Monday, October 27, 2008

The Business of Medicine

Things are always more complicated than they appear to be. In the past, I was always very much behind the idea of socialized medicine, but learning a few things about medical care in Japan have cooled my ardor for it over the past year or so. I still think it's better than the situation with private insurance in the U.S., but I think a lot of care should be taken when developing a universal health care system given some of the problems I've been made aware of.

One of my students is married to a doctor and occasionally she offers me some insights into the business of practicing medicine in Japan. For instance, when I mentioned the recent news that yet another pregnant woman was turned away at multiple hospitals, she told me that part of the problem in Japan is that being a specialist, as opposed to a general practitioner (GP) isn't profitable. It costs more to become one and you get less business.

This particular student's mother and husband are both doctors and her mother ran a clinic as a GP which her husband later took over. Running such a clinic allows her husband to operate fast food medicine for people who want their coughs checked and their stomachaches medicated. He spends about 2-5 minutes with each patient and gets a cut of the sales of the prescriptions he makes. For the record, if you visit a Japanese doctor, you will (almost) always be given at least 3 kinds of medicine and one will always be a powder.

The average Japanese person goes to the doctor 14.4 times a year. Most of these visits are with GPs. The only way a person will visit a specialist is if that person is deemed to have a serious enough illness to require added care. This is why being a specialist in a particular area of medicine is less profitable than being a GP. My student further told me that being an obstetrician is the least desirable specialty. If you consider that the birth rate in Japan is low, this also makes sense. Not only are you a specialist, but your client base has been eroding for quite some time. This is one of the reasons why pregnant ladies are finding "no room at the inn" signs up when they are taken to the hospital.

This all relates to socialized medicine because the prices for services are fixed. The only way for a doctor to make more money is through volume rather than quality of care. Being a specialist not only limits your customer base, but it also increases the time you may have to spend with each patient because it's easier and faster to take a temperature and look at a throat then prescribe medicine for coughs than it is to deal with cancer.

A lot of people praise the health care system in Japan and there are good points to it for certain. It is better on the whole than the U.S. system, but it certainly is not perfect. The benefit is that people with common problems who want to be checked regularly can get what they need and health maintenance is affordable. The down side though is that emergency treatment and quality of care are vastly inferior to that in the U.S. Also, the system is certainly overused and abused by people who could just as easily wait out a cold, a headache, or a sore throat and get better on their own, but they don't hesitate to run to the doctor because costs are so low.

If you don't believe the latter statement, I can tell you something that my student wrote in a sociology paper she did for a recently completed college course which surprised me. This particular paper was comparing universal health care to a private system where medical care is treated as a commodity (the current U.S. model). She wrote that if she has a headache, the cost of buying aspirin is higher than going to a doctor so it is more economical to go to the doctor than to buy a bottle of aspirin over the counter. If this sounds absurd to you, then you've never bought a box of aspirin in Japan. Typically, a small box with 10-20 tablets will cost about $6-$8. A visit to the doctor, because only 30% of the tab is paid by the person and the other 70% is picked up by the taxpayers, may cost between $2-$3 with a small additional cost for the prescription. If you're retired, the cost to you is only 10% with the other 90% of the bill being covered by insurance.

The main problem is that the system should somehow reward people for not overusing the system for minor problems or at the very least fail to make it more economical to go to the doctor for every pimple and stubbed toe rather than buying and popping an OTC pill or buying some zit cream. The trick is to not penalize people for regular check-ups and for going when it is necessary such that they stop using the system as it is intended for health maintenance. Right now, Japan doesn't ration health care at all, but I have to believe that there should be some sort of limit on casual visits. Going to the doctor on average more than once a month per capita seems like far more than what is required for health maintenance for an average person.


Wombat said...

I hadn't realized that there were no limits on the number of visits for socialized health care out there. My company health care plan only allows us a certain number annually, after which we have to pay the full amount. Always seemed like a rip-off to me, but your explanation of the flip side of the coin leads me to believe maybe this is for the best after all. I just don't notice it as a possible problem since I am usually hesitant to go to the doctor anyway.

Sherry said...

You make some interesting points, but you seem to have left out an important point. Doctors, on average, only give about 3 days worth of medicine at one time. This is rarely if ever enough to fully treat something so are repeat visits for more medicine being counted in the numbers you mention? Doctors will claim they do this so they can keep a closer eye on the patient and change the medicine if need be; but obviously, this makes more money for the doctor. I believe there are laws or rules about how much medicine they can prescribe at one time so it isn't entirely them being greedy either.

Personally, I am very happy with the health care system in Japan, even though it does have problems. It is especially a wonderful system regarding children. I am totally against limiting anyone's visits to the doctor. Who gets to decide what is a serious problem and what isn't? What if someone has used up their allowance with serious illness and then another serious problem strikes?

Frankly, at least in Japan I feel like I am getting some real benefits out of the taxes I pay instead of the government taking my money and leaving me and my family to fend for ourselves as best we can, even if it means some old granny goes to the doctor every single day of her life.

Orchid64 said...

wombat: Since I also don't run to the doctor often, I think that it's okay to limit visits. That being said, if you had a serious problem, it might seem pretty bad to be limited.

Sherry: I don't go to the doctor much at all, though the last time I went, I insisted they give me more than 3 days worth of medicine so I wouldn't have to come back and they did. You can escape at least some of the situation, but you have to push a little.

I did mention in my post that I felt the Japanese system was better than the U.S. system. That being said, I don't see an inefficient system which wastes money as a comfort or money well spent. There has to be a happy medium between health care as a commodity which is limited to those who can afford it or as a right which results in wasting it and manipulating the system as is done in Japan.

When I've discussed this issue, the issue of who decides what is serious always comes up. The answer is the person who is sick does, but the culture has to provide basic education about what is to be considered serious and what is not. In Japan, the main problem is that people are indoctrinated to believe only a doctor can make them well and they have no confidence in their body's natural ability to overcome minor illnesses like colds, sore throats and headaches. There is also the problem that old people simply massively overuse the system as a way of getting attention and using it as a social outlet.

I think most people know the difference between a low grade fever that passes in a day and one that doesn't pass and a cough that lasts a week as compared to one that lasts a month or more. It's not that hard to know the difference between typical and atypical health issues. Most people manage pretty well in other countries, but the Japanese go to the doctor for things like headaches or sore muscles. The idea that you need to go to a doctor for treatment of these things, particularly when he's going to give you a few minutes of face time and give you palliative medicine is absurd. I wouldn't trust most Japanese doctors to recognize a serious problem for at least several visits anyway given how cursory their exams are.

I suggest a system that finds a balance between catering to hypochondriacal behavior and overly fretful people and reasonable care. It doesn't have to be all or nothing.

Incidentally, Japan has the highest per capita national debt than any country in the world. Much is made of the U.S.'s debt and it is bigger on the whole, but not when you consider population differences. Japan's problems are only fueled by wasteful entitlement programs.

Thanks for reading and commenting (both of you).