Why is the Japanese medical system a good example?
Japan’s diverse and bottom-line medical service system
Japan’s primary medical care is provided by individual clinics, and hospital medical services are mainly provided by private non-profit hospitals. However, Japan has a bottom line for privately run hospitals, and social capital is prohibited from running private, for-profit hospitals.
Grassroots clinics mainly appear in the form of specialist clinics. There are also a small number of public hospitals that provide primary medical services. In Japan, medicine is divided into separate industries, and most hospital outpatient clinics have been completely divested.
In the primary medical system, one-third of the doctors are employed by clinics, and the rest are doctors themselves. Clinics are usually run by individual doctors or organized by groups of doctors.
In Japan, a doctor group is composed of several doctors, all of whom own a hospital or a clinic.
Clinics can provide both general and specialist services. The organizational form of primary medical services in Japan is usually one doctor + several nurses. In 2011, the average full-time staffing of Japanese clinics was 7.2 people, including 1.2 doctors, 1.8 nurses, and 2.1 front desks.
In terms of hospital composition, in 2013, 15% of hospitals in Japan were run by the central government or local government, and the rest were private non-profit hospitals.
In terms of beds, 20% of the beds belong to public hospitals and 80% of the beds belong to private non-profit hospitals.
It is important to note that private non-profit hospitals are considered part of public health care, receive various subsidies from the government, and are also within the payment scope of public health insurance funds.
Japan does not allow private for-profit hospitals to open, but it allows corporate hospitals to exist to provide medical services to corporate employees. We can understand profit-making and non-profit in this simple way: "profit-making" means that the hospital's balance can be used to distribute dividends, and "non-profit" means that the hospital's balance is considered to be public funds, and the funds cannot be handled privately and can only be used for dividends. All of it is used to develop hospitals, and more requirements are reflected in Japan’s medical law. Taiwan, our country, has also learned from Japan’s practices.
Clearly defined the boundary between public medical insurance and private medical insurance
Japan has established a compulsory national medical insurance system, which is the public medical plan. Residents or employees must join the public insurance plan, and legal immigrants are also required to join the social insurance plan, but illegal immigrants and tourists are not included. If a resident withdraws from compulsory medical insurance, he will have to pay an additional two years of premiums when he rejoins, which is equivalent to a penalty. Approximately 3,400 insurance agencies provide public medical insurance.
Except for children and the elderly, the self-payment ratio of public medical insurance is 30%. The self-payment ratio for children under 3 years old is 0%, the self-payment ratio for seniors aged 70 to 74 is 20%, and the self-payment ratio for seniors over 75 years old is 10%.
Public *** medical insurance has no deductible, and self-payment and some prescription drug costs can be subsidized from income tax deductions. In addition, the situation of personal self-payment is not clear. Looking at the entire medical expenditure in Japan, personal self-payment accounts for about 14%. The employer bears half of the cost of premium financing, and the premium burden ranges from 3% to 10% of the company's revenue.
The boundary between private medical insurance and public medical insurance is very clear, and the former is in a supplementary position in the Japanese insurance plan. The first is supplementary insurance to compulsory public health insurance, which residents voluntarily participate in. It mainly pays medical expenses in the form of a lump sum to make up for the lack of protection of public health insurance, such as daily hospitalization expenses. . The second type is Complementary Insurance, which covers items not covered by public health insurance and has a supplementary status in Japan. Finally, the comprehensive medical insurance (Substitutive Insurance) developed by private insurance to replace public medical insurance is not allowed in Japan.
Successfully counterattacking aging through long-term care insurance
Japan quickly adjusted its layout before the aging crisis and developed long-term care insurance.
In 2000, Japan implemented long-term care insurance, which is a compulsory insurance that covers elderly people over 65 years old and disabled elderly people aged 40 to 64 years old.
Nursing services include many contents, including home care, temporary care, door-to-door services and various auxiliary facilities for nursing needs. These facilities are also covered by public insurance. Most home care service providers are private institutions, of which 62.6% are private for-profits, 36.4% are private non-profits, and 0.4% are government-run.
Long-term care insurance is not allowed to cover services provided by private, for-profit institutions.
Nursing care insurance is financed half from premiums and half from taxes. People over 40 years old need to pay premiums, and those over 65 years old need to pay premiums based on their income. In Japan, employers and employees pay 50-50 long-term care premiums equally. In addition, the self-payment ratio of long-term care insurance for residents is 10%, and Japan will set a cap on the total self-payment based on income.
On the whole, Japan’s compulsory public medical insurance and nursing insurance cover both hospitalization expenses, emergency room expenses, mental illness treatment expenses, legal prescription drugs, home care, and physical therapy. and most dental services, and also covers medical services provided by clinics. People with different identities have their insurances operated by different agencies. For example, the health insurance of employees of civil servants is operated by independent insurance agencies, as is the health insurance of some professionals, such as doctors in private practice.
For China, the biggest inspiration from Japan is that the development of "market" in the medical field is not a generalization, but a clear encouragement of non-profit hospitals and doctor-led clinics, prohibition of for-profit hospitals, and determination of The boundaries of public health insurance payment. In addition, China is at the crossroads of changes in demographic structure and medical needs, and rapid layout adjustments may cause the medical system to overtake.
Extended reading:
Why is the American medical system a "bad example"?
Text | Wang Jianxiu
This article is excerpted from: WeChat official account "Qingdian.com"
ID: geekheal_com
See this Question, I am sure many friends will jump up and ask: Whether it is the diversity of medical service providers, the strength of health insurance companies, or various technological innovations and Internet medical innovations, the United States is at the forefront of the world. In the U.S. medical field The free market and organizational efficiency are so high, why do you say he is a "bad example"? Isn’t it worth learning from China?
Don’t worry, this is not to deny the American medical system, but for China, to learn from the experience of a certain system, first of all, we must check whether the shoes fit properly on the feet. We can think carefully about how comparable a developed country with a per capita GDP of US$54,629 and a developing country with a per capita GDP of US$7,590 are comparable? In what dimension can we compare a country with medical expenditures accounting for 17.5% of GDP and a country that has just established a universal health insurance system and with medical expenditures accounting for 5.5% of GDP?
Let’s first take a look at the overall structure of the American medical system.
According to data from Health Affaires, U.S. medical expenditures were US$3,031.3 billion in 2014, accounting for 17.5% of the entire GDP. The total US GDP that year was US$17,348.1 billion, of which out-of-pocket expenditures were US$329.8 billion, accounting for 17.5% of the entire GDP. 10.8% of expenditure; the total population of the United States is 318 million, the per capita medical expenditure is 9,523 US dollars, and the per capita GDP is 54,502 US dollars. In 2014, U.S. medical spending increased by 5.3% over the previous year, exceeding the 2.9% increase in 2013.
Private non-profit hospitals are the main force, and the medical prevention system is weak
From the perspective of the medical service supply system, all primary medical care in the United States is completed by private family doctors. The primary medical care services of these family doctors are often included in a certain medical insurance network and play the role of health gatekeepers.
Looking at hospital bed resources, only 15% of the beds in the United States belong to government-run public hospitals, about 70% of the beds belong to private non-profit hospitals, and about 15% of the beds belong to private for-profit hospitals.
According to 2016 data from The American Hospital Association, the number of general hospitals (excluding prison hospitals, university clinics, etc.) in the United States is 4,926, of which 1,003 are government-run hospitals, accounting for 20.3%; 2,870 are private non-profit hospitals. , accounting for 58.2%; there are 1,053 private for-profit hospitals, accounting for 21.3%.
In terms of resources, the number of private hospitals in the United States accounts for 80%, but private non-profit medical institutions dominate. The United States remains open to hospital ownership, unlike Japan, which prohibits private for-profit hospitals. In a free and relaxed environment, U.S. medical service providers include: hospitals, various types of freely practicing doctor groups, individual clinics, and partnership clinics.
In the United States, the concept of medical services is still based on treatment. For example, it is easy for people to have a joint replacement surgery, but the United States does not do a good job in preventing chronic diseases.
Medical resources are increasingly concentrated, and private insurance companies have consumed too many social resources
From the perspective of the entire insurance system, the U.S. government assumes the responsibility for the elderly over 65 years old, the poor, and Medical insurance for people with disabilities, namely Medicare and Medicaid, private insurance institutions cover at least 56% of the population. Before 2012, the United States did not require people to purchase insurance compulsorily. After the introduction of the Obama ACA bill in 2012, most people were required to purchase insurance compulsorily, and employers were required to purchase insurance for their employees. Of course, now that Obamacare is still reeling from the 2016 election, its fate is uncertain.
There are various models of insurance networks in the United States. The most typical ones are managed medical institutions HMOs, such as Caesars Group. This insurance system has set up a strict hierarchical diagnosis and treatment system, and the insurer must choose a Family doctors can only reimburse after referral. Outside the HMOs system, insurance companies do not bear any expenses.
In an ecosystem of multi-party competition among insurance companies, medical services, patients, and pharmaceutical companies, the biggest winners are insurance companies. According to the US statistic website, the revenue of the US life and health insurance industry reached US$877.9 billion in 2014 (Figure 1). Followed by the pharmaceutical market, the U.S. pharmaceutical market was US$374 billion in 2014 (Figure 2), accounting for 40% of the world's pharmaceutical market. Finally, there is the medical device market. In 2014, the US medical device market was US$136 billion (Figure 3).
Figure 1
Figure 2
Figure 3
As insurance companies become more and more powerful, medical service organizations in the United States There is a trend: individual clinics are exhausted in the face of insurance negotiations, and many individual clinics have either switched to practicing in Canada, or simply closed their clinics and been hired by hospitals. Individual hospitals tend to join forces to increase their negotiating leverage with insurance companies. Doctor groups are also growing from small to multi-disciplinary alliances. One of the reasons is to increase the intensity of negotiations with insurance companies.
The administrative and management costs of insurance companies have placed a heavy burden on society. According to US media reports, 21% of US medical expenditures are spent on administrative costs, 85% of which come from private insurance companies (Source 1).
The biggest problem is: medical investment and health output are not directly proportional
Health outcomes and financial sustainability are almost the most criticized targets of the US medical system (Figure 4, Figure 5). The United States spent 17.5% of its GDP, and its average life expectancy was not far different from that of Cuba, whose per capita medical expenditure was only a fraction of the United States. In terms of health output, the average life expectancy in the United States is lower than that of OECD countries, especially developed countries.
Figure 4 Figure 5 (the highest item is the United States)
In 2014, medical expenditure in the United States increased by 5.3% over the previous year, exceeding the 2.9% increase in 2013. The average per Personal medical expenses were $9,523. Over the past 35 years, U.S. consumption of total goods and services has grown at an average annual rate of 7.2%, while the growth rate of health care consumption has been as high as 9.8%.
The growth of U.S. health care costs has long been higher than the growth of the overall economy. For this reason, the U.S. federal government, business employers, and families have all borne huge financial pressure.
Reflection on the book “Ameiricas’ Bitter Pill” in the United States: Medical expenses are also the largest single consumption and expenditure item for American families. These expenses include personal out-of-pocket expenses and premiums paid. According to data from Health Affaires, among the US$3 trillion in medical expenditures in the United States in 2014, financial sharing was as follows: households accounted for 28%, federal government accounted for 28%, and private businesses accounted for 20%. %, local governments accounted for 17%.
Let’s summarize the characteristics of the U.S. medical system:
First, the United States invests more in medical innovation than any other country, in terms of the use of new technologies and new drugs. , the United States is also at the forefront of the world.
Second, the decentralized payers in the United States, dominated by commercial insurance, have insufficient joint efforts to control the rise in medical costs. The medical burden on employers is getting heavier and heavier. In addition, in order to increase their bargaining chips with insurance companies, hospitals tend to be concentrated and consolidated, resulting in a concentration of supply sides and an increasingly narrow space for individual clinics to survive.
Third, the basic medical system in the United States is weak, especially the medical system that focuses on prevention. As a result, many chronic diseases and geriatric diseases are not actively intervened, thus driving up the overall cost.
Fourth, the operating mechanism of U.S. commercial insurance has raised the administrative costs of the entire industry and greatly consumed social resources.
Fifth, the United States invests a lot of money in disease treatment, but is very passive in health intervention such as chronic diseases and geriatric diseases. Lifestyle diseases including obesity have long plagued the United States.
After seeing this, we will understand why medical expenditures in the United States are so high. The United States' diverse medical service system and market competition mechanism are worth learning from China. But we must also understand that a country’s health care system must maintain a balance in medical quality, medical delivery efficiency, health outcomes and finance. Observing the US medical system can bring us a lot of reflection: for example, we can better understand the importance of basic medical care to China’s future. nature; be wary of the financial sustainability pressure caused by the expansion of medical insurance financing; strengthen chronic disease management and health intervention, etc.