2011年9月18日 星期日



Health care in Japan

THE Japanese spend half as much on health care as do Americans, but still they live longer. Many give credit to their cheap and universal health insurance system, called kaihoken, which celebrates its 50th anniversary this year. Its virtues are legion. Japanese people see doctors twice as often as Europeans and take more life-prolonging and life-enhancing drugs. Rather than being pushed roughly out of hospital beds, they stay three times as long as the rich-world average. Life expectancy has risen from 52 in 1945 to 83 today. The country boasts one of the lowest infant-mortality rates in the world. Yet Japanese health-care costs are a mere 8.5% of GDP.

Even so, the country's medical system is embattled. Although it needs a growing workforce to pay the bills, Japan is ageing and its population is shrinking. Since kaihoken was established in 1961, the proportion of people over 65 has quadrupled, to 23%; by 2050 it will be two-fifths of a population that will have fallen by 30m, to under 100m. "The Japanese health system that had worked in the past has begun to fail," Kenji Shibuya of the University of Tokyo and other experts write in a new issue of the Lancet, a British medical journal, devoted to kaihoken. "The system's inefficiencies could be tolerated in a period of high growth, but not in today's climate of economic stagnation."

By 2035 health care's share of GDP will roughly double, according to McKinsey, a consultancy. The burden falls on the state, which foots two-thirds of the bills. Politicians are unwilling to raise taxes, so they squeeze suppliers instead: more than three-quarters of public hospitals operate at a loss.

Like other service industries in Japan, there are cumbersome rules, too many small players and few incentives to improve. Doctors are too few—one-third less than the rich-world average, relative to the population—because of state quotas. Shortages of doctors are severe in rural areas and in certain specialities, such as surgery, paediatrics and obstetrics. The latter two shortages are blamed on the country's low birth rate, but practitioners say that they really arise because income is partly determined by numbers of tests and drugs prescribed, and there are fewer of these for children and pregnant women. Doctors are worked to the bone for relatively low pay (around $125,000 a year at mid-career). One doctor in his 30s says he works more than 100 hours a week. "How can I find time to do research? Write an article? Check back on patients?" he asks.

On the positive side, patients can nearly always see a doctor within a day. But they must often wait hours for a three-minute consultation. Complicated cases get too little attention. The Japanese are only a quarter as likely as the Americans or French to suffer a heart attack, but twice as likely to die if they do.

Some doctors see as many as 100 patients a day. Because their salaries are low, they tend to overprescribe tests and drugs. (Clinics often own their own pharmacies.) They also earn money, hotel-like, by keeping patients in bed. Simple surgery that in the West would involve no overnight stay, such as a hernia operation, entails a five-day hospital stay in Japan.

Emergency care is often poor. In lesser cities it is not uncommon for ambulances to cruise the streets calling a succession of emergency rooms to find one that can cram in a patient. In a few cases people have died because of this. One reason for a shortage of emergency care is an abundance of small clinics instead of big hospitals. Doctors prefer them because they can work less and earn more.

The system is slow to adopt cutting-edge (and therefore costly) treatments. New drugs are approved faster in Indonesia or Turkey, according to the OECD. Few data are collected on how patients respond to treatments. As the Lancet says, prices are heavily regulated but quality is not. This will make it hard for Japan to make medical tourism a pillar of future economic growth, as the government plans.

The Japanese are justly proud of their health-care system. People get good basic care and are never bankrupted by medical bills. But kaihoken cannot take all the credit for the longevity of a people who eat less and stay trimmer than the citizens of any other rich country. And without deep cost-cutting and reform, the system will struggle to cope with the coming incredible shrinking of Japan.

©The Economist Newspaper Limited 2011


2011-09 Web only 作者:經濟學人

日本人的醫療支出是美國人的一半,但還是活得比較久;許多人將此歸功於日本的全民健保系統。日本人看病的次數是歐洲人的二倍,吃的 藥比較多,在病床上待的時間也是富有世界平均的三倍。平均壽命至1945年的52歲增至目前的83歲,新生兒死亡率極低,但日本的醫療支出僅佔GDP的 8.5%。

即使如此,日本的醫療系統仍如臨大敵。日本人口呈現老化與衰退,預估到2050年,65歲以上的老人將佔人口的2/5,總人口則會下 滑至1億以下。研究公司預估,醫療支出佔GDP的比重將於2035年翻倍,此重擔將落至政府肩上。政治人物不願加稅,只好從供給者身上想辦法;超過3/4 的公立醫院呈現虧損。

日本的醫生佔人口比例較富有國家的平均少1/3,鄉村和特定領域的醫生嚴重缺乏。病人通常一天內就能看到醫生,但常得 等上數小時才能看診三分鐘;複雜病例缺乏關照,日本心臟病發生率是美國的1/4,但死亡機會卻是二倍。有些醫生一天得診療100位病人,由於薪水偏低,他 們通常會開太多藥、進行太多檢查,也會拉長病人的住院時間。