Introduction

The average longevity of the Japanese people is 79 years in men and 86 years in women [1]. The long average life span of the Japanese people is a result of support by the Universal Medical Care System based upon the Constitution of Japan along with monetary allowances provided for under this system. No other countries in the world have a medical insurance system comparable to that of Japan which has the two characteristics mentioned above.

Characteristics of the health insurance system of Japan: medical insurance system and health care system for the long-lived

The health insurance system of Japan comprises primarily the medical insurance system and the health care system for the long-lived (also referred to as the health care system for the elderly above 75 years).

The people pay an insurance premium according to their normal level of income. The amount of premium is determined in accordance with their income at the time when the insurance came into effect. Patients pay a part of the cost of medical care that they have received, although a substantial part of it is paid for either by their employers or by public expenditure (tax revenues of national and/or local government). Medical benefit is covered fully by health insurance as needed, irrespective of the amount of the premium that they have paid. A big difference from private insurance is that its resources come entirely from the premium paid by the policy holders.

The medical insurance system of Japan originated with the Health Insurance Law that was enacted in 1922. In 1946, the new Constitution of Japan was promulgated in 1946 after the end of World War II. It stipulates as follows: “All the people shall have the right to live a healthy, cultural and minimum standard of life,” and “In all the spheres of life, the State shall make every effort to promote and extend social welfare and social insurance together with public health.” The Universal Medical Care System was completed in 1961 when the social security system was put in order on the basis of the provision of the new Constitution,

The health care system comprises Employees’ Health Insurance (Social Insurance) that covers employees of private companies and their families and National Health Insurance that covers the self-employed. Each system has its own programs of medical care services for the retired and their families. Currently, the Japanese people under 70 years of age must pay 30% of medical care cost and 70% is paid by the insurance system.

On the other hand, the medical care cost of the elderly over 70 years of age became free of charge in 1973. However, as a result of the extended longevity of the Japanese people and an increase in medical expenses, the Health Care Law for the elderly was enacted in 1983 that introduced a system under which a part of the medical cost is paid by patients. Along with a further decrease in the proportion of the elderly and a decrease in the birth rate in Japan, the proportion of contribution from the revenue of health insurance societies decreased. Also, there is not a small number of the retired who maintain the same level of income as that of the working generation. In consideration of such backgrounds, innovation of the health care system for the elderly is underway, and the health care system for the long-lived was implemented in April 2008 [2]. According to the provision of this system, the elderly of 70–74 years of age are classified into the category of the elderly who are in the early phase of old age (zennki koreisya) and they have to pay 30% of medical care expenses. On the other hand, the elderly of over 75 years of age are classified into the category of the elderly who are in the late phase of old age (koki koreisya) and they have only to pay 10% (30% in the elderly who maintain the same level of income as that of the working generation). Furthermore, it is stipulated that the elderly must also pay a premium regularly, although it is only a small amount.

Payment system of medical expenses

There is also a system under which the government pays all or part of the medical expenses or expenses not covered by medical care insurance (Table 1). This system is called collectively the ‘payment system of medical expenses.’

Table 1 Public Health insurance and payment systems in Japan
Full size table

The purpose of providing medical care whose cost is paid by the government lies in the improvement and development of social welfare and public health. This system is put into practice by the national government or local government on the basis of normal financial resources (including tax revenues) so that medical benefits may be conferred. To be concrete, a diverse range of services is provided for according to this system including payment of medical benefit based on the Livelihood Protection Law, the Child Welfare Law, the Maternal and Child Health Law, the Independence Supporting Law, the Infectious Disease Law, the Law Related to Mental Health and Welfare, medical care services for people certified as atomic bomb victims, the payment of medical benefit based on the Law for Aid to wounded and sick-retired Soldiers. Furthermore, as an enterprise of measures for control of intractable diseases including severe acute pancreatitis, there is a ‘Treatment and Research Enterprise for Specified Diseases.’

A research enterprise of treatment of specified diseases including acute severe pancreatitis

In 1973, a research enterprise of treatment of specified diseases including acute severe pancreatitis was initiated as one of the enterprises of measures for control of intractable diseases. As mentioned above, a substantial proportion of overall medical expenses are to be borne by the insurance system. However, in intractable or severe diseases, the cost of medical care may amount to a large sum even if patients pay a small proportion of it. The purpose of this system is to reduce the cost of medical care to be borne by patients themselves with serious and/or rare intractable diseases (45 diseases are specified at present) including severe acute pancreatitis. For such diseases, the total amount of treatment cost is reimbursed from the public expenditure dating back to the day when the application was made for a certificate to receive treatment of serious and/or rare intractable diseases.

The application for receiving payment should be made by patients themselves or their families to their public health office or prefectural government (depending upon the area in which they live) by submitting: an application form for a certificate to receive treatment for a specified disease and a resident card together with a clinical examination record prepared by their physicians. Once a patient has been proven to have a specific disease, medical expenses paid by the patient will be borne, on principle, by the national and local (prefectural) government on the basis of 50/50 for a period of 6 months (or longer, if severe acute pancreatitis persists) from the date when the application was made for receiving payment. Note should be taken that the payment of medical care expenses starts on the date of the application for receiving payment, so the application should be made as soon as possible. Also, it should be noted that the definition of severe acute pancreatitis under this system is based on the criteria for severity assessment established under the sponsorship of the Ministry of Health, Labour and Welfare.

The homepage website of the Japan Disease Center (http://www.nanbyo.or.jp) provides patients and their families with information on subjects such as “Severity Assessment Criteria” and the “Clinical Examination Record”. The information is prepared by the Research Group for Specific Intractable Pancreatic Diseases under the sponsorship of the Japanese Ministry of Health, Labour and Welfare.

Specific medical checkup and specific health guidance

Along with changes in lifestyle and dietary habits of the Japanese, there is an increase in lifestyle-related diseases such as obesity, diabetes, hypertension and metabolic syndrome. Also, diseases induced by the conditions mentioned above (or aggravation factors) are increasing currently. Under these circumstances, large-scale preventive measures including specific medical checkup and specific health guidance were implemented in April 2008 in Japan.

Specific medical checkup is conducted for all the Japanese people of 40–74 years of age by focusing on examinations of metabolic syndrome in particular. Included in the examinations are history taking (use of medication, smoking habit, etc.), physical measurement (height, abdominal circumference and BMI: body mass index), blood pressure, physical examination, urinalysis (urine sugar and urine protein) and blood test (lipid, sugar and liver function).

Medical checkup is optional and expenses are paid primarily by health insurance companies. Patients will get feedback on test results and information on appropriate guidance in about a month.

In those people who have been assessed as having a high risk of developing lifestyle-related diseases and requiring guidance, health care guidance for improvement in dietary and exercise habits is provided for by physicians, public health nurses and nutritional managers. The contents of guidance include support for motivation and active support, and more active support is provided for those with a higher risk. The assessment of the improvement in a dietary habit is to be conducted in 6 months.

Ten months have passed since the implementation of this system, and there is a report of news coverage from the overseas governments and media [3].

It is expected that such national-scale efforts as these will result in a reduction in the occurrence of severe acute pancreatitis or its aggravation in future.