The National Science Foundation's (NSF) Tokyo Office periodically receives and disseminates reports on research developments in Japan that are related to the Foundation's mission. NSF-sponsored researchers currently working in Japan prepare many of these reports. These reports present information for use by NSF program managers and policy makers; they are not statements of NSF policy.
Special Scientific Report #99-20 (December 10, 1999)
Ms. Veronica R. Lim, a graduate student in Schools of Public Health and Social Work at Columbia University, New York, prepared the following report. Ms. Lim was a participant in the 1999 Summer Institute sponsored in the United States by NSF/NIH/USDA and the Science and Technology Agency and Japan Science and Technology Corporation in Japan. Dr. Shinji Takemura of the National Institute of Public Health, Ministry of Health and Welfare, hosted Ms. Lim. Ms. Lim can be reached via email at: vrlim@hotmail.com
Introduction:
I. Research at the Host Institute
My host institution during this summer was the National Institute of Public Health, Ministry of Health and Welfare's Department of Public Health Administration, under the direction of Dr. Shinji Takemura. My goal for the summer was to learn about the Japanese Health Insurance System. During my stay, Dr. Takemura provided me with relevant books and reports in English to allow me to gain an extensive understanding of the system. In conjunction with my reading, I also had frequent discussions with him on this subject. Besides my host's tutorial, I also had many opportunities to have direct communications with Dr. Takemura's colleagues, many of whom are authors of different health care reports.
What I have learned this summer is that Japanese Health Insurance
System embodies a system that is a lot more complicated than often
perceived. This national health insurance system is not solely
a "single payer" system, but a hybrid that incorporates
both the "single payer" and "all-payer" systems
(Campbell & Ikegami, 1998). The name of such a combination
is the "bellwether" approach. Manifestations of this
approach can be seen through the many subsidiary insurance providers.
The national government is still the largest payer, but citizens
also contribute accordingly to their income to the insurance provider
that matches their occupation. There are six different insurance
providers within the Japanese Health Insurance System; they include
the Government-managed Health Insurance (Seikan), Society-managed
Health Insurance (Kumiai), Seamen's Insurance (Sen-in), Mutual
Aid Associations (Kyosai), National Health Insurance (Kokuho),
and Health Services for the Aged (Roken). Although the providers
have different premiums and co-payment rates that caters to various
segments of the population, the participants can choose to go
to any health service provider of their choice.
The reason why Japanese health expenditures are so low is that
the fee-schedules are set by the Ministry of Health and Welfare
(MHW). MHW sets the fee for all services provided by physicians
and hospitals, and it adjusts the fee bi-annually. Besides the
weight that MHW seems to carry in the health care market, the
Japanese Medical Association (JMA) is the key opposition player.
JMA is interested in preserving the income and the rights of private
physicians.
II. Purpose of this Survey
The purpose of my survey was to find out how people feel about and view their health care providers. During the course of my research on the structure of the Japanese health care system, I learned that there are four different types of health service providers: public hospitals, private hospitals, university hospitals and clinics. Among these four types of providers, only public hospitals and university hospitals receive subsidies from the government. It is questionable whether subsidies can advance the quality of care provided by the respective types of provider and promote the appearance of the facility. Since Japanese citizens have the freedom to choose among different types of provider, it is interesting to see which they would prefer, what led them to make such a choice, and what attributes were taken into considerations during their selection process.
III. Composition of the Questionnaire
The objective of the questionnaire was to help me acquire professional insights into opinions of different types of provider and of the different attributes that are associated with providers. I consulted with my host scientist, with Dr. Takemura of the Ministry of Health and Welfare, and with Dr. Fukuda of University of Tokyo, to find out what are some of the principal concerns of participants regarding health care providers. We discussed the issues relating to the services provided to the patients during their visit to hospitals and to services received from doctors. The long waiting time to be seen by the physician and the way physicians treat their patients were examples of frequent complaints. In Campbell and Ikegami's (1998) book, a chapter is devoted to the quality problem of the Japanese health-care system. There are five problem areas in the health-care systems that were spelled out by Campbell and Ikegami, and they are:
1. Long wait and short consultation time.
2. Lack of information and accountability by physicians and within
the health-care system.
3. Run-down and understaffed hospitals.
4. Low quantity and quality of medical research.
5. Poor quality of professional judgement in diagnosis and treatment.
Gaining a better awareness of the reasons behind these negative attitudes allowed me to create questions that would yield measurable and comprehensible answers.
The questionnaire was composed of opinion questions and rank-order questions. Questions include participants' provider choice, attitude towards physicians, view towards the different types of providers, and questions that asked the respondents to rank order different characteristics of providers. The questionnaire was first created in English, and later translated into Japanese by Dr. Takemura. After finding groups of subjects from voluntary organizations for fitness of two communities, we realized that the questions would need to be altered. The subjects we found are people who are very health conscious; therefore, we felt that they would not be frequent visitors to health care providers. As a result of this conclusion, we changed many questions that asked for previous experiences to hypothetical situations.
IV. Survey Process
The data were collected from two cities within the Tokyo Metropolitan
area: Kunitachi City and Machida City. At Kunitachi Community
Center, there were 43 subjects who participated in the questionnaire
session. The age of participants ranged from 40 to 60 years of
age. There was one male participant and 42 female participants.
After the questionnaire session, there was an interview session
held during the lunch hour at the Kunitachi Community Center.
Nine volunteers from the class attended the session; they answered
the interview questions and shared with us their personal experiences
with hospitals.
There were 33 participants in the Machida study, and the data
were also collected at the Machida gymnasium. Subjects ranged
from 39 to 65 years of age, and they were all female. An interview
session was not conducted at this location.
V. Results
This section will first review the results obtained from the
interview session, and then the data from the questionnaire. Since
an interview session was conducted only in Kunitachi City, the
discussion can only draw upon the opinion and viewpoints of the
residents of this city. The section describing the data collected
from the questionnaire will present a brief comparative analysis
of the combined data; i.e., the Kunitachi data and the Machida
data.
The interview session was conducted in a very relaxed atmosphere
over a warm meal during lunch. After Dr. Takemura translate each
of my questions from English to Japanese, participants raised
their hands as they sought appropriate to provide their view and
experience. The first question asked them what are the problems
that they see within the Japanese health care system. The problems
they felt were: short consultation time with their physician;
doctors prescribe too many drugs and give little or no information
about them; doctors are not very kind to patients without referrals;
it is hard to trust doctors; doctors are not very competent. Respondents
prefer public or university hospitals because their quality is
perceived to be higher than clinics, and there are few health
care providers in rural areas.
Regarding the copayment system, the respondents felt that they have no problem paying the premium if the medical services are reasonable. Unfortunately, they felt the Japanese health care system does not provide reasonable medical services. When they were asked whether they would choose the health care system in the United States, where they would pay more to receive immediate care from a reputable physician, all of the interviewees responded in the negative. Among the 9 participants, 7 of them had visited a health care provider within the recent 6 months. Of the 7 participants, 2 went to the public hospital, and 5 went to the clinic. The waiting time at the public hospital was about half an hour to one hour, and the wait at the clinic was only 5 or 6 minutes. The consultation time with the doctor is about 5 minutes in both the public hospital and the clinic.
The data collected from the questionnaire are included in Table 1. The first question asked for subjects' preference for the type of health care provider. An analysis of the table shows that majority of the subjects prefer to go to a clinic for medical service. The result for this question gave an average score of 4 for the combined data, 4.06 for Machida and 3.95 for Kunitachi. The combined data showed that the qualities that seem to be important for them in their selection of a health care provider, on a scale of 1 to 5, are "close proximity to residence" (avg. = 4.01), "friendly and sensitive doctors" (avg. = 4.37) and "reputable doctors and/or hospitals" (avg. = 4.43). When looking at the data separately on the quality of "close proximity to residence," Kunitachi City (avg. = 3.91) had a lower average than the Machida City (4.16). Another difference that was worth noting is that on the quality of the age of the facility, Kunitachi City had an average score of 3.44, while Machida City had an average of 3.09. This result suggests that the citizens of Kunitachi City might have a higher preference for newer medical facilities. The combined data showed that majority of the people (56.6%) think that doctors provide only some, but inadequate information to the patients. 67.1% of the subjects only has little trust in doctors' diagnosis and treatment. Under the category of "little trust," Machida data was 72.7% compared to Kunitachi data of 62.8%. For the category of "trustworthy," Kunitachi data showed a 32.5%, almost 11% higher than Machida data of 21.2%. The citizens of Machida City seem to trust the doctor a lot less than the citizens of Kunitachi City. Most of the participants were willing to wait for about 30 minutes to an hour to be seen by a doctor. For the question that asked the respondents what should be the ideal time allowance to be seen by the physician, the result showed a split between 3 to 10 minutes and 10 to 20 minutes. The Kunitachi data resulted in identical percentage of 46.5% for both categories, while the Machida data had a higher percentage (48.4%) for the category of 3 to 10 minutes than the 10 to 20 minutes category (39.34%). Among the four types of health service providers, on a scale of 1 to 4, clinics were perceived to have the highest quality (avg. = 2.86) and public hospitals were perceived to have the lowest quality (avg. = 2.15). When the two data sets were analyzed separately, both agree that clinics have the highest quality of service, but they differ in their opinion of the provider with the lowest quality. The Machida data showed that university hospital (avg. = 1.87) has the lowest quality, while the Kunitachi data yielded the same result as the combined data.
VI. Conclusion
From this small survey, I have learned that Japanese citizens actually prefer clinics to large hospitals, despite the fact that the most important quality that they look for in their provider is "reputable doctors and/or hospitals." What they want and where they seek care contradict each other. They want "reputable doctors and/or hospitals", but prefer to go to clinics because they would rather sacrifice that for a more personal physician care with a short waiting time. The other reason people choose clinics over hospitals is that clinics are usually close to their residence. If they perceive their ailments to be minor, the Japanese citizens prefer to go to their local family doctor than to travel far to visit an unfamiliar doctor at a large hospital. During the course of my research, I paid visits to a clinic, Sanno Hospital in Tokyo, and the University of Tokyo Medical Center. From what I witnessed, it is understandable why people prefer clinics to hospitals because there were definitely a lot more people waiting to be seen by the physicians at the hospitals than at the clinic.
The Japanese Health Care System differs from the American Health Care System in at least five ways. The first difference is the doctor-patient relationship. Within the Japanese paternalistic relationship, communication goes only one-way, from doctor to patient. Informed consent does not exist. The medical professionals know what it means, but it is hardly practiced. Patients' medical conditions are often communicated to people outside their immediate families with neither their awareness nor approval. Doctors are notorious for over prescribing necessary drug dosage to treat patients' symptom, and often give them prescriptions without informing them what they are about to take.
Second, there are very few malpractice suits. Besides the shortage of lawyers, patients allow the doctors to do what they think most fit. Patients do not question a physician's decision.
Third, Japanese health care expenditures are low.
Fourth, there is little research conducted within the medical field in Japan. A principal reason why American health expenditure are so high is because of the emphasis in medical research.
Fifth, medical training in Japan is different from training in the United States. Unlike the American's system of four years of undergraduate study and four years of medical school, Japanese medical students enter a six-year medical school right after high school.
There are four areas where the American Health Care System could learn from the Japanese Health Care System. First, it would help lower the medical costs if the United States established a universal fee-schedule to regulate charges on medical services.
My second suggestion is to have centralized insurance providers for different occupations. Since the United States already has Medicare and Medicaid, it may be worthwhile to use this approach to find insurance for those that fall outside of these two programs.
The third area that United States might adopt would be to give patients' the freedom to choose any doctors and/or hospitals. This would make it easier for people who may have to change jobs or health insurance providers. If this freedom can be made available, then it would be feasible to introduce the universal billing system.
This idea leads to my fourth point, which is to have universal billing forms. Not only would this save time, it would help save the money that now goes into training people how to read and understand forms from different health care providers.
The National Science Foundation (NSF) and the Japan International Science & Technology Exchange Center (JISTEC) provided the opportunity for me to come to Japan and allowed me to learn extensively about the Japanese Health Insurance System. The knowledge I am walking away with is so rich that it is hard to imagine that I have only spent six weeks at my host institute. It was very fulfilling to be able to learn about the Japanese Health Insurance System at the place where all the important decisions take place and to be able to conduct a short study to learn how people feel about the quality of different health care providers through the guidance of my host and experts in the field.
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Symposium on Environmentally Conscious Design and Inverse Manufacturing, Tokyo, Japan, February, 1999.