Posts Tagged ‘national health insurance’

Some local governments think health checkups save money, and some don’t

Saturday, April 5th, 2014

Preemptive stride: If you do have metabolic syndrome you can guess what the doctor will tell you to do

Preemptive stride: If you do have metabolic syndrome you can guess what the doctor will tell you to do

Though there’s a minority opinion to the contrary, conventional wisdom says that regular health checkups are the only way to prevent the development of major illnesses, so, logically, they should also help reduce healthcare costs in the long run. This is the concept behind tokutei kenko kensa, or “special health checkups,” that were started six years ago by the Ministry of Health, Labor and Welfare. The main target is metabolic syndrome, the inevitable gain in fat that accompanies midddle age and which, unchecked, is thought to be the gateway to many so-called lifestyle diseases, like diabetes.

The idea is that local governments would provide checkups to insured residents between the ages of 40 and 74 with national insurance, which, in principle, doesn’t cover regular general health checkups since Japan’s public health system is designed to treat existing problems. If the special checkups uncover unhealthy situations, then the individuals are advised with regard to better diets or exercise regimens, or even pharmaceutical assistance, so as to head off costly treatment down the road, like, for instance, dialysis, which can cost on average ¥5 million a year, most of which ends up being paid for by the government, both local and central.

According to the Asahi Shimbun more than half the nation’s local governments are struggling with deficits in their health insurance programs, and thus usually have to shift money from other sectors to pay for them. Consequently, many are intensifying their checkup programs in the hope that it will reduce these costs in the future. The tricky part is that with such programs you have to spend money to save it. As of 2012, Soja in Okayama Prefecture was only seeing 27 percent of residents eligible show up for the special checkup, so they came up with a scheme.

The special checkup and the locally sponsored cancer screening each cost ¥5,000, so if anyone who undergoes the checks and doesn’t use their insurance for a year afterward, the money will be refunded. Though it may not sound like much of an incentive, the main idea is to spread awareness of the checkups. Kiyosu, a city in Aichi Prefecture, increased its checkup rate to 46 percent after offering coupons that can be used for substantial discounts at over 100 stores and restaurants in the area to people who come in for the checkup. People who undergo the checkup are told not to eat anything that day beforehand, so the coupons are a kind of reward, though one has to wonder if it’s wise to encourage people who really do have metabolic syndrome to go out afterwards and partake of the town’s meibutsu (special local product), fried pork cutlet in sweet brown sauce.

Kumagaya in Saitama Prefecture saw its participation rate rise from 23 to 27 percent after it started offering travel coupons. Takanabe in Miyazaki Prefecture partnered with a local bank to offer participating residents a 0.05 percentage point bonus in interest on savings accounts, and the rate of participation jumped from 32 to 40 percent. Six separate districts in Higashi, Okinawa Prefecture started a competition to see which one could raise their participation rate the most, with the winning districts receiving cash bonuses ranging from ¥30,000 to ¥100,000, but since it was the district offices themselves getting this money it was difficult to pass the excitement of competition on to individual residents. In fact, after an initial spurt in participation the rate has fallen back down again, so the local governments are thinking of a new scheme that directly rewards residents.

Nationwide, however, the idea hasn’t been very successful. The health ministry aimed for a 65 percent participation rate, but latest figures show it’s only about 34 percent, a rise of only 2.8 percentage points since the checkup scheme was launched. For the most part, according to Asahi, local governments have no choice but to raise premiums on health insurance to address their deficits. The reasons for non-participation are not complicated. In surveys, people say they already visit a doctor regularly or don’t feel sick or just think it’s too much trouble, especially since many municipalities charge a nominal fee for the checkup.

In any case, there isn’t any real consensus on the efficacy of regular checkups on long-term medical costs. The city of Amagasaki did a study from 2008 to 2011 that found during these four years the average amount of money spent by the health insurance system on a resident who had undergone the checkups “and received medical advice” — about 65,000 people — was ¥990,000 less than the money spent on a resident who didn’t receive the checkup. However, Kure, in Hiroshima Prefecture, managed to decrease its outlays for medical care by ¥160 million in 2011-12 by eliminating “unnecessary” examinations, meaning they actively discourage residents from seeing a doctor for routine matters, and didn’t promote the special checkups, either. One bureaucrat told the Asahi that he understands the “significance” of the checkup but wonders if it may actually be a waste of money given that its underlying purpose is economical.

Insurance companies main beneficiaries of scheme to protect obstetricians from malpractice suits

Thursday, June 13th, 2013

In late May, 1,041 former obstetrics patients of 28 medical facilities submitted a plea to the National Consumer Affairs Center (NCAC) to arbitrate a settlement with the Japan Council for Quality Health Care (JCQHC) that would partially refund money they had paid during their pregnancies for insurance purposes. The JCQHC is a foundation that carries out third-party evaluations of hospitals and clinics, but it also oversees a special compensation system enacted by the government in 2009 to protect obstetricians from career-threatening malpractice suits.

The system allows for a form of insurance that all obstetrics patients, meaning pregnant women, pay into. If a fetus or baby suffers brain damage before or during delivery, the insurance pays up to ¥30 million in damages over the next 20 years to the child and his or her parents. This no-fault insurance system was put in place because fewer medical students were opting to become obstetricians, partially because the dwindling birthrate has made obstetrics less profitable, but mainly because malpractice awards in the cases of babies born with disabilities have been extremely high. It was just too financially risky to go into the field.

Pink is the color of the obstetrics department

Pink is the color of the obstetrics department

Unless a pregnancy threatens the well-being of the mother, childbirth is not covered by national health insurance. Though in theory the obstetrics insurance is optional, if a pregnant woman patronizes a medical facility that pays into the insurance system (meaning 99.8 percent of them) they automatically charge her the ¥30,000 premium and incorporate it into her bill. What complicates the matter is the so-called “public aspect” of the system, according to a recent article in Aera magazine.

To encourage women to have babies, local governments compensate them for the money they spent on childbirth after the fact with something called shussan ikuji ichijikin (one-time payment for childbirth), a handout administered by the National Health Insurance Union (NHIU) of up to ¥420,000 per birth, regardless of how much money the patient spent.

This amount includes the ¥30,000 premium that the woman paid for the obstetrics insurance, so in effect the public is paying for the insurance since the NHIU uses taxpayer money as well as national health insurance funds for payments. In that regard, Aera has characterized the JCQHC as an amakudari institution; in other words, a bureaucratic entity whose main purpose is to justify its own existence.

Since the insurance system was launched in 2009, it has paid out about ¥4.1 billion in compensation for damages suffered during childbirth. At the end of the last fiscal year there was still about ¥80 billion in the reserve pool of funds and it is estimated the pool, which is controlled by the five insurance companies, will increase to ¥100 billion by the end of the present fiscal year.

According to Aera, the JCQHC originally estimated that between 500 and 800 babies would suffer brain damage every year out of the country’s 1.2 million births, but real statistics for fiscal 2012 show that only about 200 babies suffered such damage. The mothers who requested arbitration from the NCAC are claiming they overpaid for the insurance and are demanding ¥20,000 each in refunds from the JCQHC. If they win, the organization will have to pay a total of ¥20.8 million. As Aera notes, more than 50 million women have paid this premium since 2009, though, strictly speaking, it is the public who has paid the premiums.

One obstetrician interviewed by Aera says that the reason all medical institutions sign up for the insurance is that part of the law mandates that any medical facility which applies for “high-priced medical care” compensation to the NHIU cannot be approved if it doesn’t pay into the obstetrics compensation insurance plan. Otherwise, the facility can only receive maximum compensation of ¥400,000 for each delivery, regardless of what it cost the facility. That’s too risky for smaller clinics.

The main beneficiaries of the system are the private insurance companies that participate. The premiums are practically free money since the companies are allowed to collect and administer the funds. Also, brain damage resulting in cerebral palsy is difficult to diagnose in an infant, and there is a five-year time limit for insurance claims.

In many cases, developmental disorders arising from brain damage don’t manifest themselves until the child is older and the time limit has passed. However, the insurance companies are also using this aspect to explain why they need such a huge pool of money.

Of children born in 2009 who were eventually found to suffer from cerebral palsy due to brain damage, 12 were discovered in 2009, 100 in 2010 and 158 in 2011. Diagnoses are thus progressive, so the insurance companies say they need this huge surplus to meet future claims. But there has already been discussion in the Diet that the funds should be administered by a government body so as to relieve some of the public burden associated with medical care.

In any event, as some pediatricians have noted, ¥30 million over 20 years is insufficient to take care of most people who suffer from cerebral palsy. They tend to require 24-hour care the older they get. As one mother who is part of the arbitration claim told Aera, a system for compensating brain damage victims directly would be cheaper, more efficient and more humane than the obstetrics compensation insurance, which benefits administrators more than doctors or patients.

Should healthy people pay less for health insurance?

Saturday, April 27th, 2013

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.

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.

Working the system: Beware of doctors with private rooms

Friday, December 14th, 2012

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...

Poorer people passing up cancer screenings

Friday, August 24th, 2012

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.

Cancer screening menu

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 →

How to keep your health insurance when you can’t pay for it

Saturday, July 14th, 2012

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 →

Hospitals redefine the meaning of ‘weekend getaway’

Tuesday, February 7th, 2012

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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