A tragic casualty

Many of us have been reading in the medical journals for years Japanese doctors discussing the growing financial crisis in their country’s medical system. But we never realized how serious things had become until this week. It is unimaginable what this poor man and those paramedics must have been going through in the back of that ambulance...

News from Kobe, Japan, brought the tragic story of a 69-year old man who was critically injured in a traffic accident while riding his bicycle. Suffering from massive head and back injuries, his condition worsened as paramedics raced him from hospital to hospital — 14 in all — and none could accept him because they had no beds, staff, specialists or equipment. He died of hemorrhagic shock by the time a hospital was found for him, three hours after the accident.

According to Japanese Times, this was yet another sign that the nation’s medical services are failing:

The incident is the latest in a growing number of rejection cases. Hospitals and other medical institutions are increasingly declining to accept patients who need emergency treatment because they lack medical staff or proper equipment and facilities. In one notable case that stirred public outcry, a pregnant woman from Tokyo, suffering a brain hemorrhage, was rejected by eight hospitals and died three days after a Caesarean section was performed.

The newspaper added that “the 29-year-old motorcyclist was taken to a university hospital in Nishinomiya, Hyogo, as soon as his rescuers determined that his injuries were more severe. He survived.”

Mari Yamaguchi, reporting from Tokyo, said that “more than 14,000 emergency patients were rejected at least three times by Japanese hospitals before getting treatment in 2007, according to the latest government survey. In the worst case, a woman in her 70s with a breathing problem was rejected 49 times in Tokyo.”

A troubling comment was made by Health Minister Yoichi Masuzoe, who “told a parliamentary committee last year that the rising number of elderly patients hospitalized for months was taking up space that could be used to treat emergency cases.”

What the world is watching is a form of supply rationing.

Looking to better understand what was going on, the reasons for the growing crisis in Japan’s healthcare system were described by professors Hideki Nomura from Ishikawa and Takeo Nakayama from Kyoto in the September, 2005 issue of the British Medical Journal. They said:

The Japanese medical insurance system has a unique combination of characteristics that has led to the overuse of tests and drugs, unconstrained demand from patients, and an explosion of costs. Unless the system of medical insurance and reimbursement of healthcare providers changes, the combination of increasing technological advances, an ageing population, and unconstrained demand will produce a crisis in Japanese health care. Japan is only belatedly waking up to this crisis.

The Japanese medical insurance system has four characteristics that lie at the root of the problem. Firstly, Japanese citizens are covered comprehensively and exclusively by either national medical insurance (for the self employed) or social insurance (for employees). Beneficiaries have to make some co-payments, which are capped depending on income. Secondly, mixed private and insurance payments are prohibited—that is, beneficiaries cannot pay privately for medical services that are covered by their medical insurance. Thirdly, beneficiaries have guaranteed access to any healthcare providers, from general practitioners to specialists, without being charged a premium fee. Finally, healthcare providers and institutions are reimbursed through fees for service…

Because they are paid for each prescription or test rather than time spent with patients, healthcare providers, both private and public, are driven to prescribe more drugs and to order more imaging and tests… Healthcare expenditures, both per head and as a percentage of gross domestic product, continue to increase despite the economic growth rate remaining low throughout the past 10 years.

Single-payer medical insurance systems fail in part because of what they called “the tragedy of the commons.” Japanese health care is a typical example, they said. By “tragedy of the commons,” they were referring to grazing land: “free access to common grazing land drives each herdsman to maximise his own take from the commons, even when it becomes overcrowded with grazing animals.” Ultimately, this behaviour ruins the common land, as well as those who depend on it for survival, they said. The problem is clearly complicated, but their frustrations were palpable.

In December of 2002, advisors to the Cabinet Office in Japan recognized the need to move to back to allowing a private pay medical insurance system because the ban had proven to lower the level of medical care and services Japanese patients were receiving. It also had inhibited incentives for the medical industry to bring new technologies and treatments, leading to Japan falling behind international competitors, they said. But the Ministry of Health, Labour and Welfare, instead, adopted a system of reimbursements for hospital care based on patients’ diagnoses and procedures performed. “Hospitals are paid daily fees proportionate to the length of stay for each condition and treatment, irrespective of actual interventions,” they wrote. This leads healthcare institutions to reduce services to contain costs to ensure reimbursements exceed their overhead. The Ministry also began promoting protocol medicine, based on adherence to practice guidelines written by academic medical societies.

Seven years later, Japan’s healthcare system is nearing collapse, according to Japanese news.

Doctors working in countries with nationalized health insurance responded to the BMJ article, noting other consequences to the “tragedy of commons.” Dr. Akira Ehara with Koala Medical Research pointed out the serious shortage of doctors, providing government statistics showing that by 2002, there were only about half the number of pediatricians needed to cover pediatric departments in Japanese hospitals. Doctors were working 32 consecutive hours and could not continue without burn-out, he said.

Dr. Chiehfeng Chen from Taipei, Taiwan, wrote that “most of the countries with health insurance for all, share the same destiny. “The National Health Insurance has been implemented in Taiwan since March 1995…by the end of 2001, 97% of the population was enrolled. However, health insurance system in Taiwan is impending bankrupt due to ‘overcrowded grazing on the common land,’” he wrote. The solutions being proposed, he said, include ever increasing health taxes and co-payments, and tighter managed care to discourage patients from seeking medical care. [That was striking because Massachusetts, testing such a system here, ran into financial solvency problems and moved towards these solutions within the first year.]

It is hard to stop thinking about those elderly patients who lost their lives for the common good.