“Tax money should be used for improving medical services and increasing doctors”

HONDA Hiroshi
Vice-President, Kosei-kai Kurihashi Hospital, Saitama

　The shortage of medical doctors has become a serious social problem in Japan. Dr. Honda Hiroshi, Vice-President of Kosei-kai Kurihashi Hospital in Saitama has long maintained that without doctors themselves speaking up on the present crisis, the entire medical service system of Japan would collapse. In the NHK TV program “Future of Japan: Can you feel safe with medical services? (Aired on October 14)”, Dr. Honda appeared as a commentator, together with the president of the Japan Medical Association and the Administrative Vice-Minister of the Ministry of Health, Labor and Welfare, and lead discussion in the program.
　The following is the gist of Dr. Honda’s argument that “Tax money should be used for improving medical services and increasing doctors”, as presented in the TV program and also in his lecture given at the Min-Iren’s Doctors Committee meeting.

Absolute shortage of the total number of medical doctors
　According to a survey conducted by the NHK, 347 medical departments in 224 public hospitals have been closed during the last 3 and half years. Highest among them were obstetrics department closures, which numbered 96, followed by 36 pediatrics departments. While the remuneration for medical services of these departments is kept low, they are required to cope with emergency 24-hours a day and in case of accident, these doctors are subject to criminal prosecution. The two departments typically represent the harsh working conditions of doctors, who are most likely to “burn him/herself out and leave the hospital”.

Consolidation of doctors gives rise to more medically-underserved areas
　However, the Ministry of Health and Labor says, “As a whole, there are enough doctors. The problem is their uneven distribution. More doctors live and work in urban areas.” Claiming that the “consolidation” is necessary for securing safety in response to more sophisticated medical treatment and for lessoning the workload of the doctors, the ministry requests prefectural governments to promote the consolidation of doctors.
　Among the typical cases of such consolidation, which was also covered several times by the mass media was that in Mie Prefecture. Mihama Town and Owase City used to have two obstetricians each, but one of the two doctors of Owase City was moved to Mihama Town, and the other was moved to another city. As the result, while Mihama Town now has three obstetricians, Owase City has no obstetrics department. With the strong demand of its citizens, Owase City decided to hire obstetricians on its own account, but the high salary paid to the doctors has become a burden on city’s finance. Such a top-down “consolidation” initiative is giving rise to new contradictory situations and medically-underserved areas.

Negative effects on quality and safety of medical services
　“It is absolutely wrong to say that uneven distribution of doctors is the cause of the problem. There is not a single prefecture where even in urban areas sufficient number of doctors are secured”, Dr. Honda says. In the TV program, the real situation of a doctor on duty was presented. It was a case of a doctor working at Kurihashi Hospital, where Dr. Honda serves as Vice-President.
　The doctor on duty was a woman surgeon who had 16 years of career. After conducting operations both in the morning and in the afternoon, she started her night duty from 5:00 p.m. (she kept such night duty 6 times a month). In spare moments of attending to the needs of emergency patients, she prepared medical certificates to submit to insurance companies (as more patients take out private insurance, such clerical work of doctors is increasing). At 2:00 a.m., after 18 hours since she started her work of the day, she was able to have a nap. Next morning, she attended to the outpatient care, and in the afternoon conducted another operation. It was 9:00 p.m. when she finally finished her work after the night duty. 37 hours had passed since she started working the previous morning.
　The doctor said, “It is a routine work schedule. As I am tired, the possibility of causing an accident gets higher. I try hard to be careful not to cause any trouble to my patients”. Dr. Honda says, “The shortage of doctors does not only mean that there is no doctor in the community. Because the number of doctors is not enough, one doctor should play multiple roles as surgeon, chemo-therapist, palliative therapist and emergency doctor and others. This causes serious negative effects on the quality and safety of medical services.”

Japanese doctors see 3.5 times more patients than in other OECD countries
　How small is the number of Japanese doctors? The average number of doctors per population of 100,000 in OECD (Organization for Economic Cooperation and Development) member states is about 290. Japan ranks 26th among the 29 member states, with the average number of doctors being a little less than 200.
　“There are 260,000 medical doctors in Japan. There should be 380,000 to reach the average level of the OECD nations. We have the shortage of as many as 120,000 doctors (Table 1). There is not a single prefecture in Japan, whose number of doctors exceeds that of the OECD average (Table 2). According to the annual report of the WHO (World Health Organization) of 2006, Japan ranks as low as 63rd among 192 countries of the world”, Dr. Honda says.
　In terms of the average number of patients one doctor examines per year, while a Swedish doctor sees 900 patients, the number is 2,200 in the U.S.A. A Japanese doctor examines as many as 8,400 patients (Table 3).
　“As the average number among the OECD countries is 2,400, Japanese doctors work 3.5 times more. This naturally leads to the ‘3 minutes of consultation time after 3 hours of waiting time’, or not being able to give sufficient explanation to patients.”

Despite the reputation of “world best” medical services…
　Japan’s medical services won No. 1 in the comprehensive evaluation by the WHO and the OECD. The reasons are: The share of medical expenditure of the GDP was the 18th lowest among the OECD countries (It’s cheap); The rate of achieving health was No. 1 in the world (It’s efficient); and It ranks 3rd in equality (Available to all). The role played by the national health insurance system has been significant.

Comment by Hillary Clinton
　But we need to look at the other side of the coin. The unavailability of medical care is a big problem in the U.S.A., where 1 out of 7 people is without medical insurance and only rich people can enjoy sufficient medical treatment. When President Clinton was in office, he examined the possibility of introducing the national health insurance system like in Japan. But his conclusion was that it was not possible, because American people could not be satisfied with the level of medical care provided in Japan, where “3 minutes of consultation after 3 hours of waiting” is normal, many inpatients had to share a big room, and the quality of medical treatment was very poor…
　“At that time, Hillary Clinton said, ‘The Japanese medical care system is maintained by the Saint-like self-sacrifice of medical workers.’ Such is how Japan’s medical system is viewed by the people in the world. Japan has aimed to achieve low-cost, accessible and quality medical care. After all, the “quality” was dropped. You can choose only two of the three factors; achieving all these three at once is not possible. Just as no 100-yen shops sell Louis Vuitton products, you cannot expect a five-star hotel’s level of service at an ordinary business hotel.”

Patient’s payment amounts to double the European standard
　“Although the medical expenditure is low in Japan, patients are not convinced of the fact, because they pay high amount of health insurance expense and also high out-of-pocket expense at the window. The problem is the usage of tax money by the national government. Many European countries try to suppress the ratio of medical expense in the household account within 5% by utilizing the tax money, while in Japan, it accounts for 11%, more than double. No European countries impose such heavy burden on the people.”

Though medical fee is exceptionally low…
　Table 4 shows the average total cost of treatment and number of days in hospital for appendicitis patient in different cities of the world.
　“Ranking 1st is New York, U.S.A., where it would cost 1.9 million to 2.4 million yen for an overnight hospitalization. Patient charge would depend on what kind of medical insurance he/she takes. In London, the cost would be 1.14 million without patient’s pay. Also in Vancouver (Canada), Madrid (Spain), and Rome (Italy), no patient’s pay is required. It would take 470,000 yen in Paris for two nights hospitalization, while the burden on the patient is 28,600 yen. In Frankfurt, the patient’s pay is only 10,000 yen, because the government covers it.
　In Japan, the medical fee is as cheap as in Vietnam, but the patient should pay 100,000 yen, 30% of the total, as well as private room fee. In short, the biggest problem in Japan is the exceptionally low medical cost and the very heavy burden on the patient.”

Hospital doctor’s salary is lower than major company workers
　“In spite of high cost of living in Japan, the unit price of medical service fee is low, while the prices of pharmaceutical products and medical equipments are the highest in the world. The price at which Japanese hospitals purchase these equipments would be three times higher than that in other Western countries. It is impossible for Japanese hospitals to get into the black.
　Some people claim that doctor is a high-paying job, but the reality is otherwise. According to an economic journal, the lifetime earnings of a general hospital doctor is lower than that of a worker in a major corporation.”

Health & Labor Ministry should grasp the real situation
　Most developed societies use their tax money to keep the quality of medical services, while trying to avoid giving heavier burden on their people. In contrast, the Japanese government, with the pretext of curbing the growth of medical spending of the nation, is willing to put more burden on its people. Several cases of patients were presented in the TV program as in the following:
　A man in his 50s had no choice but to leave his job and nurse his father at home, after the hospital he had been staying closed down.
　A patient of hepatitis C in his 30s, as no regular employment is available, worked on part-time basis, earning only 150,000 yen per month. As his medical condition declined, his doctor suggested that he should take an interferon therapy, which cost 50,000 yen a month lasting for a year. But this treatment would involve strong side-effects, which would prevent him from working, while giving him no 100% guarantee of recovery. He could not decide whether he should take the therapy, knowing that doing nothing would increase the risk of developing liver cancer.
　The monthly fee of national health insurance system for an elderly couple, whose only income is 50,000 yen of retirement pension, amounts to 10,000 yen. If the amount in arrear continues for one year, their health insurance card would be taken away and they would have to pay 100% of medical fee at the hospital window.
　The mayor of Yukuhashi City of Fukuoka Prefecture sternly criticized the government, saying, “I want to say something to the Health and Welfare Ministry. They instruct local municipalities to take the health insurance cards away from those who cannot pay national health insurance premium and forward them to the welfare benefits system. However, they also tell us not to increase the number of households to be covered by the welfare system. What do they want us to do?”

Japan is not a “country of social security”, but a “country of road construction”
Social security spending is half and public works spending is three times more of average Western countries

266 trillion yen reserved in the Special Account

Emergency telephone equipment on highways costs 2.5 million yen per unit
　Dr. Honda says, “What is the priority for this government is evident if we look at the national budget”. The budget for social security amounts to 23% of the General Account, while 10% is allocated for public construction works.
　“But the Special Account amounts to 266 trillion yen, three times more than the General Account (Table 5), where the budget for public works, including the tax revenue earmarked for road construction, is included. In all, the budget for public works projects in Japan goes up three times more than other Western countries, while that for social security is only half.
　I was surprised at the cost for emergency telephone equipment on highways. According to the government’s response to questions at the Diet, one unit of such telephone would cost 2.5 million yen, while the original cost is only 400,000 yen. Such equipment is installed at 1 kilometer interval on both sides of the highways. This is how road-related corporations can bring profit. Naturally, they are eager to encourage more road construction. This information made me realize that Japan is not a country of social security, but a country of road construction.”
　As of 2004, OECD member states governments on average bear 73% of the total medical spending. In Japan, 33% of the medical spending was paid by the national and local governments, while the people were forced to bear 45% of it (15% as out-of-pocket payment and 30% as national insurance premium payment).

Medical service breakdown already started in Britain
　“Further increase in people’s burden would be nothing but outrageous. Unless we press very hard now to use people’s tax money on medical services and increase doctors, the whole Japanese medical system would be sure to collapse.”
　Just like Japan, Britain has aggressively promoted the reduction of an overall health care cost to the point where some enraged patients got violent and attacked doctors. Many doctors began to run out of the country, leading to a situation of medical service breakdown. Prime Minister Blair decided to increase the medical service cost to 1.5 times of the present level, and also raised the quota of enrollment in medical universities to 1.5 times more.
　“In Japan also, the breakdown of medical service is already underway. Doctors have become scapegoats, and out of exhaustion they choose to leave their jobs. Doctors themselves need to raise their voices to say that in order to keep the quality of medical care, both human and financial resources are necessary. Otherwise, patients would suffer. After an accident happens, it would be too late to say that you did your best but failed”, Dr. Honda emphasized.

Well-off people should pay more in the form of tax
　“One more thing we should stop is the government’s attempt to lift the restriction on the mixture of public and private medical care services, along with its effort to reduce the medical care spending. This would amount to creating the differences in quality of medical treatment, according to one’s financial means available. It is absolutely unacceptable.”
　In the TV program, one proponent of the mixed medical care system said, “Well-off people should bear the cost commensurate with the treatment they receive.”
　“But President Karasawa Yoshihito of the Japan Medical Association sharply responded to this comment, saying, ‘Well-off people can pay more in the form of tax, so that when they get ill, both well-off and not-so-well-off people can enjoy good medical treatment equally.’ I totally agree with him. It is the question posed to the entire Japanese people: whether we should allow the widening gap to grow, or we should start aiming at a society where everyone can feel safe and secure by narrowing the social gap.”
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Table 1: 120,000 more doctors needed in Japan to reach OECD average
(Per population of 1000: OECD members in 2003)

Table 2: The cause of shortage of doctors is not their uneven distribution! Not a single prefecture reaches OECD average (Number of doctors per population of 100,000)

Table 3: Annual number of outpatients and per visit medical care fee

Table 4: Cost for operation and hospitalization of appendicitis patient in different cities
City Cost Number of days in hospital
※ Total cost includes fees for normal operation and a private room fee for average number of days at a private hospital, nursing care and technical charge. US$1.00 = 105 Japanese yen.
※ Source: “Handbook for living outside Japan” (AIU Insurance Co., 2000)

Table 5: Gross total of Japan’s national budget is 347 trillion yen: Special Account amounts to 77% of the total
Budget allocation per ministry in 2002
(Source: Administrative Reform Task Force of the Liberal Democratic Party)