Reaching a resolution on ‘balance billing’ won’t come soon


The government’s ban on health insurance coverage of medical treatment provided in combination with uninsured therapy creates unnecessary financial problems for patients who need the uninsured but advanced treatment, critics charge.

Some experts, however, support the health ministry position that lifting the ban on “kongo shinryo,” or balance billing or extra billing, would run counter to the principle of the public health insurance system — providing all people with the same medical service at uniform prices.

The Health, Labor and Welfare Ministry says it approves treatments, drugs and equipment to be covered by public health-care insurance policies after examining their safety and effectiveness.

Because medical institutions and drugmakers can freely set the prices of uninsured treatments and drugs, profit-minded doctors or hospitals might push their patients to take on the costly uninsured therapies if the ban is lifted, the ministry argues.

This could increase the financial burden on patients and prompt more people to take out private medical insurance — a situation that could widen the gap between the haves and have-nots in terms of access to medical services, experts point out.

“If a doctor recommended an extra uninsured treatment, the patient, who would have little knowledge about the proposed therapy, would agree,” said Naoki Ikegami, a professor of health policy at Keio University in Tokyo.

If the combination of insured and uninsured treatments became the norm, patients would also have trouble estimating how much it would cost when they see a doctor, he said.

The Japan Medical Association, with some 164,000 member doctors nationwide, supports the current rule.

Critics say this is because lifting the ban on balance billing, which would likely promote uninsured treatments, would intensify competition among medical institutions as patients “shop around” for the best services.

A deeper problem related to the dispute over balance billing, some experts say, is the time-consuming process under which medical treatments and drugs are approved for health insurance coverage.

James Kondo, an associate professor of health policy at the University of Tokyo, said the government’s approval process is too slow even for treatments that are readily available overseas.

The health ministry’s Central Social Insurance Medical Council, comprising experts, academics, officials from health insurance associations, representatives of insured people as well as government bureaucrats, examines the prevalence, effectiveness, safety and technological maturity of new and advanced therapies and drugs, before they are authorized for insurance coverage.

Medical institutions and drug companies are required to submit data on the new treatments or drugs after conducting clinical testing.

The process often takes longer in Japan than in other countries because the number of officials who examine them is limited and patients tend to shy away from participation in clinical testing.

Both proponents and opponents of balance billing agree that lifting the government’s ban would increase public expenditures on medical bills because more treatments would be covered by health insurance. And Kondo said the issue relates to the future of the health-care system — and how much people are willing to pay for it.

If people want to receive advanced treatments and drugs, someone has to pay for it — whether through higher taxes, increased insurance premiums or higher bills at the hospital counters, he said.

It is also important to discuss the health-care costs that should be paid either publicly or privately, Kondo said.

If the public can agree on answers to these fundamental questions regarding the health-care system’s future, “the balance billing problem will be resolve itself naturally,” he said.