by Elyse M. Rogers
THE THREE “K”s
Although I love my work and can’t think of anything nicer than running around Tokyo and environs tracking down good medical information for you nice foreign residents and visitors to Japan, some assignments or interviews are more fun than others. Recently I had a delightful time simply sitting down and chatting with a Japanese physician who is a fine personal friend. This gentleman (who shall remain nameless in this column to protect his privacy and not endanger his professional standing in the Japanese community), is the head of a department in a major hospital in Japan.
For the sake of convenience, let’s call him Dr. Watanabe (sort of the Japanese equivalent, in my mind, to “Smith” in the states). Dr. Watanabe wanted to explain to me about the “new” three “K”s in Japan today. As you’ve probably already surmised, one “K” is related to medicine.
But I’m getting ahead of myself. Many of you probably know about the three “C”s that represented the good life for the average Japanese after the war—1) Car, 2) Color (TV), and 3) Cooler (air conditioning). If you gained all three, you really had it made.
In the last decade or so, the 3 “K”s came into vogue as sort of a tongue-in-cheek shorthand for the top three national problems of Japan: 1) Kome (rice), because it is subsidized and expensive, 2) Kokutetsu (the JNR or national railroad) that was always running a deficit and had strikes every spring that inconvenienced commuters), and 3) Kyoiku (education), because of the “examination hell” and the competition for limited top universities.
According to Dr. Watanabe, now that the JNR has been privatized (and become the JR), that “K” has been replaced by another “K”—Kenko Hoken or the National Health Insurance system. As many of you probably know, the system itself is extremely costly and last year totaled almost $20 billion (U.S. dollars).
The good doctor feels (as do many others) that the system is heading for real problems of cost containment. Japan has one of the world’s largest aging populations and will have a tough time dealing with that problem in the future because of the high cost of medical care for the aged population who have more medical problems and expenses than youth or middle-aged persons of any nation.
THE DRG SYSTEM IN AMERICA
Today, in America, the big new change in medicine is being brought about by DRGs (Diagnostic Related Group). Health insurance companies such as Blue Cross and Blue Shield, Metropolitan Life, etc., have set up 400 classifications of DRGs. Total payment and length of hospital stay are dependent on the classification. In other words, a patient who needs an appendectomy would be in one DRG and under that plan the doctor would be paid so much, the hospital paid a specified amount, and the number of days in the hospital restricted.
The DRG system has led to significant outcries in the American medical and hospital community because they argue that not all patients fall into one category. For example, one patient may sail through an appendectomy and be ready for discharge before the specified final day of paid hospitalization; another patient may be very slow in recovery and need an extended stay which, according to the DRG, would not be paid for by his insurance.
Anytime you make a system that has limits, naturally there will be problems. However, the cost of medical care in the U.S. has skyrocketed (went from $201 per capita in 1966 to $1,220 in 1982) so something had to be done.
Other cost-saving measures are being implemented, such as: 1) More patient involvement in care (the nurse does less for the patient—the patient takes on more responsibility for his/ her own recovery). 2) Day-surgery departments, where the patient is admitted, has surgery and goes home on the same day, thereby limiting hospitalization time while still providing special sections where intensive one-day treatment is safe and effective. 3) Emphasizing home health care, where patients who need some on-going treatments can recover at home because professional medical personnel (nurses and/or technicians) will provide the daily or weekly care needed.
Home health care is much cheaper, of course, than in-hospital care because whenever a patient is in the hospital he/she must be provided with food and lodging similar to an expensive hotel. (You may not think that hospital food is as tasty as that of the Tokyo Hilton, but is costly to produce and deliver.)
HOSPITALIZATION POLICIES IN JAPAN
In Japan, instead of limiting the patient’s stay in the hospital, it is often artificially extended because the Japanese health insurance in most cases only pays when the patient has been in the hospital more than 20 days. Currently the average hospital stay in Japan is 30 days; in the U.S. it’s 6.7 days (1983). The long hospital stay in Japan creates the problem of long waiting times for surgery and treatments in many Japanese hospitals, and is why, very often, even in cases of severe emergency, no hospital beds are available.
SPECIALISTS AND PAY SCALE
In Japan, there are no specialty boards one must pass to practice a specialty such as pediatrics, surgery or orthopedics. Any licensed physician can call himself/herself a “specialist” if he/she wishes. What is perhaps more important, the doctor is paid through the health-insurance payment procedure and his/her education and/or experience has no impact on that payment.
For example, in an appendectomy case, a brand new physician, with no special surgical skills, just out of medical school, would receive the same payment for the procedure as would a doctor who had gone through the six-year specialty program that most major university medical schools in Japan require. Payment is by the point system in Japan. The government reimburses ¥10 for each point. So, if an appendectomy were rated at 3,000 points, any doctor performing the surgery would get reimbursed no more or less than ¥30,000.
Doctors in Japan who own private clinics get to keep that money but doctors who work for general hospitals or university hospitals are staff physicians and they merely get a salary. This means, very often, that a top specialist in a major university hospital makes far less income than a minimally-qualified general physician who owns his own clinic.
CME (CONTINUING MEDICAL EDUCATION)
In the U.S., in order for a physician to get his/her license renewed he/she must get so many CME credits per year. This means the physician must attend professional symposia, write medical reports or do whatever type of research/ practice has been decided is important for keeping him/her current and up-to-speed in that special field.
In Japan no additional medical education after medical school is required—ever! In Tokyo, the Tokyo Medical Association has a program for its physicians but it’s a voluntary one. Also, of course, many specialists in universities are obliged to keep up to date because of the pressure from colleagues or international associates.
INFLUENCE OF KYOIKU (EDUCATION)
Dr. Watanabe feels medical education has some of the same problems that face general education. According to the doctor, in general education in Japan, if one gets into a good university he/she can be assured of a good life. That person doesn’t really have to work hard in university—he/she only has to graduate. As the doctor puts it, “The university is more for meeting friends and future associates than for studying.” He/she (but remember in Japan it’s still usually he) can get into a good company and progress through seniority in the ranks and there is very little incentive to excel.
Dr. Watanabe feels the system is much the same with physicians. Once a physician gets his license, he/she is assured of a good life and a good income; if that person never bothers to pick up a medical book or attend a medical conference, he/she will still have a good practice and a good income. As is often true, the people who need the most extra study rarely want to be bothered getting it, so the less competent physician often becomes progressively more so as the years pass and he/she gets no new medical data.
The whole system, Dr. Watanabe feels, provides no real competition to excel or any incentive to become a skilled specialist.
WHICH SYSTEM IS BETTER—THE AMERICAN OR JAPANESE?
When I put the question “Which is the better system?” to Dr. Watanabe, he immediately replied, “The American system.” Certainly from his own professional point of view, I’m sure that’s true. He is a fine, skilled specialist and deserves to reap some of the rewards for his dedication, hard work and just plain brilliance. However, let’s not forget he is human and, like most of the rest of us, would appreciate more money and a better lifestyle for his efforts.
As to which system is better for the patients, I’m not always sure. I think there are problems in both since systems run by human beings are never perfect. In Japan I think the average citizen often gets inferior medical care; however in the U.S. I think the average citizen often pays an exorbitant price for albeit superior medical care. However sometimes superior care isn’t needed, whereas the on-going availability of medical care (and the security that provides) is desperately needed.
So, I’ve told you what one Japanese medical specialist has to say on the subject of medical care delivery.
