One of the criticisms of the “Medicare for All” government-run health care scheme proposed by U.S. Democratic presidential candidates Bernie Sanders and Elizabeth Warren is that eliminating all limits to treatment would lead to “overuse” of the medical care system, meaning people would be seeing doctors for every little perceived ailment, which is wasteful. Given the vast number of Americans who presently forego medical attention because they cannot afford private insurance, overuse of medical resources should be considered at worst a necessary evil.
In Japan, which has national health insurance, the government is trying to address this overuse problem, which is exacerbated by the country’s rapidly aging population. Because the elderly pay less out of pocket than others, when many visit the doctor they tend to go more often, even when their issues aren’t serious. But medical professionals have a hand in the problem, too, encouraging such visits and suggesting treatments and procedures that may not be necessary. After all, they can charge the government for their services with complete confidence that they will be paid. More to the point, they can prescribe as much medication as they like, which also pleases drug manufacturers and pharmacies. Anyone who has lived in Japan for any length of time will likely have had the experience of leaving a pharmacy with a duffel bag full of pills and powders for a common cold.
A lot of these drugs, in fact, go unused. If the patient’s complaint is not related to a chronic condition — and sometimes even when it is — they may stop taking the drug once the symptoms go away. Consequently, many people have “leftover drugs” (zan’yaku) in their homes and, according to a Nov. 4 article in the Tokyo Shimbun, a research group tied to Kyushu University’s graduate school estimates that “reusing” these drugs could reduce medical costs by ¥330 billion a year.
The newspaper reports that three local pharmaceutical associations — one in Tokyo and two in Fukuoka — are testing a drug return system wherein people bring unused medications back to pharmacies. The drugs are registered and the pertinent doctors informed that medication they previously prescribed were returned. Redistributing drugs that have already been paid for has its own built-in problems, including possible fraud, but the real purpose of the scheme is not recycling but rather getting doctors to prescribe less once they understand about the leftovers.
This theory presumes a lot about doctors’ — and even pharmacies’ — motivation for distributing drugs, but, in fact, there is a concerted movement in the medical community to cut back on prescriptions for reasons other than money. Another Tokyo Shimbun article that appeared Nov. 9 described “polypharmacy,” the practice of taking multiple types of medication at the same time. The interaction of certain drugs can lead to unforeseen side effects, which means doctors must know exactly what other medications a patient is taking before prescribing new ones.
An 84-year-old Tokyo man showed the Tokyo Shimbun his huge stash of drugs. He regularly visits two hospitals, which, together, have prescribed eight different medications. In addition, he sees an orthopedist for his bad knee who gave him an additional two or three drugs. In October, he was hospitalized after falling down and doctors told him the drugs he was taking were likely the cause. For one thing, he was taking two sleep inducing medications prescribed by different physicians. The man’s son called the pharmacy where both prescriptions were filled and the pharmacy admitted that it should have noticed the redundancy. However, the pharmacy refused to talk to the newspaper.
The problem of polypharmacy is not limited to prescription drugs. Often people take over-the-counter medications and health supplements that can react dangerously to prescription drugs. However, the over-the-counter industry is a trillion-yen-a-year business, and companies involved in the production of health supplements such as DHC Corp. and Suntory Holdings Ltd. are huge advertisers, so the media may not have covered this problem as much as it should.
NHK, which does not air advertising, caused a stir with its Oct. 22 installment of the in-depth news show “Close-Up Gendai Plus” about the risk of taking too many drugs. The most pertinent point brought up by the program was that dementia, which an estimated 5 million Japanese people suffer from, is often thought to be partially caused by polypharmacy, and that some dementia patients recover significant cognitive function when they stop taking certain medications.
According to a survey cited by NHK, 24 percent of people over 75 take seven or more medications. Obviously, the more drugs you take, the more likely you are to suffer side effects. The problem with polypharmacy is that it causes problems that a doctor may not be able to diagnose using conventional means if they aren’t aware of all the drugs the patient is taking, and thus may prescribe yet another one to treat a condition that would likely go away if the patient simply stopped taking drugs altogether. Weekly magazine Shukan Gendai picked up on the NHK show and outlined which prescription drugs, supplements and over-the-counter medications react adversely with one another and how those reactions manifest as symptoms. Another weekly, Shukan Asahi, ran a story that said two of the most common chronic conditions in Japan, high blood pressure and high cholesterol, are over-diagnosed, so many people who take regular medication for such conditions may not actually need it and, in fact, taking such medication could be harmful.
The implication of all this coverage is that the problem of overused medications is as much a function of medical culture as it is of universal health care. During the last year of her life, my mother was continually sick and her doctors couldn’t figure out what was wrong with her. She was covered by Medicare but much of her treatment was paid for by supplemental private insurance, which is supposed to limit her access to medication for cost reasons. It wasn’t until a few weeks before she died that cancer was discovered, at which point she was taking a dozen different drugs. She was 73.