From Paternalism to Consumerism: Challenges of Patients' Growing Participation and Implications for the Future
AtoZ Okamoto, MD, MPH (Kinki University Medical School Department of Public Health)
Preponderance of health care over welfare services
To most observers, Japan's health and welfare system presents some confusing and imcomprehensible facts, the most typical of which would be an enormous number of hospital beds and their unusually long average length of stay.
Japan has nearly two million hospital and clinic beds for 1.2 million population. This translates into one bed for every 64 people. The average length of stay is 35 days for somatic hospitals. If psychiatric beds are included, the ALOS will jump to 46 days.
These figures do not reflect the health status of the Japanese, instead they indirectly evidence the fact that a considerable number of health care facilities are actually serving as substitutes of long term care facilities.
On the other hand Japan's welfare facilities such as nursing homes and care houses have long been in short supply. There is a long waiting list for virtually everywhere.
In short, Japan is notoriously deviated toward health care services away from welfare services. The preponderance of health care over welfare can be explained by financing system.
Japan's health care system has been financed by national health insurance whose sources come from insurance premium withheld from the working population's pay checks, while welfare system has been financed from general revenue whose sources are mainly tax.
The difference between tax and premium is crucial in determining the growth of health care and welfare services. As for tax, the rate is determined first and then the size of tax revenue will follow. For premium, the size of revenue is first estimated and then the rate will be determined.
Under these differences, health care services financed by insurance premium can grow in an unbridled manner but welfare services financed by tax have always been subject to budget restrictions. In extreme cases, municipal governments may have to curtail their welfare budget to help finance their health insurance program if premium revenues fall short of the health care cost claimed by providers.
Tactics to boost welfare services
Having these differences of financing between health care and welfare services in mind, the tactics to boost welfare services are rather easy to conceive: having health insurance to pay for welfare facilities, or switching the financing of welfare services from tax to insurance.
The first option was adopted in 1988, when a new entity of facilities dubbed Elderly Health Facilities were created. These are actually skilled nursing facilities but they are categorized as health care facilities, thereby entitling them to get reimbursed from health insurance not from general revenue.
The second option is currently being hotly debated as a national policy: the creation of LTC insurance for the elderly. Although details of the new insurance schemes are yet to be decided, it is highly likely that it will be implemented at around the year 2000, then the long awaited integration between health care and welfare services will eventually be achieved. Prospect of Japan's welfare system under the new insurance system
A few years ago one journalist deplored the state of Japan's welfare system for the elderly saying that "Japan lags behind the Nordic countries by as long as 25 years!". However his remark delighted other observers by reassuring that even Nordic countries were in a state of present Japan as short as 25 years ago!
Actually it will not take Japan as long as 25 years to catch up Nordic countries at least in terms of quantity of services given the sheer power of insurance. Rather Japan might well worry about oversupply of services. This may sound surprizing particularly for welfare workers who always deplore the shortage of services, but health care professionals are painfully aware the consequences of laissezfaire economy.
Japan's national health insurance system was established in 1961. At that time there was no idea of planned economy. Establishing hospitals and clinics were totally left to the initiatives of local doctors. The result: serious geographical maldistribution of health care resources. To cope with the maldistribution of doctors, government established medical schools in every prefecture in early 1970s, but it proved to be of little effect in solving the plight of the underserved areas.
In 1985, the government declaired a radical departure from laissezfaire economy toward planned economy by launching Regional Health Plans which were to control growth of hospital beds. However an ironical phenomenon took place: the rush–in hospital construction boom. Through this the govenment learned a bitter lesson that effective control against oversupply should be preempted to the introduction of any insurance system.
In 1993, all municipal governments, both prefectural level and township were required to develop Regional Elderly Health & Welfare Plans, which delineates the amount of service volumes to be attained by the year 2000. The targetted volume of services were objectively calculated using the formula dictated by government.
Of course, the "target" will automatically turn to "cap" once the target is achieved. This was a prerequisite for the new LTC insurance not to repeat the mistake in health care system.
How to establish consumerism in health and welfare
There are considerable debates over the new LTC insurance nation wide. Still many authorities believe that tax revenue relying more on indirect tax should remain the main financial sources of welfare services. Insurance system has many drawbacks: it lacks effective control against oversupply, it is inefficient to enforce collection of insurance premium. The governmental campaign for the LTC insurance emphasizes "consumerism" that paying premium will nurture the right consciousness and enhance the free choice of the recipients. Though this may appear plausible, one should be reminded that Japan's national health insurance system failed to establish patients' consumerism despite its firm existence for decades.
Although Japan's health insurance system guarantees relatively free choice of providers by patients, informed consent and patients' access to health records are far from being established even today. This means that introduction of insurance will not automatically bring with it the consumerism of the recipients.
In responce to the evolving consumerism among the nation, the proposal for the new LTC insurance includes some considerations on these matters, such as creation of ombudsman system, appealing system for the assessment of care needs and care managers as patients advocates.
From paternalism to consumerism
It is also an encouraging trend that government and organized medicine alike are increasingly aware of the importance of holding the lay public more responsible for health and welfare by giving them enough information to make informed choices. The most typical experience may be that of lung cancer. When the relationship between smoking and lung cancer was demonstrated in early 1960s, many experts believed that most Japanese would quit smoking for fear of contracting cancer. However it did not prove to be what experts had expected: the smoking rate of Japanese is still high and the mortality of lung cancer is growing.
Public health workers are bitterly reminded that their success in controlling tuberculosis by way of mass screenings failed to repeat again. Paternalistic approach which neglects patients' active participation is not effective in combatting lung cancer.
The same thing is proving to be true for cost control effort in the field of health care. To detect fraud and abuse of insurance claims, Japan deploys as many as 8,000 auditors who are all MDs or dentists. However rigorous reviewing system is proving to be defeat in controlling the internationally high pharmaceutical spendings of Japan.
Also uninformed patients had no protection against potentially hazzardous drug side effects, which might have been responsible for repeated iatrogenic disasters involving drugs, the most prominent of which would be the present iatrogenic HIV infections.
Disclosure of health information such as insurance claims to patients would be more effective in achieving both cost control and quality of care is increasing convincing government and organized medicine. Already some insurers went so far as to disclose fully the personal health record to the patients.
Conclusions
Japan has been successful in guaranteeing financial ground to health care and will be able to do so for the provision of welfare services for the elderly. It is a matter of time for Japan to emerge as a well developed welfare statesurpassing the Nordic countries in terms of sheer volume of services.
The more challenging for Japan, however, would be a departure from long held paternalism to consumerism, in which patients and recipients will play active roles. And this will be a requisite for Japan to overcome social and cultural challenges in the coming aging society.
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