Table of Contents

v
PREFACE
vii
FOREWORD
ix
INTRODUCTION
3
I. HEALTH CARE RESOURCES AND UTILIZATION

II. HEALTH CARE FINANCING AND NATIONAL HEALTH INSURANCE

7
A. The evolution of national health insurance
7
B. Health care financing
8
C. The structure of the national health insurance system
10
D. The extent and regulation of health insurance benefits
12
E. Government subsidies and cross-subsidization between plans
12
F. Provider reimbursement
III. THE ORGANIZATION OF MEDICAL CARE
A. Hospitals 15
B. Clinics and ambulatory care 17
C. Services for the elderly 18
IV. EVALUATION OF JAPAN'S HEALTH CARE SYSTEM
23
A. Cost control
23
B. The fee schedule
24
C. Patient satisfaction
24
D. Quality

V. LESSON'S FOR THE UNITED STATES

28
A. Points of convergence
30
B. Learning from comparative experience
31
C. Lessons for the United States
33
D. Concluding observations

APPENDICES
36
1. Japan in International Perspective: OECD Data
41
2. Japan's National Health Insurance System
44
3. Profile's of the Conference Participants
REFERENCES 47

PREFACE

Health care has emerged as perhaps the most urgent issue in America, and health
care reform as the most ambitious initiative in domestic policy since the New Deal.
Japan, on the other hand, already boasts the world's lowest infant mortality rate and
longest life expectancy, while achieving more success than America at containing
medical costs: in 1991, spending on health care accounted for a mere 6.6 percent of
Japan's total gross domestic product versus 13.4 percent of America's. How does
Japan do it? What aspects of the Japanese model might be applicable to the United
States?

To explore these questions, on Friday, April 30, 1993, the Japan Society organized
a one-day conference entitled Making Universal Health Care Affordable: How Japan
Does It. Three distinguished panels of Japanese and American health care specialists
discussed the management of Japan's universal health care coverage, ways to balance
quality care and cost containment, and how the United States might profit from
Japan's experience. Professor Victor Rodwin was one of the conference participants
(see Appendix 3) and agreed to draw on the conference discussions as a starting point
for this more extensive monograph.

The Japan Society is grateful to KPMG Peat Marwick; New York Pharma Forum;
the International Leadership Center on Longevity and Society (U.S.) of The Mount
Sinai School of Medicine, an affiliate of The City University of New York; the
Japanese Ministry of Health and Welfare; and the New York Academy of Medicine
for their generous support of the conference and this publication.

We offer special thanks to the conference participants for their valuable

presentations. We also thank John Campbell and Michael Reich for their close
reading and comments on this manuscript; Toshihiko Takeda and Masaru Hiraiwa
(JETRO-Ministry of Health and Welfare) for providing details on the Japanese health
system and for reviewing key parts of the document; and Frank Schwartz for his
diligent editorial assistance. Finally, we gratefully acknowledge David Forbes at New
York University's Wagner Graduate School of Public Service for his secretarial
assistance; Jennifer Capson McManus for proofreading the manuscript; and Donna
Keyser and Lou Montesano for assisting in its publication.

William H. Gleysteen, Jr.

President, Japan Society

FOREWORD
by Marianne C. Fahs, Ph.D.
Associate Professor and Director
Division of Health Economics
International Leadership Center on Longevity and Society (U.S.)
Mount Sinai Medical Center

International study is gaining recognition as a useful method of inquiry into

questions of how best to allocate national resources to improve health. Yet policy
analysis of the Japanese system of health care remains underdeveloped.. Indeed,
serious debates regarding health care reform strategies for the United States often
exclude references to Japanese health care delivery and financing. This exclusion is
unfortunate and obscures some outstanding successes of health policy in Japan. For
instance, in only 20 years and starting from a level similar to the United States, Japan
has achieved the lowest infant mortality rate in the world. The United States remains
19th among developed nations. Japan became the world's leader through a well-
thought-out plan for prevention, coupled with government investment. Now, Japanese
policy leaders are turning their attention to the elderly.

The United States and Japan face similar problems. Both countries face a
demographic revolution in the decades ahead as the population ages. Medical
expenditures, as a proportion of GNP, are increasing at similar rates. Both
governments face fiercely competing demands for resource allocation among
prevention, treatment and basic science interest groups. Both medical care systems
face a diverse mix of patients with increasing rates of functional disability. Both
systems are financed by a large number of employer-based private insurance plans in
addition to public insurance for the poor and the elderly.

In this information era, we face a world hungry to know what works in health care
and what it costs. One of medicine's great challenges is to inform policy-makers and
the public of long-term produc tive benefits and costs to our society of preventing
and postponing disability. Many initiatives in the United States will require
fundamental change. The most cost effective will be those targeted with sensitivity
and respect for cultural tradition to reach the myriad of groups in our pluralistic
society. Enlarging our understanding of socio-cultural patterns of health behavior,
disease and economic productivity and costs calls for increasing international
communication and research partnerships.

Professor Rodwin and his associates provide an excellent overview of the health
care system in Japan. This comprehensive and well-documented monograph will
serve as an essential reference for policy leaders and researchers alike who are
interested in pursuing comparative policy analysis. The Japan Society is to be
commended for organizing this timely conference. Professor Rodwin, a leading
expert in the comparative analysis of health systems, has taken the conference
presentations and discussions and used them as a springboard for his own further
investigation of political and economic aspects of Japan's health care system. In this
monograph, he presents a clear and well-organized perspective on what the United
States can learn from Japan. Let us hope that the challenges Professor Rodwin raises
will be met in the years ahead as we pursue health care reform to achieve the goals of
effectiveness, efficiency and equity.

INTRODUCTION

Japan's health care system is characterized by universal coverage, free choice of

health care providers by patients, a multi-payer, employment-based system of
financing, and a predominant role for private hospitals and fee-for-service practice.
Virtually all residents of Japan are covered without regard to any medical problems
they may have (so-called predisposing conditions) or to their actuarial risk of
succumbing to illness. Premiums are based on income and ability to pay. Although
there is strong government regulation of health care financing and the operation of
health insurance, control of the delivery of care is left largely to medical
professionals and there appears to be no public concern about health care rationing.

Like the Australian, Canadian and many European health care systems, Japan's
national health insurance program is compulsory. But Japan surpasses all 24 member
countries of the Organization for Economic Cooperation and Development (OECD)
in life expectancy at birth and also has the lowest infant mortality rate (Appendix 1,
Table 1).1 It achieves these successes at a cost of only 6.6 percent of gross domestic
product, $1,267 per capita - half that of the United States (Table 1) .

Japanese-style national health insurance raises a fascinating question: how has

Japan reduced financial barriers of access to medical care and achieved a No. 1
ranking on health status at a cost that is among the lowest of wealthy industrialized
nations?2 In addressing this question, we begin with a comparative analysis of health
care resources and the use of medical care in Japan, the United States and other
OECD countries. Next, we review the financing and organization of medical care in
Japan, evaluate some strengths and weaknesses of the health care system, and explore
possible lessons for health care reform in the United States.

In adopting this comparative approach to health care reform in the United States,
we have relied on an extensive review of the English-language literature on Japan's
health care system and on information presented at the Japan Society's April 30
conference, "Making Universal Health Care Affordable: How Japan Does It."3 We do
not presume to have analyzed Japan's health care system in depth. For example, we
remain intrigued by Japan's exemplary health status and by such societal values and
traditions as egalitarianism and consensus- building upon which the health system is
built. We have aimed, in earnest, to raise more questions than we are able to answer.
We hope that these questions may lend a sense of perspective to the on-going public
debate on health care reform in the United States.

NOTES:
1
For comparisons between Japan and the other OECD countries, see the Tables in
Appendix 1.
2
This is a reference to Vogel's (1979) classic book, Japan as Number One: Lessons for
America. (Cambridge: Harvard University Press).
3
We also refer the reader to a previous monograph on health and medicine in Japan
and America based on a conference organized by the Japan Society in 1978 (Reich
and Kao, 1978).

HEALTH CARE RESOURCES AND UTILIZATION

Japan has 15.8 inpatient hospital beds per 1,000 persons, the highest number
among OECD countries and more than three times the American ratio (Table 1). By
contrast, with 1.6 physicians per 1,000 population, Japan has the fifth lowest
physician-per-person ratio, 43 percent less than the American rate of 2.3 per
1,000 (Table 1). Japan also has one-half to one-third the American number of
intensive care beds per capita (Table 1). And Japan is tied with Austria for the lowest
hospital staffing ratio (that is, the number of employees per bed) among OECD
countries (Appendix 1, Table 3).

As for the use of these resources, at 8.3 percent, Japan admits a smaller proportion
of its population to hospitals every year than any other OECD country except Turkey,
a rate barely over one-half that of the United States (Table 1). On the other hand, of
all OECD countries, at 50.5 days, Japan has the longest average length of stay for
inpatient hospital services, more than five times that of the United States (Table 1).

Although Japan has one of the lowest physician-to-population ratios among OECD
countries (Appendix 1, Table 3), at 12.9, Japanese doctors have the highest number of
physician contacts per capita, more than twice the American rate . It must be
noted, (Table 1) however, that the average length of a physician visit in Japan is only
6.9 minutes, compared to over 20 minutes in the United States.1

To the extent that OECD data are available on hospital admission rates for selected
procedures, with the exception of appendectomies, Japan's rates are lower than those
in the United States (Table 2).2 Comparative survey data indicate that surgeons in
Japan perform fewer than one-fourth the number of operations per capita that their
colleagues in the United States do (Table 1).3 This pattern is supported by findings on
cesarean section rates, which are half as frequent in Japan as in the United
States.4 The United States is known abroad for its unusually high cesarean section
rate.

It would be wrong to conclude from these data that Japan rations high-tech medical
care. On the contrary, among OECD countries, Japan has the highest number of
computerized axial tomography (CT) scanners per capita, the highest number of
extra-corporal shock wave lithotriptors per capita, and the highest number of patients
per million treated for end-stage renal disease failure.5 In addition, Japanese spend
more than any other nation on drugs as a percent of total health expenditures, more
than twice the American rate.6

Japanese doctors' clear preference for non-invasive procedures is demonstrated by

the kinds of medical technologies imported and exported. Equipment requiring
invasive operations (e.g., pacemakers and artfficial heart valves) is almost all
imported, whereas diagnostic equipment (e.g., CT scanners) is produced in Japan and
exported in large quantities.7

In contrast to the United States, Japan's low rate of hospital admissions (Table
1)reflects its tendency to emphasize ambulatory over inpatient hospital care.8 But
once hospitalization occurs, as we have seen, Japan holds the OECD record for long
lengths of stay and low hospital staffing ratios (Appendix 1, Tables 3 and 4). This is
encouraged by a reimbursement system that pays hospitals on a per diem basis and a
style of medical practice that emphasizes bed rest and complete recovery while a
patient is still in the hospital.

Beyond these more measurable differences in resource availability and use of

medical care in Japan and United States, there are a host of political-institutional and
cultural factors that reinforce each health care system's distinctiveness. The United
States is a federal system whose 50 states have significant autonomy on matters of
health insurance and public health policies. Although the federal government
exercises a dominant role over the Medicare program and regulatory aspects of health
policy, Americans are multiethnic, suspicious of excessive governmental authority
and inclined to solve social problems at the local level. Japan is a centralized, unitary
state with a highly homogeneous population and a tradition of powerful state
intervention in the economy, including its many health insurance plans.

NOTES:
1
Okamitsu (1993).
2
McPherson (1989).
3
Ikegami (1992).
4
Notzon, Placek and Taffel (1987).
5
Yoshikawa et al. (1992). In Japan in 1991, there were 945 patients per million
treated for end stage renal disease failure in contrast to 784 in the United States
(OECD Health data file, 1993).
6
lglehart (1988) reports that in 1981 reimbursement for drugs by Japanese health
insurance was equal to 38.7 percent of all health expenditures and that in 1987 this
figure dropped to 28 percent. More recent data from OECD Health Systems: Facts
and Trends (Paris: OECD, 1992) indicate that this figure has dropped to 18.4 percent,
in contrast to the U.S. figure of 8.3 percent. However, these data exclude
pharmaceutical expenditures for inpatients, which are substantial. Ikegami (1990)
reports that "about 30 percent of Japan's personal health expenditures are for drugs,"
which we assume include inpatient drugs, and supports the contention that the
Japanese are among the highest spenders on drugs.
In terms of pharmaceutical expenditures per capita, in U.S. dollar pharmaceutical
purchasing power parities, Japanese spent $332 per capita, Americans $182.
However, if these expenditure data are adjusted by GDP purchasing power parities,
the difference narrows: $179 for Japan, $182 for the United States.
7
Ikegami (1989).
8
Ikegami (1992a).

Table 1

Comparisons of the United States and Japanese Health Systems (1990)

U.S Japan
Health Status
Life Expectancy at Birth
Males 72.00 75.90
Females 78.80 81.90
Infant Mortality Rate 9.10 4.60
Life Expectancy at 80
Males 7.10 6.90
Females 9.00 8.70
Expenditures
Per Capita Health Spending1 $2,867 $1,267
Total Health Expenditures as % of GDP2 13.40 6.60
Resources
Active physicians per 1,000 2.3 1.6
Inpatient hospital beds per 1,000 4.70 15.8
3
Hospital staffing ratios 3.35 .79
4
Intensive care unit beds per million 244.50 79.20
Coronary care unit beds per million4 46.30 17.80
4
Neonatal intensive care unit beds per million 44.70 22.40
Medical Care Use
Physician visits per capita5 5.30 12.90
Hospital admissions as % of population 13.70 8.30
Average length of hospital stay 9.10 50.50
Inpatient days per capita6 1.20 4.10
7
Number of surgical operations per 1000 91.0 22
Source:OECD Health Data (CREDES), 1993
1. These figures are in $U.S. price purchasing parities for 1991.
2. 1991
3. Non-medical staff per bed.
4.Woodward and Asano, 1991. U.S. data from the American Hospital Association,
U.S. ICUs and CCUs Table 13. Japanese data, from 1987, are from the Health and
Welfare Statistics Association, 1989.
5. 1988
6. 1991
7. Surgical operation rates are based on survey data. For Japan they are from a
patient survey done by the Ministry of Health and Welfare. For the U.S., they are
from the 1986 Annual Survey of the American

Table 2

Admission Rates for Selected Procedures (1980)*

Number of Admissions per 1,000 Population
U.S Japan
Tonsillectomy 205 61
Coronary Bypass 61 1
Cholecystectomy 203 2
Inguinal Hernia Repair 238 67
Exploratory Laporotomy 41 -
Prostatectomy 308 -
Hysterectomy 557 90
Operation on lens 294 35
Appendectomy 130 244
Renal dialysis1 784 945

Adapted from K. McPherson, "International Differences in Medical Care Practices,"

(Health Care Financing Review, 1989, Annual Supplement).

* These figures are not age standardized and assume equal proportions of men and
women. Some are likely to be incomparable for artifactual reasons.
Source: OECD Health Data File, 1989.

1. These data for 1991, not based on hospital admission rates, are from the OECD
Health Data File, 1993. These rates are per 1 million population.

HEALTH CARE FINANCING AND NATIONAL HEALTH

INSURANCE

The evolution of national health insurance

National health insurance emerged in Japan as the result of a gradual process that
can be traced back to 1905, when the Kamegafuchi Textile Company provided
limited benefits for its employees.1 In the decades that followed, more and more
corporations began offering benefits through mutual aid societies. A health insurance
law enacted in 1922 was inspired by the German system established by Chancellor
Bismarck in 1883. As in Germany, this first law extended health insurance coverage
to industrial workers and miners but excluded the self-employed and employees in
companies with fewer than five workers.2 This law, implemented in 1927, established
the practice of mandating coverage by enterprises and created an important
government role in the provision of health insurance to those individuals not covered
by employers. In 1938, health insurance was extended to farmers, fishermen,
foresters and other groups not covered by the 1922 law.

After World War II, the effort to rebuild Japan gave new impetus to the
achievement of universal coverage. In 1958, the 1938 law was revised to include the
remaining 30 percent of the population not previously covered. This revision broke
the precedent of extending health insurance to occupational groups by calling for
universal coverage on the basis of residence. Every government jurisdiction, whether
city, town or village, was required to provide health insurance to every uncovered
resident by 1961. Since 1961, virtually all Japanese have been covered by either
employers or the government.

Health care financing

 Health insurance expenditures in Japan are financed by payroll taxes paid by
employers and employees and by income-based premiums paid by the self-employed.
In contrast to the United States, where the federal, state and local governments
finance roughly 42.9 percent of all health care expenditures and out-of-pocket
payments contribute another 22 percent, in Japan, only 31.7 percent of national health
care expenditures derive from national and local public funds and 12.2 percent from
out-of-pocket payments. The largest share of health care financing in Japan is raised
by means of compulsory premiums levied on individual subscribers (34.6 percent)
and employers (21.7 percent).3 This employment-based share of health care financing
in Japan (56.4 percent) raised by means of voluntary employer, employee and
individual subscriber premiums in the United States (Figure 1).

The structure of the national health insurance system

At first glance, understanding the system seems to be an impossible task. Japan's

national health insurance program is made up of some 2,000 private insurers and
more than 3,000 units of government. The system can be simplified, however, by
distinguishing between two broad groups of beneficiaries (Appendix 2, Figure 1):1)
employees and their dependents, including some elderly dependents (65 percent of
the population); and 2) the self-employed, unemployed, elderly and their dependents
(35 percent of the population).4

Ignoring some administrative complexities and small beneficiary groups, health

insurance plans for employees may be categorized into four groups:

1. Government-managed plans - These plans provide coverage for the almost 30

percent of the population comprised of employees (and their dependents) of
small enterprises with more than five but fewer than 300 employees. These
plans are managed by the government's Social Insurance Agency through a
network of some 300 local offices. Premium contributions are set by law at a
fixed rate (8.2 percent of monthly income before taxes) and evenly split
between employees and employers.

2. Society-managed plans - Known as health insurance societies, more than

1,800 company plans provide coverage for 26 percent of the population.
These health insurance societies are managed jointly by representatives of
labor and management in enterprises with more than 300 employees. Society-
managed plans can be also established by several enterprises employing 3,000
or more employees. Payroll taxes for such plans range from 5.8 to 9.5 percent
of gross monthly income.5 Employers are required to pay at least half of these
contributions, and some pay as much as 80 percent.

3. Mutual aid association (MAA) insurers - Covering almost 10 percent of the

population, these include 27 plans for government employees in the national
public service, 54 plans for local government employees, and one plan for
quasi-public employees like teachers and other school employees. The
average payroll contribution of these plans in 8.5 percent of the employee's
 wage.

4. Plans for day laborers (for those who work less than two months during the
year) and seaman - These independent plans cover only 0.1 and 0.4 percent of
the population, respectively.

In addition to the employee groups noted above, employees in enterprises with

fewer than five workers, the self-employed and retirees are covered either by
municipal governments or by national health insurance societies. Roughly 3,000
municipal governments cover over 90 percent of such self-employed individuals as
farmers, shopkeepers, their dependents, and a large number of elderly people on
pensions. There are also 166 national health insurance societies that directly manage
plans for certain trade and occupational groups such as physicians, lawyers, dentists,
food retailers, carpenters, and barbers. Contributions to these national health
insurance societies are based on reported income and assets as well as on the number
of individuals per household.

In contrast to health insurance for employees, municipal governments and national

health insurance societies receive no direct contributions from employers. Moreover,
the self-employed and retirees earn less on average than employees in large
enterprises, so the government ends up paying slightly less than 50 percent of their
health insurance expenditures - four-twelfths by the national government and one-
twelfth each by prefectures and municipalities.6 Once the elderly reach the age of 70
(or 65 if bedridden), since they use the lion's share of health care resources but do not
pay premiums, under the Health Services System for the Elderly the other half of
their expenses are financed by taxes on premium payments to all insurers of
employees and the self- employed.

Most of Japan's health insurance plans are private organizations in terms of

administrative law; in practice, they have a quasi-public status insofar as they are
largely bound to provide uniform benefits and to cover all eligible beneficiaries. All
employers with at least five employees are mandated by law to insure them (along
with their dependents). Employers have little freedom to alter premium levels, which
range from 5.8 to 9.5 percent of the wage base.7 The self- employed are required to
contribute premiums to health insurance plans that are administered by local
governments or trade associations. And all of these premiums are taxed to finance the
national fund which, along with government subsidies, finances national health
insurance for the elderly.

The extent and regulation of health insurance benefits

Health insurance benefits are designed to provide basic medical care to the
maximum number of individuals. Although there are exceptions, mandated benefits
are similar across the four groups of employee plans and for the self-employed and
retirees. They include ambulatory and hospital care, extended care, most dental care
and prescription drugs. Not covered are such items as abortion, cosmetic surgery,
most traditional medicine (including acupuncture), certain hospital amenities, some
high-tech procedures, and childbirth.8 Expenses that fall outside the normal
boundaries of medical care are either not covered, dealt with on a case-by-case basis,
or covered by the welfare system.

Differences between plans include the level of copayments, the amount of cash
benefits, and the extent of cross- subsidization and government subsidies (Appendix
2, Figures 2 and 3). With regard to copayments, all plans for employees have a 10
percent rate for plan members and their dependents, a 20 percent rate for inpatient
care, and a 30 percent rate for outpatient care. For the self-employed and their
dependents, the copayment rate is 30 percent for both inpatient and outpatient care.
For the retired, the copayment rate is 20 percent, and for their dependents, the rate is
20 percent for inpatient care and 30 percent for outpatient care. But under Japan's
system of catastrophic health insurance, there is a monthly ceiling for each
beneficiary on all copayments for all health insurance plans.9 This has limited private
insurance to coverage of copayments. There is, however, a small market for
supplemental benefits that pay for amenities like private rooms.

Health insurance plans for employees provide cash benefits for extended sickness
and injury and for maternity leave and delivery expenses. National health insurance
plans for the self- employed and retirees provide cash benefits for midwifery and
general expenses. Cash benefits can be substantial. Nearly $2,400 is provided to
cover child delivery expenses under most employee plans, for example.10 If the
mother is the primary beneficiary, the cash benefit may be 50 percent of her monthly
salary. Maternity leave amounts to 100 days and is compensated at 50 percent of a
mother's salary in the case of working women. In the event of prolonged sickness or
disability, an individual collects 60 percent of monthly remuneration for 18 months.

Society-managed plans provide more extensive benefits in kind. In addition to

providing the cash benefits noted above, 74 percent of these plans also have a
"patient cost-sharing restoration" program which picks up a portion of the mandatory
10 percent copayment.11 Society-managed plans are also actively involved in health
screening and promotion. Enterprises own and operate more than 3,500 sanitoriums,
1,000 gymnasiums and 300 health centers, for example.12

There is thus a widely held perception that employees of large corporations

covered under society-managed plans are getting a "better deal." There is no evidence
that these beneficiaries enjoy better health status, however. As John Campbell noted
at the Japan Society conference, among all plans, individuals enrolled in society-
managed plans receive the least value back for what they pay. For every dollar paid in
premium contributions, only 62 cents is received in health insurance benefits. The
beneficiaries of government-managed plans receive 84 cents in benefits for every
dollar of premiums paid, the self-employed receive $1.66, and retirees receive $4 to
$5.13

Government subsidies and cross-subsidization between plans

Age and income disparities among health insurance plans result in an unequal
distribution of health risks. Plans that insure beneficiaries who are older or in higher
risk occupational groups will incur higher costs and therefore often generate deficits.
Given the Japanese commitment to equity, these inequalities are reduced through
government subsidies and cross-subsidization between plans.

With the exception of mutual aid associations for government employees, all
insurance plans receive some form of government subsidy. Even society-managed
plans, for example, receive government funds (Y4.85 billion in 1992) to defray their
administrative costs. Likewise, government subsidies financed 50 percent of the
benefit payments to self-employed individuals covered by national health
insurance(Appendix 2, Figure 3).

Cross-subsidization supports the poorer plans. As noted above, the most generous
example is the national pool created as part of the Health and Medical Service Law
for the Aged of 1983. Government (national and local) provides 30 percent of this
special fund, and local governments another 20 percent. The remaining 70 percent
comes from other insurance plans based upon the total enrollment of retirees in each
fund.14 As a percentage of their total expenditures, government- managed plans,
society-managed plans and national health insurance plans contribute 15.4, 20.4 and
24.2 percent, respectively.15

Provider reimbursement

Under Japanese national health insurance, all insurance plans pay health care
providers low fees by American standards (Table 3). The fees must conform to a
uniform national fee schedule known as the point-fee system. For any particular
service, the same fee is paid by all insurers to all providers. As in Canada or
Germany, there is no "extra-billing": neither physicians nor hospitals may bill their
patients more than the authorized fee; but illegal side-payments are common and
condoned. All covered medical procedures are ranked by complexity, and neither
geographic location, the institutional setting (e.g., type of hospital or ambulatory
care), the qualification of the provider, nor the actual cost of the service are
considered in this rating system.16

Medical procedures are assigned a number of points, each of which is worth 10

yen.17 Only the basic charges for hospital room and board services are covered; the
costs for additional hotel amenities are not covered.18 The fee covers all supplies,
materials, capital depreciation and personnel costs. There is no flexibility in this
system of price controls for insurers or for providers. Hospitals can bill patients extra
only for room and board and a restricted number of specialized services, for
example.19 As John Campbell noted at the conference, "cheap stuff is profitable and
expensive stuff is unprofitable. A doctor who sees a few extra patients and prescribes
drugs for them makes money; coronary bypass surgery at an urban hospital loses
money."

The Ministry of Health and Welfare sets the fee schedule. Its Central Social
Medical Care Council has 20 members who represent a cross section of health care
interests: eight providers (five physicians, two dentists, and one pharmacist), eight
payers (four insurers, including government representatives, two employers and two
labor representatives), and four public interest representatives (three economists and
one lawyer).20 Every other year, this council renegotiates the fee schedule with the
medical profession, but these negotiations are constrained by a rate cap set by the
Ministry to limit the overall increase in costs. This rate cap results in an effective, if
implicit, global budget for all health care expenditures.21

NOTES:
1
Kemporen (1990).
2
Steslicke (1989).
3
From a table distributed at the Japan Society conference by Toshiro Murase,
president of the Japanese Medical Association.
4
J. Campbell (1993a).
5
Ikegami (1992b) p. 616.
6
These figures are taken from documents provided by representatives of the
Ministry of Health and Welfare in New York (JETRO).
7
Ikegami (1992).
8
Cash benefit payments, although they vary between plans, are generally sufficient
to cover the costs of childbirth.
9
Amounts in excess of about $400 a month are fully reimbursed; for those with low
incomes, amounts in excess of about $200 are fully reimbursed (Ikegami, 1991).
10
Kemporen (1990) p. 12.
11
Ibid p. 22.
12
Ibid.
13
John Campbell, presentation at the conference.
14
Yoshikawa et al. (1992) p. 8.
15
Kemporen (1990) pp. 43-44.
16
lkegami (1992b).
17
Yoshikawa et al. (1992).
19
lkegami (1992a) p. 702.
20
Yoshikawa et al. (1992).
21
lkeganii (1992).

Table 3

Fee Schedule Rates in $U.S.: U.S. and Japan (1992-93)

Japan U.S. (Medicare)
Chest X-Ray 13 32
EKG 12 20
Pap Smear 13 32
Total Colonoscopy 127 427
First Consultation
17 79
(office visit)
Appendectomy 369 647
Cataract Operation
292 747
(incisional)
C-section1
454 1149
(delivery only)

1
The Japanese fee for this procedure was reported in Yoshikawa (1992) p.12, Table 1

Sources: Japan's fees in yen were converted to $U.S. at a rate of 130 yen per dollar.
Data provided by Toshiro Murase at the Japan Society conference. U.S. Medicare
rates are for the New York area. They were taken from the Datasheet Charge
Summary Report, Empire Blue Cross and Blue Shield, 1993. These charges apply to
physicians who do not accept the Medicare rate as payment in full.

THE ORGANIZATION OF MEDICAL CARE

Hospitals

Despite Japan's relatively high hospital bed-to-population ratio (Appendix 1, Table

3), the number of hospital beds is not decreasing Between 1970 and 1988, in fact, it
increased by 25.8 percent.1 This reflects at least five characteristics of Japan's broader
health system First, until the late 1980s, few barriers were placed on entry into the
hospital market in Japan's rapidly growing postwar economy. Second the
organization of medical care in Japan is heavily centered around hospitals. Third, 81
percent of hospitals are privately owned, and the) have had few restrictions on their
capital investments. Fourth because hospitals have competed fiercely with one
another, expansion has served as a key strategy to gain a competitive edge. Finally, al
least until the mid 1980s, the Ministry of Health and Welfare has not played an active
role in containing the total number of hospital beds.

Close to 90 percent of hospital facilities with 20 or more beds are classified as

"general hospitals." The remainder are mental health facilities or tuberculosis and
leprosy centers. General hospitals are dominated by small, privately owned and
operated "nonprofit" facilities. The average number of beds in a Japanese hospital is
163 -slightly fewer than the 190 in an average American hospital - and half have
fewer than 100 beds.2 Although the last few years have witnessed a proliferation of
national hospital chains, the majority of small hospitals continue to be privately
owned and managed by physicians As in public hospitals, physicians in private
hospitals are salaried.

With 283 beds, the average public hospital is larger than its private counterpart.
Although 19 percent of hospitals are public, they account for 33 percent of all beds.
About 75 percent of public hospitals are under the jurisdiction of municipal and
prefectural governments the remainder are national institutions. About 1 percent of
hospitals are owned and operated by quasi-public agencies and organizations such as
the Red Cross, social insurance agencies and employment related groups.

Despite these distinctions, all hospitals in Japan tend to be viewed as recuperative

centers rather than as merely therapeutic institutions, Even large teaching hospitals do
not limit themselves to providing acute-care services. Hospitals have traditionally
functioned, in part, as long-term care facilities. Of the nearly 400 hospitals that have
more than 500 beds, only about 60 percent have adult intensive care units, and only
30 percent of them have neonatal intensive care units, the majority of which have
only five to seven beds.

As a result of this orientation, patients in Japanese hospitals have the longest

average length of stay in the world.3 Even accounting for the lengthy stays of
psychiatric patients, the average patient's stay in a Japanese hospital far exceeds that
of most other OECD countries both in the aggregate and by specific disease
categories (Appendix 1, Table 5). In addition to the nursing home functions played by
hospitals, other factors accounting for the lengthy stays are probably the large
number of beds, the low admission rates, the per diem form of hospital
reimbursement, and the emphasis on recuperation over invasive medical and surgical
interventions.

As is the case with intensive care units, there are far fewer emergency rooms in
Japan than in the United States. But while Japan has roughly half the population of
the United States, it has only 7 percent of the murders, 2 percent of the reported
rapes, and 0.3 percent of the armed robberies, so there would seem to be less of a
need for extensive trauma facilities.4 In addition, unimpeded access to health care
through the clinic system has the effect of steering non-urgent care away from
emergency rooms. An integrated system of primary, secondary and tertiary-level
emergency facilities appears to meet the need for emergency and trauma care.5

As in the United States, university hospitals in Japan are centers for research,
teaching and the delivery of tertiary-level "cutting edge" medical care. In contrast to
America's 129 academic medical centers with an average size of 664 beds, Japan has
131 university hospitals (half of them public) with an average size of 735
beds.6Despite their larger average size, Japanese teaching hospitals have far fewer
inpatient admissions, less than 30 percent of the American rate. And the 36.2 day
average length of stay in these hospitals far exceeds the 7.9 days in American
teaching hospitals.7

Although Japanese university hospitals generally incur higher costs, they also have
shorter lengths of stay and higher staffing ratios than other Japanese hospitals.
Increasingly, the public perceives these facilities as preferred sites for receiving
medical care.

A recent innovation for the delivery of high-tech medical care has been the
establishment of officially designated centers for such procedures as open-heart
surgery. This "Highly Advanced Medical Technology System" provides a mechanism
by which new medical devices can receive broader use and evaluation despite their
ineligibility for reimbursement under the normal benefits plan of Japan's health
insurance program. Most often, highly advanced medical procedures are performed at
teaching facilities.8 For third-party reimbursement to be awarded, these procedures
must now be performed at these centers, which are required to have appropriate
equipment and personnel.
Clinics and Ambulatory Care

Japanese physicians have traditionally operated on a small scale, working out of

their homes to provide health care services to their community. Although these clinics
have typically provided a low-level intensity of care, many have recently acquired a
wide range of sophisticated medical equipment including ultrasonic testing and
gastrointestinal fiberscopes.9

Small, privately owned clinics provided most outpatient services until the 1970s.
In addition, roughly 25,000 physicians' offices, equipped with up to 19 beds and also
referred to as "clinics," function as small hospitals. They add 276,000 beds to Japan's
already high number (15.8 per 1,000 persons), thus increasing the total number of
hospital beds by 17 percent.10

Since the 1970s, clinic physicians have become concerned about losing their share
of primary-care services to hospitals. Although the number of clinics has increased
from about 50,000 in 1955 to more than 80,800 in 1990, the number of clinics with
beds decreased by almost 20 percent during the 1970s and 1980s.11 Likewise,
although the number of physicians has increased by 113 percent since 1960, the
proportion of physicians running clinics has dropped from 44.8 percent in 1960 to
only 27.5 percent in 1990.12 This decrease in the number of clinics with beds and the
proportion of physicians running clinics is due largely to direct competition with
larger hospitals in outpatient services and high land prices that prohibit the
establishment of new clinic facilities. Larger hospitals are attracting both young
doctors and outpatients with their sophisticated technology and services.13

Despite the competition between clinics and hospitals, two structural aspects of
Japan's health care system appear to constrain the trend toward specialization and
high-tech care and to promote primary-care services. First, clinic physicians do not
have admitting privileges to hospitals. Second, once referred to the hospital, many
patients do not return to a clinic but continue to be treated by the hospital's outpatient
department. These barriers give clinic physicians an incentive to put off
hospitalization.14

Beyond the barriers to referring patients to hospitals, two financial incentives also
appear to support primary-care services. First, clinic physicians are remunerated
under the fee schedule each time they write a prescription for a dispensing
pharmacist. Second, they make an average profit of 26 percent of the reimbursement
rate every time they prescribe - and sell - a drug to their patients.15 Because
pharmaceutical manufacturers and wholesalers routinely sell drugs to physicians at
prices well below the fee schedule's reimbursement rates, drug sales have become an
important source of profits for clinics.16

The average net monthly income for clinic physicians was $22,900 in 1990, while
specialists based in private hospitals earned only $6,300.17 A 1985 study indicated
that revenues and net profits of clinic physicians vary with the quantity of drugs
prescribed and sold by physicians, the age of the physicians and the size of the clinic.
This finding supports the contention that clinic physicians maximize their income by
prescribing and selling more drugs.18
 Despite clinic physicians' practice of selling the drugs they prescribe, which strikes
most Americans as a blatant financial conflict of interest, the doctor-patient
relationship presumably is based on trust. Patients are typically told little about their
diagnoses, and doctors explain away problems in "soothing terms without necessarily
providing precise information about what exactly the problem is."19 Pills frequently
go unlabeled, and patients are not always told when they are part of an experiment.
Such practices were recently supported by a court decision that doctors need not
share the full details of a diagnosis with a cancer patient.20

The clinic physician, however, does not provide the kind of primary health care so
often extolled by family physicians in the United States. Most clinic physicians
operate in solo practices without hospital privileges, thus making it difficult to
collaborate with specialists as well as with peers. Standards of practice, professional
competence and patient care are neither monitored nor evaluated in any formal way.
In addition, as in the United States, Japanese physicians do not typically subscribe to
the idea of "comprehensive primary health care and often fail to respect the person as
a whole person operating in a complex social and economic environment."21

Services for the elderly

Since the early 1970s, the elderly enjoyed a privileged status in the Japanese
welfare state. With the economic growth of the 1960s came demands for the
expansion of social benefits that could not be ignored. In 1973, the government
responded to social pressures by creating an almost free medical care system for the
elderly, the national insurance plan administered by local governments. In 1982, in
response to rising health care costs, the Health and Medical Service Law for the Aged
established the national pooi to subsidize medical care.22 The government sought to
increase equity in financing by taxing all health insurance plans based on a formula
related to each plan's number of beneficiaries and past medical expenditures on the
elderly.23

Despite universal coverage under national health insurance, the range of services
designed to meet the needs of the elderly is limited. In general wards, no distinction
is made between acute and long-term care facilities.24 A significant fraction of
hospital beds are routinely occupied by elderly people requiring long-term care.
Seventy-five percent of the institutionalized elderly are in hospitals and clinics, for
example, and survey data indicate that 45 percent of elderly inpatients are
hospitalized for more than six months.25 Due to the shortage of rehabilitation
services, roughly 4.6 percent of the elderly population is bedridden.26 In 1987, 34
percent of patients in Japan's long-term care facilities were bedridden, a striking
contrast to America's 6.5 percent.27

There are now a growing number of hospitals specializing in treating and caring
for the elderly. There are also three other types of facilities that serve the elderly in
Japan: a small number of nursing homes (10 beds per 1,000 elderly persons in 1988,
in contrast to 46.2 in the United States in 1985), welfare institutions for those who
need constant care, and facilities providing rehabilitation services.28 But the relatively
limited number of home health aides leads to an absence of reliable support
services.29 Compared to the United States, Japan has a far more severe shortage of
long-term care services. There are long waiting lists for admission to nursing homes-
applicants commonly wait for more than a year.30

In addition to the lack of appropriate institutions and support services, at least three
other factors contribute to Japan's high rate of "social admissions" to hospitals. First,
medical practice generally tends to emphasize passive care and bed rest. Second, a
lack of space at home to accommodate elderly relatives pushes more of the frail
elderly into hospitals and clinics. Finally, women, the traditional care givers for the
elderly, are entering the work force in increasing numbers. Thus, although some 62
percent of the elderly live with their children or other relatives, in contrast to less
than 33 percent in the United States, Japan's institutionalization rate (6.2 percent) is
comparable to America's.31 Where Japan diverges from the United States and other
OECD countries is in its rapidly graying population. In 2020, 26 percent of Japanese
will be over 65, compared to 17.3 percent of Americans.32 Because there are already
about 700,000 Japanese aged 65 and over (4.6 percent of the elderly population) who
are so severely disabled that they are bedridden or require constant supervision, these
projections impelled government policy-makers to publish the "Golden Plan" and
make a commitment to solve this anticipated crisis.

The Golden Plan is a 10-year national health care and welfare plan for the elderly
agreed upon by the Ministries of Health and Welfare, Finance and Home Affairs in
1989.33 At the Japan Society conference, Ministry of Health and Welfare Director-
General Nobuharu Okamitsu described it as an attempt to integrate welfare services,
medical care and insurance in a comprehensive manner. The plan outlines an
ambitious set of goals at a projected cost of $40 billion during the 1990s. This is in
contrast to the $11.3 billion spent in the 1980s.

The plan relies on four principal strategies to build the infrastructure necessary to
accommodate the growing needs of the elderly:

1. Expansion of existing services by increasing the number of home helpers

from 40,900 in 1991 to 100,000 in 1999 and the number of nursing home
beds from just over 144,600 to 240,000;34

2. Creation of a more diverse range of services by defining the respective roles

of corporations and of the national, prefectural and municipal governments;

3. Decentralization through an increased role for municipalities in the design of

programs;

4. Reduction of fragmentation by developing government entities to provide

services, support research, disseminate information and coordinate the
regional administration of model projects.

In addition to expanding infrastructure for the elderly, the Golden Plan seeks to
rationalize services. It aims to reduce the geriatric population of hospitals and to
increase capacity in skilled nursing homes and particularly in new institutions known
as geriatric rehabilitation centers. In addition, it calls for a three-fold increase in
government-employed visiting homemakers, a 10-fold growth in adult day centers,
and a 12-fold increase in respite care centers. If the plan is implemented, the
bedridden elderly will be shifted over the next decade away from hospitals toward
home care support services, informal support services and nursing homes.

The government has recently adjusted the fee schedule's reimbursement rates to
encourage those general hospitals that provide mostly long-term care for the elderly
to become approved geriatric hospitals. The fee schedule's per diem rates for long-
term care in general hospitals have been reduced to provide an incentive for many
private, medium-sized hospitals to become chronic and geriatric care facilities that
would be reimbursed on the basis of a more favorable geriatric fee schedule.35

Another major change in the reimbursement of medical care for the elderly was the
reinstatement of copayments. When the elderly were first covered under national
health insurance in 1961, their copayments were set at 50 percent of the allowed fees.
Free medical care for the elderly was established in 1973 and lasted until 1983. When
reinstated, the copayment was kept at a low level, far lower than the pre-1970 levels
of patient contribution.36 But cost-sharing for care of the elderly has continued to rise.
Moreover, the government is now emphasizing programs that draw on family
resources. In contrast to inpatient services, local governments now ask the children of
residents in nursing homes and geriatric hospitals to contribute toward the cost of
care.37

NOTES:
1
Statistics Bureau, (Iryo-Shisetsu Chosa). Cited by Yoshikawa et al. (1992) p. 15.
2
Holt et al. (1992).
3
OECD (1993).
4
Crime statistics are from JETRO (Ministry of Health and Welfare) 1991, p. 30.
Cited by M. Calhoun, "The Japanese Health Care System in Perspective," ch. 16 in
Okamoto and Yoshikawa (1993).
5
1n 1990, about half of all patients entering emergency facilities were considered
"emergencies," 28 percent were "injuries," and 23 percent were "traffic-related."
From "Present Situation of Emergency Care and Services," Fire Defence Agency,
1992. Document provided by Japanese Ministry of Health and Welfare
representatives in New York.
6
Holt et al. (1992).
7
Ibid
8
Yoshikawa et al. (1992) p. 47.
9
lbid.
10
This calculation is based on 1988 data from the Ministry of Health and Welfare,
cited by Yoshikawa et al., How Does Japan Do It? Stanford University, Spring 1992.
11
Yoshikawa et al. (1992) p. 15
12
Presentation by Aid Yoshikawa at the conference.
13
Yoshikawa et al. (1992). At the conference, Nobuharu Okamitsu pointed out that
a new policy was introduced last year requiring patients to obtain a referral from
primary-care doctors before going for outpatient services to large hospitals. Without a
referral, patients would have to make larger copayments. However, at this time we
have no information on the extent to which this policy has affected the flow of
outpatient visits to large hospitals. Only two hospitals are currently slated to
participate in this program beginning in September 1994.
14
lkegami (1991) p. 99.
15
Yoshikawa et al. (1992).
16
lglehart (1988b); Ikeganii (1992a).
17
Yoshikawa et al. (1992) p. 15.
18
Abe (1985).
19
M. Yamamoth, "Primary Health Care and Health Education in Japan," Social
Science and Medicine 17(19) 1419-31. Quoted in Powell and Anesaki (1990) p. 173.
20
Sterngold (1992).
21
Powell and Anesaki (1990).
22
John Campbell (1992b). Perceptive analysis of the evolution and politics behind
the policy changes so briefly summarized here.
23
Fujii and Reich (1988).
24
Health and Welfare Statistics Association, Health and Welfare Statistics in Japan.
Tokyo, 1992. Table 60.
25
Ikegaini (1991). This figure is from a 1987 nationwide patient survey conducted
by the Japanese Ministry of Health and Welfare: Kokumin Eisei no Doko (Health
State of the Nation, Annual Report). Kosei Tokei Kyokai, Tokyo, 1990. Cited by
Kobayashi and Reich (1992).
26
Butler (1990).
27
K. Takenaka et al., The Report of the Task Force on the Current Status of the
Bedridden Elderly in Comparison to Several Foreign Countries. Tokyo: Ministry of
Health and Welfare, 1989. Cited by Kobayashi and Reich (1992) p.7.
28
Okamoto (1992); Kobayashi and Reich (1993) p. 347.
29
Kobayashi and Reich (1993). Table 10 from Harvard School of Public Health,
Working Paper No. 7.
30
Kobayashi and Reich (1993).
31
Ikegarni (1991).
32
Kobayashi and Reich (1993) p. 16.
33
The Golden Plan: Japan's 10 year strategy to Promote Health and Social
Services for the Aged, 1990. New York: International Leadership Center on
Longevity and Society, Mt. Sinai Medical Center.
34
Ministry of Health and Welfare (1992a) pp. 145, 150.
35
Yoshikawa et al. (1992) pp. 18, 19.
36
Okamoto (1992) p. 403.
37
Japan Economic Institute (1992), p. 13.

4.1 pengenalan

Sistem pelayanan perawatan kesehatan di Jepang yang disampaikan oleh sistem

asuransi kesehatan umum wajib, nirlaba, dan bukan oleh penyedia layanan untuk
keuntungan. Sistem asuransi kesehatan masyarakat Jepang terdiri dari tiga jenis asuransi
kesehatan: berbasis pendudukan, berbasis kotamadya, dan sistem yang terpisah untuk
orang berusia 75 tahun dan di atas. Setiap penduduk di Jepang harus milik asuransi
umum sebagai silau. Semua asuransi kesehatan adalah tidak-untuk-laba
organisasi. Disediakan layanan kesehatan tidak hanya oleh penyedia yang umum, tetapi
juga orang-orang pribadi yang memenuhi prinsip "nirlaba". Pasien menikmati "kebebasan
pilihan," yang meyakinkan orang-orang dapat memilih dan Hubungi dokter di setiap
institusi medis. Biaya perawatan medis yang dibiayai melalui premi asuransi, pajak
pendapatan, dan copayments. Orang tua, bayi dan orang-orang berpenghasilan rendah
sepenuhnya atau sebagian dibebaskan dari copayments. Orang lain harus membayar
copayments yang 30% dari total biaya medis ketika mereka menggunakan layanan
medis. Menurut tingkat pendapatan dan usia pasien, jumlah maksimum copayment
ditentukan. Keberlanjutan sistem tergantung pada apakah redistribusi inter-institutional
beban dapat bekerja atau tidak, dan Apakah cukup sumberdaya manusia tersedia untuk
penyediaan layanan untuk orang tua.

4.2 asuransi kesehatan masyarakat

4.2.1 Sejarah

Sistem asuransi kesehatan di Jepang telah terus berkembang sejak tahun 1920-
an. Pada awalnya, undang-undang asuransi kesehatan diundangkan pada tahun
1922. Sementara terjadinya gempa bumi besar Kanto di 1923 membuat hukum yang
tertunda hingga 1927, asuransi kesehatan masyarakat ini tertutup "biru warna" pekerja di
pabrik dan pertambangan. Kedua, undang-undang asuransi kesehatan nasional
diundangkan pada tahun 1938. Undang-undang ini memperluas cakupan asuransi
kesehatan masyarakat tidak hanya bagi petani, tetapi juga masyarakat umum yang tidak
dilindungi oleh undang-undang asuransi kesehatan. Undang-undang asuransi kesehatan
nasional diresepkan bahwa kotamadya bisa asuransi dari asuransi kesehatan bagi
masyarakat yang tinggal di daerah mereka. Namun, hukum diizinkan bahwa kotamadya
bisa memilih untuk tidak membangun asuransi kesehatan nasional, dan bahwa orang
bisa mendaftar asuransi kesehatan umum oleh keputusan mereka. Oleh karena itu masih
ada orang-orang non-Tertanggung. Dari 1939 melalui 1941, undang-undang asuransi
kesehatan masyarakat lain mulai untuk menutupi "warna putih" pekerja, termasuk
pejabat pemerintah. Selain itu, sistem asuransi kesehatan masyarakat juga mulai untuk
menutupi pelaut oleh undang-undang asuransi pelaut pada tahun 1940. Dalam
ringkasan, sebelum Perang Dunia II, sistem asuransi kesehatan umum di Jepang secara
bertahap dikembangkan oleh memberlakukan undang-undang asuransi kesehatan yang
berbeda untuk setiap sub-grup di seluruh masyarakat.

Umum asuransi kesehatan dikembangkan lebih lanjut setelah PD II. Undang-undang

kesehatan umum asuransi yang sudah ditetapkan sebelum berakhirnya Perang Dunia II
berturut-turut digunakan setelah perang. Maka asuransi kesehatan masyarakat telah
mengambil lebih dari karakteristik sebelum. Setiap hukum asuransi kesehatan umum
diatur anggaran keuangan sendiri, oleh karena itu manajemen mereka telah independen
satu sama lain. Lebih penting lagi, kurangnya hukum untuk perlindungan asuransi
kesehatan yang komprehensif tersirat bahwa masih ada kemungkinan bahwa ada orang-
orang non-Tertanggung. Masalah ini diperbaiki oleh berlakunya undang-undang asuransi
kesehatan nasional baru pada tahun 1961, yang Jepang mencapai cakupan
universal. Undang-undang asuransi kesehatan nasional baru mengamanatkan semua
warga di Jepang untuk mendaftar di asuransi kesehatan nasional, kecuali dalam kasus
yang mereka telah didaftarkan dalam asuransi kesehatan masyarakat lainnya.

Edisi berikutnya dari pengembangan asuransi kesehatan umum adalah peningkatan

manfaat asuransi, dan peningkatan ketidaksetaraan dalam manfaat asuransi antara
skema yang berbeda. Pada awal 1960', obat-obatan mahal antibiotik beberapa obat-
obatan steroid dan obat kemoterapi telah dilarang untuk digunakan dalam sistem
asuransi kesehatan masyarakat. Pembatasan ini dihapuskan pada tahun
1962. Mengangkat biaya perawatan kesehatan, tetapi biaya diperluas diserap surplus
keuangan diperluas dalam sistem asuransi kesehatan masyarakat, karena tingginya
tingkat pertumbuhan ekonomi.

Di awal 1960', tingkat copayment adalah 50% untuk semua pendaftar dalam asuransi
kesehatan nasional, sementara itu 0% kepala rumah tangga (kepala silau) asuransi
kesehatan yang dikelola masyarakat dan dikelola oleh Asosiasi Asuransi
kesehatan. Dengan demikian jumlah subsidi dari pemerintah kepada perusahaan
asuransi dalam asuransi kesehatan nasional meningkat, dalam rangka untuk menurunkan
tingkat copayment untuk pendaftar dalam asuransi kesehatan nasional.

Beban copayment cenderung lager untuk pasien dengan penyakit parah atau
penyakit kronis. Pada 1960-an, kotamadya mulai mensubsidi elderlies (lebih dari 70
tahun dan lebih tua) sehingga tingkat copayment mereka menjadi 0%. Subsidi ini untuk
copayment untuk orang tua menjadi universal pada tahun 1973. Untuk orang berusia
kurang dari 70 tahun, tinggi biaya perawatan manfaat sistem medis diperkenalkan juga
pada 1973 untuk topi beban copayment.

Di awal 1970-an, minyak krisis ekonomi Jepang. Untuk mencegah kenaikan cepat
harga, pemerintah menerapkan kebijakan untuk mengontrol kegiatan ekonomi, seperti
pemotongan belanja publik. Kebijakan ini yang berhasil, dan kemudian resesi datang
tahun depan. Mengurangi pendapatan keuangan pemerintah serta pendapatan premi
asuransi dari sistem asuransi kesehatan masyarakat. Pemerintah mulai mengisi
kesenjangan keuangan tahunan dengan mengeluarkan Obligasi nasional, dan
pengeluaran pemerintah mulai berkurang. Jamsostek pengeluaran juga mulai
terkandung, bersama dengan subsidi pemerintah untuk itu.

Walaupun penurunan pengeluaran Jamsostek, pengeluaran kesehatan untuk orang

tua telah meningkat dengan pesat. Salah satu alasan adalah subsidi pemerintah untuk
copayment untuk orang tua. Perawatan kesehatan biaya untuk orang tua meningkat dari
40 miliar yen di 1973 untuk 67 miliar yen pada tahun 1974, dan 87 miliar yen pada
tahun 1975. Setelah 1975, tingkat pertumbuhan adalah sangat tinggi. Mengandung
kenaikan biaya cepat, sistem perawatan kesehatan baru untuk orang tua
diperlukan. Namun kenaikan biaya bukan satu-satunya alasan untuk pengenalan sistem
baru. Pada waktu itu, orang tua punya hanya pelayanan kesehatan, bukan layanan untuk
promosi kesehatan, pencegahan seperti kesehatan check-up, rehabilitasi atau
perawatan. Layanan ini bekerja sama dengan perawatan medis yang diperlukan harus
diberikan dengan cara yang lebih terintegrasi. Maka pada tahun 1983, sistem layanan
kesehatan untuk orang tua diperkenalkan. Copayment dasar per diem diperkenalkan
untuk pemanfaatan perawatan medis.

Sistem layanan kesehatan untuk orang tua merupakan bagian dari inter-institutional
fiskal penyesuaian terhadap biaya perawatan kesehatan untuk orang tua. Sejak
pertengahan 1980-an, biaya penahanan kebijakan telah dipekerjakan. Ketidaksetaraan
suku copayment antara asuransi kesehatan umum yang berbeda yang dipersamakan
siapa hingga 30% pada tahun 2003. Inter-Institutional fiskal penyesuaian terhadap biaya
perawatan kesehatan untuk orang tua telah dikuatkan, dan ini dikembangkan untuk
sistem perawatan medis untuk orang tua di dalam tahap terakhir kehidupan di tahun
2008.

4.2.2 sistem asuransi kesehatan masyarakat: hari

Sebagaimana dinyatakan sebelumnya, Jepang 's medis layanan yang dibiayai melalui
sistem asuransi kesehatan wajib umum, yang terdiri dari tiga jenis asuransi kesehatan
umum: asuransi kesehatan berbasis pendudukan, berbasis kotamadya dan terpisah
untuk orang berusia 75 tahun dan di atas. Orang tua berusia 75 atau lebih yang
mendaftar di kesehatan masyarakat asuransi, yang disebut sistem perawatan medis untuk
orang tua di dalam tahap terakhir kehidupan. Mereka yang di bawah usia 75 tahun
mendaftar di asuransi berbasis pekerjaan umum kesehatan atau asuransi kesehatan
nasional. Ada tiga jenis berbasis pekerjaan umum kesehatan asuransi. Salah satunya
adalah asuransi kesehatan bagi pekerja di perusahaan-perusahaan dari ukuran tertentu
yang disebut asuransi kesehatan yang dikelola masyarakat. Masing-masing perusahaan
besar memiliki tugas untuk membangun masing-masing asuransi kesehatan masyarakat
berbasis perusahaan nirlaba untuk menyediakan perlindungan asuransi kesehatan
masyarakat untuk karyawan mereka. Bagi mereka yang bekerja di perusahaan-
perusahaan kecil, Asosiasi Asuransi kesehatan Jepang, yang merupakan asosiasi publik
asuransi kesehatan, menyediakan asuransi kesehatan kolektif, yang disebut yang dikelola
oleh Asosiasi Asuransi kesehatan. Selain itu, Khusus profesi seperti PNS, guru sekolah
swasta dan karyawan, hari buruh dan pelaut, bentuk terpisah asosiasi profesional
nasional.

Mereka yang di bawah 75 tahun dan tidak dilindungi oleh asuransi kesehatan
masyarakat berbasis pendudukan dilindungi oleh asuransi kesehatan nasional. Asuransi
Asuransi Kesehatan Nasional adalah kotamadya, pemerintah daerah yang lemari untuk
masyarakat. Skema ini meliputi orang-orang yang bekerja sendiri, para pekerja yang
terlibat dalam pertanian, kehutanan dan Perikanan, pekerja di usaha kecil, yang masih
menganggur dan para pensiunan.

Asuransi kesehatan masyarakat ini menyediakan cakupan universal penduduk di

Jepang. Garis dari setiap sistem ditampilkan dalam tabel 4.1 (terletak pada akhir bab
ini). Asuransi Kesehatan Nasional mencakup 31% dari total populasi, 27% untuk yang
dikelola oleh Asosiasi Asuransi Kesehatan, 24% asuransi kesehatan yang dikelola
masyarakat, dan 11% untuk sistem perawatan medis untuk orang tua di dalam tahap
terakhir kehidupan.

Manfaat asuransi standar sepanjang semua skema asuransi kesehatan

masyarakat. Seperti yang ditunjukkan dalam gambar 4.1. Tingkat pelayanan medis yang
ditanggung oleh asuransi kesehatan masyarakat dibincangkan dalam pusat asuransi
sosial Dewan medis, anggota yang terdiri dari wakil-wakil dari klinik dokter dan rumah
sakit, asuransi dalam asuransi kesehatan masyarakat, dan masyarakat umum. Dewan juga
membahas tentang Tarif resmi layanan medis. Berdasarkan saran dari Dewan,
Departemen Kesehatan, Perburuhan dan kesejahteraan memutuskan cakupan dan harga
pelayanan medis.

Gambar 4.1 struktur cakupan layanan kesehatan oleh dan seterusnya asuransi
kesehatan umum

4.2.3 pembiayaan asuransi kesehatan

Secara umum, individu kesehatan pengeluaran lebih tinggi sebagai usia / lebih
tinggi. Hal ini juga berlaku di Jepang. Maka pengeluaran kesehatan rata-rata per silau
tertinggi dalam sistem perawatan medis untuk orang tua dalam tahap terakhir kehidupan
(\844,382/tahun), karena orang lebih dari 75 tahun mendaftar di dalamnya, seperti
telah kami jelaskan. Sebagian besar individu berusia 65 dan 74 mendaftar di asuransi
kesehatan nasional, sehingga rata-rata pengeluaran kesehatan per silau \
168,658/tahun, lebih tinggi daripada yang ada di pekerjaan lain - berbasis asuransi
kesehatan. Biaya manfaat kesehatan dalam asuransi kesehatan masyarakat
mencerminkan perbedaan ini pendaftar umur struktur seperti ditunjukkan di bagian atas
tabel 4.2.

Tabel 4.2 situasi keuangan asuransi kesehatan masyarakat (tahun 2009)

Unit: yen per pendaftar

Sumber: Departemen Kesehatan, Perburuhan dan kesejahteraan (MHLW), "tahunan Kesehatan,
tenaga kerja dan kesejahteraan laporan 2012"

Skema asuransi kesehatan masyarakat yang dibiayai oleh premi, subsidi dari Umum
anggaran dari pemerintah, dan rekan-pembayaran dari pasien. Premi asuransi adalah
salah satu sumber daya keuangan utama untuk asuransi kesehatan umum. Metode
koleksi premium berbeda antara skema asuransi kesehatan masyarakat. Asuransi
berbasis pekerjaan umum kesehatan asuransi mengumpulkan premi oleh deducting
gaji. Batas bawah dan atas premi ditetapkan sebesar 30/1000 dan 120/1000, masing-
masing. Premi asuransi kesehatan nasional yang dikumpulkan melalui pembayaran
langsung kepada pemerintah kotamadya oleh pelanggan secara rumah tangga. Premi
terdiri dari bagian proporsional berdasarkan pendapatan, aset, dan jumlah orang dalam
rumah tangga dan menjadi bagian yang tetap per rumah tangga. Asuransi dalam sistem
perawatan medis untuk orang tua di dalam tahap terakhir kehidupan mengumpulkan
premi terutama oleh deducting pensiun dibayar untuk orang tua.

Pemerintah pusat, Prefektur, dan municipal mensubsidi asuransi dari asuransi

kesehatan nasional untuk biaya menjalankan mereka. Pemerintah pusat mensubsidi 41%
manfaat kesehatan, dan pemerintah Prefektur mensubsidi 9% dari itu. Jumlah ini \
57,657 per silau seperti yang ditunjukkan dalam tabel 4.2. Dalam hal keuangan asuransi
menghadapi defisit, kotamadya mengelola akan menanggung biaya sebagai bentuk
subsidi kepada penanggung. Jumlah ini termasuk dalam kategori "orang lain" pendapatan
dalam tabel 4.2. Kita dapat melihat dalam tabel 4.2 bahwa manfaat asuransi biaya lebih
tinggi dalam asuransi kesehatan nasional dan sistem perawatan medis untuk orang tua di
dalam tahap akhir kehidupan, tetapi pendapatan premi lebih rendah dalam asuransi dua
ini. Hal ini menyebabkan ketidakseimbangan fiskal dalam asuransi dua ini. Untuk
menyesuaikan ketidakseimbangan fiskal, penyesuaian fiskal inter-institutional telah
diperkenalkan. Dalam skema ini, beban biaya perawatan kesehatan untuk orang tua
berusia 65 dan 74 yang dialokasikan kembali antara asuransi dari asuransi kesehatan
umum. Jumlah yang menerima asuransi kesehatan nasional dari penyesuaian fiskal ini
adalah \52,618 per silau.

Sistem perawatan medis untuk orang tua di dalam tahap terakhir kehidupan bagi
mereka berusia 75 dan lebih tua itu sendiri dapat menganggap sebagai skema untuk
penyesuaian fiskal inter-institutional. Orang tua berusia 75 dan lebih dari mendaftar
dalam sistem ini, dan mereka harus membayar premi. Premium keuangan 10% dari biaya
medis. Sisa 90%, 50% ditutupi oleh pemerintah pusat dan daerah subsidi dan 40% oleh
kontribusi dari asuransi program asuransi lainnya. Jumlah yang menerima sistem
perawatan medis untuk orang tua dalam tahap kedua kehidupan dari penyesuaian fiskal
ini adalah \361,262 per silau.

Tabel 4.2 menunjukkan rekan-pembayaran tetapi jumlah copayment tidak dapat

diabaikan, sebagai rekan-pembayaran harga pada dasarnya adalah 30% untuk sistem
asuransi kesehatan umum di Jepang. Pembayaran dilakukan setiap kali kunjungan ini
dibuat untuk sebuah lembaga medis. Pembayaran bersama tingkat bervariasi menurut
pasien usia dan pendapatan, seperti 20% untuk anak-anak di bawah usia sekolah, atau
30% untuk orang tua yang berpenghasilan lebih dari 70 tahun, yang memperoleh tingkat
pendapatan yang sama sebagai generasi bekerja, 10% untuk sebagian orang tua lebih
dari 75 tahun. Tingkat pembayaran bersama perundang-undangan adalah 20% untuk
orang tua yang berusia antara 70 dan 74, tingkat pendapatan yang tidak begitu
tinggi. Namun, tingkat pembayaran bersama orang-orang ini adalah temporal 10%
memobilisasi ukuran anggaran.

Manfaat perawatan medis biaya tinggi diterapkan untuk semua umum asuransi
kesehatan. Sistem ini bertujuan untuk menahan jumlah pembayaran bersama dengan
menetapkan topi menurut usia dan pendapatan, dan perusahaan asuransi beruang
perbedaan antara topi dan jumlah dibayarkan bersama pembayaran. Jumlah topi yang
terletak lebih rendah untuk berpenghasilan. Sebagai contoh, cap bulanan untuk pencari
nafkah berpenghasilan rendah yang berusia di bawah 70 adalah \35,400, dan di bawah
perawatan sistem medis untuk orang tua di dalam tahap akhir kehidupan,
berpenghasilan hanya membayar sampai \8,000 untuk pengobatan rawat jalan, dan \
24,600 rawat inap.

4.2.4. masalah dalam pembiayaan asuransi kesehatan masyarakat

Ketika penuaan penduduk masih melanjutkan, biaya perawatan kesehatan untuk

orang tua akan meningkat sesuai. Hal ini secara otomatis meningkatkan berbasis
pendudukan asuransi beban subsidi untuk sistem perawatan medis untuk orang tua di
dalam tahap terakhir kehidupan. Peningkatan beban harus ditutupi oleh peningkatan
jumlah premi asuransi di asuransi mereka. Namun, situasi keuangan asuransi bervariasi
dan mungkin terlalu berat beban bagi beberapa asuransi. Untuk membuat beban lebih
adil, kebijakan berubah untuk menentukan jumlah subsidi dengan jumlah pendaftar
pendapatan. Dengan kebijakan ini, asuransi dari asuransi kesehatan berbasis
pendudukan meningkatkan premi hanya ketika tingkat premi mereka terlalu rendah
untuk tingkat pendapatan mereka pendaftar.

Asuransi kesehatan nasional memiliki sejumlah besar pelanggan pendapatan lebih

rendah dan penatua pelanggan dari asuransi kesehatan berbasis pekerjaan. Sebagai
akibatnya, pendaftar relatif miskin menghadapi tingkat premi yang relatif lebih tinggi. Hal
ini menyebabkan peningkatan premi asuransi tidak dibayar dalam asuransi kesehatan
nasional. Pada tahun 2011, besarnya premi asuransi yang belum dibayar adalah
merupakan 10.6% dari jumlah total premi yang dipungut. Dalam sistem asuransi sosial,
premi asuransi tidak dibayar berarti mereka kehilangan kelayakan, dan moral hazard
terjadi. Untuk menghindari hal ini, kelompok target pembebasan pembayaran premi
telah diperbesar. Juga, rumah tangga sangat miskin dijamin akses ke layanan kesehatan
tanpa pembayaran premi, berdasarkan sistem bantuan umum.

4.3 provisi
4.3.1. Tinjauan

Dasar-dasar sistem penyediaan perawatan medis dibangun sebelum

WWII. Pengelolaan lembaga medis memenuhi prinsip "nirlaba" sementara pemilik
lembaga medis mengikutsertakan publik dan swasta. Dokter medis pendidikan dengan
program pendidikan Universitas enam tahun dan dilatih dengan lima tahun program
pelatihan setelah lulus. Mereka dapat mendidik diri mereka sendiri untuk memperdalam
spesialisasi klinis mereka. Praktek umum tidak secara eksplisit diakui sebagai salah satu
spesialisasi klinis, sehingga tidak ada dokter umum sebagai spesialis klinis. Ada tidak ada
sistem pemelihara gerbang. Pasien dapat memilih lembaga medis yang mereka ingin
mengunjungi. Oleh karena itu, peran masyarakat klinik dan rumah sakit khusus telah
tidak jelas dipisahkan. Pasien dapat memilih untuk kontak pertama mereka spesialis di
Departemen rawat jalan rumah sakit. Pada pertengahan 1970-an, tingkat copayment
elderlies ditetapkan pada 0%. Jelas, itu telah meningkat penggunaan perawatan medis
antara elderlies. Namun, ini adalah ukuran Genting diambil karena kelangkaan fasilitas
perawatan jangka panjang pada hari-hari. 0% copayment tingkat dihapuskan pada tahun
1983 dan bersama-sama dengan kebijakan meningkatkan fasilitas perawatan jangka
panjang, efisiensi dalam penyediaan layanan perawatan rawat inap untuk orang tua telah
ditingkatkan dengan amandemen kebijakan hukum lembaga medis, dan bujukan
kebijakan oleh perubahan tarif untuk layanan perawatan medis. Pengenalan Asuransi
perawatan jangka panjang menciptakan banyak alternatif untuk orang tua yang
membutuhkan layanan dukungan hidup selain rawat inap di rumah sakit. Sekarang
masalahnya adalah bagaimana mengkoordinasikan perawatan medis dan perawatan
jangka panjang.

4.3.2 penyediaan pelayanan kesehatan: sejarah

Sebelum zaman Meiji, dokter ada di Jepang yang disebut "Kusushi" berdasarkan obat
oriental pada waktu itu. Mereka membuat mendiagnosa, memutuskan resep, dan
menjual obat-obatan kepada pasien. Namun, mereka dikeluarkan dari praktek dengan
peraturan sertifikasi yang menggantikan mereka oleh dokter dididik oleh Kedokteran
Barat yang diperkenalkan di zaman Meiji.

Dokter medis menjual obat-obatan kepada pasien sementara mereka dididik di

Kedokteran Barat. Ini adalah karena ada beberapa apoteker pada waktu itu. Apoteker
berharap untuk mencapai pemisahan praktek medis dan obat pengeluaran, tapi itu tidak
boleh dicapai, karena mereka kekuatan politik yang lemah. Rumah sakit yang didasarkan
pada obat Barat pertama kali didirikan di Nagasaki pada tahun 1861. Banyaknya rumah
sakit meningkat menjadi 106 pada tahun 1878. Rumah sakit yang didirikan oleh
pemerintah pusat, pemerintah daerah, dan warga negara dan organisasi. Pada masa itu,
ada tidak umum kesehatan asuransi. Maka orang-orang miskin tidak bisa mengakses
layanan perawatan medis. Palang Merah Jepang didirikan sebagai Hakuai-sha pada
1878, dan sosial organisasi Saiseikai Imperial hadiah Yayasan Kesejahteraan (The
Saiseikai) didirikan pada tahun 1911. Mereka dibangun rumah sakit dan mulai
menyediakan pelayanan medis kepada orang miskin.

Pada masa itu, dokter bisa mulai praktek swasta mereka dimana mereka lebih suka
(bebas-masuk). Maka institusi medis berada padat di daerah perkotaan karena dokter
sebagai pengelola lembaga medis ingin menjaga keuangan status mereka lebih baik. Hal
ini membuat berbagai kemudahan pengaksesan untuk perawatan medis yang tidak
seimbang antara wilayah geografis. Di daerah pedesaan, misalnya, dokter tidak bisa
memperoleh cukup roti karena petani relatif miskin daripada orang lain, dan tidak dapat
membayar biaya layanan perawatan medis. Di sisi lain, dikatakan bahwa dokter yang
sangat kompetitif di daerah perkotaan bahwa mereka juga tidak bisa memperoleh
mereka cukup roti di daerah tersebut. Setelah Perang Dunia II, rumah sakit dan klinik
kehilangan personel berfungsi, yang bekerja di mereka, dan bahkan bangunan mereka
karena hasil perang. Untuk meningkatkan pasokan layanan perawatan medis, berbagai
kebijakan dipekerjakan. Institusi medis yang dikendalikan oleh Departemen angkatan
laut dan Departemen Perang digabung menjadi Departemen Kesehatan dan
kesejahteraan, dan lembaga-lembaga medis tersebut dibuat tersedia untuk penggunaan
umum sebagai rumah sakit nasional. Pemerintah Jepang memutuskan untuk membuat
keuangan subsidi untuk pribadi (tapi tidak untuk keuntungan) institusi medis untuk
investasi mereka ke klinik konstruksi dan/atau peralatan medis. Karena kebijakan ini dan
efek booming ekonomi tahan lama, jumlah rumah sakit swasta dan klinik diperluas.

Pemerintah daerah, seperti sebelum Perang Dunia II, mendirikan rumah sakit dan
klinik. Palang Merah Jepang, Saiseikai, dan organisasi nirlaba juga mendirikan institusi
medis. Investasi baru ini memberikan kontribusi sebagian untuk perbaikan bertahap dari
distribusi institusi medis. Namun, ada tidak ada metode yang efektif untuk
menyembuhkan geografis institusi medis tidak meratanya penyebaran air. Di
pertengahan 1980-an, hal itu menunjukkan bahwa variasi regional rawat biaya
berkorelasi untuk pasokan tempat tidur rawat inap. Undang-undang lembaga medis
diamandemen sehingga pemerintah bisa menentukan daerah dimana tempat tidur rawat
inap yang berlebihan disediakan relatif terhadap jumlah penduduk pada tahun 1985.

Antara amandemen lembaga medis hukum sejak itu, kedua amandemen hukum
memperkenalkan kategorisasi rumah sakit rumah sakit berfungsi khusus dan tempat tidur
tipe kategorisasi "Jangka panjang perawatan-jenis tempat tidur" pada tahun
1992. Rumah sakit berfungsi khusus adalah sebuah klasifikasi dari rumah sakit yang
menyediakan teknologi tinggi dan intensif rawat. Tempat tidur tipe kategorisasi "Jangka
panjang perawatan-jenis tempat tidur" diperkenalkan karena penggunaan tempat tidur
tidak selalu didasarkan pada kebutuhan medis. Pada masa itu, seperti yang kita lihat
dalam Bagian 4.2.1, tingkat copayment untuk orang tua adalah 0%. Kebijakan ini
membuat pasien yang membutuhkan dukungan untuk perawatan hidup daripada medis,
memanfaatkan tidak perlu rawat.

Jangka panjang perawatan asuransi hukum ini diberlakukan pada tahun 2000. Sejak
saat itu, penggunaan paling jangka panjang perawatan tempat tidur diganti bukan oleh
asuransi kesehatan masyarakat, tetapi dengan Asuransi perawatan jangka panjang. Oleh
pengenalan jangka panjang perawatan asuransi, pasien yang relatif kurang memerlukan
perawatan medis rawat inap diinduksi menggunakan layanan dukungan hidup.

Rawat inap akut juga direformasi sehingga layanan dapat diberikan dengan lebih
efisien. Pada tahun 2003, Diagnosis prosedur kombinasi (DPC) diperkenalkan untuk
diadili sebagai alat klasifikasi penyakit. Sistem penggantian untuk rawat inap akut mulai
menggunakan DPC pada tahun 2006. Penggantian berdasarkan DPC adalah dasar per
diem. Maka itu tidak mempunyai dampak langsung untuk mempersingkat rata-rata lama
menginap.

4.3.3 penyediaan pelayanan kesehatan: hari

Salah satu karakteristik dari sistem perawatan kesehatan Jepang adalah ketersediaan
tempat tidur dan durasi panjang tinggal di fasilitas medis. Menurut definisi, hukum
lembaga medis, klinik dapat memiliki kurang dari 20 tempat tidur, sementara rumah sakit
harus memiliki tempat tidur 20 atau lebih. Pada 2012, ada 8,565 rumah sakit, klinik
100,152, dan 68,474 klinik gigi di Jepang. Tempat tidur di rumah sakit 1,578,254
(tempat tidur 12.4 /1,000 orang), dan jumlah tempat tidur di klinik adalah 125,599
(0.99beds / 1.000 orang). Rata-rata lama menginap di rumah sakit adalah 31.2 hari
untuk rumah sakit dan 17,5 hari untuk klinik, yang lebih lama daripada 8 hari untuk
negara-negara OECD.

Kedua, ada dokter umum tidak secara eksplisit ditetapkan, sehingga kita pada
dasarnya tidak ada sistem pemelihara gerbang. Dokter medis berpendidikan obat dalam
enam tahun studi tingkat sarjana. Mereka harus melewati Nasional praktisi kualifikasi
pemeriksaan kesehatan. Setelah lulus ujian mereka dilatih sebagai seorang dokter medis
di sebuah kursus pendidikan pasca Universitas lima tahun. Setelah menyelesaikan kursus
pendidikan pasca Universitas, mereka diajarkan sebagai spesialis dalam spesialisasi klinis
mereka. Jumlah dokter yang bekerja di lembaga medis adalah 288,850 (2.4 orang /1,000
orang), 188,306 yang bekerja di rumah sakit, dan 100,544 di klinik. Ada beberapa orang
asing yang bekerja sebagai dokter medis klinis; 1.580 di rumah sakit dan 828 di klinik.

Ketiga, ada tidak ada praktisi perawat Nasional berkualitas, yang dapat
mempraktekkan perawatan secara mandiri, sedangkan jumlah perawat terdaftar yang
bekerja di rumah sakit 725,560. Mereka dapat bekerja sebagai perawat terdaftar setelah
pendidikan minimal tiga tahun, dan melewati Nasional perawat kualifikasi
pemeriksaan. Dalam beberapa tahun terakhir, pendidikan perawat yang ditransfer dari
sekolah kejuruan ke Universitas. Perawat pendidikan di Universitas mengambil 4-
tahun. Lulus dari Universitas perawat pendidikan kursus memberikan persyaratan untuk
national perawat pemeriksaan kualifikasi, tidak hanya untuk perawat, tetapi juga untuk
perawat kesehatan masyarakat. Persyaratan untuk ujian kualifikasi Nasional perawat
Bidan yang diberikan oleh menyelesaikan kursus pendidikan perawat Universitas dengan
program pendidikan tambahan bagi bidan. Asosiasi profesi perawat masalah sertifikat
khas Keperawatan di beberapa daerah; perawatan darurat, keperawatan kemoterapi
kanker, dan sebagainya. Ini dapat dilihat seperti klinis perawat spesialis di negara lain.

Keempat, kebebasan pilihan untuk memanfaatkan lembaga medis dijamin oleh

undang-undang untuk semua pendaftar dalam asuransi kesehatan masyarakat. Dengan
ini, pasien dengan keputusan mereka dapat memilih sebuah klinik atau Departemen
rawat jalan rumah sakit. Akses gratis terjamin tetapi mungkin menyebabkan inefisiensi
dalam berfungsinya klinik dan rumah sakit dibedakan. Rumah sakit dengan fungsi klinis
tinggi biaya pasien untuk biaya tambahan selain harga berdasarkan tarif untuk layanan
perawatan medis. Biaya ini secara hukum diperbolehkan. Jumlah biaya tambahan
bervariasi dari rumah sakit ke rumah sakit.

Kelima, tarif untuk perawatan medis Layanan ditentukan di Dewan medis asuransi
sosial yang tengah. Dewan terdiri dari wakil-wakil dari klinik dokter dan rumah sakit,
asuransi dalam asuransi kesehatan masyarakat, dan kepentingan umum. Sekali dalam
dua tahun, Dewan menentukan dan update tarif untuk layanan perawatan medis sebagai
publik diatur harga. Pembaruan yang dibuat oleh bukti-bukti yang menggunakan hasil
survei untuk situasi keuangan klinik dan rumah sakit, dan hasil survei untuk pemanfaatan
perawatan medis. Pembaruan juga hasil dari negosiasi politik, dan ini adalah alat
bujukan politik. Ketika Komite mengakui bahwa ada perlu untuk memperluas
penggunaan beberapa layanan, tetapi bahwa profitabilitas rendah menghambat
penyediaan layanan, kemudian menentukan Komite untuk meningkatkan harga untuk
mendorong lebih banyak institusi medis untuk menyediakannya. Kementerian Kesehatan,
tenaga kerja dan kesejahteraan memutuskan cakupan dan tarif layanan medis,
berdasarkan saran dari Dewan.

Terakhir, lembaga medis harus nirlaba. Gagasan "nirlaba" berarti bahwa surplus
keuangan dari menjalankan lembaga medis tidak bisa dibagi untuk modal pelanggan
dan/atau investor. Keuangan surplus, jika ada, harus digunakan untuk investasi untuk
peralatan medis, Fasilitas, dll atau milik sebagai cadangan internal. Sangat, perusahaan
swasta sendiri lembaga medis, dalam rangka untuk mempromosikan kesehatan
karyawan. Dalam kasus ini, pengelolaan lembaga-lembaga medis tersebut harus
mematuhi prinsip nirlaba.

4.3.4 isu-isu aktual dalam sistem penyediaan layanan kesehatan

4.3.4.1 kurangnya dokter

Penuaan menyiratkan bahwa jumlah lanjut usia meningkat, yang akan membutuhkan
tidak hanya perawatan untuk penyakit kronis, tetapi juga perawatan akut. Sejak 1970-an,
Universitas setidaknya satu dengan Departemen Kedokteran didirikan di Prefektur
masing-masing. Diperkirakan pada hari-hari bahwa kebijakan ini akan memuaskan
kebutuhan masa depan untuk layanan dokter. Namun, peningkatan dokter mungkin tidak
telah terperangkap kebutuhan yang terus meningkat akibat penuaan cepat. Seperti yang
kita lihat dalam Bagian 4.3.2, jumlah dokter yang bekerja di lembaga medis adalah 2.4
orang 1.000 orang. Angka ini relatif lebih kecil daripada yang di negara-negara OECD
(gambar 4.2).

4.2 gambar: Perbandingan internasional jumlah dokter oleh OECD kesehatan

Data (tahun 2010)
 Masalah ini serius di kawasan Tohoku, yang terkena besar Timur Jepang gempa bumi
di 2011. Bahkan sebelum gempa, ada relatif sedikit dokter di kawasan Tohoku. Gempa
melanda tidak hanya orang-orang, namun tenaga medis dan institusi medis juga,
sehingga jumlah dokter menurun setelah gempa. Sekarang ini adalah di bawah diskusi
apakah sekolah medis yang baru harus didirikan di wilayah Tohoku atau tidak.

4.3.4.2 pembentukan sistem perawatan terpadu komunitas

Orang tua perlu layanan perawatan medis dan layanan perawatan jangka panjang
untuk mendukung hidup mandiri dari orang tua. Sangat wajar untuk berpikir bahwa
kedua Layanan disediakan untuk pengguna dengan baik koordinasi. Di pandang ini,
pembentukan masyarakat perawatan sistem yang diperlukan. Untuk berhasil dalam
pendirian ini, komunikasi harus dipromosikan antara personil di bidang perawatan
jangka panjang, dan orang-orang di sektor kesehatan ketika layanan mereka
disediakan. Bagian 5.3.2 lebih lanjut menjelaskan poin lain ini.