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In its first report on medical reform, the council to promote deregulation — an advisory body to Prime Minister Junichiro Koizumi — recently recommended lifting some restrictions on “mixed medical care,” easing conditions for the private operation of hospitals and reorganizing the government’s Central Social Insurance Medical Council, which, at present, lacks transparency and neutrality at present.

The report comes as Japan’s medical system faces serious problems, notably a shortage of doctors and a growing number of medical malpractice cases.

Mixed medical care is a combination of services covered and not covered by public health insurance. Under the existing system established by the health ministry, a patient receiving mixed medical care must, in principle, pay the entire cost of services. Exceptions are made in cases involving “highly advanced care” and extra-charge hospital beds.

Earlier, the advisory council had proposed that medical institutions meeting certain standards be allowed to use new drugs and treatments for mixed medical care — without government approval in individual cases — if the treatments had been successfully used overseas.

But while the business community and patients’ groups supported the proposal, the Japan Medical Association (general practitioners) and the Japan Trade Union Confederation opposed it on the grounds that it would lead to the collapse of public health insurance coverage for all Japanese. The advisory council ended up limiting its recommendations to some expansion of “exceptional” mixed medical care services.

In connection with mixed medical care, though, a new panel of experts will decide in three months whether unlicensed drugs should be approved for use in clinical tests, whether drugs already approved for use in the United States, Britain, Germany and France should be automatically approved for testing, and whether new medical technology should be introduced.

The business community, which has favored the liberalization of mixed medical care so that private companies could operate hospitals, views the new proposal as inadequate. It is good news, though, for cancer patients seeking treatment with new drugs.

Most medical institutions in Japan are family-run, exclusive organizations. If private companies with fundraising expertise and management knowhow were allowed to run hospitals, they would stimulate competition, which would lead to better medical care.

Although the predecessor of the current advisory council recommended allowing companies to operate medical institutions in special-reform districts, no such facilities are open. Last October the government solicited applications for privately run hospital operations within local autonomies, but it didn’t receive any. And the health ministry did not get a single corporate inquiry.

This is probably due to the strict requirements for private operation of hospitals. One restriction, which permits advanced medical service only when a patient is without health insurance coverage, raises doubts about the profitability of such service.

A review of conditions for private operation is expected soon. I am perplexed by the health ministry’s imposition of some operation restrictions even in the special-reform districts.

The recent advisory council report also called for letting medical corporations invest in each other to facilitate their grouping and increase their management efficiency. Although the proposal is late, reform on medical care has finally started. Still, the council’s discussions showed the Japanese medical system as a laggard.

The doctor shortage, which was exposed after newly licensed doctors were obliged to begin undergoing two years of clinical training last April, is baffling. It was in 1994 that a health ministry advisory council first proposed the training period. Thus the health ministry had 10 years to anticipate a possible doctor shortage.

Another contributor to the current shortage was the ministry’s decision in the 1980s to reduce the number of doctors by 10 percent because of an expected glut. The education ministry went on to curtail the number of students admitted to medical schools.

Yet the number of doctors in Japan is not large on an international scale. According to a 2000 report compiled by the Organization for Economic Cooperation and Development, the number per 1,000 population averaged 2.9 in member nations. Japan, with 1.9 doctors, ranked 27th among the 30 member nations.

The health ministry reportedly curbed the number of doctors to help prevent a rise in medical costs. Meanwhile, the chronic shortage in rural areas is aggravated by the reluctance of many Japanese doctors to work there.

Medical university staffs, faced with a doctor shortage as a result of the two-year training period, exacerbated the shortage in rural hospitals when they began recalling young doctors on assignment in outlying areas.

Many hospitals on paper do not have enough doctors to meet the health ministry’s standards, so they borrow the names of graduate students at medical schools. It is not uncommon for hospitals to donate millions of yen to medical schools to secure a supply of doctors.

The health ministry says it plans to review the demand and supply outlook for doctors in fiscal 2005, but it is not moving fast enough. The education ministry should come up with strong measures to deal with the shortage by increasing admission quotas at medical schools and expanding quotas for local students at medical schools in outlying areas.

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