Ii The role of health insurance
As long as Japan legal residents pay the required insurance premiums, they are entitled to medical services covered by the NHIS. The insured co-pay 10–30 per cent of the service fees to the medical provider. While NHIS coverage is wide and includes most basic medical services and conditions, there are medical services, such as heavy particle beam therapy or certain new experimental therapies, that are not covered. The NHIS does not allow NHIS-covered medical treatment to be provided alongside uncovered treatment, and considers the entire NHIS-covered and uncovered medical treatments as not covered by NHIS at all, except in very limited circumstances. Thus, many individuals opt to take out private health insurance for medical services not covered by the NHIS.
Iii Funding and payment for services
The NHIS has allowed Japan to enjoy the world's highest level of life expectancy and healthcare standards, but because it allows free access to medical facilities and providers, an enormous amount of public subsidy is required to maintain the universal health insurance coverage. Thus, its sustainability is heavily affected by tax revenues and other public funds.
To control the supply and demand of medical recourses, Japan adopted the Medical Care Plan in 1985, under which the Ministry of Health, Labour and Welfare (MHLW) obligates each prefectural government to make periodic reports on its prefecture-specific healthcare system. These reports must include an estimate of future supply and demand of hospital beds in the 'secondary medical service areas'3 and their medical functions (such as acute phase function and recovery phase function), basically targeting (1) cancer, cerebral apoplexy, cardiovascular diseases, diabetes and mental disorders, referred to as the 'five diseases'; (2) emergency medical care, medical care in case of disasters, medical care in remote areas, perinatal medical care, and paediatric medical care (including paediatric emergency medical services), referred to as the 'five services'; and (3) home medical care. The reports used to be required every five years, but from 1 April 2018, the reports must be submitted once every six years with provisional revisions to be made every three years. If the number of existing hospital beds with certain medical functions exceeds the standard number of that type of hospital beds in the secondary medical service areas set out in the Medical Care Plan, the prefectural governor can directly or indirectly refuse applications for additional hospital beds.
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From 2015, the MHLW further obligated each prefectural government to create, within its Medical Care Plan, a prefecture-specific vision called the Regional Healthcare Vision. This vision requires the use of a newly adopted reporting system (introduced from 2014) on medical functions of hospital beds to estimate supply and demand for healthcare for 2025 (when the baby boomers will reach the age of 75) and establish region-specific healthcare systems by 2025.
Medical service fees payable to medical institutions and pharmacies for insured medical services, medication and devices are determined every two years by the MHLW based on discussions within the Central Social Insurance Medical Council. The FY 2018 revision of medical fees covered by the NHIS applicable for two years from 1 April 2018 showed an average decrease of 1.19 per cent from the previous fees. That average decrease represents an increase in medical service fees but a decrease in the prices of drugs and supplies.
III PRIMARY / FAMILY MEDICINE, HOSPITALS AND SOCIAL CARE
Unlike some countries where patients are required to first see a general practitioner even for insurance-covered medical services or have no direct access to high-functioning hospitals, Japan's free access policy allows patients to directly access high-functioning hospitals for medical services covered by the NHIS. In order to cope with increasing medical costs, however, public policy guides patients and physicians to seek a general practitioner first. For example, in the FY 2018 revised fees, medical fees are increased for medical institutions that strengthen its general practitioner practice. Generally, patients without a referral from a general practitioner have to pay ¥5,000 as a first consultation fee to visit hospitals with at least 400 beds.
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