Yen for Living

Finance Minister Taro Aso has been shooting his mouth off again. Tokyo Shimbun reports that at a recent “meeting” he said it “wasn’t fair” that the country had to pay for the medical costs of people who “eat as much as they want and drink as much as they want and then end up with diabetes.”

Japan’s national health insurance does not discriminate between people who maintain good health and those who don’t. You pay according to your income. “Of course, if you have an inherent weakness, that’s another story,” Aso added, obviously recognizing that some people will take offense at his opinion.

Hospital bill for specified elderly patient (over 75), who only pays 10 percent out of pocket.

But apparently it’s something he’s thought about a lot. The Asahi Shimbun reports that during opening remarks at a Lower House “party” of some kind Aso said, “I think we should make an incentive for people who are making an effort to stay healthy.”

The government is trying to reduce medical costs, and he believes if someone over, say, 70 continually foregoes treatment for minor complaints that person should be rewarded. “Maybe give them ¥100,000 in cash,” Aso suggested. Then, those people who think they might as well go to the hospital for something small will think twice.

This idea has been floated before, but doctors’ groups, which would suffer financially from such a change in the public mindset, have protested, saying that discouraging people from seeking medical advice for anything is tantamount to killing them.

Aso claims that the average medical cost for a person over 70 is a million yen a year. We couldn’t corroborate that statistic, but fellow Liberal Democratic Party lawmaker Taro Kono, in his email newsletter, said that the average Japanese person costs the government ¥24 million in health care during his/her lifetime — paid for through both insurance premiums and taxes — and that 49 percent of all medical outlays are spent on persons 70 and over.

Then we thought of our own situation. We’ve been paying into the national health insurance scheme for 26 years and reckon we’ve spent almost ¥10 million. We can also count on the fingers of one hand how many times we’ve actually gone to the doctor in those 26 years for something that falls under our coverage, so obviously we aren’t getting our money’s worth — so far.

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Sleeping alone in a place like this could cost you.

Japan’s national health insurance system isn’t perfect, but it’s fairly airtight. Unless you have a condition that might benefit from some sort of experimental treatment which has yet to be approved by the government, everything is covered, meaning you won’t pay more than 30 percent of the cost of that treatment. And if the amount you do pay exceeds a certain amount, the government will pay for most of that as well, so there is very little danger of, say, a patient having to mortgage his house to pay for care, even for a so-called catastrophic illness, which is something that occasionally happens in the United States.

But that doesn’t mean there aren’t medical situations where people end up paying a lot of money; it’s just that they probably don’t have to. This is why we’ve always been mystified by the supplemental health insurance business in Japan. Why buy extra insurance when the national system takes care of everything? One of the main reasons is private rooms, which the government doesn’t pay for. National insurance covers overnight stays, but only for non-private rooms, and only a very limited amount. If a patient wants a private or semi-private room, or even a special type of bed in a non-private room, he or she has to pay for it out of pocket.

Some doctors use this exception to make money. An acquaintance of ours, whom we’ll call A-san, recently told us a story about a visit she made to a private gynecology/obstetrics clinic in Saitama Prefecture. A-san was worried about her 77-year-old mother, who lives separately from her and has been suffering from a gynecological disorder for almost a year. Though she had been to her local hospital, the doctor there said he could not treat the condition properly, and while it wasn’t life threatening, it made everyday life difficult. A-san’s mother is on a fixed income and not tech-savvy, so A-san Googled the name of her condition and the first clinic that came up in the search said it had experience treating elderly women for that particular condition and happened to be not far from her mother’s home. She made an appointment.

The clinic’s owner and only doctor was quite chatty, and, after examining her mother, he told A-san that she needed an operation, and that because she had special insurance for elderly people she would only pay 10 percent of the surgery cost. In addition, since the surgery was expensive, she could apply for the kogaku iryo (high cost medicine) system, which would refund most of the 10 percent she would normally have ended up paying. In the end, she would only have to pay ¥44,400 for the actual operation.

But there was a catch. The clinic, which mostly catered to expecting mothers, only offered private rooms for ¥16,900 a night. The doctor said that following the operation, A-san’s mother would need to remain in the clinic for 10 nights, so altogether the operation would cost more than ¥200,000, not counting transportation to and from the hospital and whatever medication she would have to take. An interesting justification for extra charges...

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As long ago as the early 1980s the health ministry made it a priority to get more people to undergo cancer screenings in order to detect the disease at its earliest and easiest-to-treat stages. By 2009, the goal was to have 50 percent of the targeted adult population receive annual tests for five types of cancer — colon, stomach, breast, uterus, lung — by 2012. That goal was not reached, so they moved it back another five years, but since the overall screening rate at present is still somewhere between 20 and 30 percent, it doesn’t appear the ministry is going to achieve that goal either.

I’ll take one from column A, and…: Cancer screening menu distributed by local government (click to enlarge).

According to an article in Asahi Shimbun, the main obstacle is income. A center for adult diseases in Osaka analyzed surveys carried out by the health ministry and found that the higher a person’s income is, the more likely he or she is to undergo cancer screenings. In fact, screening rates have a direct correlation to the public health insurance program a person is enrolled in. For instance, 48 percent of males enrolled in the Kyosai Kumiai insurance program receive colon cancer screenings. The rate drops to 38 percent for a man in the Kumiai Kenpo program, 27 percent for one in the Kyokai Kenpo program, 19 percent for those who use regular kokumin hoken (national insurance), and only 13 percent for people on public assistance, who get their insurance free.

Kyosai Kumiai members are national and local civil servants, including public school teachers, whose average income in 2009 was ¥2.36 million. Kumiai Kenpo is insurance for companies with 100 or more companies, of which the average member makes ¥1.95 million. Kyokai Kenpo is for companies with less than 100 employees. Their average salary is ¥1.39 million. Regular kokumin hoken is for part-timers, pensioners and the self-employed, who average ¥910,000 a year. People on welfare, of course, don’t have income.

Cancer checks are managed by local governments, who set up screenings at public facilities or cooperating hospitals and clinics, usually for limited periods at specific times of the year. The Osaka center found that part-timers, the self-employed and workers at smaller companies usually cannot take time off whenever they want to, and thus are less likely to be able to go to the facility when the screenings are being conducted, usually on weekdays. Moreover, they may not have the money to pay the nominal fees for the screenings, which can cost anywhere from a few hundred yen to ¥2,000 or more. Even though welfare recipients get free insurance, they have to pay these fees as well. And there’s a fee for each screening, so if you are a woman and undergo all five of the tests recommended it could cost as much as ¥10,000. And there are lots of tests for other types of cancer, each of which requires a fee.

Continue reading about cancer screening →

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The damage: bill for national health insurance

Last week, the Ministry of Health Labor and Welfare released the results of a survey of about 60,000 households regarding the government-run basic pension plan. The ministry found that about one-fourth of the people who are supposed to be paying into the plan had no income in 2009. In addition, 38 percent of participants made less than ¥500,000 for the year, and 54.7 percent made less than ¥1 million.

The basic pension, kokumin nenkin, is for people who don’t work for companies or organizations that contribute to their employees’ government-run pensions, meaning they are either self-employed, part-timers or unemployed (and not wives of salaried workers). In 2011 only 58.6 percent of people who were supposed to pay into the basic pension plan actually did. The obvious conclusion the ministry drew from these numbers is that the ranks of the poor are growing.

These findings are sobering, but one should keep in mind that while not paying one’s pension contributions certainly undermines the system it doesn’t affect the person in a direct way, since he or she does not benefit from those contribution until he or she is old. In any case, if a person can’t pay the monthly ¥14,980 basic pension contribution because he or she is unemployed, the person can apply for an exemption.

Continue reading about national health insurance →

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As the government continues looking for ways to reduce expenses in the face of the world’s biggest debt burden, every ministry is expected to pitch in. The Health, Welfare and Labor Ministry has probably the biggest job in this regard since it is responsible for the primary drain on future fiscal resources, namely all those old people on the horizon. We’ve already talked about the ministry’s attempt to make elderly patients pay a little bit more for their care, a scheme that was shot down by doctors who say such a move would discourage older people from seeking the help they need, though critics suggest the doctors are worried more about their own bottom lines.

In light of the health ministry's plan, patients looking to save on healthcare would do well to fall ill early in the week (Kyodo photo)

Now the ministry has come up with another money-saving plan that will likely irk the medical profession. Starting in April, the ministry will start withholding reimbursements for basic hospitalization fees if the hospitalization is deemed to be “unnecessary.” At issue is weekend hospital stays, which the ministry believes are wasteful. When the length of a hospital stay was measured against the day that the hospitalization began, the longest ones were found to start on Fridays, with an average of 18.14 days. In contrast, hospitalizations that begin on Wednesday average three days less. The ministry concludes that Friday-start hospitalizations are longest because nothing is really done over the weekend, and that whatever treatment is involved begins in earnest on Monday. However, the patient has to pay for the weekend hospitalization and national insurance will reimburse him or her for much of that payment. Hospitals can charge the full amount for the stay even though their personnel and overhead costs over the weekend are less than they are during the week.

The health ministry’s plan is to pay less for weekend hospital care. The point is to dissuade hospitals from starting patient stays on Fridays, but the ministry also wants to persuade them to discharge patients before weekends as well. The basic hospitalization fee (nyuin kihon ryokin) that the ministry now pays is between ¥9,340 and ¥15,550 per day, and no matter what time of day the patient is discharged, the hospital seeks payment for the full day, so theoretically a hospital can discharge a patient early on Monday morning and receive three extra days of fees without doing much of anything except feed the patient. Hospitalizations that end on Monday last for an average of 17.9 days, while those that end on Saturdays last three days less. Consequently, the ministry will not reimburse payments for a full day when the patient is discharged before lunch.

Japan is famous for its long hospital stays, which critics say have more to do with Japan’s national health insurance system than it does with quality of care. Hospitals want to make as much money as possible from patients and so are believed to “recommend” long hospitalizations. It’s why old people in Japan invariably die in hospitals rather than at home or in hospices and nursing homes.

So far, private insurers haven’t commented on the ministry plan. Since private medical insurance is mostly supplemental in that it provides subscribers with cash depending on how many days one is hospitalized, these private insurers should also be concerned if hospitals are keeping patients for unnecssarily long stays, but then again the whole idea of long hospitalizations is what makes their insurance policies attractive. If hospital stays were significantly shorter, most people wouldn’t see the need for supplemental insurance in the first place.

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Drive 'n' drill: Former convenience store turned into dentist's office

Recently, the Japan Medical Association protested the government’s desire to increase the number of medical schools as a means of solving the doctor shortage. The JMA says that more physicians will undermine the pay potential of all doctors and points to the situation of dentists, whose average salaries have decreased markedly in recent years due to a glut.

In a society aging as rapidly as Japan’s is, you can never have too many doctors, but dentists? As a medical practice, dentistry tends to be self-defeating. The better job dentists do in promoting oral hygiene, the less there is for them to do. Like America in the ’50s and ’60s, Japan became more aware of dental health in the ’80s and ’90s and people spent more money on their teeth and those of their children. Such a development had two outcomes: More young people turned to dentistry as a career, and people’s teeth became healthier. Since the latter meant that people required less capital-intensive dental work in the long run, dentists on the whole made less money, especially since their numbers grew as the years progressed.

Consequently, fewer students are opting for careers in dentistry, which is bad news for dentistry schools, especially private ones. According to a recent article in the Asahi Shimbun, the number of university students who said they “wanted to enter dentistry” dropped below 10,000 for the first time in 2008. A year later that number had plummeted to less than 5,000. This year, the number of applicants to the nation’s 17 private dentistry schools is less than the number of openings.

Continue reading about dentistry in Japan →

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At the end of September the Ministry of Health Labor and Welfare released figures for medical care expenditures in fiscal 2009. Based on national insurance records, Japanese people spent ¥36.67 trillion on medical care that year, a 3.4 percent increase over 2008. That boils down to ¥282,400 for each man, woman or child, which is a 3.6 percent increase over the previous year. Broken down demographically, patients between the ages of 65 and 74 accounted for 55.4 percent of money spent (¥19.94 trillion) and patients 75 and over 32.6 percent (¥11.73 trillion). Per capita, Japanese under 65 spent ¥163,000 for the year, those between 65 and 74 ¥687,000, and those 75 and older ¥855,800. In terms of sources of revenue, 48.6 percent (¥17.5 trillion) came from premiums for both the Kokumin Kenko Hoken (National Health Insurance) and the Kenko Hoken (Employees Health Insurance) systems; 37.5 percent (¥13. 49 trillion) came from national and local taxes; and the remaining 13.9 percent (¥4.99 trillion) came from patients’ pockets.

The kid stays in the picture: JMA ad against proposed ¥100 fee

These amounts were the highest since MHLW started keeping track. Japan’s Gross Domestic Product went down in 2009, but the portion of GDP accounted for by medical care, 7.6 percent, was higher than the previous year’s portion, which means that not only is more money from premiums being spent, but more people are paying out-of-pocket for medical care, since 10-30 percent of a doctor’s and pharmacist’s bill is paid for by the patient. This portion can be extremely large when hospitalization or special treatments are involved, and in many cases where patients’ expenses are exceedingly high (kogaku iryohi) the government will reimburse them depending on their individual incomes. The MHLW has decided that the current pay schedule for this excessive medical expense system is obsolete, and has restructured it to allow more income brackets and higher reimbursements. The problem is that as the population ages revenues from premiums are going down since people over a certain age pay less, even as they use more insurance. So where are they going to get the money to fund this new excessive medical expense system?

The provisional answer is something called the madoguchi futan (literally, “window burden”), a ¥100 fee that will be added to every doctor’s visit and paid by the patient. The Japan Medical Association has roundly condemned this fee, saying that it penalizes older people and others on fixed incomes, effectively widening the gap between rich and poor. In the long run, it will discourage lower income people from seeking medical help.

Continue reading about bump in doctots' fees →

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