By John Carruthers, staff writer, December 03, 2012
Each month Dermatology World tackles issues “in Practice” for dermatologists. This month, dermatologists from Japan, Yoshiki Miyachi, MD, PhD, Satoko Minakawa, MD, PhD, and Masayuki Amagai, MD, PhD, discuss the positive and negative aspects of practicing dermatology there.
As health care reform has been a battleground issue in the last two U.S. election cycles, the current situation in Japan provides an illustration of universal care when the costs are combined with a rapidly aging population and the world’s longest life expectancy.
With its own set of opportunities and challenges, dermatology in Japan offers specialized care to a population of over 127 million, the 10th largest in the world.
Public care, rising costs
One oft-reported notable fact about Japan is the above-average life expectancy of its population. The average lifespan for Japanese men is 79, and the lifespan for women in the country is 86. The country has had a system of universal health insurance since 1961. The system, according to Kyoto dermatologist Yoshiki Miyachi, MD, PhD, allows patients relatively easy access to any dermatologist. [pagebreak]
“Everybody can enjoy a standard, reasonable, and less expensive health care, because 70-100 percent of the cost is covered by the insurance depending on your status, age, and income,” Dr. Miyachi said. “Poor patients under a national welfare system can enjoy any approved therapy free of charge.” However, most patients hesitate to receive expensive treatments such as biologics, he said, as the cost is not fully covered unless they are poor.
In most cases, Dr. Miyachi said, 30 percent of the cost of treatment is not covered by health insurance. Those over 65, however, pay only 10 percent of their own costs, while those unable to afford treatment are fully covered. In addition, if the total cost paid by the patient exceeds 70,000 yen ($1,000) per month, the additional cost will be reimbursed to the patient, providing patients with the security of knowing their medical expenses are capped. As one might expect, however, this has led to significant health care costs as Japan’s population ages.
“The per capita medical expenses for those 75 and older are said to be approximately five times as high as those for people of working age,” Hirosaki University dermatologist Satoko Minakawa, MD, PhD, said. “As a result, the share of medical costs borne by people of working age grew increasingly unfair as the birthrate declined and society aged.” [pagebreak]
Complicating the issue, Dr. Minakawa said, is the fact that the Japanese government is seeing a skyrocketing rate of health care spending, which presents a very significant danger to the current framework. Currently, nearly a quarter (22.9 percent) of the Japanese population is 65 or older. (In the U.S., 12 percent of the population is 65 or older, according to the 2010 census.) Health care spending represented 9.3 percent of GDP in 2009, a figure that will continue to rise in the short term.
“Japan needs a quick and revolutionary approach to save the failing system now in place,” Dr. Minakawa said.
Access to dermatology
Patients can see dermatologists directly under the Japanese health care system. Primary care physicians, according to Keio University dermatologist Masayuki Amagai, MD, PhD, are usually bypassed by patients in favor of a dermatologist when seeking treatment for a skin or nail condition. Both Dr. Amagai and Dr. Sakoto said that it’s not unusual for patients to visit dermatologists at their respective universities.
“In our university, doctors have to see six patients per hour because doctors have to see patients if patients with dermatologic problems want [to be seen],” Dr. Sakoto said. [pagebreak]
Dr. Miyachi said that dermatologists in Japan are increasingly pursuing research or private practice to supplement their incomes.
“Since I am working in a national university, we are not allowed to see patients in private practice which makes our income low. In other words, our income is fixed irrespective of our clinical works, which reduces our motivation to contribute to clinical works,” Dr. Miyachi said. “This is [a] reason why we work more on basic research and recently more academic dermatologists go to private practice or industry.”
While Dr. Miyachi said that physician income is relatively lower than in the U.S., the cost to the patient is much lower since the inception of the public health system.
“My father was an office internist. I witnessed that he received no money from poor patients. However, after the development of the public health care system, everybody has an equal opportunity to visit doctors. This is partly why our medical cost is low. For example, if you receive an appendicitis operation in the U.S. with a few days admission, you may have to pay more than $30,000, but in Japan you will be charged only the equivalent of $5,000,” Dr. Miyachi said. “Since most of the patients are brand-oriented,’ many patients visit our university hospital directly, even patients with contact dermatitis, though we charge them $70 per visit without a reference letter from local doctors,” he said. “Also, we have to keep in mind that physician income is not so high in Japan.” The mean annual income of the private dermatologist may be 30 million yen ($400,000), Dr. Miyachi said, but the salary of doctors working in university hospitals is half of that figure though he noted that academics do have additional income “from lectures and writings.” [pagebreak]
The problem, he said, is that because patients are free to shop around for care, the system creates incentives for doctors to agree to request or order unnecessary care that patients may want, not realizing that it will not be helpful for them.
“The payment system allows doctors to order some needless exams and treatments. In Japan we have too many MRIs and CTs, four times more than other developed countries,” Dr. Miyachi said. “Some patients visit as many doctors as they want, receive as many CT/MRI exams and drugs as they want, which is a great waste of money.”
In addition to these challenges, Dr. Miyachi noted that while Japanese dermatologists do enjoy direct access to patients, and many patients take advantage of this access, dermatologists also see many patients only after treatment by another physician has failed.
Challenges to care and treatment
The March 2011 Tohoku earthquake, one of the most dramatic events in recent Japanese history, continues to have a lasting impact on the state of care in the nation.
“When the earthquake went down, we were at Hirosaki University Hospital. We suffered a level-four quake on the Japanese earthquake scale. The earthquake left us without electricity and water for two days. In our district, we are now in almost back to normal living, but in a part of our prefecture and the nearest prefectures, the disaster had a larger impact,” Dr. Minakawa said. (Japan is subdivided into 47 prefectures.) “More than 450,000 people had crowded into shelters because their homes were damaged or destroyed by the quake, which had a magnitude of 9.0. Our university medical team is providing medical treatment to survivors. I have a lot to be thankful for, and good health is the most important of them all. I appreciate very much the mission by the United States Armed Forces, support, and people hoping for Japan’s early recovery.” [pagebreak]
In addition to dealing with unique circumstances, dermatologists in Japan also see a range of diseases that differ from those in the U.S. Behet’s disease, rare in the West, is fairly common in Japan. In addition, Dr. Amagai said, Japanese dermatologists see non-HIV related eosinophilic pustular dermatosis, prurigo pigmentosus, and nevus of ova. Japanese dermatologists have a well-documented history of identifying and treating new conditions, first describing conditions such as Kawasaki disease in 1967, prurigo pigmentosa in 1971, and papuloerythroderma in 1984, among others.
Unfortunately, Dr. Miyachi said, Japanese dermatologists often have a difficult time obtaining new drugs and treatments. The country’s Pharmaceuticals and Medical Devices Agency (PMDA), which serves many of the same purposes as the FDA in the U.S., must approve all medicines and techniques, and almost always requires clinical data. This creates an effect known in some circles as the Galapagos phenomenon. The moniker refers to how a segment of a society can evolve in seeming isolation from global advances, in reference to Charles Darwin’s observations of the Galapagos Islands. The agency’s conservative approach has led to nearly 30 percent of drugs available to U.S. dermatologists being unavailable to their Japanese colleagues, according to Dr. Amagai.
About the contributors
Masayuki Amagai, MD, PhD, is a professor and the chairman of the department of dermatology in the Graduate School of Medicine at Keio University.
Yoshiki Miyachi, MD, PhD, is a professor of dermatology and the chairman of the Kyoto University Graduate School of Medicine.
Satoko Minakawa, MD, PhD, is a professor of dermatology at the Hirosaki University Graduate School of Medicine.