In Japan, approximately 7,900 neurosurgeons currently serve a population of 127.3 million, a ratio of 1 neurosurgeon to 16,114 people. Healthcare consumed approximately 8 percent of Japan’s gross domestic product in 2001, according to the World Health Organization.
Japanese medical care, including neurosurgery, is completely covered by National Health Insurance alone. The insurance covers 70 percent of the total payment except for premium room charge. The Japanese NHI is often thought to be among the best systems in the world, and it functions well in that it allows those in the lower socioeconomic groups to receive an average level of medical care, including neurosurgery. But the NHI does not allow people to choose their surgeons or to select advanced medical techniques. Until recently, people did not complain about these limitations because they were generally uninformed about potential choices, in part due to a law that prohibits hospitals from delivering any information regarding medical results. However, recent advances in information technology such as the Internet allow them to compare hospitals, surgeons and treatments, and this has negatively impacted patients’ level of satisfaction with the NHI.
In addition, the NHI faces two major economic threats. The first is the increasing expense related to recent advances in medical technology, such as intracranial stents, navigation surgery, and intraoperative neurophysiological monitorings, for which the NHI excludes payment. Patients who require these techniques must pay all related medical fees themselves because additional payment to cover them has been prohibited by law for patients using the NHI. The original intent of this law was to protect the NHI system, but it has limited patient choice and delayed medical advancement. The second economic threat to the NHI is low physician reimbursement. For example, a neurosurgeon will receive the same fee for operating on either a large skull base meningioma or a small convexity meningioma. The hospital payment to neurosurgeons is equal to that of dermatologists or ophthalmologists. The NHI system has been supported in part by doctors’ self- sacrifice and willingness to work with relatively low payment, in the spirit of Samurai, but this spirit, which characterizes my generation, threatens to disappear in those who are training today. Given these challenges, it may be time to reconsider the NHI system. I anticipate that private insurance will become an option for people in the near future.
Neurosurgical training in Japan lasts four years, and trainees work an average of 85 to 90 hours per week. The number of qualified medical students aspiring to neurosurgery, and to other demanding specialties such as cardiac surgery and obstetrics, is decreasing. The main reason relates to reimbursement, or, more specifically, to the low fees and the comparatively high demands on neurosurgeons. The physician fee system is not present in Japan, and young physicians cannot justify the sacrifice of their private lives without commensurate compensation.
Malpractice litigation in Japan still occurs less frequently than in the United States, and a Japanese neurosurgeon’s annual payment for medical liability insurance is only $500 for $1.8 million dollars of coverage. However the number of malpractice lawsuits in Japan is increasing, doubling in the last 10 years, and the fee for medical liability insurance no doubt will increase in the near future. Interestingly, the Japanese government recently increased the number of law school admissions, a troubling choice to those who have observed the relatively high number of U.S. lawyers compared to U.S. doctors and the frequent occurrence of medical malpractice lawsuits in the United States.
Takeshi Kawase, MD, is professor and chair of the Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan. The author reported no conflicts for disclosure.