/ |

Health care system needs a new diagnosis

by Philip Brasor

Special To The Japan Times

In March 2007, the city of Yubari in Hokkaido became the first Japanese municipality to declare bankruptcy, letting loose a flood of media coverage characterized by expressions of sympathy for residents. Yubari’s debt had reached ¥63 billion, the result, according to national press reports, of an inept, self-serving local government. Monta Mino, the busiest man on TV at the time, visited the town himself and produced a program that commiserated with locals on their suffering at the hands of “politics.”

One fixation was the loss of vital medical services, since hospitals had to cut staff and clinics were closing or moving. Old people and the chronically ill were left to die, it was implied, but Dr. Tomohiko Murakami, who used to run the city hospital, says this was mostly fiction. In his book “Iryo ni Takaru na” (“Don’t Be a Medical Parasite“), Murakami pins Yubari’s fiscal problems on its residents.

Yubari was once the wealthiest mining region in Japan. Contrary to the image of coal-producing towns as dark, dirty places, it was a city of 116,000 people whose standard of living in the 1960s and ’70s was higher than the Japanese average. The companies that grew rich from their employees’ labors provided them with free housing, free utilities, free medical care and even free movie tickets.

When the mines closed, the town’s fortunes deteriorated, but expectations remained the same. The local government couldn’t provide the same level of service, though it tried and went broke in the process. Media outlets ignored this reality because it didn’t fit a dramatic narrative of common folk betrayed by the system.

Murakami’s main point is that his hospital’s fiscal problems were not caused by mismanagement so much as a social attitude that sees medical care as an entitlement exclusive of other health considerations. As a doctor, he tried to emphasize preventive measures, which not only help people stay healthy but reduce medical costs, but the people he served only cared about treatment because the medical system encourages this attitude. Moreover, the media reinforces it by looking at all sick people as objects of pity rather than individuals who don’t take care of themselves.

Murakami’s thesis is at the heart of the government’s difficulties in reining in the enormous cost of the national health insurance system. Medical expenses in Japan now amount to ¥39 trillion a year, ¥10 trillion of which is used to treat so-called lifestyle diseases, including ¥2 trillion for high blood pressure, ¥1.2 trillion for diabetes and ¥800 billion for cardiovascular problems. Lifestyle diseases are preventable, but they are also profitable, and unlike Murakami, many physicians don’t mind their patients’ entitlement-minded approach to health maintenance since that’s how they stay in business.

According to Dr. Kazuyo Tsushita, writing in the Tokyo Shimbun, “relying solely on medical effectiveness can place a greater burden on your body” through overuse of medication and treatments. It also has other negative effects, as demonstrated in some recent news stories. Several weeks ago a doctor in Machida, western Tokyo, was arrested for deliberately trying to kill a dialysis patient by removing his connecting tube, causing him to bleed out. The doctor’s bizarre behavior was reportedly prompted by overwork that led him to attempt suicide and then murder. His clinic specializes in dialysis, which accounts for 10 percent of all medical outlays in Japan. More than 280,000 Japanese receive dialysis treatment, which is expensive and thus a major revenue source for clinics and hospitals. Some experts believe Japanese doctors diagnose kidney disease too easily so that they can prescribe dialysis.

The same goes for the mental health field. Japanese psychiatric institutions have 340,000 beds — 20 percent of the world’s total. Outpatient care isn’t as profitable as inpatient care. International mental health groups have criticized this tendency, and the health ministry has responded by proposing that the classification for psychiatric hospitals be changed to that of “general housing with attendant medical services,” which, inadvertently or not, would hide the inconvenient statistic.

The government is compromised. On the one hand it must cut medical expenses. On the other hand it is in thrall to the medical profession, and despite the occasional horror story about botched surgeries and improper use of anesthesia, so is the media, which promotes cutting-edge treatments on news and variety shows with the help of the Japan Medical Association (JMA). Last week, Asahi Shimbun, which has been the most dogged media outlet in reporting profligate medical care, nevertheless ran a long article on a new diabetes drug that will make its American manufacturer and Japanese distributor very rich.

Some years ago the health ministry formed two inspection organizations to check billing statements to find out if hospitals and clinics were properly charging the insurance system. In 2010, the then ruling Democratic Party of Japan decided it was inefficient to have two bodies doing the same thing and proposed merging them, but so far nothing has been done. According to Asahi, the two groups charge a total of ¥120 billion a year for their work while collecting only ¥60 billion in refunds for incorrect billings.

Interestingly, South Korea’s inspection system, which has reduced medical costs by 20 percent since 1997, was devised by a man who studied billing systems in Japan. The main difference is that Korea uses computers. All Japanese inspections are done by people from the medical field, which is like asking foxes to review security designs for a new henhouse. In 2009, the man returned to Japan as an adviser on medical charges, but his suggestions were rejected because JMA is opposed to “machine inspections,” which is the norm in the developed world. Japan may have vanguard medical technology, but it’s still facing backward when it comes to medical self-regulation.

  • Stephen Kent

    I think Dr. Murakami is right to some extent when he says Yubari’s bankcrupcy was the fault of the its citizens for not taking care of themselves, but leaving it at that would probably be to ignore the problems of inadequate provision of information by the government and media, little if any legislative reform to ensure an environment in which people at least have the chance to take care of themselves, and the much wider problem of whether it’s a good idea to have a profit based medical system in the first place.

    Even in the US, with its largely privatized medical system, you still see government sponsored public service announcements attempting to raise awareness of the need to take care of your own health, and most rich countries now have smoking legislation to reduce the effects of second hand smoking. Not only does Japan have none of these things, but the government can’t even enforce its own labour laws which on paper allow people the requisite time for daily rest, exercise, and general well-being if properly implemented. On top of this, the finance ministry holds a 30% stake in Japan Tobacco and most TV programs have at least one sponsor from the medical industry. The overall message seems to be “get as sick as you like and we’ll fix ya”, but the fiscal health of the country shows that isn’t the case.

    Still, at least the current government are increasing military spending to make sure we’re all safe.