Ruling on ‘mixed’ treatment

If one combines medical treatment covered by public health insurance with medical treatment not covered by such insurance, using newly developed treatment methods or drugs not yet approved by the public health insurance system, in principle one has to pay all the costs for both types of treatment.

A kidney cancer patient from Fujisawa, Kanagawa Prefecture, received interferon treatment, covered by public health insurance, and another treatment not covered by such insurance. He had to shoulder all the costs for both types of treatment due to the government rule on “mixed medical treatment.” He filed a lawsuit to get public health insurance benefits for the interferon treatment.

In 2007, the Tokyo District Court ruled in his favor, saying that no explicit legal provisions to back the rule existed. But in 2009 the Tokyo High Court reversed the ruling. On Oct. 25, in its first ruling of its kind, the Supreme Court supported the government rule.

Under the Health Insurance Law, certain types of advanced treatment methods or drugs not yet approved by the public health insurance system are allowed to be used in combination with medical treatment covered by public health insurance. In these cases, public health insurance benefits are provided for the portion of the treatment covered by such insurance, constituting exceptions to the rule on mixed medical treatment.

The 2009 high court ruling said that the existence of these exceptions means that mixed medical treatment not covered by them cannot receive any public health insurance benefits. The top court’s No. 3 Petit Bench in a 5-0 decision upheld the high court’s reasoning. It said that some constraints on public health insurance benefits are unavoidable in order to ensure safety and efficiency of medical treatment and due to financial restrictions. But the government must pay attention to the fact that three of the five justices called on it to expand the exceptions to the rule on mixed medical treatment by accepting medical treatment methods and drugs whose safety and efficiency have been established abroad.

The government must engage enough experts to quickly test newly developed medical treatment methods and drugs with a view to safety, efficiency and reasonable prices. It should realize that its approval system is not speedily responding to calls by doctors and patients for advanced medical treatment methods and drugs.