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Perspective |
1 Department of Radiology, Iwate Medical University School of Medicine, 19-1
Uchimaru, Morioka, 020-8505 Japan.
2 Department of Radiology, St. Marianna University School of Medicine, Kawasaki,
Japan.
3 Department of Radiology, Kanazawa University Postgraduate School of Medicine,
Kanazawa, Japan.
Received March 1, 2008; accepted after revision March 6, 2008.
Y. Nakajima is president of the Japanese College of Radiology (JCR), and O.
Matsui is president of the Japanese Radiological Society (JRS). Indicated in
this article are their personal views and opinions, not those of the College
or the Society.
Keywords: health care systems • Japan • practice of radiology
In the traditional health care system, high overall health status and long life expectancy had been accomplished in Japan. The average life expectancy reached 78.64 years in men and 85.59 years in women in 2004—the longest in the world. Fair access to medical care and its low cost have been things of which we have been proud. However, this system has been challenged by the growing demand for high-quality health care and a physician manpower crisis caused by the new mandatory postgraduate training system. Media in Japan describe this situation as the "collapse" of the health care system [1, 2].
Changing Health Care System and Radiology
The demand for high-quality health care is a universal trend because people are now aware of the possible diverse options for medical care. However, the cost will increase to accommodate such diverse demands. Health care cost (per gross domestic product [GDP]) has been kept low in the National Health Insurance System (NHIS), which is supposed to cover all nationals in Japan. The total health care expenditure was ¥33 trillion (i.e., Japanese yen, or U.S. $300 billion), 8.1% per GDP, or ¥247,100 per person per year (U.S. $2,200) in 2003 [3, 4]. The Organization for Economic Co-operation and Development (OECD) data also showed health care expenditures at 15.2% of the GDP in the United States and at 10.8% in Germany in 2003. Although it is still extremely low, the Japanese government Ministry of Health, Labor and Welfare (MHLW) is strongly opposed to any increase in the health care budget because of expected future increases due to an increase in the elderly population. Diagnosis–procedure combination (DPC), a Japanese type of diagnosis-related group (DRG) with a mixture of fee-for-service component, was introduced in 2003, and an increasing number of hospitals are accepting this payment system. So far, adjustment of payments has been performed on the basis of the previous year's health care cost, but this will be discontinued in the next few years.
For high-quality health care, physician manpower is another important factor, but a significant shortage in the physician workforce has emerged as a serious problem. The new mandatory 2-year postgraduate training system, introduced in 2004, has significantly changed the traditional medical school–based training system. Department heads of the medical schools used to have the power to control staff positions and training of young physicians in medical schools and its affiliated hospitals. Since the introduction of the new postgraduate training system, the young physician trainees have suddenly disappeared from local community hospitals. Many such young trainees are now concentrated in urban medical centers. Local community hospitals, supported by the young physician workforce in the traditional system, have difficulty maintaining their medical service, partly due to the continuing policy of the MHLW to cut the number of hospital beds. Many physicians in community hospitals are suffering from heavy workloads caused by physician shortages and are gradually leaving such hospitals.
Radiologist manpower has always been a problem. The number of radiologists is approximately 7,000 (2.7% of all physicians); the number of certified radiologists is 5,000, including approximately 4,500 diagnostic radiologists and 500 therapeutic radiologists. Radiologist shortages have become even more serious since only "full-time" radiologists are entitled to the professional fee component in NHIS (U.S. $17 for CT, MRI and nuclear imaging, and U.S. $6.5 for others), in the 2008 revised payment schedule. The limited availability of radiologists results in low rates of radiologist coverage for CT and MRI services. The radiology training system, currently suffering from a lack of systematization, is now in the process of renovation by the Japanese Radiological Society (JRS), and we hope we can attract excellent young trainees.
The distribution of CT and MRI scanners is dense in Japan because there is no control over the installation of expensive equipment and devices. As for the number of scanners, Japan has the largest number in the world. A low health care expenditure together with a large number of expensive CT and MRI scanners is possible because of low payment costs for examinations and low professional fees. Under the NHIS, the payment for imaging studies is kept extremely low. The payment for CT scans is only U.S. $80, with an additional payment for contrast medium and films, and the payment of MRI is only U.S. $155–180, with the additional payment for contrast medium and films. PET is only U.S. $680. Overall payment through the NHIS may be lower than the actual cost. A radiology department is considered the major cost spender, not profit maker. The quality of radiology service varies and depends on the overall performance of the health care facility.
Malpractice crisis is now an ongoing problem. The number of malpractice lawsuits has significantly increased: 794 new cases in 2000 and 1,107 in 2004. The average length of a malpractice trial is 27.3 months, more than twice as long as other suits. Because of the increased number of lawsuits, the Tokyo District Court has established a special section. Although the legal system in general is different from that in the United States, the logic used by the lawyers is the same as that of U.S. malpractice lawyers. Radiology is not free from this overall trend because errors in imaging diagnosis are frequently considered to be a cause of a delayed or missed diagnosis.
Current Status
The NHIS is still a strong framework for health care in Japan. It decides the types of medical care to be covered, the prices, the manpower, and the software and the hardware of the health care providers. So far, screening imaging studies are outside the framework of the system, but the price in NHIS strongly affects the price in such practices. Many imaging centers are operated by for-profit private enterprises, although semipublic enterprises are still the major players in the health screening business—for example, the Anti-Cancer Association and the Association for Tuberculosis Prevention. Many PET imaging centers have been started up in the past several years. However, because of the low price of PET in the NHIS, most such imaging centers are now in a financially difficult situation.
A mixture of approved and unapproved care had been prohibited in the NHIS, but a few exceptions to this rule exist: additional payment for hospital beds, dental materials, and approved new technology (e.g., payment for heavy-particle radiation therapy: $30,000). Because of the increased demand for diverse health care, this kind of mixed health care will expand. Interventional radiology is one of the areas that is deeply affected by the introduction of mixed health care because off-label use in general is so far prohibited.
For-profit health care business now has only a limited role, but the strict restriction of hospital organization will be changed. Teleradiology business, not included in the NHIS, is now an established business of radiologists and private enterprises. The market is still small and has been dominated by a few for-profit corporations. A limitation exists in small professional fees under the NHIS, which is actually the limit for most hospitals to pay for this service.
Legislation for personal data protection took effect in 2005. Its changes not only extend physicians' duties to all health care workers but also requires a change in the whole process of health care systems. Digital data management is still a difficult problem. Imaging data size has increased significantly, and the technology for data management and protection is still underdeveloped. Threatened by regulatory agency inspection, personal data management is becoming a more difficult problem.
Overall, radiology research has been active, even with manpower shortages and government restrictions. In particular, the low payment for advanced imaging and treatment procedures is negatively influencing technologic innovation. Because of a need for more rigorous research, randomized controlled trials through multiinstitutional groups and national societies have now been performed. Funding for research grew only in limited areas, and the overall funding is of a similar level or less since governmental medical schools became public corporations in 2004.
The Future
There has been a paradigm shift from a fair-access and low-cost health care system to a high-quality care system; limited access to health care has emerged as a serious problem in the overall system. Radiology is a key player for high-quality care at this time and in the future.
The future of radiology in Japan depends on whether we can maintain high-quality radiology practice and whether we are recognized by other specialties as a provider of high-quality medical care. Manpower shortage is a serious obstacle to becoming a topnotch specialty. We have a slightly optimistic perspective because radiology is a rapidly advancing specialty and is attractive to young trainees. Systematization of training programs will also be important for promoting the best and brightest young trainees. So far, modernization of imaging and radiation therapy facilities is stable, but effective utilization by concentration and sharing may be needed in the near future. A significant change in radiology practice may occur in the future, and we believe we are fortunate to participate in this innovation, although hard times due to the current manpower shortages will continue for some time.
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