Who is paying the price of health care?

Committee slow to bring transparency to matters of national insurance


Japan’s health-insurance program is touted as being egalitarian, with treatment available at any medical institution in the nation to those people who pay monthly insurance premiums and 30 percent of their medical treatment, including diagnoses, tests and prescriptions.

Everyone who pays a premium has a stake in this system. Of the approximately 30 trillion yen yen that Japan spends on health care every year, about half is financed by monthly premiums. Not surprisingly, in a 2003 Cabinet Office opinion poll, Japanese citizens cited health and health care issues as their No. 1 concern.

But how many people actually know who decides medical fees and what is covered by national health insurance? The answer is very few.

Medical fees are determined by the Chuo Shakai Hoken Iryo Kyogi Kai (Central Social Insurance Medical Council), commonly abbreviated as Chuikyo. Once every two years, the Health, Labor and Welfare Ministry chooses Chuikyo’s 20 members from academia and various interest groups, ranging from a 160,000-member doctors’ group (Japan Medical Association) to a 97,000-member pharmacists group (Japan Pharmaceutical Association) to the 6.6 million-member labor union Rengo (the Japan Trade Union Confederation). On Feb. 15, the committee gathered at a banquet hall in the Kasumigaseki Building in central Tokyo to put the final touches on various medical fees, all to be published in a dictionary-thick book.

Although new faces have appeared on the committee over the years, the predominance of industry-group representation at Chuikyo and the its role as a price regulator has changed little during the past 50 years. In short, what is missing from this equation is the public’s voice.

Behind closed doors

For decades, the health ministry has had a quiet but crucial role in organizing Chuikyo meetings and drafting price-tweaking proposals, but it has done little to involve ordinary citizens. In fact, until 1997, all the decisions of the Chuikyo meetings were made behind closed doors.

While the Chuikyo has considerable influence over our lives, it has traditionally worked under the public’s radar. It took a scandal to bring the panel onto the front pages. In 2004, five officials from the Japan Dental Association were found guilty of bribing two Chuikyo members to speak in the group’s favor at the committee meetings.

In a report that examined the scandal the same year, the health ministry acknowledged that it needed to determine whether the scandal was caused by individuals, or by the outdated Chuikyo system itself. “People have said that even though the meetings have been opened to the public, the decision-making process is difficult for outsiders to follow,” the report stated, “leading to the impression that it lacks transparency.”

Since the scandal, Chuikyo has made efforts to become more open. This was partly reflected in the committee appointment last spring of Hisashi Katsumura, a high school teacher from Kyoto who is free of medical-industry ties.

Katsumura, who lost his newborn daughter due to malpractice 16 years ago, has campaigned for the mandatory disclosure of billing records by doctors. Previously, it was difficult for patients to receive detailed records of treatment expenses, and therefore submit them as evidence in malpractice suits.

It would appear that Katsumura scored a small victory on Feb. 15 when Chuikyo decided that hospitals must give patients receipts with rough breakdowns of the services provided, following a six-month grace period beginning in April. At the same time, the panel requested hospitals to “strive to give ‘detailed expenditures’ when patients request them.”

This wasn’t enough for Katsumura, however. He had fought the JMA representative, who claimed that such requirements would mean more costs, in the form of new printers, for hospitals.

“Supermarkets or convenience stores give you receipts showing exactly what you’ve paid for,” he said in an interview last week. “I’ve never heard of convenience stores that say that they can’t afford to buy a cash register. . . . The promise made by Chuikyo to give priority to patients views has been broken.”

Paying the price

Chuikyo is also responsible for deciding what kinds of medical care can be covered by national insurance. On Feb. 15, it was decided that smoking-cessation treatment could, on an experimental basis, be covered by insurance. This proposal, aimed at curbing overall cancer-treatment costs, was controversial from the beginning, with some members of the panel, including Rengo representative Shigeru Ojima, arguing that there was no national consensus on whether such visits should be covered by insurance.

“We are not disputing the existence of nicotine dependency, nor would we deny the problem of alcohol dependency,” Ojima said. “But we’re not sure how cost-effective it is to have insurance cover it.”

JMA, meanwhile, has generally advocated more spending and more insurance coverage for patients, though its reason for doing so might be self-serving. “JMA argues that whatever helps patients should be covered by insurance,” said Yasuhiro Yuki, a Tokyo-based social worker and author of a recently published book “Iryo no Nedan (The Price of Health Care).” “The fact is, though, they are only concerned about their own finances.”

There have been other small steps toward change. Since January the health ministry has announced the Chuikyo meetings on its Web site and allowed members of the public to attend sessions, if they register in advance. But such notices have generally come less than a week before the meetings. The ministry has also solicited, for the first time ever, feedback and suggestions via its Web site and held a public hearing on fee changes in Yokohama in late January.

Yuki, however, argues that these changes were only excuses. “If the ministry was really serious about incorporating the opinions of the public, it should have held a public hearing last year and put specific fee proposals on the table,” Yuki said. “A meeting in January was too late. What’s more, the ministry didn’t share its fee proposals with the public.”

Even to the most casual observer, the ministry’s lack of enthusiasm for involving the public is obvious. Although a ministry official present at a February meeting said that the minutes of the Chuikyo meetings are usually released “a month after meetings,” after each member has agreed on their content, the latest minutes — posted on the health ministry’s Web site — are from a Nov. 25 meeting and 10 more meetings have taken place since then.

Because the media has no reason to cover the proceedings in detail until final decisions are made, it’s virtually impossible for the average person to stay abreast of the discussions.

The health ministry, however, says it has tried to broaden access to the Chuikyo debate.

“This time, we did what we had never done before,” Atsushi Kawai, an official at the health-care section of the ministry, said. “We actively sought the opinions of the public, for example, by holding a public hearing.”

In the back row

I attended meetings held on Feb. 8 and Feb. 15. According to the health ministry’s Kawai, roughly 30 percent of the 426 attendees of the Feb. 15 meeting were health-ministry bureaucrats and officials from the very same professional organizations represented there. As for the remaining 70 percent, Kawai said they ranged from drug-company officials to private-sector researchers to college students. At any rate, the room was packed with besuited people.

While trying to follow the hours-long proceedings from a back row, I had to wonder if public opinion will have an effect on these meetings. Kawai admitted this is the first time the ministry had sought input from the Japanese citizenry.

Yuki said a drastic reform of the panel is unlikely — unless there is more external pressure to be more transparent. And it’s not just the government that is to blame, he noted.

“Patients still have the mind-set of ‘the doctor knows best,’ ” he said. “Maybe we need another scandal. Maybe we need a bunch of them.”

Katsumura, on the other hand, believes that no matter how open the committee is, the receipt issue is crucial. “The complete disclosure of the bills to the public would be good enough to empower patients,” he said. “As it is, they have no way of knowing for sure what medical procedures have been performed on them.”