About the Japanese health care system

by liberal japonicus

Below the fold is post 2, about the Japanese medical care system.

When I first came to Japan, about 4 months after I arrived, I broke my collarbone during a judo practice. I actually had broken my little finger about 3 weeks after arriving, doing sumo with the students at the cultural festival. But it was basically splinted up and I was off.

 The collarbone was a different matter. If you haven't broken your collarbone, it is several times worse. The break was clean, and I went to the clinic that served the HS I was teaching at. I stayed that night at the clinic and the plan was for me to live at the clinic until the bone healed. This was because I was a single foreigner with no family to support me. My Japanese was rudimentary, and so the head English teacher translated, explaining that normally, my family would bring a futon and visit me but because I was a foreigner, they were going to loan me a futon. I slept one nite there and then explained that I could get by, and asked to be released, which they did reluctantly.

This was over 30 years ago, so things have changed. I was asking my wife about this and she said that this sort of arrangment was common (and may still be) in Tohoku, where I was, but other places in Japan, not so much. However, that principle that the hospital is a place you stay and your family comes and visits is one of the first differences between the Japanese and American health systems. Hospital stays are much longer than in the US, and often for much milder aliments. But before explaining that, let's jump ahead 25 or so years to my next brush with the Japanese hospital system

About 5 years ago, one afternoon, I say white flashes in one eye and then suddenly, it was as if someone had dropped a dirty piece of clear plastic in front of my eye. It didn't hurt, so I went to bed and thought it might be better in the morning. It wasn't and because I didn't have classes that day, my wife said I should go and have the doctor take a look at it. I saw the doctor at 11 the next morning. The doctor looked and said, well, you have to go to the hospital. I said I had 3 more weeks of classes, but August, I could probably squeeze it in. He said, no, right now and I checked in to the hospital and was on the operating table having emergency surgery for a detached retina at 2 that afternoon.

 Though a detached retina often happens with boxers, mine was the result of getting old. I've always had bad eyes, which is another risk factor, because the flattened shape of the eye causes the retina to be stretched, and the vitreous (the clear fluid in the eye) loses consistency and can pull the retina away from the back of the eye in your 50's.

 There are a number of things people could complain about in the Japanese health system, set costs, lack of innovation, but had I not had that surgery, it would have been likely that I would have lost vision in my right eye. The surgery reattaching the retina, like a waterlogged tissue, to the back of the eye, and then removing the liquid from your eye and replacing it with oil. Because the retina floats, it is then necessary to keep your head down 24 hours a day and sleep on your stomach. Because of the possibility that I might turn over and lie on my back while I slept, I stayed in the hospital for 3 weeks and a nurse came by every hour during the night to make sure I hadn't turned over. I can't remember how much we paid (30% of total cost) which we deducted from our taxes. Google told me that it's usually a one night stay in the US and you are released with an admonition not to lift your head. From http://www.visionaware.org/info/your-eye-condition/guide-to-eye-conditions/macular-hole/macular-hole-surgery/suggestions-for-maintaining-face-down-positioning/12345

 Unfortunately, Medicare (and therefore many health plans) considers face-down positioning equipment to be "comfort" and "convenience" equipment, and therefore does not provide reimbursement for rental as durable medical equipment.

 LMG vitrectomy equipment FY. Then tell me how people without savings afford it.

 So I'm pretty kindly inclined to the Japanese health system. But what is interesting is that while the US system is geared to 'efficiency', the Japanese system seems to be built to have you stay. However, in the US, this is a profit opportunity. Because the hospital provides everything, they choose to charge for individual items. Many have heard about wildly overinflated charges for patients in the US and these charges don't exist in the Japanese system. There are things that are charged for. At the beginning of my stay, I was told if I wanted to watch TV, I needed to rent it. I was given a list of supplies I needed to bring or buy and if I didn't have them, I could purchase them (at standard retail prices) at the hospital store. The things that I brought or bought probably didn't make a huge difference in cost savings, but it did underline that it is not the hospital that does everything, hospitalization is a shared burden.

 If you know anything about Japan, you know that Japan is on the cutting edge of demographic trends. One example is that in 2013, the sale of adult diapers surpassed that of diapers for children. My most recent encounter with the Japanese health system was not emergency, but going thru the process of appointments, checking in, waiting. It seems that hospitalization in Japan has a secondary purpose to provide elderly with something to do. The waiting areas of the hospital, while allowing you to check in, give you a card if you need to come back so your records are immediately accessible, but this is not about processing as many people as quickly as possible. There is a lot of waiting time built in. The nurses come out, squat down next to the patient so they are lower than them and explain what they need to do. There is a constant flow of nurses coming out to talk to various people.

 Recently, Japanese love the phrase omotenashi. No good translation, it is basically the 'over-offering' of hospitality. As bob mcmanus will point out, offering too much hospitality is a way of control. You reach a point where you don't want to say 'gee I don't want my steak pre-chewed, I actually like to chew it myself'. I exaggerate, but only a little. Japan is full of stories of taxi drivers running after you to return some change you forgot, lost wallets full of money turned in to the police koban, the offhand remark that then has the Japanese driving a couple of hours out of their way to get you to your destination. Japanese hospital culture is full of omotenashi.

 Someone might go back and say, how can hospitals maintain a sterile environment if the family is toting in whatever they have at home. The other thing that happens, not just in the hospital system but in Japan society in general, is the ready adoption of techniques and procedures designed to deal with these sorts of things. A non hospital example is the Yubisashi kosho (finger pointing check system). These sorts of systems permeate Japanese hospital culture. Check offs to wash hands, requiring the patient state their name and birthdate to make sure that the right sample is coming from the right patient. Russell, I think, spoke of a doctor acquaintance who balked at asking patients he had known for years to tell him their name and birthdate. Japanese don't balk at this. Also death due to medical error is often treated as a criminal offense. While the question of what constitutes medical error is fraught, systemic causes are targeted aggressively in the Japanese system.

 A lot of ink goes into comparing national health systems. Japan spends far far less than the US, but gets much better results. I don't think this is something to dismiss out of hand. However, one reason it gets better results is that many things in the health care system are based on the cultural norms and expectations. As I have mentioned, I'm in the process of taking Japanese citizenship. However, I'm very cognizant of the fact that this is a terrible country if you don't have family. 30 years ago, when I was lying in a dingy clinic with virtually no Japanese, I was young, it was a broken bone and I knew that I was going to recover. When you are young, you think you are indestructible. Now, I wonder how I could have ever been that stupid.

 

Comments

[JanieM]

Fascinating post, lj.

I can echo your last line in so many ways.

[Countme-a-Demon]

Exceptional, in many ways.

We have an American word that sounds exactly the same as "exceptional", but with a different meaning.

[JanieM]

The different customs around staying in the hospital and about having family members visit are...interesting.

A couple of echoes/contrasts --

When my great-niece had cancer at the age of three, ten years ago, she was in Rainbow Babies and Children's in Cleveland for a month. Her parents were with her, although I don't remember if they were allowed to actually sleep in the hospital or just stayed nearby. I think maybe one parent could be there overnight, and they traded off.

(My other great-niece, her little sister, was cared for by grandparents and great-grandparents. I often thought about how confusing that must have been for her on the one hand, and how fortunate she was on the other hand, even if as one-year-old she didn't know it, that there was so much extended family to care for her. I can't imagine how much worse the ordeal would be for families without that kind of support structure.)

One thing that struck me about that month was that my great-niece had her own "person" in the hospital. Not a doctor, not a nurse, probably some kind of social worker, who helped not only the patient but the patient's parents navigate the ordeal.

Skip to more recent years, and my mother, who is almost 94, has been in the hospital a couple of times for a few days each. Nothing serious turned out to be going on, but she had a lot of tests both times before they decided they could send her home, probably with some new pills but that's about it.

My mother wears hearing aids but still can't hear all that well; she has macular degeneration so she can't see all that well; she can't understand all that medical gobbledegook anyhow; and being in the hospital stresses her out horribly.

As an adult, my mother did not have "her person" in the hospital, there is no such thing. But luckily one of my sisters is a retired nurse who lives near enough so that she could be on hand. I thank the FSM every time I think about it that we have a nurse in the family. And again I think: what do families do that don't have such a resource within their own ranks?

The hospital *people* are mostly okay, but the system is just...fncked up.

Best I not get going on US health care in general, or I might get riled up enough to need some.

[hairshirthedonist]

Is your great-niece okay now, JanieM?

[JanieM]

Yes, she's doing great. The variety of tumor she had was one that has a good recovery rate, especially if it's caught early.

Thanks for asking, hsh.

[Fair Economist]

The aggressive attitude towards medical errors may help explain why the Japanese get such good results. Medical errors are one of the leading causes of death in the United States, causing as many as 250,000 deaths per year. Naturally the Republican worry only about reducing medical malpractice insurance, helping the bad doctors stay in business.

[Pollo de muerte]

Except that medical malpractice is not a very efficient tool for dealing with medical errors. I'm not on the tort reform bandwagon (I had a tiny role in the McD's coffee case on the plaintiff's side), but between the drag created by defensive medicine and civil settlements which allow bad doctors to continue practicing, I'd rather attack medical errors by enforcing sane working hours for medical professionals and a more robust licensing review apparatus.

[russell]

Russell, I think, spoke of a doctor acquaintance who balked at asking patients he had known for years to tell him their name and birthdate

yes, except for "balk", substitute "believed it to be just another step toward total government control of every aspect of our lives".

plus, it's not among the enumerated powers.

the health care system in this country is no longer about health care. it is about making money, or not spending money.

i.e., it is about money.

in that, it is like every other good and useful thing that has been absorbed by the calculus of commodification.

hope all goes well for you LJ.

[wj]

I've always wondered why hospitals don't get sued for criminal negligence over the hours that they require their interns to work. It's not like the negative impact of sleep deprivation aren't well known.

[Countme-a-Demon]

WRS

This is me:

https://www.youtube.com/watch?v=jiBtQ221Yhw

[JanieM]

the health care system in this country is no longer about health care. it is about making money, or not spending money.

i.e., it is about money.

in that, it is like every other good and useful thing that has been absorbed by the calculus of commodification.

Yes. Everything is commodified, except maybe those things that are about racism before they're about money.

We are being skimmed all day long for money to enrich the already rich. Phone/internet/cable charges, online ads, drugs pushed at us at every doctor's visit, spectacularly unheathy food pushed at us everywhere else, low wages and irregular hours, low hours so as not to trigger benefits, no benefits either way, more ads to elect lying politicians who will do their damnedest to make sure even more money gets funneled to the already rich....

[Countme-a-Demon]

A human life saved by subsidized, socialist, union-secured and backed, government health insurance:

http://talkingpointsmemo.com/livewire/scalise-returns-to-capitol-for-first-time-since-baseball-shooting

He's back just in time to ruin it for everyone else.

Opening the VA to private medical choices leads to budget overruns.

http://talkingpointsmemo.com/news/mccain-demands-accounting-from-veterans-affairs

[Countme-a-Demon]

We may have to go back to the cheaper system wherein it is alleged veterans died waiting for specialized care.

Or maybe raise their copays and deductibles to the extent that they self-select to die and thereby save us money and then it's their fault, not mine, because they had a choice whether or not to spend money many don't have.

Take a knee.

[jrudkis]

Last year I broke my leg in Kumomoto on a Japanese military base.

I had excellent care from the two hospitals I had to go to, and will forever thank the god's for Google Translate, especially when it came to medications.

It was, however, a very different experience from a US hospital. I would liken the Red Cross hospital that I went to first to Jiffy Lube, where I waited in a waiting room last decorated in 1979, with doctors working in very small offices. Before I got in the door, they had to verify my insurance and get permission to treat me. The wait time was reasonable, but it really reminded me of the set of Night Court, kind of dark and old.

The next day I had to go to a Japanese military hospital (which was closed the night before), because the hospital I first received treatment in was now closed. This was also relatively dark and not updated, and so far as I could tell I was the only patient there.

Both were very professional, and when I came home with my cast, the US military hospital I went to thought the cast was artistry, and they took it apart to see how it was done.

Most hospitals in the US now look like the lobby of a hotel. Presumably like college campuses in the US, the need to recruit patients has hospitals investing in niceties rather than simply medical requirements.

I also got an email a month ago still seeking payment: so much for being precleared by insurance.

[liberal japonicus]

Geez, I wish I had known you were here. I've met folks but the rotation and the schedule is just bumping into them, saying hello and that's about it.

A lot of those buildings got damaged in the earthquake and are now being updated/renovated/rebuilt. I also think that because of the postwar ban of offensive war, Japan doesn't have the challenges that the US has in providing medical care, which means that it tends to get the short shrift. The hospitals that deal with the public have all be upgrading, and are often gorgeous.

That the hospital was closed brings up another funny quirk about Japanese health care. If you have to go to the hospital for an after hours emergency, but it didn't rise to the level of calling an ambulance, you have to figure out which hospital is open. When I first came to Japan, it was published in the newspaper. Now it's on a webpage. But I don't think it is multilingual.

While this seems horrific, when you think of staffing a 24 hour emergency room, how much that would cost (why, the salary for George Clooney alone!) you can see how much savings could be gained.

jrudkis, if you need any help with sorting thing out here in Kumamoto, drop a line to the libjpn address.

[liberal japonicus]

Ahh, a year ago, you were here for Operation Tomodachi?

[jrudkis]

It was Yamasakura 17. The Red Cross hospital was a civilian hospital rather than military.

The earth quake was still quite fresh at that time, about half the houses still had blue tarps on the roofs, half the buildings on post could not be occupied. The reason I broke my leg is a fell in a monsoon ditch at night while trying to get away from a truck. After that they put up safety cones and reflective tape around the ditches so other dumb Americans don't fall in. Apparently the Japanese know not to fall in holes without warning signs.

[CharlesWT]

Apparently the Japanese know not to fall in holes without warning signs.

Perhaps much of Aisa is the same. From Google Street View you can see many miles of narrow, open concrete drains that would seem to make excellent kid-catchers.

[wonkie]

LJ, I have had that exact same surgery! Retinoplasty. My retina came off as a side effect of having a cornea transplant which was a side effect of pruning roses.

I was supposed to go home right after the surgery but imstead spent another thirty six hours in teh hspital because I was so nauseated by the anesthesia. I was back at work about three days after leaving he hospital. No one ever said anythign about lying down They just told me to stay off airplanes until he gas left my eye.

[CharlesWT]

I've had outpatient surgery for a minor tear. Followed by a month-long tedium of various kinds of eye drops and gas bubble bobbing about. However, when looking straight down, the gas bubble optics made for a nice magnifier for reading very small print.

[bob mcmanus]

Well, not an open thread, but about Japan, and there is a orthogonal headline at Guardian etc:

Sagrada Reset (Japanese: サクラダリセット Hepburn: Sakurada Risetto), also known as Sakurada Reset was one of the better manga/anime of the last two seasons. Just teenagers with superpowers and romance and plot, but the title interests me. Pretty good, but a little slow, smart, strange and talky to be popular. After midnight anime can be very intellectual, one show used Raymond Roussel.

The story is set in Sakurada 咲良田, but the manga title is in katakana.

At the very end of the series, the end page translates the katakana as "Holy Reconstruction" For those who don't know, I think the "u" in sakurada is so short and soft as to be nearly silent.

"Sagrada" I am told in the series is Catalan. A picture of the Gaudi Cathedral is shown at one point. The plot does involve state repression, separatism, and revolution.

And of course I can't help but see "cherry blossoms" there. I guess there would need to be a particle for the "da" to be a copula. And I have done some looking, but found no uses for sakura as "sacred" or "holy" but it has a little of those connotations, or something. And this "u" is fairly strong, it never sounds like "sakra"

Anyway, wordplay, allusiveness, and maybe even global politics is being played with here. Just messes with me some, trying to find an allegory.

[liberal japonicus]

There are two types of this surgery, google tells me. When it is a tear and the retina is still attached pretty well, they use a gas transfer, but when the retina detaches, they have to keep it next to the back of the eye to make sure that the cells reattach. Then they use a laser to 'weld' the retina back on (ouch!)

Bob mcmanus, interesting stuff. Gaudi's Sagrada Familia is something that all Japanese students learn, I'm assuming it is in the standard textbooks about world history. I can see Sagrada=sakura connection, (though the katakana is サグラダ SaGUrada, not saKUrada) I haven't read the manga so if life slows down (maybe something to take to the hospital) I'll give it a read. I wonder if there is any portrayal of the characters as sacrificing themselves, and sakura is often representative of lost youth and is also tied to kamikaze. The end date of the Japanese school year March was chosen in Meiji in part because sakura suggests death and rebirth. However, when I asked a few Japanese, they said nah.

I hate to say this, but I think what Japanese say is not dispositive. I once had a colleague who wrote an article about baseball and noted that Home plate was shaped like a home (this was before the internet, had we had it, I would have just pointed to this
http://www.todayifoundout.com/index.php/2015/08/home-plate-baseball-shaped-different-bases/

So I thought it wasn't real, but then I thought about how we 'come home' and that the home team is listed last
http://wtop.com/news/2014/12/why-do-we-list-the-home-team-last/
Meaning still happens even if you are unaware of it.

More recently, I read about a student who was asked how he picked the correct answer for a cloze involving the verb 'shoulder' and the student said he thought shoulder was masculine. The teacher (a sharp soul) rather than saying well, that's not right, then checked a corpus and found that the overwhelming majority of subjects for the verb shoulder were masculine.

[Priest]

A quick look found this account of changes in home plate/base: http://www.19cbaseball.com/field-2.html

Seems more precise than the article lj linked to, but no telling if it's more accurate.