Health insurance system and payments provided to patients for the management of severe acute pancreatitis in Japan
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The health insurance system in Japan is based upon the Universal Medical Care Insurance System, which gives all citizens the right to join an insurance scheme of their own choice, as guaranteed by the provisions of Article 25 of the Constitution of Japan, which states: “All people shall have the right to maintain the minimum standards of wholesome and cultured living.” The health care system in Japan includes national medical insurance, nursing care for the elderly, and government payments for the treatment of intractable diseases. Medical insurance provisions are handled by Employee’s Health Insurance (Social Insurance), which mainly covers employees of private companies and their families, and by National Health Insurance, which provides for the needs of self-employed people. Both schemes have their own medical care service programs for retired persons and their families. The health care system for the elderly covers people 75 years of age and over and bedridden people 65 years of age and over. There is also a system under which the government pays all or part of medical expenses, and/or pays medical expenses not covered by insurance. This is referred to collectively as the “medical expenses payment system” and includes the provision of medical assistance for specified intractable diseases. Because severe acute pancreatitis has a high mortality rate, it is specified as an intractable disease. In order to lower the mortality rate of various diseases, including severe acute pancreatitis, the specification system has been adopted by the government. The cost of treatment for severe acute pancreatitis is paid in full by the government from the date the application is made for a certificate verifying that the patient has an intractable disease.
Key wordsMedical care system Acute pancreatitis Japan’s health insurance system Government payment system
The scope of Japan’s medical security scheme is characterized by the Universal Medical Care Insurance System, which is based on the Constitution, and by the monetary allowances provided for by this system. No other country has a medical security system with these characteristics. The system has made it possible for Japan to achieve and maintain high health standards at low cost.
Japan’s medical security system is characterized by its provisions for universal medical care, nursing care for the elderly, and payment of health care expenses
In Japan, patients pay an insurance premium that is linked to their normal level of income. They also contribute toward the cost of treatment when they receive medical care. A substantial part of the cost of medical treatment is paid for either by their employers or by national and local governments from their financial resources (tax revenues). The amount of the premium is determined by the person’s income at the time the medical service is provided, and the cost of his or her medical treatment is fully covered, irrespective of the amount of the premium the person has paid. The biggest difference between this system and private insurance schemes is that the resources of the latter come entirely from the premiums paid by policyholders.
Japan’s medical insurance system originated with the Health Insurance Law, which was enacted in 1922. Article 25 of the new Constitution of Japan, promulgated in 1946 after the end of the Second World War, stipulates: “All people shall have the right to maintain the minimum standards of wholesome and cultured living.” It also states: “In all spheres of life, the State shall use its endeavors for the promotion and extension of social welfare and security, and of public health.” The social security system is based on the Constitution, and the provisions for universal medical care insurance were completed in 1961. Currently, subscribers themselves and their families must pay 30% of medical care costs and the elderly must pay 10% to 20%.
In broad terms, Japan’s health care system is responsible for (1) medical insurance, (2) healthcare for the elderly, and (3) government payments for medical care. Medical insurance is provided for by Employee’s Health Insurance (Social Insurance), which mainly covers the employees of private companies and their families, and by National Health Insurance, which provides for the needs of self-employed people. Both schemes have their own medical care service programs for retired persons and their families. The health care system for the elderly is for people 75 years of age and over and for bedridden people 65 years of age and over.
The medical treatment payment system applicable to patients with severe acute pancreatitis
There is also a system under which the government pays all or part of the medical expenses and/or medical expenses not covered by insurance. This system is referred to collectively as the “medical expenses payment system”.
The purpose of the medical expenses payment system is to improve and develop social welfare and public health. The system is funded by national and local governments from their normal financial resources (e.g., tax revenues). This system provides for a range of services, such as medical aid based on the Livelihood Protection Law; medical allowances based on the Child Welfare Law, the Maternal and Child Health Law, the Tuberculosis Control Law, and the Law Related to Mental Health and Welfare; medical care services for those certified as atomic bomb victims; benefits under the Law for Aid to Wounded and Sick-Retired Soldiers; and medical aid for specified intractable diseases, including severe acute pancreatitis.
Medical aid for specified diseases
In 1973, medical aid for specified diseases — namely, the medical treatment cost payment system — was launched by the Ministry of Health, Labour, and Welfare as a measure to reduce mortality caused by intractable diseases. It is designed to reduce the cost of medical treatment to be borne by patients with severe and/or rare intractable diseases (45 such conditions are currently specified). Severe acute pancreatitis is one of the specified diseases, and the entire cost of the medical treatment for these specified diseases is recovered from public funds from the date when the application for a certificate to receive treatment for a specified disease is filed.
The patients themselves, or their families, apply for payment to their local health center or prefectural government (depending on where they live) by submitting (1) an application form for a certificate to receive treatment for a specified disease, (2) a certificate of residence, and (3) a clinical examination record prepared by their medical practitioner. Once it has been proven that a person has a specific disease, the cost of medical treatment paid by the patient under the terms of the standard medical insurance scheme will, in principle, be borne by the national and local (prefectural) governments (on a 50%-50% basis) for a period of 6 months (or longer, if the severe acute pancreatitis continues) from the date of the application for payment. Because the medical treatment costs are paid for only after the date of application, this application should be made as quickly as possible. It should be noted that, under this system, the definition of severe acute pancreatitis is as specified by the severity assessment criteria established by the Ministry of Health, Labour, and Welfare.
The homepage website of the Japan Intractable Disease Center (http://www.nanbyou.or.jp) provides patients with severe acute pancreatitis and their families with information on subjects such as the “Severity Assessment Criteria”1,2 and the “Clinical Examination Record.” The information has been prepared by the Research Group for Specific Intractable Pancreatic Diseases, which is sponsored by the Japanese Ministry of Health, Labour, and Welfare.
Comparisons between Western health insurance systems and the Japanese system
Medical insurance in the United States is primarily provided by private insurance companies. As of 2004, there were 44 million people in the United States without health care insurance.3 Wealthy people are able to obtain very advanced, but expensive, medical care services, whereas the uninsured poor can only afford some of the medical services available.
Many insurance companies, whose operations are principally influenced by the critical issue of how medical expenses should be paid, have introduced “managed care” and “medical management guidelines” in an attempt to standardize medical management procedures. Moreover, some insurers endeavor to limit medical expense payments by introducing “gatekeeper” systems,4 under which patients can receive medical services from a specialist physician only after being referred by their primary care physicians.
In Germany, patients can freely choose their general practitioner, but they cannot change their practitioner for at least 3 months after the first visit, unless there is a special reason for so doing. Access to a hospital specialist is subject to referral by their primary care physician and often takes a very long time. If patients consult a specialist without being referred, they must pay the cost of medical treatment.
Under the pressure of health care reform in Germany in the 1990s, interactions among the state, medical insurance funds, and providers are said to have entered a new era.5
Access to physicians and medical institutions in the United Kingdom is via a registration system.6 Everyone must register with a general practitioner and, except in emergencies, patients are referred to a hospital after first being examined by that physician. However, because of a severe medical cost-control program imposed by the government, clinical care units are facing rapid increases in the lengths of their waiting lists.
It is fair to say that Japan’s primary care system, which enables patients to receive treatment at advanced specialist medical institutions from the very outset, is very unusual. This is extremely beneficial for patients with severe acute pancreatitis, who require treatment with minimal delay.