November, 2004
Twelve Proposals -- To Promote the Health Care Reform for Patients and Citizens
We demand that the government should;
Outlines of General Remarks and Each Chapter
The general remarks point out that it is necessary to promote access to systematic medical services while clarifying the special roles of medical institutions, in order to efficiently utilize medical resources. Moreover, the general remarks note the following three matters for spreading and developing patient- and citizen-oriented, high-quality and efficient health care: (1) Promote the appropriate provision of information on medical institutions and health care to assist patients in choosing health services; (2) Create a safe and reliable medical management system through ensuring an informed consent and facilitating access to medical information as well as "evidence-based medicine" (EBM); (3) Encourage health awareness among citizens, daily efforts to maintain health and prevent diseases and active participation in efforts to improve the quality and efficiency of regional health services.
Chapter 1 -- What Kind of Health Care Are People Looking for?
This chapter addresses the question of whether health care in Japan is really efficient and high quality, living up to the reputation that "Japan provides the best health care in the world," and discusses what type of health care patients and citizens want. While Japan enjoys a reputation for providing the world's best health care, some reports indicate that Japanese hospitals provide less efficient services and have higher in-hospital mortality rates than hospitals in the United States. Under such circumstances, as well as various opinion polls that have revealed anxiety and dissatisfaction with health care among Japanese citizens, the types of health care sought by patients and citizens include: (1) safe and high-quality health care; (2) health care that is open and allows patients to choose; (3) humane health services; (4) fairness of health care in all regions.
Chapter 2 -- Present Situations of Information Provision on Health Care and their Future
This chapter points out that, while more information on medical institutions and doctors has become available owing to deregulation of advertising by medical institutions and the Internet, users have not necessarily been able to effectively use such information due to the difficulty of accessing the required information, and doubts as to the reliability and objectivity of such information. Although efforts need to be made to widen the use of such information, it is difficult to eliminate the asymmetry of information between doctors and patients. Therefore, to enable patients to make their own choices, it is necessary to establish a system in which a patient designates a third party other than his/her doctor as his/her "agent" and "regional health care information centers (tentative name)" in charge of collecting, analyzing and evaluating information on regional medical institutions and health services as well as disclosing the results.
Chapter 3 -- "Patients' Rights to Know and to Self-Determination" and the Legislation
This chapter discusses the trends and issues concerning patients' rights both in Japan and overseas as well as the challenges facing the enactment of these rights. In the United States and Europe, basic rights for patients include: (1) the right to receive equal health care; (2) the right to self-determination; (3) the right to know; (4) the right to receive the best health care available; (5) the right to receive safe health care; and (6) the right to protection of privacy. These have already been either legislated or socially established in the form of a Patients' Charter, having advanced beyond the discussion stage and incorporated into the practice stage. Japan should immediately legislate these rights instead of implementing non-binding guidelines. To this end, it is necessary to rebuild the relationship of mutual trust between health care providers and patients, encourage patients and citizens to get involved in the management of health care, and develop conditions in terms of human and material resources that enable health care providers to perform their work more comfortably.
Chapter 4 -- Prevention of Medical Accidents and Relief for Victims
This chapter discusses the design of a system for preventing medical accidents and save victims by examining the rising number of medical accidents and their causes, with reference to overseas cases. Behind the recent increase in medical accidents and malpractices lie immature medical expertise and complacency among medical care providers, attributable to the negative effect of sectionalism in medical institutions. The review council on medical safety measures was established by the Ministry of Health, Labour and Welfare in 2001, and is belatedly advancing its activity. We propose ways to further reform the medical system and point out the need for tougher administrative punishment to deter medical accidents and for establishing a new relief system for victims of medical accidents.
Chapter 5 -- Securing Sufficient Medical Personnel and Challenges of Medical Care Providing System
This chapter focuses on issues involving medical personnel who are at the forefront of medical services and discusses how to rebuild the trust of patients and citizens in the medical care system. Firstly, a sufficient number of medical personnel should be secured to provide adequate medical care. Although there are enough doctors on a macro-level, doctors remain unevenly distributed both in terms of region and specialty. These circumstances need to be corrected to ensure that safe medical care can be provided. Secondly, medical personnel should be properly trained and developed as medical professionals with strong expertise. It is required to review the current situation of pre-graduation education and post-graduation clinical education as well as to enhance the expertise of co-medicals such as nurses. Thirdly, it is necessary to develop a medical care system that can constantly provide medical services, especially to solve the pressing issues involving emergency medical care, medical consultation services on holidays and at night as well as medical care in remote areas.
Chapter 6 -- Establishment of Quality and Efficient Medical Care System
This chapter takes up the issues of promotion of EBM (Evidence-Based Medicine), standardization of medical care, methods to assess functions performed at hospitals, provision of advanced medical care, and a medical care fee system that will encourage appropriate medical care. It also discusses the prospects for achieving a high-quality and efficient medical care system for the future. In order to utilize the resources necessary to provide quality medical care usefully and efficiently, the promotion of EBM and the standardization of medical care are required. In essence, the quality of medical care is determined by three factors: the skills of those who provide medical care, the relationship between medical care providers and patients, and the environment in which medical care is provided. The aim of assessing the functions of hospitals is to systematize and evaluate hospital medical care from such a perspective, and has started to take root in Japan. As for advanced medical treatments, the more effective they are, the wider they should be made available, so that people can equally enjoy such benefit, though they incur heavy costs. Amid the growing social constraint on medical care expenditures, the issue of how to incorporate advanced medical treatments into medical care coverage by health insurance represents a big challenge and needs to be dealt with carefully together with the issue of combined use of treatment under public insurance and uninsured treatment.
Chapter 7 -- Appropriate Medical Care Expenditures
This chapter considers why medical care expenditures have become such a serious issue and why these have increased in recent years, and looks at the regional difference in their expenditures. An increase in medical expenditures is not necessarily evil if it is viewed as a social cost necessary to help improve citizens' health, but the important issue is how to assess medical expenditures and to what extent to regard them as appropriate. In recent years, rising medical expenditures for the elderly have become a major problem. Although this is largely due to the growing number of people eligible for geriatric medical care, there are limits to curbing the increase through policies. Therefore, emphasis should be placed on curbing the increase in medical expenditures per elderly person and eliminating or alleviating the current regional difference in such expenditures. It is therefore necessary to consider abolishing the present health services system for the elderly and establishing a new system, as well as to integrate and reorganize insurers by region and enhance their functions in the new arrangement.
Chapter 8 -- Health and Life
This chapter points out the importance of joint efforts by employers, trade unions and health insurance societies to promote health for citizens. Promoting health will not only lead to individual well-being, but is also an important challenge to curb medical costs in the medium to long term. Desirable initiatives in the workplace include labor unions' participation in health-promoting projects and strengthening the role of health insurance societies with insurer function. Also, the development of a system to gauge corporate-wide health level would increase health awareness among workers if the system was one of the criteria for assessing CSR (Corporate Social Responsibility). On the regional scale, while each prefecture now has an "insurers' council," promoting cooperative health services between corporate health insurance societies and regional health insurance societies, regional organizations of the national center or industrial federations should play a central role in its management for the efficient and effective promotion of cooperative health services.
Chapter 9 -- Perspective of Health Insurance System Reform: Focus on Regions
This chapter discusses health insurance in terms of institutional systems as well as the roles of insurers and the prospect of enhancing their function. In order to ensure the stability of the health insurance system in the future, the current system must be drastically reviewed and the role of insurers enhanced. As medical care should be provided and received within the same locality and in relation to the medical care providing system, insurers' organizations should be reorganized to a regionally unified system, being in charge of deciding the burden of medical costs according to use of medical services, and the structural risk factors beyond the control of insurers should be fully adjusted with health insurance premiums and public funds. Specifically, (1) the government-run health insurance system should be reorganized to the regionally unified system, and each prefecture should have a regional insurer federation formed jointly by national health insurance and employee's health insurance societies; (2) each regional insurer federation should be authorized to designate medical institutions as well as registered doctors, and should be in charge of audits and reimbursement within the entire region; (3) unit prices of medical treatment fees should be determined by regional social insurance medical councils.
Chapter 10 -- How Should Health Care Reform Be Carried Out? ? Beyond Conflicts; Dialogue Towards Citizen-oriented Health Care System
This chapter discusses the characteristics of Japanese health care reform and how health care reform should be carried out to help doctors establish good neighborly relations with patients, while reviewing efforts toward health care reform made so far, following the 2nd Ad Hoc Commission on Administrative Reform. Until now, health care reform has constantly been stalled by conflicts between medical care provider organizations and insurers who do not want to shoulder further costs. It is important to consider a health care system appropriate for the 21st century, based not only on how the financial crisis facing the medical insurance system can be overcome but also on what kind of medical care is expected. Accordingly, this chapter proposes that a private ad hoc commission on medical reform be established as a voluntary forum of the private sector, to discuss and promote health care reform. A new era of dialogue between those who support and those who provide health care should be created, transcending the previous era of conflicts.
Reform of Health Care System for Patients and Citizens
－ Reconstruction of a Modern Welfare State (Study Series II) －
Since FY2002, we, RENGO-RIALS has been conducting a series of researches on the reconstruction of a modern welfare state as a medium-term study, analyzing the present policies and systems concerning social security and welfare, putting together key policy issues and making proposals on the contents and direction of the reform.
This fiscal year, we established "Reconstruction of a Modern Welfare
State (Part II) - Study Committee on Reform of Health Care System for Patients
and Citizens" (Chairman: Yasuhiko Yamasaki, Professor, Kanagawa University
of Human Services) to discuss the issue of health care reform in Japan
from the perspective of patients and citizens. The study committee compiled
a report in November 2004 on the present state and challenges of the Japanese
health care system and the direction of reform through a series of surveys
and researches as well as discussions on how to secure the safety and quality
of medical care from the perspective of its recipients.
The gist of the twelve proposals, general remarks and each chapter
included in the report, which is designed to promote the health care reform
for patients and citizens, is as follows.
Twelve Proposals -- To Promote the Health Care Reform for Patients and Citizens
We demand that the government should;
- Establish a safe, high-quality and efficient health care system securing transparency.
- Actively promote EBM (Evidence-Based Medicine) and standardize medical care.
- Properly provide highly advanced medical treatment and carefully correspond to combined use of treatment under public insurance and uninsured treatment."
- Establish an "agent" system and "regional health care information center (tentative name)" designed to help patients make choices.
- Legislate, as soon as possible, a "law for patient's rights" that provides patients' rights to know and for self-determination.
- Enhance safety measures and establish a new medical accident relief system.
- Correct the omnipresence of doctors depending on region and specialty.
- Promote appropriate medical care expenditures under a new framework.
- Change the government policy to cap medical care expenditures, from "the cheaper, the better" system to guaranteeing higher-quality and more efficient health services.
- Establish regional insurer federations and reinforce their functions.
- Establish a "private ad hoc commission on the health care reform", to promote reform of the health care system.
- Recognize health promotion strategically and demonstrate the roles of trade unions and employers.
Outlines of General Remarks and Each Chapter
The general remarks point out that it is necessary to promote access to systematic medical services while clarifying the special roles of medical institutions, in order to efficiently utilize medical resources. Moreover, the general remarks note the following three matters for spreading and developing patient- and citizen-oriented, high-quality and efficient health care: (1) Promote the appropriate provision of information on medical institutions and health care to assist patients in choosing health services; (2) Create a safe and reliable medical management system through ensuring an informed consent and facilitating access to medical information as well as "evidence-based medicine" (EBM); (3) Encourage health awareness among citizens, daily efforts to maintain health and prevent diseases and active participation in efforts to improve the quality and efficiency of regional health services.
Chapter 1 -- What Kind of Health Care Are People Looking for?
This chapter addresses the question of whether health care in Japan is really efficient and high quality, living up to the reputation that "Japan provides the best health care in the world," and discusses what type of health care patients and citizens want. While Japan enjoys a reputation for providing the world's best health care, some reports indicate that Japanese hospitals provide less efficient services and have higher in-hospital mortality rates than hospitals in the United States. Under such circumstances, as well as various opinion polls that have revealed anxiety and dissatisfaction with health care among Japanese citizens, the types of health care sought by patients and citizens include: (1) safe and high-quality health care; (2) health care that is open and allows patients to choose; (3) humane health services; (4) fairness of health care in all regions.
Chapter 2 -- Present Situations of Information Provision on Health Care and their Future
This chapter points out that, while more information on medical institutions and doctors has become available owing to deregulation of advertising by medical institutions and the Internet, users have not necessarily been able to effectively use such information due to the difficulty of accessing the required information, and doubts as to the reliability and objectivity of such information. Although efforts need to be made to widen the use of such information, it is difficult to eliminate the asymmetry of information between doctors and patients. Therefore, to enable patients to make their own choices, it is necessary to establish a system in which a patient designates a third party other than his/her doctor as his/her "agent" and "regional health care information centers (tentative name)" in charge of collecting, analyzing and evaluating information on regional medical institutions and health services as well as disclosing the results.
Chapter 3 -- "Patients' Rights to Know and to Self-Determination" and the Legislation
This chapter discusses the trends and issues concerning patients' rights both in Japan and overseas as well as the challenges facing the enactment of these rights. In the United States and Europe, basic rights for patients include: (1) the right to receive equal health care; (2) the right to self-determination; (3) the right to know; (4) the right to receive the best health care available; (5) the right to receive safe health care; and (6) the right to protection of privacy. These have already been either legislated or socially established in the form of a Patients' Charter, having advanced beyond the discussion stage and incorporated into the practice stage. Japan should immediately legislate these rights instead of implementing non-binding guidelines. To this end, it is necessary to rebuild the relationship of mutual trust between health care providers and patients, encourage patients and citizens to get involved in the management of health care, and develop conditions in terms of human and material resources that enable health care providers to perform their work more comfortably.
Chapter 4 -- Prevention of Medical Accidents and Relief for Victims
This chapter discusses the design of a system for preventing medical accidents and save victims by examining the rising number of medical accidents and their causes, with reference to overseas cases. Behind the recent increase in medical accidents and malpractices lie immature medical expertise and complacency among medical care providers, attributable to the negative effect of sectionalism in medical institutions. The review council on medical safety measures was established by the Ministry of Health, Labour and Welfare in 2001, and is belatedly advancing its activity. We propose ways to further reform the medical system and point out the need for tougher administrative punishment to deter medical accidents and for establishing a new relief system for victims of medical accidents.
Chapter 5 -- Securing Sufficient Medical Personnel and Challenges of Medical Care Providing System
This chapter focuses on issues involving medical personnel who are at the forefront of medical services and discusses how to rebuild the trust of patients and citizens in the medical care system. Firstly, a sufficient number of medical personnel should be secured to provide adequate medical care. Although there are enough doctors on a macro-level, doctors remain unevenly distributed both in terms of region and specialty. These circumstances need to be corrected to ensure that safe medical care can be provided. Secondly, medical personnel should be properly trained and developed as medical professionals with strong expertise. It is required to review the current situation of pre-graduation education and post-graduation clinical education as well as to enhance the expertise of co-medicals such as nurses. Thirdly, it is necessary to develop a medical care system that can constantly provide medical services, especially to solve the pressing issues involving emergency medical care, medical consultation services on holidays and at night as well as medical care in remote areas.
Chapter 6 -- Establishment of Quality and Efficient Medical Care System
This chapter takes up the issues of promotion of EBM (Evidence-Based Medicine), standardization of medical care, methods to assess functions performed at hospitals, provision of advanced medical care, and a medical care fee system that will encourage appropriate medical care. It also discusses the prospects for achieving a high-quality and efficient medical care system for the future. In order to utilize the resources necessary to provide quality medical care usefully and efficiently, the promotion of EBM and the standardization of medical care are required. In essence, the quality of medical care is determined by three factors: the skills of those who provide medical care, the relationship between medical care providers and patients, and the environment in which medical care is provided. The aim of assessing the functions of hospitals is to systematize and evaluate hospital medical care from such a perspective, and has started to take root in Japan. As for advanced medical treatments, the more effective they are, the wider they should be made available, so that people can equally enjoy such benefit, though they incur heavy costs. Amid the growing social constraint on medical care expenditures, the issue of how to incorporate advanced medical treatments into medical care coverage by health insurance represents a big challenge and needs to be dealt with carefully together with the issue of combined use of treatment under public insurance and uninsured treatment.
Chapter 7 -- Appropriate Medical Care Expenditures
This chapter considers why medical care expenditures have become such a serious issue and why these have increased in recent years, and looks at the regional difference in their expenditures. An increase in medical expenditures is not necessarily evil if it is viewed as a social cost necessary to help improve citizens' health, but the important issue is how to assess medical expenditures and to what extent to regard them as appropriate. In recent years, rising medical expenditures for the elderly have become a major problem. Although this is largely due to the growing number of people eligible for geriatric medical care, there are limits to curbing the increase through policies. Therefore, emphasis should be placed on curbing the increase in medical expenditures per elderly person and eliminating or alleviating the current regional difference in such expenditures. It is therefore necessary to consider abolishing the present health services system for the elderly and establishing a new system, as well as to integrate and reorganize insurers by region and enhance their functions in the new arrangement.
Chapter 8 -- Health and Life
This chapter points out the importance of joint efforts by employers, trade unions and health insurance societies to promote health for citizens. Promoting health will not only lead to individual well-being, but is also an important challenge to curb medical costs in the medium to long term. Desirable initiatives in the workplace include labor unions' participation in health-promoting projects and strengthening the role of health insurance societies with insurer function. Also, the development of a system to gauge corporate-wide health level would increase health awareness among workers if the system was one of the criteria for assessing CSR (Corporate Social Responsibility). On the regional scale, while each prefecture now has an "insurers' council," promoting cooperative health services between corporate health insurance societies and regional health insurance societies, regional organizations of the national center or industrial federations should play a central role in its management for the efficient and effective promotion of cooperative health services.
Chapter 9 -- Perspective of Health Insurance System Reform: Focus on Regions
This chapter discusses health insurance in terms of institutional systems as well as the roles of insurers and the prospect of enhancing their function. In order to ensure the stability of the health insurance system in the future, the current system must be drastically reviewed and the role of insurers enhanced. As medical care should be provided and received within the same locality and in relation to the medical care providing system, insurers' organizations should be reorganized to a regionally unified system, being in charge of deciding the burden of medical costs according to use of medical services, and the structural risk factors beyond the control of insurers should be fully adjusted with health insurance premiums and public funds. Specifically, (1) the government-run health insurance system should be reorganized to the regionally unified system, and each prefecture should have a regional insurer federation formed jointly by national health insurance and employee's health insurance societies; (2) each regional insurer federation should be authorized to designate medical institutions as well as registered doctors, and should be in charge of audits and reimbursement within the entire region; (3) unit prices of medical treatment fees should be determined by regional social insurance medical councils.
Chapter 10 -- How Should Health Care Reform Be Carried Out? ? Beyond Conflicts; Dialogue Towards Citizen-oriented Health Care System
This chapter discusses the characteristics of Japanese health care reform and how health care reform should be carried out to help doctors establish good neighborly relations with patients, while reviewing efforts toward health care reform made so far, following the 2nd Ad Hoc Commission on Administrative Reform. Until now, health care reform has constantly been stalled by conflicts between medical care provider organizations and insurers who do not want to shoulder further costs. It is important to consider a health care system appropriate for the 21st century, based not only on how the financial crisis facing the medical insurance system can be overcome but also on what kind of medical care is expected. Accordingly, this chapter proposes that a private ad hoc commission on medical reform be established as a voluntary forum of the private sector, to discuss and promote health care reform. A new era of dialogue between those who support and those who provide health care should be created, transcending the previous era of conflicts.