

Out-patient In-patient

MHLW ”Patient Survey 2012”

Back up for paying

High-cost medical care benefit system

If your (dependent’s) payment at medical institutions exceeds the ceiling amount of personally-borne medical expenses, the portion exceeding the ceiling will be reimbursed as a High-Cost Medical Care Benefit. ※Excluding the hotel cost and extra charge for bed

＜ Example ＞Medical expense is \1 million and out-of-pocket fee is \300 thousands

Medical Expense \1 millionOut-of-pocket fee \

300 thousands

Supply as High-cost medical care benefit 　 \3,000,000 － \87,430 = \212,570

The celling of burden \80,100+(\1million － \267,000 ） ×1% 　 = 　 \87,430

By age and income, the celling of burden is change

The celling of the burden rely on the insured person’s age and income bracketFor Age 70 and over, out-patient fee ceilings are available

Income level Maximum co-payment per monthOut-patient （ by individual ）

For persons with general income （ Income level is more than \280 thousands per month ）

\44,400 \80,100 ＋（ Total Medical Expense per month－ \267,000 ） ×1%

General \12,000 \44,400

Extreamly low income（ exempt the residnet tax ）

Ⅱ （ exceptⅠ ）

\8,000

\24,600

Ⅰ （ the tax imposition of standards is zero person who are

only pension income and less than pension income \

800thousands ）

\15,000

＜ Age 70 and over ＞

By age and income, the celling of burden is change

　 The celling of the burden rely on the insured person’s age and income bracketFor Age 70 and over, out-patient fee ceilings are available

Income level Maximum co-payment per month

High Income （ more than \530 thousands ） \150,000 ＋（ Total Medical Expense per month － \500,000 ）×1%

General \80,100 ＋（ Total Medical Expense per month － \267,000 ） ×1%

Extreamly low income（ exempt the residnet tax ）

\35,400

＜ Under age 70 ＞

（注）同一の医療機関等における自己負担（院外処方代を含みます。）では上限額を超えな　　いときでも、同じ月の複数の医療機関等における自己負担（７０歳未満の場合は２万１　　千円以上であることが必要です。）を合算することができます。　　　　この合算額が負担の上限額を超えれば、高額療養費の支給対象となります。

Redundantly or frequently visit hospitals

• Low back pain and High blood pressure– Moral hazard• Marketed compress and prescribed compress

– Compatible with• the doctors• the medicine

• psychiatric disorder– Criminal act – resale psychoactive drugs

And…

Social Hospitalization

• Doesn't have any relatives to depend on and no other place to go from the present hospital– Japanese English?

• The bedridden old persons– 1968 Japan National Council of Social Welfare

reported “The Survey of the bedridden persons in the house ”

Small hospital way

Elderly hospital in (1982-2003)

The elderly patients' hospitals for intensive care (1990-2003)

General hospital in sanatorium-type wards(1993-2011)

347 thousands beds in sanatorium-type still alive in 2013!In primary purpose, cure and care are different.Owing to the expanding of medical field, the number of facilities and labourforce in the care field are short in Japan. And…

Ratification of real!

Second revision of the Medical Service Law in 1992Systematization of the Functions of Medical Care Institutions (Establishing systems governingSpecial Functioning Hospitals and Sanatorium-type Wards)

　① Systematization of the functions of medical care institutions and the flow of patients

Special Functioning Hospitals

Clinics

Patients requiring aadvanced medical

care

General(acute stage)

patients

Patients requiringlong-term

hospitalization

General Hospital Beds

Sanatorium-type Wards

GeneralHospitals

Too many

Two types of medical facility called a elderly hospital

• In 1982, the hospital where the rate of hospitalization of the chronical disease patient 65 years and over is more than 60% called special authorized hospital for the elderly. If the rate is less than 60%, the hospital called non special authorized hospital for the elderly. In 1983 special authorized hospital for the elderly was 4.8% of total hospital, however, in 1989, the rate was rapidly increasing in 8.7%. If the hospitals received the designation of the elderly hospital, the hospital could manage by the smallest level in nursing staff.

• The elderly patients' hospitals for intensive care was also available. This type hospitals adopted episode-based payment. If these hospitals wanted more money from medical treatments, they must increased the number of nursing staffs. The fee related to the number of staffs.

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From the point of hospital management view

• Why did MHW accept elderly hospital; the management of the hospital by the smallest staff?

• The effort to fill the beds → Hospitalize the elderly persons positively

• Any special treatments for old age did not carry out in the hospital( except for the gastrostoma).

• The patient would not wish the doctors to prolong his/her life.

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Percutaneous Endoscopic Gastrostomy(PEG)

The sales statistics of gastrostoma tube maker, newly 100thousands gastrostoma patient emerging in every year and the accumulated number is probably more than 50thousands.

Percutaneous Endoscopic Gastrostomy(PEG)

• a rehabilitation training for the dysphagia

• PEG (tube feeding), from nose 6%, from stomach 2.7%

• 65% of family support the PEG in Japan

Percutaneous Endoscopic Gastrostomy(PEG)

Merit• To reduce a burden of

the meal assistance

• A changing hospital or a leaving hospital are possible

Demerit• Living will

A view of life and death

Tracheotomy

• Among the oldest described surgical procedures, tracheotomy, consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea (windpipe).

?• The aspiration of the sputum• The Exchanging the tube of gastrostoma

–sterilization• Medical Practitioners Act 17

– Methods of surgery, therapy or diagnosis of humans have been termed "medical activity" and are normally practiced by medical doctors only (including those who are directed by medical doctors, hereinafter referred to as “medical doctors”).

• Under the instructions of the doctors, the nurse can do both activity.

• The certified care worker can make the aspiration of the sputum in 2016 after training.

Japan’s healthcare challenge• During the late 1990’s and into the 2000’s, Japan saw

an annual 5% increase in health related expenditures.• Most of the increase is attributed to the high cost of

providing services to the overwhelmingly increasing number of elderly citizens

• Economic growth has slowed and family size has decreased.

• The system must struggle and experience reform now in order to afford to be able to provide high quality cost in the near and long term.