1. Healthcare System of Japan
Tracey Lynn Koehlmoos, PhD, MHA
Lecture 13
HSCI 609 Comparative International Health Systems

2. Before heading to Japan…
Let’s go regional
In Europe we talked about the EU and its relation to health systems
In the Pacific Rim we must talk about APNHAN:
Asia-Pacific National Health Accounts Network
APNHAN—a far cry from the EU but definitely worth another slide…

3. APNHAN
Collective partnership of regional experts (government and non-government) interested developing and maintaining national health accounting systems
APNHAN hopes to provide a forum for regional collaboration and mechanisms for dialogue and technological exchange
Broad range of economies in the region: Japan and Aus (OECD, highest % GDP spent on healthcare) and South Korea, Thailand and Bangladesh (lowest GDP % on healthcare)
We should never ignore collaboration

4. Japan Official name: Japan Capital: Tokyo
Constitutional monarchy w/ parliamentary government
Administrative divisions: 47 prefectures
2nd most technologically powerful economy; 3rd largest economy in the world
Keiretsu: manufacturers, suppliers, and distributors working together in closely-knit groups

5. Update for Japan Population: 127.4 million (2006)
Life expectancy: 77.9 male/ 84.7 female (highest)
Infant mortality: 3.2 per 1000 (lowest in world)
Population >65 years: 20% (highest in world)
Leading causes of mortality: cancer (31.0%), heart disease (15.5%), cerebrovascular disease (13.2%), and pneumonia (8.9%) (2002)
Health expenditure as % of GDP: 7.9 (2003)
Per Capita health expenditures: $2,139 US

6. Overall View of the System
Universal coverage through a Bismarkian system of employer-based health insurance with strong government financial control
Most provision takes place in the private sector with physicians having a powerful role in the healthcare system and in society

7. Organization Ministry of Health, Labour and Welfare—
High amount of government regulation
Gov’t sets fee structure via the Medical Fee Table and for drugs via the NHI drug price list
Provide funding for…
Prefecture and municipalities
Conduct comprehensive planning and implementation

8. Source of Funding Healthcare Expenditures
2000 data. Source: OECD Japan Country Study
Accessed 30 May 2006:

9. Where is all the money spent?
2000 data. Source: OECD Japan Country Study
Accessed 30 May 2006:

10. More information on health expenditures…
51% of health expenditures are for hospital based services
29% goes to ambulatory providers
12.2% medical goods and supplies
2.9% nursing and residential facilities

11. How National Health Insurance Works
Aged 3 to 74 years pay 30% of medical expenses
Under 3 years pay 20%
Over 74 years pay 10% or 20%
Insurance carrier renumerates the doctor, hospital, clinic, or other medical care provider directly
Fee-for-service, determined by the Ministry of Health, Labour and Welfare
Individuals and families are assigned to an insurance type based on career/employment

12. More on Health Insurance
Two Major Types
Kokuho: National Health Insurance (45.45 million subscribers) covers the self-employed, farmers and jobless
Employees' health insurance includes:
Shaho: Health Insurance Society (32.58 million) covers employees of large companies
Government-Managed Health Insurance (37.58 million) covers employees of small to medium size companies.

13. Physicians 2.0 per 1000 in 2003 (very low for OECD)
No academic differentiation between specialist and generalists
Doctors are highly revered and well paid
Most clinics and small hospitals are owned and operated by private physicians
However, the trend is now away from private FFS practice toward more prestigious, salaried hospital-based practice

14. Physicians Physicians as businessmen Physicians as pharmacists
Physicians as policy makers
No emphasis on informed consent or full disclosure

15. Nursing
Nurses in Japan have similar situations as in other OECD nations—lack of autonomy, low salaries, lack of professional recognition, MDs in teaching positions

16. Nursing Four levels of nursing:
Public health nurse: graduate program, provide home health, pediatric check-ups, industrial health
Clinical nurse: 3 yrs beyond high school, 80% in hospital, 15% in clinics
Nurse Midwives: Critical role in prenatal care and delivery, clinical training & practicum, 50% hospital based, 33% own practice
Assistant nurse: 2 year vocational program, like LPN in US

17. Hospitals An excess of beds, duplication of services
80% are privately owned
20% large, public (mostly) teaching hospitals
94,819 general health clinics
Even these clinics have inpatient beds

18. Long Term Care Long-term Care Insurance System: Started April 2000
Five Basic tenets:
1) Requires certification of condition for all plan recipients
2) Fixed-fee payment system
3) Professional collaboration among providers
4) Private companies MUST participate
5) Responsibilities delegated to regional authorities

19. Long Term Care
LTC system seeks to unify nursing and health services in a single framework
Removed responsibility for home-and facilities-based services from the auspices of the National Health Insurance system
Source: JPMA website accessed 25 May

20. The High Cost of Aging
National medical expenditures 2002 were 31 trillion yen, or 8.6% of the national income
Of health expenditures, geriatric medical care (for people aged 65 and over) comprised 49.0%
The financial viability of the entire Japanese health insurance system is threatened with tremendous decline due to geriatric expenses

21. The High Tech/High Cost Challenge
Japan is famous for adopting and adapting the best of other cultures—the same is true for healthcare and health technology
The private ownership of hospitals/clinics and the cultural love affair with high technology combined with fee-for-service reimbursement has led to an explosion in the use of MRI’s and CT Scanners in Japan
Example of potential of overuse of services

22. Japan v. USA Japan USA* MRI per million population 35.3 8.6 CT Scanner
92.6
13.1
USA under reports due to sampling technique of asking only if there is one piece of equipment in a facility rather than the actual number.
Source: OECD 2003

23. 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

24. Summary
Japanese culture values health and promotes a healthy lifestyle
Japan enjoys some of the best health outcomes in the world (low infant mortality, high life expectancy)
The future of the Japanese healthcare system will revolve around caring for an aged population to include the high cost of treating chronic illness and adapting new systems (nursing homes, home health) to fill the gap caused by societal changes