The hidden economics of diabetes
Last week the medical journal Lancet published the results of a study that found the number of diabetes patients rising rapidly throughout the world. Right now about 10 percent of the world’s population suffers from the disease, which is traditionally associated with countries that have higher standards of living, like the United States. However, Lancet reported that diabetes is reaching epidemic proportions in the developing world as well owing to obesity and inactivity. Since diabetes leads to all sorts of serious health problems, including kidney failure, heart attacks and blindness, the epidemic will add an insupportable burden to medical costs in the next century.
Diabetes is on the increase in Japan, too, and is one of the reasons the national health insurance program is in trouble. A recent report on NHK’s “Closeup Gendai” showed how local governments are trying to reduce doctor visits among local residents. In Kure, Hiroshima Prefecture, officials have compiled a database of people who may be contributing to “wasteful medical costs.” To qualify for the database, a person has to have visited a clinic or hospital at least 15 times during the course of a single month. An official then talks to this person to learn the reason for the frequent visits.
NHK points out that these inquiries are delicate. The doctor-patient relationship is a private one, and the local government is careful not to come across as interfering with that relationship. Nevertheless, many older people, because they pay very little out-of-pocket for a doctor’s visit, go to the hospital often even if their medical complaints are very slight. Some have even confessed to going to the hospital for social reasons, to chat with friends or make new ones. In any case, the local government official often suggests other ways of dealing with health problems in order to cut costs, such as asking for generic drugs when filling prescriptions or recommending lifestyle changes that can prevent future illnesses.
Lifestyle changes are central to controlling Type 2 diabetes, which accounts for 90 percent of diabetes cases in the world. Type 2 is controllable, which means in some cases changes in diet and exercise habits can keep the disease at bay. However, the program suggested that the local governments’ efforts may not have any effect since doctors aren’t necessarily participating. One physician interviewed by NHK said he didn’t think that any of his patients “didn’t need” to make so many visits to his office; and if, in fact, the number of visits they made — each of which is charged to national health insurance — was not justified medically, frequent visits contributed to a patient’s “psychological well-being” and were, thus, better for their overall health.
The suspicion that Japanese doctors take advantage of the health insurance system to boost income is widespread, and at least one physician, an anonymous neurosurgeon, has written on his blog that diabetes has proven to be a cash cow for many clinics. Though Japan’s outlay for medical treatment, about ¥30 trillion a year, is comparable to other developed countries, the amount it spends on dialysis is conspicuously large, about ¥1 trillion a year, or one-thirtieth of total medical costs. Dialysis is an expensive treatment for people with kidney disease, a common outcome of diabetes, and most clinics prescribe in-house treatments twice a week, which adds up to a bill of ¥400,000 per patient per month. Because it is so expensive, health insurance pays a higher percentage of the cost, so patients only pay between ¥10,000 and ¥20,000 a month. According to the neurologist’s calculations, there are 280,000 people in Japan receiving dialysis treatments, which means that 0.002 percent of the Japanese population is responsible for one-thirtieth of the country’s medical costs.
Japan accounts for 16 percent of the world’s dialysis patients, second only to the U.S., but in terms of “prevalence” of dialysis patients, Japan is No. 1. This isn’t to say that people in Japan who receive dialysis treatments don’t need it, but they may not need it as much. The neurologist implies that some clinics are making a lot of money by scheduling frequent dialysis sessions and then charging the insurance administration. They usually offer their dialysis patients free rides to and from the clinic. It’s a service for regular customers.