1. HEALTH SYSTEM IN FOCUS JAPAN Reporters: Lustre,Ceferino Salisi, James Members: Sabularce, Joey Motos, Jeffrey de Guzman,Angelo Dubrico, Gretchen

2. Profile of JAPAN 3 rd largest economy in the world (recently surpassed by China) constitutional monarchy with a parliamentary government 47 perfectures

3. Japan has a healthcare system characterized by universal health insurance coverage, as all Japanese citizens belong to one of the country’s health insurance systems.

4. hybrid system funded by job-based insurance premiums and taxes -- is universal and mandatory, and consumes about 8 percent of the nation's gross domestic product

5. BISMARCKIAN Model State-mandated social insurance, started by Bismarck in 1883, 1 st Chancellor in Germany Covers all or most citizens through employer and employee payments to insurance, while providing care through public & private providers found in Germany, Japan, Belgium, France, Netherlands

6. DEMOGRAPHIC Characteristics and Health Status of the Japanese People

7. Demographic Characteristics As of May 2010: population 127, 360, 000 Male: 62, 010, 000 Females : 65, 340, 000

8. Distribution by Age group

9. The average life expectancy remains among the highest in the world. In 2009: 86.44 years - women 79.59 years – men In 2008, the crude birth rate was 8.7 per 1000 persons and the crude death rate was 9.1 per 1000 persons

10. NATALITY

11. 8.6 per 1,000 19.6 per 1,000

12. Yearly comparison of live birth rates by age group of mother

13. GENERAL MORTALITY

14. General Mortality death rates had gradually declined since 1957, recording the lowest rate of 6.0 in 1979 and 1982. deaths have demonstrated an upward trend, and death rates have been growing, reflecting the aging of the population

15. Trends in deaths and death rates, 1955-2006 8.5 per 1,000

16. General Mortality Due to a highly-technological, competition-oriented society, the stress levels felt by all age groups are rising. The number of suicides in Japan surpassed the 30,000 mark for the first time in 1998 and has since remained in the range of 30,000 per year, registering at 30,649 in 2009. The number of suicides was particularly high for men in their 20s, 30s and 40s.

17. 273 143

18. INFANT MORTALITY

19. Trends in infant deaths and infant death rates, 1955-2006

20. Causes of infant deaths

21. Causes of Infant Deaths 30% congenital malformations 13.8% respiratory and cardiovascular diseases

22. FETAL MORTALITY

23. Trends in foetal deaths and fetal death rates, 1955-2006

24. Health Service Delivery (Organization and Administration)

25. Four Primary Mechanisms: Public health centers – prevention and maintenance, Physician offices – solo-practice physician in smaller communities Clinics – in large communities, in-/outpatient care offered Hospitals – more than 20 beds and contain higher level of technology

26. Public Health System 411 Public health centers by perfectures – doctor, dentist, pharmacist, veterinarian, X-ray specialist, nurse, dietician – Regulatory (licensing, sanitation) 2,692 Municipal health centers – Community health promotion – General services

27. The four subsystems are not always closely coordinated and continually compete for resources. Traditional medicine is extensively practiced and herbal medicines are widely sold.

28. Organizational Structure

29. Health Insurance System There is universal coverage of the population by statutory health insurance Three insurance schemes: – SMHI, for employees of large companies and their dependents – GMHI, for employees of small to medium-sized corporations and their dependents – NHI, for the self-employed

30. Public-administered financing through numerous schemes, Delivery is highly fragmented/decentralized, Private hospitals dominate the hospital system, Hospitals operate as a closed system, There is freedom to choose providers, There is no gate-keeper system,

31. Payment system is fee-for-service under a national uniform price schedule, There is long waiting time but short consultation time, Expenditure on drugs comprises a high share of total health expenditure, There is no complete separation of drug prescribing and dispensing,

32. Utilization of Health Facilities Overutilization – 14 consults per person per yr (vs 4 consults in US, 2003) – 13.8 days ave. stay in acute beds in hospital (vs. 5.6 US,2006) – Overprescribing of diagnostic tests (doctors own equipment) Source: The Challenge of Reforming Japan’s Health System. McKinsey &Company Nov 2008

33. Responsiveness and Client Satisfaction Long waiting time – 50% of the time > 30 mins Short care time spent with physician -13.5 % < 3 mins, 54% 3-9 mins Source: 2010 Japan Ministry of Health data

34. Financial Risk Protection Overall Health spending – 14% in out of pocket expenditures

35. HUMAN HEALTH RESOURCE James Salisi

36. Pharmacists Only secondary role versus physicians in dispensing medications

37. Nurses 980 nurses per 100,000 (2008 data), improved from 821 in 2000 Nurses in Japan have similar situations as in other OECD nations—lack of autonomy, low salaries, lack of professional recognition, MDs in teaching positions Public health nurses have most advanced training Clinical nurses Nurse midwives Assistant nurses

38. 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 ( Tracey Lynn Koehlmoos, PhD, MHA,Lecture 13, HSCI 609 Comparative International )

39. Physicians Decline in number especially in pediatrics and obstetrics – 222 per 100,000 in 2008 (very low for OECD, since average is 300 per 100,000) No academic differentiation between specialist and generalists 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 ( Tracey Lynn Koehlmoos, PhD, MHA, Lecture 13, HSCI 609 Comparative Internation )

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

41. Midlevel and other Health Professionals Allied medical professions have been slow to develop Midwives, health admin, mental health counselling, psychotherapy, Medical technology Emergency medical services Long term care

42. HEALTH FINANCING

43. Universal insurance (all employers offer coverage for employees and dependents, 1995) –started 1961 National insurance program supplements for those not fully employed Health Insurance Law of 1922 New Medical Service Law 1948

44. Health costs are lowered by: – limiting prices for pharmaceuticals and discouraging high-cost services

45. Promoting an appropriate combination of the fee-for-service reimbursement system (medical fees are paid for each medical act) and fixed payment system (a fixed amount of fee is paid regardless of individual medical act), and encouraging appropriate division of roles and collaboration between hospitals and clinics.

46. Health and welfare services for disabled and senior citizens The proportion of Japan's social security expenditure to national income registered 24.4 percent. (70% elderly cost) – SHJ 2010

47. Distribution of health spending 49.2% insurance 36.4% taxes 14.4% out of pocket 1/3 of spending for elderly Source: Japan:Health Systems Review,vol. 11, No.5, World Health Organization, 2009

48. Health Spending 6.6% of GDP (Gross Domestic Product), among the lowest in OECD countries, from a low of 2.6% of GDP in 1956, yet GDP growth is stagnating $ 2,600 per capita in 2005

49. Health Facilities 80% of hospitals and 94% of clinics(20 beds) are privately owned

50. Health Regulation and Governance

51. The New Medical Service Law (1948)  basis for development and regulation of healthcare facilities  Medical Care Council recommends and coordinates hospital services and clinics Health Promotion Law (2002) – importance of an environment conducive to healthier lifestyles as strategy for the ageing society

52. Universal Insurance coverage  Coverage for all citizens including nonemployed in 1961

53. 1.Medical Care Act human and capital resources are regulated 2. Health Insurance Act financing is regulated

54. Regulation at central government level Supervision and regulation of health care providers (hospitals and clinics)regarding health insurance Pharmaceutical manufacturing and imports supervises the pharmaceutical industry over manufacturing, clinical trials and post-marketing surveillance

55. Regulation at prefecture level The Medical Care Act delegates regulation of health care providers (hospitals, clinics, pharmacies and health care homes) to the prefecture governments. stand in the forefront of activities and responsibilities health insurance reimbursement and health service management

56. Regulation and governance of the purchasing process Contracts for the insurance system with providers are made between the government and individual providers, and there is little room for the discretion of the insurers the government possesses sole purchasing power over health insurance practices

57. Regulating quality of care Medical Care Act sets the minimal standards of health care based on structural indicators such as health personnel and hospital facilities, the violation of which may result in criminal charges

58. Key Challenges to Japan’s Health System

59. Challenges to Japan’s Health Sector Aging Population Differential Insurance Benefits Inadequate Coordination between Public and Private Health Care Obsolete physicians Health worker shortage Duplication and Overlap of Providers Inadequate Incentive Structure Insufficient Attention to Modern Management

60. Aging Population ¹ Japan has the world's oldest population¹ – by 2050, 40 percent will be 65 or older – Treatment will be more expensive for anticipated case mix – Demand for medical care will triple in the next 25 years ¹Harden B. Health Care in Japan: Low-Cost, for Now: Aging Population could Strain System. The Washington Post. September 9, 2009.

61. Differential Insurance Benefits Basic benefits are universal Special benefits vary widely – Extras services are covered by private insurers – Costs are not effectively controlled² – Access to health care becomes a problem ²McKinsey. The Challenge of Reforming Japan’s Health System

62. Inadequate Coordination between Public and Private Health Care Little formal cooperation and coordination between the private health care system and locally based public health care system – Physicians as entrepreneurs Unmitigated development of private health care providers

63. Obsolete Physicians No continuing medical education for physicians – Head Surgeon of Tokyo Medical University lost 3 out of 20 patients he performed a heart valve operation on; he was not trained to do heart valve surgeries No academic differentiation between general practitioners and specialists

64. Health Worker Shortage Physicians aggregate in lucrative fields like dermatology and ophthalmology and avoid surgery because of its stressful nature Not enough surgeons, obstetricians, and nurses, anesthesiologists, emergency room physicians – Low pay, long hours, stressful job

65. Duplication and Overlap of Providers Hospitals experience a “crowding-out” effect – Space for emergency care and serious medical conditions are taken by routine treatment³ No gatekeeper for medical care or hospital stay Japan has three times as many hospitals as the US per capita 3 3 Harden B. Health Care in Japan: Low-Cost, for Now: Aging Population could Strain System. The Washington Post. September 9, 2009.

66. Inadequate Incentive Structure Does not encourage careful practice because services are rewarded regardless of quality or the skills of provider – Physicians are revered, their decisions are rarely questioned

67. Insufficient Attention to Modern Management Relative lack of hospital administration – Lack formal systems to evaluate quality and appropriateness of care Overutilization of unnecessary medical procedures – Physicians with no administration training continue to dominate decision making

68. HEALTH CARE REFORMS

69. Outline of Reforms YearREFORMS 1922Health insurance law(private sector) 1938Ministry of Health & Welfare established National Health Insurance Law 1948Medical Service Law, Public Health Center Act, Act on Nurses & Midwives 1961Universal Health Insurance completed 1982Health Services for the Elderly Act 1985Revision of Medical Care Act 198910 year Plan for Elderly (Gold Plan) 2002Health Promotion Act or Healthy Japan 21 2006Structural Health Care Reform Act, 2008Elderly Health Care Security Act

70. Medical Service Law 1948 –Post war period –Medical facilities destroyed, shortage of Personnel –Formalized the system, allowing physicians to open own practice or clinics –Together w/ Act on Medical Practitioners, Nurses and Midwives

71. National Health Insurance National Health Insurance Act in 1938 – Included the farmers, self-employed – Low coverage since voluntary participation – Approximately 30 million still uninsured Source: Growth of Economy and Accomplishment of Universal Medical Insurance and Pension Programs: 1955-1964, Japan Ministry of Health website

72. Universal Health Insurance Completed in 1961 – Required all citizens to be insured – Increased subsidies to 30% from the national to municipal government

73. Separation of prescribing & dispensing Stipulated in 1874 Medical Act but not implemented 1980s Advocacy for implementation 1990s – 54% drugs dispensed by pharmacists

74. Health Services for the Elderly Act 1982 – Financial redistribution mechanism for elderly insured – insurers with higher than national average enrolment will contribute less and vice versa

75. Gold Plan 1989 –10 year Strategic Plan for Health & Welfare Services for the Elderly –Each municipality then had own Health & Welfare Plan –However, heavily relied on taxes for financing the plan

76. Healthy Japan 21 2000 –Addressed the increasing # of lifestyle-related diseases –Influenced by the Healthy People 2000 of US, where smoking is declining –National Health Promotion in the 21 st century –Community level involvement

77. Healthy Japan 21 2000 – 9 areas (smoking, alcohol, nutrition, exercise, leisure, circulatory, diabetes, cancer)

78. Health Care Reform Package 2002 – For 1 st time in Japan history, Health expenditures decrease due to price reduction in medical fee (2.7%), thus *decrease in overall health spending by 0.7% Source: “Japan and Massachussetts: a Comparison of Universal Health Care Systems”

79. Structural Health Care Reform Act 2006 – Addressed problems in inequality in elderly enrolment – Effectively separated the insurance of 75 yrs old from other insurances

80. Elderly Health Care Security Act 10% co-insurance for old-old above 75 yrs 30%co-insurance for young- old,65-75 yrs

81. TELEMEDICINE and COMMUNITY Health Centers addressed lack of physicians in rural areas – Manned by nurses – Use of Information technology

82. 2 year Mandatory Internship in General Medicine 2006 – Addressed the “stagnation” of Japanese doctors – Mandatory before practice of medicine – General residency (focus medical and surgical areas)

83. Japanese Residency Matching Program 2003 – Addressed the “stagnation” of Japanese doctors – Similar to US, where a doctor is matched to the appropriate training hospital

84. Recent Innovations Toyono town in Osaka Perfecture – Telephone consultations – Primary care services in emergency rooms – 80% drop in # children treated in emergency rooms

85. Remaining Issues Lack of monitoring in reimbursements of insurance Lack of assessment mechanism of cost effectiveness of medical interventions Lack of incentives for personnel for results (more incentives if more patients) Lack of accreditation of physicians

86. THANK YOU and Have a Good Day!