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Organizational Structure of the Health Care System

• Public-administered financing through numerous schemes
• Delivery is highly fragmented/decentralized
• Low current integration, though many regional disease-specific efforts to integrate care between local clinics and hospital specialists (e.g. Chiba for diabetes)
• Recent incentives introduced to increase primary referral to specialists as a means to stimulate systemic integration
• Most healthcare delivery in medical private sector
• 8,943 hospitals; 18% public
• 98,609 clinics; 5% public

Primary, Specialty and Hospital Care

• Primary care delivered primarily through local solo clinics
• Specialty care divided into:
  • Less complex (delivered by local solo specialty care clinics)
  • More complex (delivered by hospital specialist departments)
  • Highest level of care delivered by ~150 hospitals including medical schools, government specialty centers, and strong urban hospitals
• Little or no formal system for integration and referral. Strongest current motive for referral choice is alumni relationships.
• Internal Medicine, Peds, GYN, at local solo clinics provide most primary care
• Doctors and nurses; no mid-levels

Key Health Care System Reforms

• Reduction in spending through reductions in national price list
• Reduction in demand by gradually increasing copayments
• Promotion of Evidence-Based Medicine (EBM) use
• Primary prevention of lifestyle related diseases
• Introduction of integration between clinics and hospital for improved chronic disease care
• Conversion of excess acute care beds into long term care beds under separate payment system

Health Care Workforce

• 8.4 acute care beds per 1,000 population
• 263,540 practicing physicians (2006)
  • 2.0 practicing physicians per 1,000 population
  • 49% primary care (Internal Medicine, Peds, GYN)
  • Average hospital physician income = 14,100,000 yen = 145,565 USD
  • Average solo clinic owner income = 25,300,000 yen = 261,178 USD
• 46,764 Public Health Nurses (2005)
• 27,047 Midwives
• 822,913 Registered Nurses
• 411,685 LPNs
  • 10.3 total nurses per 1,000 population
• Average RN salary = 4,561,800 yen = 47,095 USD
• Health care workforce issues
• Physicians and other health care professionals public or private employees?
  • Most physician and nurses are private employees
• Physicians and other health care professionals hospital employees or in independent practice
  • 64% hospital employees
  • 36% solo clinic practice
• Board certification or other credentialing of physicians, nurses and other providers
  • Licensing administered by Ministry of Health, Labor and Welfare
  • Board certification by medical specialty societies
• Sophistication and rigor of credentialing
  • Relatively less rigorous
• Health care workforce training
  • At four year universities and junior colleges
  • Medical school is six year combined undergraduate and professional school

Health Care Benefits

• National health insurance covers medical and dental care, including medications
• National long term care insurance covers long term care for disabled

Access to Care

• 100% of population required to purchase insurance from source based on place of income
• All have access to all institutions; virtually unfettered access for all, everywhere
• Primary care generally delivered first come first serve/appointments often required for hospital specialty care
• No local budget caps; no rationing of care per se; competition among institutions to attract patients; no long waits for needed care

Availability & Adoption of New Medical Care Technologies

• Unfettered ability to install latest technologies; Japan has highest per capita level of high tech medical equipment

Medical Equipment, Supplies and Facilities

Health Care Performance Data

• Delivery of evidence-based care
  • Relatively less dispersion of EBM; relatively more reliance on institutional experience
• Safety and medical errors
  • Coming under increasing scrutiny as lawsuits increase
• Patient outcomes
  • Little data available

Health Information Technology

• Level of Electronic Medical Record (EMR) adoption (% of physicians or clinics)
  • Very low
• Funding sources for EMR and outlook
  • In flux; government to require EMR in future
• PHR adoption and funding sources
  • Still new
• Telemedicine adoption
  • Used in rural settings

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