Congratulations to the government of Japan for revising the health insurance scheme to reward medical clinicians for preventative as well as curative care – meaning paying them to prevent disease, not just for pills, potions and injections, hospital treatment, and operations to fix problems after they have happened.
But hold the applause. The decision is a baby step compared to what could, should and must be done. Japan needs radically to reform the health insurance scheme, which is creaking with its own elderly costs. There are two main elements: to change to holistic healthcare that is based not merely on prevention but on healthy living; and to bring dentists fully into the medical fold, instead of being seen as a fringe band of modern-day torturers.
This needs to be done for the sake of the government budget and for the well-being and healthy long lives of all Japanese people. Health and social security spending, the biggest component of an overstretched budget, faces further strains as the population turns from grey to white. Japan’s taxpayer base will fall, even if people can be persuaded to keep working until they are 75 years old, while growing numbers of elderly people need more money to keep them fit.
The quest for solutions to these entrenched questions of government finances and human behavior is coming from an unlikely direction, left field in baseball parlance. Mikako Hayashi, a professor at Osaka University (and my wife), has fresh ideas about reforming the healthcare system. She starts by asking an unexpected question – What is the world’s most prevalent disease? No, the answer is not cancer, nor even heart attack, nor pneumonia, nor malaria, nor diabetes, nor even more mundane complaints like backache. It is dental caries, along with associated gum disease.
Yet if you look at healthcare internationally, dentistry is regarded as the ugly sister of medicine. “I’d rather die than go to the dentist,” is a prominent answer in surveys of what people worldwide love and hate. Hayashi points to ancient folk wisdom.
She cites the expression “down in the mouth”, meaning unwell, expressing the central importance of a healthy mouth, teeth and gums, as evidence of good health. In addition, if a plan “has teeth”, it has prospects of success; if it lacks “teeth” or “bite”, it is not to be taken seriously. Clinical studies of elderly people indicate that those who have kept their teeth, or even have dentures, are more likely to be active longer, whereas the edentulous lose their appetite for life.
Wise modern medics recognize the importance of oral health. Then U.S. surgeon general David Satcher said, “The mouth is a mirror of the body, it is a sentinel of disease, and it is critical to overall health and well-being.” Professor Deborah Greenspan in California discovered lesions in the mouth were an early indicator of HIV/AIDS. Osaka University Professor Kazuhiko Nakano and colleagues found that gingival bacteria can cause critical cardiovascular conditions. Economists have calculated that dental disease costs the global economy more than $440 billion a year.
But Japan’s main aid agency, JICA, the World Bank and others talk of “healthcare” without managing to mention dentistry. Hayashi recalls, “On the World Bank’s site, I found 3,531 publications under ‘health and disease’; but when I put ‘dentistry’ in the search line, I got ‘zero results.’”
Hayashi is hosting two important meetings in the next two weeks to promote discussion of the connections between oral health, good general health and sound government finances. The first is an international symposium on March 21 entitled, “Good oral health as the key to good global general health”*. The other is a Round Table discussion in which Professor Nairn Wilson, president of the British Dental Association and former deputy medical dean at leading British universities, and Hayashi will discuss how medical doctors and dentists can work together to create holistic healthcare within a healthy budget#.
Japan’s health ministry decisions of February, effective April, encourage preventive care across medical disciplines, and affect hospitals, doctors, dentists and pharmacies. They indicate that Japan’s healthcare insurance system is alive, but itself needs urgent treatment, which the new measures do not fully comprehend.
In the case of dentistry, the new government rules allow registered clinics to charge 2,600 yen a month for preventative treatment for early enamel caries lesions. In addition, dentists can earn 8,300 yen for supportive periodontal therapy for a patient with more than 19 natural teeth, and smaller amounts for patients with fewer teeth.
So far, so good, but the improved preventative measures are being imposed on top of an essentially curative system. In the case of dentistry, this means the old “drill and fill – and bill” system; in the case of general medicine, it means going to the doctor when the pains of sickness have become unbearable.
Makiko Nishi, a dentist completing a PhD in Cork, Ireland, notes that superficially 2,600 yen a month per patient seems generous. But she adds that a proper preventative program involves more than measures against early lesions; it means risk assessments that take into account a patient’s lifestyle, an individual and personalized preventative plan with regular, not necessarily monthly, dental visits and checks of outcomes and progress.
Therein lie critical problems. The success of superb preventative treatment is that you cannot see lesions or fillings or missing teeth; but the health ministry likes to see results before it coughs up funds. There is good reason for this: as Nishi comments wryly, “not all dentists are angels”, and Japan’s dental federation has a long history of corruption allegations. On top of this, the older generation of Japan’s dentists has been trained to drill and fill, and they make their money from such excavation and golden fillings.
J.M. “Bob” ten Cate, Academy Professor from the Netherlands, who will be a leading speaker at the Osaka symposium, commented that the switch to a preventative program in his country had failed because dentists did not back the change in philosophy. He adds, “Any restorative treatment is inferior to the original tooth material, in terms of functionality, esthetics and durability.”
On the medical side, most Japanese are not registered with a family doctor, but go to different practitioners for back or heart or skin complaints.
One solution would be to switch to a capitation system, where dentists or doctors are paid for the number of patients enrolled. This works well in Sweden, where people have superior oral health to Japanese or most other Europeans. Nishi, who has studied both systems, questions whether Japanese private dentists, who are 80 percent of the total, will accept a capitation system.
Japan’s healthcare system has stayed intact without dentistry becoming semi-detached, as happened in the UK. Besides all the intractable problems of extra costs of an ageing population, it faces the under-reported challenge of the TransPacific Partnership (TPP), which may see private insurance companies clamoring to get a slice of the health pie.
The health ministry says it continually updates the scheme, but what actually happens is that every two years, Chuikyo (Central Social Insurance Medical Council) presides over a fight between vested interests to tweak the system. It’s high time for Japan to take a fresh look at the philosophy and the practical political social and financial implications of its healthcare, especially when the squeezes of aging population and tight budgets begin to bite hard – strong teeth again needed.
Hayashi suggests that all Japanese be given a health number and enrolled with a primary care doctor and dentist who will maintain common records, and would put wellness, healthy living and preventative care as the centerpiece of treatment. This would be controversial, not least because it would require a new approach by clinicians.
A first step would be to use a control group, say of newly qualified dentists trained that drilling and filling is no longer the preferred treatment, or a university department. Greater cooperation between general doctors and dentists would certainly help, and could also be pioneered in a university.
Optimistically, Hayashi believes that if Japan can update and reform its healthcare, it could have a new model that would serve it well through the 21st century without imposing costs to bankrupt the country. In addition, it could export the new model, especially to developing countries trying to develop universal health insurance. Exporting healthy healthcare would be better for the world than Japan joining the club of arms exporters.
- March 21: Good oral health as a key to good global health: symposium (English and Japanese with simultaneous translation) at Osaka University Nakanoshima Center, Kita-ku, Saji-Keizo Hall, 10th floor, 9.15-17.00; a few places left.
April 6: Round Table, Osaka University Dental Faculty; by invitation only; contact email@example.com
The writer is a journalist, commentator and former World Bank official and quondam professor of Osaka University.© Japan Today