Working the system: Beware of doctors with private rooms
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. To many people that may not sound like a lot of money for an operation, but A-san’s mother couldn’t pay it so A-san would have to, and she was bothered by the room charge.
The doctor then gave a rather odd justification. He said for the operation he would need the assistance of two other doctors, including an anesthesiologist, and that he would have to bring them in from outside. So the fee for the private room was essentially to pay for these two doctors. After the consultation, the administrative nurse told A-san that she would need to leave a ¥100,000 deposit and sign two forms, one a consent for the surgery and the other an agreement to pay for the private room.
A-san said she wanted a second opinion. A week later she went to a public hospital where the doctor advised against the operation because of her mother’s age, and instead suggested a different, non-invasive treatment plan for the condition. It was obvious to A-san that the private gynecologist saw a good way to make money off her mother’s case. In addition to getting paid by the government for the surgery, he could make extra money on the private room, more money than if he had non-private rooms that were reimbursed by insurance. (We won’t get into the tendency of Japanese doctors to require long hospital stays after routine procedures.)
The problem is that he doesn’t have full-time doctors on staff to do these kinds of operations since he probably doesn’t do enough of them; or, he’s just too cheap to hire full-time doctors. That’s why he has to bring them in from outside on a case-by-case basis. But given the relative sophistication of his home page, which is what attracted A-san in the first place, he obviously wants more surgery business, perhaps because fewer women are having babies these days. There are a lot more older women who may need these operations, and this doctor, at least, sees a potential gold mine.
Photo by Victor Lee used under Creative Commons via Flickr.