The Structural and Historical Aspects of Healthcare Delivery in Japan and the United States After reading Chapters 4 and 6 of the textbook by Lovett-Scott and Prather (2014), write a 300-word paper by

INTRODUCTION In 2005 the population of Japan was 128 million. The land area is 377, 914 square kilometers, the equivalence in size to Montana. There is a low infant and neonatal mortality rate which has steadily declined over the past 50 years. In fact, Japan’s infant mortality rates are among the lowest in the world. According to WHO, the infant mortality rate for 1000 live births for boys is 4:1,000, and for girls, 3:1,000, with an overall rate of 3.6 per 1,000. The total fertility rate, (the average number of children a woman gives birth to in her lifetime) is low, just 1.43 (CIA World Factbook, 2006; Kaneko, 2008). Adult mortality for men is 92:1,000 and for women 45:1000 (WHO Health Statistics, 2006). The proportion of Japan’s under 15 year old age group is 14%, and the over 60 year old age group is 24% (UNO, 2004; Kaneko, 2008). The primary language spoken in Japan is Japanese and it is the largest ethnic group. Shintoism and Buddhism are the largest religious groups (WHO, 2004). Japan has one of the highest literacy rates in the world and is the third highest economic power. Japan is known as the “aging society” and it is predicted that by 2030 one in every three people will be 65+ years old and one in five people will be 75+ (Muramatsu & Akiyama, 2011). According to the WHO (2011), Japan has the highest proportion of older adults in the world, with a life expectancy for women of 86 and men 80. The Huffington Post reporters Alabuster, Yamaguchi, Tomoko, Kageyana, and Kageyama (2011, March 11) described the biggest natural disaster to hit Japan since the late 1800s and its potential to raise havoc on Japan’s public health. The 8.9 disastrous earthquake, triggering a near 30 foot tsunami and a nightmarish aftermath of repeated aftershocks, oil spills, and explosions, have become an unexpected financial and public health problem. In addition, a failed cooling of the nuclear reactor at the Fukushima Nuclear Power Plant, contamination of the water supply, and cities that were instantly converted to “junk yards,” has served a severe blow to Japan’s economy. Despite help from the Red Cross and tremendous assistance received from numerous other volunteers, it also has the potential to disrupt its health care system. HISTORICAL Reportedly, the first operation performed under general anesthesia using datura, a narcosis eliciting plant, was in 1804 by a Japanese physician called Hanaoka Seishu. One of the most challenging health problems of the 19th century was poor sanitation, partly due to cross contamination of plants from a poorly draining sewage system, a system that was greatly improved by William Burton, a Scotsman who redesigned Japan’s crumbling water supply system in an attempt to decrease communicable disease (Hays 2009, p. 3). The evolution of national health insurance began in 1905 when Japanese industries began providing limited health care to its employees. In 1922, legislation inspired by the German system, mandating coverage by enterprises, was enacted. By 1927 multiple companies followed this lead covering more and more employees. In 1938 health insurance was extended to farmers, fisherman, foresters, and other groups not covered by the 1922 legislation. By WWII, approximately 70% of Japanese were covered. After the war, in an effort to rebuild Japan, the national healthcare insurance plan was expanded and by 1958, 100% of residents in Japan had universal coverage. Three years later, the plan was further revised with improved access for everyone (Rodwin, 1993). The Japanese government’s Ministry of Health, Labor and Welfare sets all health insurance policies standardizing medical charges countrywide. STRUCTURE Graziano (2009) provides a great overview of the Japanese healthcare system structure and organization. Japan is a publicly administered healthcare system that is financed in numerous ways. Healthcare delivery is highly fragmented and decentralized with much integration among local clinics and specialized hospitals. Most of the care delivery is in the medical private sector. Of the 8,943 hospitals 18% are publicly operated, and 5% of the 98,609 clinics are public. Specialty care is described by the complexity of the services required. There are 8.4 acute care hospital beds per 1,000 population. In regard to interdisciplinary roles, responsibilities, and outcomes, there is a huge demand for healthcare services in Japan that is provided essentially by doctors and nurses. There are no mid-level professionals such as nurse practitioners, physician assistants, or clinical nurse specialists. The physician workforce in 2006 included 263,540 actively practicing physicians, equating to two practicing physicians per 1,000 persons in the population, of which 49% were primary care physicians practicing in internal medicine, pediatrics, and gynecology. The average hospital physician earned 14,100,000 yen (145,565 USD). Physicians who operate solo clinic practices earned considerably more, averaging 25,300,000 yen (261,178 USD). There is a shortage of obstetricians, anesthesiologists, and emergency medicine physicians (Harden, 2009) Of the 896,724 registered professional nurses (RNs) in Japan during 2005, 46,764 worked in public health, 27,047 were nurse midwives, and 822,913 were registered nurses working in various specialty areas. The average RN salary was 4,561,800 yen (47,095 USD). In addition to RNs there were an additional 411,685 Licensed Practical Nurses in the Japanese workforce. Including LPNs, there are 10.3 total nurses per 1,000 population in the Japanese workforce. Physicians are well educated, but relatively few in number. Medical school is six years combined undergraduate and professional school with board certifications and other credentialing of physicians, nurses, and other providers are earned through specialty societies. Licensing is administered through the Ministry of Health. FINANCING All Japanese have essentially the same healthcare coverage. Physicians and hospitals are generally paid a fee for services. Physicians typically work long hours and extensive periods without days off. Revisions to the fee structure are politically negotiated between the government and providers, usually biennially. There is a strong relationship between the National Medical Expenditure (NME) and the Gross Domestic Product (GDP); both grew at the same rate from 1980 to 1989 but the healthcare share of the economy grew out of proportion to the GDP in 1999 (Ikegami & Campbell, 2004, p. 27). Economic stagnation led to greater pressures to contain expenditures within the existing healthcare framework, but it also added fuel to longstanding proposals for more radical reforms advocating for a change in how health services are reimbursed (Ikegami & Campbell, 2004). There are two basic types of medical insurance in Japan—employee’s health insurance, covering employees and their families, and national health insurance for self-employed and unemployed individuals and their families. Subscribers pay insurance premiums calculated according to their annual income which equates to approximately 10% of their income. In other words, consumers of health care pay based on their financial ability to do so. Medical coverage is pretty comprehensive but varies by income and appreciates with age. Two-year-olds and younger are 80% covered, favoring a healthy start. Individuals who are three years to 69 are 70% covered and 70 and older are 90% covered except for those with very high incomes. In this case, they receive 80% health coverage. Individuals who pay out-of-pocket for medical expenses exceeding $600.00 per month are fully reimbursed by the government. Homes for the elderly, home care assistance and services, respite care (short-term care programs) and similar services have been covered since 1963 from funds from taxes of the central and local governments under the Welfare Law for the Elderly. The Health Service for the Elderly, enacted in 1982, covers all of the medical services necessary including hospital admissions, extended rehabilitation in extended care facilities, in-home rehabilitation, home visits for nursing care, and day care programs. The Gold Plan of 1986, and revised New Gold Plan of 1994 expanded service targets for home care aides, respite care, day care, home nursing visits, special nursing homes for the elderly, health service facilities for the elderly (providing rehabilitation in long-term care facilities) and assisted living facilities referred to as care houses (Ministry of Health and Welfare, 1998). Japan has a National Health Insurance Program. The employer also provides insurance for its workers and pays, in addition, 10% of medical costs. The government sets healthcare and physician fees so they are relatively low. INTERVENTIONAL Although Japan has one of the lowest physician-to-population ratios among Organization for Economic Cooperation and Development (OECD) countries, they have the highest number of physician contact per capita, more than twice the American rate, although their typical patient encounter is 6.9 minutes compared to over 20 minutes for United States physicians (Rodwin, 1993). In regard to service quality, primary versus acute, and restorative care, like most industrialized countries, Japan utilizes high technology medical care. However, physicians have a definite preference for non-invasive procedures and the approach to care emphasizes ambulatory, over in-patient care. In fact, Japan prides itself on its low rate of hospital admissions (Rodwin, 1993, Harden, 2009) demonstrating the emphasis on primary care over acute care. Their low cost and high quality are considered a birthright of the Japanese. In regard to long-term care in Japan, the Japanese healthcare system promotes longevity, which is demonstrated by its higher life-expectancy and decline in the live birthrate. The number of infirm elderly in Japan needing care increased 50% from 1993 to 2009. It is predicted to increase 60% by 2025. The number of older adults who are bedridden, have dementia, or have other problems requiring assistance with their activities of daily living is expected to increase from 2.8 million in 2000 to 5.2 million by 2025 (Ministry of Health and Welfare, 1998). As advances in medical care rise these numbers will likely show a further associated increase. Irrespective of whether the Japanese are in need of acute, sub-acute, rehabilitative, long-term, or community-based care, it is covered by insurance. Since 1983, Japan has had health insurance for the older adults aged 70 and over, as well as coverage for disabled persons aged 65–69. Seventy percent of the total cost for services is covered by what is known as ‘all sickness funds,’ of which 20% is financed by the national government and 10% by local governments. The proportion borne by local government is considerably lower, reflecting the importance placed on long-term care for the elderly (Fukawa, 2002). PREVENTIVE The medical insurance system is universal coverage for individuals of all ages, which includes a government managed mandatory long-term care insurance for citizens over 40 years old, and a special medical insurance program for people 75 years of age and older. Community health services focus on disease prevention and health promotion. The government sets public health policy and legislation. Public health centers in each prefecture treat, among other problems, infectious diseases, mental health, environmental problems, sanitation, and hygiene. Public health nurses provide maternal child health and elderly care. Pregnant women receive impeccable care. They receive a maternal child health handbook, and receive post-partum home visits from public health nurses. All newborns and high risk pregnant women receive routine health checkups. Annual health checkups for those over 30 are also provided for a nominal fee. Women receive screenings for breast and uterine cancer, and everyone gets screened for cancer of the stomach, lungs, colon, and rectum. Japanese pride themselves on maintaining traditional practices such as folk and herbal medications similar to the Chinese practices, and use of complementary and alternative medicine (CAM). The use of such herbal medicines as ginseng, sesame, and ginger oils, rubbed on the forehead to cure headache are common remedies. The Yin and Yang practice is important, especially during pregnancy and disease. Among the traditional Japanese medicines are gennoshoko (Japanese germanism), an effective treatment for diarrhea and digestive infections; dokudami, a low creeping plant with white flowers and a nasty smell used to treat heart problems and counteract poisons; ukon (turmeric), attributed to helping the liver and fighting bacteria; and feverfew (bachelor’s button, or natsushirogiku) a popular relief for migraine headaches. Also a popular Chinese herbal called kampo is widely used in Japan to treat diabetes, hepatitis, asthma, and menopausal and digestive disorders (Facts and Details, 2002). When it comes to maintaining beauty and health, Japanese are firm believers in the use of massage, acupuncture, and Shiatsu, a type of needleless acupuncture using the fingers to place pressure on the meridians. Reflexology, or foot massage has become almost synonymous with relaxation and stress reduction (Hays, 2009 p.8). Prevention is key as is evidenced by all children being immunized, and children receive mandatory medical and dental care. Every age is protected against disease. RESOURCES Perhaps some of the most significant demonstrations of human resource support was seen during the aftermaths of some of the most devastating natural disasters known to humankind. Although these disasters had profound physical, emotional, and economic implications, they revealed positive aspects of Japanese society, older adults’ wisdom and resilience for survival and coping, active social and labor participation at older ages, and strengths of social relationships (Muramatsu & Akiyama, 2011). It is common in Japan for a daughter or a daughter-in-law to care for older adult family. Japanese consider it to be the woman’s responsibility to take care of her parents or her husband’s parents in their old age; to not do so is considered abandonment, which brings shame to the entire family. Partly for this reason, cohabitation is higher in Japan than in other industrialized (developed) countries. Japanese women typically assume the role of caregiver for others as well. They look after and anticipate and protect the needs of children, their husbands, and other close relatives. Children are cherished and highly desired, especially the first born male, but children are usually limited to two. Men are the decisionmakers. Japanese, like most cultural groups, find strength in organized religion. Shintoism, Buddhism, and Confucianism are among the most widely practiced religions in Japan. Temples and shrines are used for prayer and healing. Death is accepted as a natural occurring process and is handled with confidence and strength. MAJOR HEALTH ISSUES From 1950 to the mid 1960s, tuberculosis was the most common illness in Japan. However, today, geriatric diseases such as chronic hypertensive disease, cerebrovascular disease, heart disease, and malignant neoplasms are dominant. In fact, as is illustrated in Table 6-1, 21 percent of the illnesses plaguing Japanese appear as some form of cancerous lesions. This table lists the top ten medical problems in Japan by number, percent, and years of life lost. The aftermath of the largest natural disaster to hit Japan since the late 1800s has severely challenged Japan’s public health. The disease-ridden conditions of contaminated water, massive debris throughout major cities, and radioactive debris around the Fukushima Nuclear Plant could eventually result in increased outbreaks of communicable diseases. The horrific conditions, with which those in communities most affected by the earthquake and tsunami must contend, could likely have far-reaching, longer-term effects than ever imaginable; potentially putting at risk the health of entire communities of people for years to come. Table 6-1 Top 10 causes of death (all ages) in Japan, 2002, with the number and percent of years of life lost by disease. Data From: Death and DALY estimates by cause, 2002. http://www.who.int/entity/healthinfo/statistics/bodgbddeathdalyestimates.xls DISPARITIES Health standards, costs, and fairness in the Japanese health system by many accounts make access to care non-problematic. The weakest part of the Japanese system is the lack of professional accountability, putting consumers at a disadvantage when seeking care. Another weakness is that doctors overprescribe medications because their salaries are linked to how many pills they dish out (Facts and Details, 2002). Enforced budget restraints for care of the elderly have resulted in financing challenges for long-term care of that group. The top three diseases causing death in Japan are stroke, heart disease, and lower respiratory infection. There is considerably more use of CAM in the treatment of diseases in Japan than in Western countries. SUMMARY Although there are unforeseen consequences of the March 11, 2011 earthquake and tsunami, Japan is a strong, resilient country with the ability to overcome most challenges. A major strength of the Japanese system of health care is its emphasis on prevention and promotion. There is universal coverage for all and progressive premium rates based on ability to pay with tremendous access to services. Major weaknesses in the system are inherent in the increased numbers of elderly. Obviously, with longevity come chronic illness, greater demand for long-term care services, and a strain on Japanese families, and on Japan’s national budget. Discussion Questions 1.  Japan is known as “the aging society.” Identify three factors that you think account for this reputation. Do you observe these same factors in your own life situation? If not, do you believe that these factors are critical to living longer? Explain your point of view. What can healthcare providers do to ensure longevity of the people they serve? 2.  The Japanese pride themselves on maintaining several traditional practices. Are you familiar with these practices and are they a part of your own health regimen? As a healthcare provider, would you recommend acupuncture or shiatsu to patients? Why or why not? 3.  What preventive measures in Japan stand out for you? For example, how does the care for pregnant women compare to your observations or experiences with pre-natal care? 4.  Japan’s healthcare structure does not include mid-level professionals. In your opinion, what are the advantages and disadvantages of this structure? How is the quality of health care affected? If you had a say in staffing a healthcare facility, would you follow Japan’s design? Explain your point of view. 5.  What are your thoughts regarding the expectations of Japanese women as caregivers for elderly family members? Have you observed these expectations for women as a healthcare provider? To what extent is the caregiver role considered in treatment plans for women patients? 6.  In view of Japan’s high literacy rate and excellent preparation of physicians, why do you think there is such a low physician-to-population ratio? Does your work setting have enough physicians? If not, how is health care managed? 7.  Describe healthcare coverage in Japan, including their approach to coverage of pharmaceuticals. What aspects of Japan’s healthcare coverage do you find particularly impressive? Explain your point of view. How would Japan’s healthcare coverage apply to you or your family? Do you know patients who would benefit from Japan’s healthcare coverage? In what way? 8.  Discuss the potential impact of the March, 2011 earthquake and tsunami on Japan’s health outcomes. What, in your opinion, are the projected epidemiological communicable and non-communicable disease trends likely to occur as a consequence? Case Scenario Mika Takashi In the following scenario, a healthcare practitioner talks about her experience with Mika Takashi, a Japanese patient. Here, she presents a time line of events and healthcare provider actions that led to a number of unintended consequences for Mika. As you move through her account, what sounds familiar and what would have happened differently if you were the healthcare provider? MIKA TAKASHI A few years ago, I conducted a history and physical examination for a 42-year-old Japanese patient who was new to my practice. After her husband was killed in an automobile accident, Mika Takashi came to the United States with her two small children (ages 2 and 5) to live with her sister and her family. She was 32 years old. Upon her arrival she spoke very little English. However, in our encounter, she spoke and understood English very well. Mika was switching primary care physicians after three years in another practice where she was dissatisfied with her care. A review of her record from the previous office revealed that soon after entering the practice, Mika complained of her heart “hurting,” resulting in a full cardiac workup; the findings were normal. She was prescribed antacids and advised to exercise more. After taking a brief history, and questioning her about her current health status, I asked if she continued to have either pain or sadness in her heart. She slowly nodded and replied, “Sad, very sad!” Her facial expression immediately changed from engaging with full eye contact, to dejection, and avoidance of my eyes. In follow up I asked, “How long have you felt sad, Mika?” She replied, “A long time,” which I later learned was for nine years. She had taken the death of her husband very hard which made her depression worse. To further complicate the situation, when her then 7-year-old son was sent to the school nurse after vomiting in class one day, the nurse, finding welts completely covering the child’s body, asked the child, “Who did this to you?” The child responded, “Mommy.” Consequently, Mika was accused of child abuse. Despite clarification by the family of the harmless Coining practice, in which warm coins are rubbed across the body for medicinal purposes, Mika was being accused of deliberately harming her child. A lengthy investigation resulted, and Mika became even more severely depressed. The Office of Child Protective Services became involved, and their lives were disrupted for three years before she was finally exonerated. I prescribed an antidepressant with the fewest side effects, and referred Mika to a clinical psychologist. She is currently doing very well. DISCUSSION POINTS 1.  When it became obvious that Mika was not “hurting” physically, why didn’t someone work at clarifying what she meant? What questions might have helped Mika address her emotional issues? 2.  It can be argued that Mika could have spoken up or found some way to be clearer about her problem. What do you think? 3. Did the school nurse respond appropriately to the situation presented by Mika’s 7-year-old? Did she rush to judgment? 4.  Suppose the school nurse knew about the Coining practice, would she still have been obligated to report the welts? 5.  Mika’s problems dragged on for approximately 6 years after arriving in the United States. Is it fair to blame the healthcare system for her troubles? REFERENCES Alabuster, J., Yamaguchi, M., Tomoko, A., Kageyama, H., & Kageyama, Y. (2011, March 11). Earthquake in Japan. Huffington Post. Huffingtonpost.com CIA World Factbook, United States Department of State, Handbook of the US Library of Congress. (2008). Retrieved October 22, 2010 from http://www.cia.gov/cia/publications/factbook/index.html Facts and Details. (2002). Health care in Japan. Retrieved, January 10, 2011 from http://www.factsanddetails.com/japan.php?itemid=8397catid=237subcatid=151 Fukawa, T. (2002). Public health insurance in Japan. The International Bank for Reconstruction and Development/The World Bank. Washington, DC: 6–15. Graziano, C. (2009). Japanese health care system structure and organization. Retrieved on December 10, 2010 from http://dmaa.pbworks.com/w/page/17960778/CareContinuumAllianceJapan-Healthcaresystem.htm Harden, B. (2009, September 7). Health care in Japan: Low cost for now. Washington Post Foreign Services. Retrieved March 11, 2011 from http://star.com.jo/main/index.php?option=com_content&view=article&id=15722 Hays, J. (2009). Health care in Japan. Retrieved on December 10, 2010 at http://factsanddetails.com/japan.php?itemid=839&catid=23&subcatid=151 Ikegami, N. & Campbell, J. C. (2004). Japan’s health care system: Containing costs and attempting reform. Health Affairs, 23:3, 26–36. Kaneko, R., Ishikawa, A., Ishii, F., Sasai, T., Iwasawa, M., Mita, F., and Moriizumi, R. (2008). Population projections for Japan: 2006 – 2055 outline of results, methods, and, assumptions. Japanese Journal of Population, 6:1. Ministry of Health and Welfare. (2002). Japan’s long-term care insurance programs. www.mhlw.go.jp/english/topics/elderly/care/index.html Muramatsu, N. & Akiyama, H. (2011). Japan: Super-aging society preparing for the future. The Gerontologist, 51(4), 425–432. doi:10.1093/geront/gnr/067l Rodwin, V. (1993). Japan’s universal and affordable health care: Lessons for the United States. Retrieved March 11, 2011 from website: http://www.nyu.edu/projects/rodwin/lessons.html UNO. (2004). Retrieved November 12, 2010 from Un.org/esa/population/publications/WorldPop.pdf World Health Organization (WHO). (2006). Health statistics. Retrieved November 12, 2010 from who.int/whosis/database/core/core_select_process.cfm World Health Organization (WHO). (2004). Health statistics. Retrieved November 12, 2010 from who.int/whosis/database/core/core_select_process.cfm World Health Organization (WHO). World Health Statistics (2011). Retrieved, November 12, 2010 from http://www.who.int/whosis/whostat/EN_WHS2011_Full.pdf