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Shocking blog post forces debate on the financial drain of dialysis in Japan

by and

Special To The Japan Times

Last month Yutaka Hasegawa, the freelance announcer who hosted the TV Osaka program “News Real Friday,” caused a stir with a personal blog post criticizing people who receive dialysis treatments.

The regular theme of Hasegawa’s blog is how certain forces are “destroying Japan,” and the original title of the post in question stated that the current social security system was doing just that because so many people were undergoing dialysis, a notoriously expensive kidney disease treatment. These patients had caused their own illnesses, Hasegawa claimed, due to lifestyle choices, and so they should just be allowed to die rather than bankrupt Japan. Hasegawa got a bit carried away with his rhetoric, and simply said, “If they can’t afford (dialysis) and cry, just kill them!”

A number of groups, including the Japan Association of Kidney Disease Patients, protested loudly, and TV Osaka decided to drop Hasegawa from “News Real Friday,” even though the announcer later regretted his choice of words. Nevertheless, a subsequent article in the weekly magazine Shukan Shincho asserted that Hasegawa did have a point.

In the blog post, Hasegawa said that 80-90 percent of patients who receive dialysis treatment developed kidney problems as a result of lifestyle choices (others say the portion is less), such as poor diet and lack of exercise. He called these people “stupid grasshoppers,” a reference to the Aesop fable about the selfish insect who lived the way he wanted to without thinking of the future, as opposed to the industrious ant who worked hard to save for the cold winter. Extending the metaphor, Hasegawa said these grasshoppers should be allowed to “starve to death,” otherwise the “ants” will lose the will to work hard.

But at the heart of Hasegawa’s rant was the cost of dialysis. For the average patient, dialysis treatment costs ¥400,000 a month, and since there are presently 320,000 people receiving dialysis in Japan, it amounts to an outlay of ¥1.6 trillion. The problem as Hasegawa sees it is that almost all of this cost is shouldered by the government.

Normally, a person with national health insurance pays up to 30 percent of their medical costs out of pocket, but when the cost of treatment rises above a certain level, it qualifies for an extra discount that reduces their payment significantly. With this “high-cost treatment exemption,” a dialysis patient only has to pay between ¥10,000 and ¥20,000 a month for the treatment, depending on their income. But dialysis patients are also classified under the law as being “disabled,” and so they get a further discount that can effectively make the treatment free in most cases. About 0.25 percent of the population require dialysis, but this group is responsible for one-thirtieth of the country’s medical costs.

According to Shincho, many medical professionals believe that dialysis patients should pay more toward their treatment, especially if they have ignored their doctors’ warnings to lead healthier lifestyles. A good portion of dialysis patients are Type 2 diabetes sufferers, which means they developed the disease later in life. And the main problem with kidney disease is that it is by and large incurable, so that means once a patient’s condition deteriorates to the point where they have to receive dialysis, they have to continue the treatment for the rest of their lives, unless they have a kidney transplant, which are much rarer in Japan than they are in other developed countries owing to the lack of donors. One physician-journalist told Shincho that kidney transplants in Japan number “about 1,300 a year at most.” There are about 50,000 a year in the U.S.

Moreover, Shincho points out, each year sees an additional 6,000 dialysis patients, which saps insurance reserves of an additional ¥30 billion, and since dialysis is a time-intensive treatment — patients normally have to receive the treatment two or three times a week, and each time spend four or five hours in the treatment center — they lose out on work hours and thus reduce economic productivity. Consequently, Hasegawa’s theory that kidney patients could bankrupt Japan isn’t necessarily a reckless one.

Obviously, allowing dialysis patients to die isn’t a solution. And even if a good number of them can be blamed for their own poor health, doctors also need to be held accountable. Dialysis is something of a cash cow, for all the reasons mentioned above, but especially for the one that counts in the long run: Once a person goes on dialysis they are on it for good, and the doctor doesn’t have to do anything except make appointments for the patient and file for repayments from the insurance authority.

Shincho compares dialysis patients to retail or service “repeaters” — customers who come back again and again. To doctors, they comprise reliable “bank accounts” that they can tap at any time and forever. Consequently, some medical professionals believe hospitals and clinics that provide dialysis don’t do enough to dissuade potential kidney disease sufferers from changing their lifestyles. And some may even be prescribing dialysis too soon, meaning before a kidney disease sufferer has reached the stage where they really need it.

These suspicions are difficult to prove but credible when you have an insurance system like Japan’s, where doctors are guaranteed fixed payments for certain treatments without much oversight. What is true is that Japan accounts for 16 percent of the world’s dialysis patients, second only to the U.S., where Type 2 diabetes is considered an epidemic. In Japan, diabetes is on the rise, but it hasn’t reached that level.

Beyond economic concerns, the possible over-prescribing of dialysis has more troubling overtones. It is a debilitating treatment, as described by former New York Times reporter Takashi Uesugi in his own blog post refuting Hasegawa’s. Uesugi’s father suffered from a kidney disorder starting in his 30s, and underwent dialysis for 20 years.

At that time each treatment session lasted six hours. The patient has to sit or lie prone with a needle in a vein as the machine cleans the blood supply. Over time, the veins deteriorate, and intravenous points are moved from the arm to the leg to the abdomen. It can be a very harsh experience, physically and mentally, and without state support, Uesugi says, his family would have been destroyed. While he admits his father didn’t always live the healthiest lifestyle, his kidney problems sprung from a condition that was genetic.

“The (Japanese) medical system supports not only the patient,” he writes, “but also the patient’s family.”

Last week, Prime Minister Shinzo Abe announced that the government was determined to reduce medical costs, and will mainly target the price of drugs, which tend to be more expensive in Japan than they are in other countries. The government would do well to look at dialysis as well, and determine ways of reducing that outlay. Hasegawa may have been a bit hyperbolic in his assessment of the problem, but that doesn’t mean his point should be ignored.

Yen for Living covers issues related to making, spending and saving money in Japan on the second and fourth Sundays of the month.