Recently, the family an 82-year old woman living in Koriyama, Fukushima, called in for emergency transport to hospital. She was suffering from what could have been food poisoning, and the Koriyama region fire department dispatched an ambulance to pick her up. She was in a bad way and the ambulance service called the nearest hospital to gain admission. They said “no” on the basis that they didn’t have a suitable doctor on duty.

The ambulance service then called another four hospitals, driving en route from one to the other, and again each declined to accept the stricken women. Finally, after nine separate calls to various hospitals, the Fukushima Medical University Hospital, 40 kilometers and 60 minutes away, accepted her. However, by this time she had gone into a coma, and died shortly after arriving at the facility.

This is not the first time that a shortage of doctors has caused a patient in an ambulance to die after a significant delay caused by having to chase available hospitals. In fact, according to the Fire and Disaster Management Agency, there were 14,387 cases in 2007 of seriously ill patients being turned away from hospitals. In one case, it took ambulance coordinators 50 calls to find an open hospital, and in 65 cases patients were ambulance-bound for more than 2 1/2 hours before gaining admittance.

The severe lack of hospital emergency availability came to public attention with a highly publicized case in August of 2007, when a 38-year old 6-months pregnant woman from
Nara miscarried inside the ambulance after operators tried frantically for THREE HOURS to find a hospital that would take her. The nearest hospital was just three minutes from her home and if they had accepted her, Japan would be one baby better off.

To cap it all, the ambulance crashed into a minivan on its way to the 9th hospital.

Clearly, Japan’s medical systems is in crisis. Is there a shortage of doctors, or other reasons that are causing people are dying while trying to find a hospital bed?

The Fire Agency has said that their ambulances transported 4.89m patients in 2006, up 51% from 1996—a pretty good effort. Out the patients served, there has been a 108% increase in people aged 65 or older, and yet as a proportion of the population the elderly have increased by a much lower figure of 40%. As a result, a director from the Health Ministry came up with the lame comment: “I do not think elderly people have become that weak in just over 10 years,” implying that ambulance services are being misused by older people.

However, the official in question probably didn’t think too hard before putting his foot into his mouth, because not only did the overall population increase for that decade, but the absolute number of elderly (and especially those aged over 100) substantially increased, too. An increase of 5 million elderly is certainly going to result in an extra 500,000 or so ambulance call-outs, because even though as a percentage of the population they are overrepresented, the fact is that it is this age segment which is most likely to need emergency services.

Furthermore, even though there has been an increase in ambulance usage by older people, the problem isn’t a shortage of ambulances (as far as we know, none has been reported), but rather of beds and doctors once the ambulance arrives.

So what is behind the current medical crisis? Let’s look at some possible reasons.

1. Slow (and not very smart) government.

Firstly, is there a shortage of doctors? Actually, in the period between 1996 and 2006, the number of doctors in Japan increased from 241,000 to 278,000 people, an increase of 15%, and so there are young people entering the profession. But this comprises only 3,500 or so fresh graduates a year, and compared to other developed countries, such as Germany or France, Japan still has 40% fewer doctors per head of population.

Since 1982, the government has been maintaining that Japan has too many doctors, and has restricted the output of them by making the exams unreasonably difficult. Currently, and at least until next year, it is easier to pass the exam to become a DNA research scientist than it is to become general medical doctor. Only in July of this year, after the recent spate of death-in-ambulance incidents has the Health Ministry admitted that maybe they got it wrong. Now they plan to increase the student intake from next year. The intake will increase by degrees, until a target of 50% more doctors graduating is reached in 10 years time.

Another problem is misallocation of resources. The biggest problem currently is a shortage of doctors in key areas such as rural postings and also in specialties such as obstetrics, trauma response, and surgery. New recruits are assiduously avoiding these regions and areas of practice because of the long hours, increase in malpractice lawsuits, and low salaries. The government has finally figured that some deregulation they enacted in 2002 led to students preferring big city hospitals to intern at, and says that from next year, interns will have to go where they are sent—which you can be sure will be the farthest-flung reaches of the country.

2. Long hours

NHK carried a news item several weeks back of a typical area hospital doctor’s work day. Unbelievably, the doctor featured had just worked 30 hours straight when he was interviewed, something he did several times a week. After the interview, he headed out for the evening, not to go back home or go drinking with his buddies, but instead to travel to another hospital, where he is covering for them during the evening shift! It’s hard to imagine how doctors can expect to even function properly let alone heal others when they’re suffering from such severe lack of sleep.

It’s not surprising then, that doctors are leaving hospitals at a high rate, and female doctors in particular are not returning to hospitals after they have a baby. Clearly, more intelligent rostering and part-time work opportunities need to be made available, as they are in other advanced countries. Indeed, I know of several young med students who were originally going to go into general medicine, but who on getting advice from parents and friends have now switched to research instead, where they can still have a social life and enjoy better pay.

3. Lousy pay

Next, is the ongoing attitude that somehow doctors are expected to serve their fellow man without thought to self or family. It would be great if doctors were specially bred to think this way. However, in this modern and connected world, such ideals hearken back to the socialist age in Japan after the war, not now. Instead, talented health professionals are being tempted by the glamor of the research world, especially now that Japan is winning more Nobel prizes; or the clean, no-fuss business of opthmology and other non-internal medicine; or the sheer cash rewards of working for an international pharmaceutical company or doing cosmetic surgery.

The government controls the nation’s “medical currency” for all health services delivered around the nation—either by salary or by volume of patients seen. This means that doctors with their own clinics can push customers through at a high rate, prescribe lots of medicine, and get a fairly decent wage. Meanwhile, doctors working in a public hospital make far less and have no control over the hours they have to work.

Apparently the average salary for a physician with their own clinic is around 25.3 million yen, while a hospital-based doctor makes only 14.1 million yen. Not surprisingly, this has led to the number of hospital doctors dropping from 64.6% of the physician population in 1998 down to 60.6% in 2006. Also not surprisingly, in those sectors which are not regulated, such as cosmetic surgery, a doctor can expect to make a very respectable 40 million yen a year.

4. Drug dependence and weak private sector

It is interesting to learn that Japan has one of the OECD’s lowest rates of hospital usage per head of population, at around 8.3%, and one of the highest numbers of in-patient beds per person—three times more than the U.S. I guess this means that your average Japanese is very healthy, and that the state has made sure that there are plenty of hospital beds. What is abnormal, however, is the hospital staffing ratio once a bed is occupied. In Japan, it is extremely low, the lowest in the OECD in fact. Further, the average length of stay at 50.5 days is extremely high, about five times longer than in the U.S.

The conclusions we can draw from these statistics are: a) there is a lack of medical staff to attend hospital patients, and so people get less doctor time and take longer to receive and thus respond to focused treatment, and b) the current government-controlled medical payments system rewards doctors for dispensing more medicine and this is probably resulting in patients being kept in their beds longer.

On making hospitals more efficient, yes, there needs to be a quest for better cost control, especially since the demand for medical services will soar in the future with the aging population. However, reducing the number of staff is the wrong area to focus on. Instead, the addiction to medicine consumption needs more urgent attention. This myopic attention to the “hard” aspects of something, in this case medicine and machines, instead of respecting and paying for “soft” skills is a hoary old nut for the Japanese and something they need to get past. The situation could be dramatically improved by recognizing technical and execution skills with proper pay awards, and by introducing ongoing physician education courses without having to send people overseas.

Lastly, because of the state commitment to providing equal health care, to the point of obsession, the private sector in Japan is extremely stunted. This means that people who
want high-quality specialty care and are willing to pay for it invariably have to go overseas to do so—or buy one of those multimillion dollar apartments in the towers next to Saint Luke’s hospital in Tsukiji. Also, there are the restrictions on hospital ownership to actual physicians, as if a doctor is a better facilities manager than a properly qualified hospital administration manager. Both of these factors ensure there is very little competitive activity, and consequently a lack of the benefits that private investment and price competition might bring.

I agree that having the state underwrite the medical system is a good idea, and certainly is a good reason for paying taxes. But state over-control in any industry inevitably leads to a loss of human incentive and an eventual break down of the system. Socialism as a national policy found this out in the 1980s and 1990s. I wonder why the Health Ministry is taking so long to learn the same lesson?

Latest 15 of 17 Total Comments Show All

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  tokyokawasaki at 10:40 AM JST - 19th November

  TIJ

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  timeon at 01:05 PM JST - 19th November

  tkoink2, please don't tell me about how great the health care system in US is. my wife waited for 3 hours at the emergency room at the Chicago University Hospital, and still no doctor was available, so she went home. and the bills are unbelievable point 2 and 3 of the article are very true, I know from my friends at the Medical School. from my experience, there is another problem with people calling the ambulance for all stupid reasons: I have a cold, I feel dizzy, I cut my finger etc. I've just seen a scene a few days ago when an about 10 year old boy fell and got a bruise on his knee. not even bleeding. he started crying and his mother promptly called an ambulance

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  memyselfI at 01:06 PM JST - 19th November

  Re-Title This: NATIONAL HEALTH INSURANCE IN CRISIS I am scared of going to Japanese Hospitals. Not because of verbal communication. But I believe I will not get the adequate care. All foreigners that pay National Health Insurance monthly. If you think about it? That's alot of cash. That's alot of ( hard working foreigners ) especially in Honshu. Why can't they change their standards ?? Who is pocketing all the money ? Where is all this money going ? They need a drastic change quickly. Alot of baby boomers and alot of older generations are retiring now. Where are these senior citizens supposed to go ? I'm a temporary worker. The fees I pay are tooooooooo HIGH. I have never went to hospital in 3 years except for physical exam ,that my company requires me to get and I have to pay that out of my own pocket. Also my health insurance doesn't cover physical exams. My health insurance doesn't cover that. I guarantee if i get hit by a car and get paralized I have to pay out of my pocket.

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  GW at 03:23 PM JST - 19th November

  Yes J-hospitals, clinics are poorly administered, docs make $$$ by over prescribing, then only giving you half the meds you need so you have to come back again & repeat the process, dentists....... been here since 1991 & may have just found an acceptable place but time will tell when I have my first cavity, the emergency case stories the last few years are down right scary & totally absurd, we regularly have hospitals who literally refuse entry of those who are dieing, its nuts.

  memyself & the rest of you better also be buying yr cancer insurance, coverage for hospital stays(Nat Health Ins doesnt cover that!!!). If you dont have all yr supplemental insurance & you get cancer, have a heart attack, get in an accident you will rack up huge expenses in no time.

  It is bizarre, my overall premiums paid in Jpn I cud buy international coverage for several familes with a couple kids fo what covers the wife & I, the only reason I dont buy the international ins is I am afraid I wud be refused at the door during an emergency.

  It is abundantly clear that major chgs are needed or it will collapse from a combination of lack of funds & not enough doctors

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  Pivot at 04:02 PM JST - 19th November

  What on earth is an exam for becoming a "DNA research scientist"? Does the author even know what he/she is talking about?

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  Deepinside at 06:01 PM JST - 19th November

  privat hospitals is the solution...

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  some14some at 07:46 PM JST - 19th November

  I think patients are in crisis not the hospitals, it didn't happen overnight, bad policies, lack of vision etc., but keep paying health insurance because it is mandatory.

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  Rodney_King at 08:54 PM JST - 19th November

  tkoind2

  I'm from the US and we have wonderful health care

  LOL ! We in Japan have also watched Michael Moore documentary called "Sicko" and we saw how "wonderful" is US health care with the HMO and american citizens crossing US-Canada border to get treatment in Canada...thank you tkoind2 for this great joke !

  Japanese hospitals are maybe in crisis but at least you can get a treatment for a cheap price. They are certainly not perfect but still japanese hospitals are working last time I used them (1 month ago).

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  gogogo at 10:42 PM JST - 19th November

  The problem is NOT shortage of doctors it is because all doctors specialize, there are no GP's in Japan and there are no trauma centers either because most people going to hospital have a runny nose or itchy skin problems so most of the doctors are skin specialists or the like.

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  Good_Jorb at 07:03 AM JST - 20th November

  The conclusions we can draw from these statistics are: a) there is a lack of medical staff to attend hospital patients, and so people get less doctor time and take longer to receive and thus respond to focused treatment, and b) the current government-controlled medical payments system rewards doctors for dispensing more medicine and this is probably resulting in patients being kept in their beds longer.

  There could be a ton of different reasons, bed availablity, cheaper ward rates(therefore less insentive to leave before your healthy) and etc. If you really want to prove the hospitals are in crisis(In terms of healthcare services provided)compare the Hospitals clinical outcomes, surgical outcomes and patient outcomes to some sort of benchmark, if they are significantly worsening then the hospitals are in crisis, otherwise like the rest of the article above it is all conjecture based irrelevant statistics.

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  Potsu at 09:32 AM JST - 20th November

  So here,you pay all that health insurance for 40 years,then you can't get into a hospital ??

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  Himajin at 10:34 AM JST - 20th November

  A hospital cannot accept an ambulance patient it does not have a physician for. If you were hit by a car, would you really want an eye doc or a skin doc to see you in the emergency room? It isn't trauma docs standing around drinking coffee redirecting ambulances at their convenience...

  At the ken-mandated one nurse per three beds, is the staff ratio low? There's also a quota for nurse assistants, but unfortunately I cannot recall it now. They have to have these minimums at least or they cannot open their doors.

  Currently hospitals get paid for keeping those beds filled, even with well patients.

  Beds are not filled with 'well patients'...would you stay in the hospital even though well? Who are these supposedly well people laying about in hospital beds? The amount of money a hospital can get decreases with the length of the hospital stay.Eventually it decreases to the point where having the person in that bed starts to cost them.

  The American day surgery set-up is great for those in their teens to say the late 40s, but as you get older getting tossed back home again with drainage tubes intact becomes harder to deal with. The longer hospital stays here are for joint replacement surgery...patient satisfaction is high with the policy of staying put until all rehab is completed...a newly operated Baa-chan is going to get to the hospital daily for rehab how?? A system of in-home physical therapy does not exist here, most homes could not fit in the equipment.

  In the US patients like my mother (knee replacement at 70) are sent to a rehab facility when there is no one at home in the daytime for meals and getting back and forth to the bathroom. Shorter hospital stays are not always a great thing. One side effect of the HMO system and 2-3 day hospital stays is the movement of MRSA infections from inside hospital walls to gyms and other facilities in the US. People are being sent home well ahead of the window in which MRSA symptoms would become apparent, and they'd be put in isolation. An unintended consequence of the policy.

  Something else that keeps the average hospitalization rate high is those people with nowhere else to go, those who are incapacitated by stroke or dementia, who are on waiting lists for tokubetsu rojin homes. They can stay for 90 days and then have to go somewhere else, and end up rotating through two or three hospitals till a bed opens somewhere. These people can comprise a good portion of hospitalized patients in rural areas where elderly care facilities are few and far between.

  As for drugs, as of 8 years ago or so, the profit incentive is being taken out of prescriptions...there is a flat fee the clinic or hospital earns per person, no matter how many types of pills they receive...prescribing 18 pills per patient is no longer profitable. Chouzai yakyoku are becoming more and more common as it no longer pays to keep a pharmacist on staff to hand out meds at a clinic.

  National health insurance does cover hospitalization on a ward, it does not cover semi-private or private rooms. You pay the 20% or 30% that your insurance stipulates, the additional coverage that they sell on TV is to cover that co-pay, and/or a private room.

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  jeancolmar at 02:13 AM JST - 21st November

  Nice article except the last stupid dig at "socialism", whatever the author means by the term. Hi-ho everyone, capitalism is the system in Japan and its under that system that this mess is happening. That system includes the Japanese government.

  The author writes: "Since 1982, the government has been maintaining that Japan has too many doctors, and has restricted the output of them by making the exams unreasonably difficult." Now why do you think the government did something as stupid as that? I'll bet the farm that the medical industry is behind that so that there is less competition for patients and the doctors in private practice don't have to engage in price wars.

  We've yet to see real socialism anywhere in the world, but we've had the next best thing, and that's the democracies where there has been a distinct socialist influence. Canada has an excellent socialized medical system (primarily thanks to the socialist influence from Saskatchewan). Then there is Scandinavia and France. Great places to get sick in.

  The stuff about lousy pay and long hours at public hospitals is interesting but in fact not really relevant to the problem being addressed. Don't forget that private hospitals have been turning emergency patients away. In the latest case in Tokyo it was a public hospital that finally took the pregnant woman in.

  Likewise, the information about the lack of doctors in rural areas while important is not relevant to why in Tokyo someone should be refused emergency care.

  The author is trying to build a case for the further privatization of medicine in Japan. Should that happen you will see the same ills here as you see in the US, the only major industrialized country without universal health care.

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  bdiego at 05:24 AM JST - 22nd November

  All the problems in Japanese hospitals exist in the US, they're just worse. So while we've certainly identified a lot of the problems, it's ironic we can't see the problems in our own system where people are dying on hospital floors screaming for help as nobody helps. It's shocking to see a video tape of a man calling 911 to save his wife's life..from inside a hospital.

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  GW at 04:41 PM JST - 23rd November

  I'm from the US and we have wonderful health care. But only a fraction of our society can afford it.

  RKing

  You cud at least do Tkoind2 the favor of putting his words into proper context, look above I added the next few words after yr very select quote, he was hardly praising the US system

  Moderator: Readers, please keep the discussion focused on Japan's health care system.

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