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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 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

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

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

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

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

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

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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Japan - Health Care System Structure and Organization