21st-century Japan needs radical health reforms

By Kevin Rafferty

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

The writer is a journalist, commentator and former World Bank official and quondam professor of Osaka University.

© Japan Today

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I heard they don't even do"teeth cleaning" appointments at all here

You heard wrong. Go to any dentist and get it done under your normal health insurance coverage.

2 ( +2 / -0 )

I wasn't overly impressed with the Japanese health system myself. Until moving to the US. Japan seems to be a bit hit and miss - fabulous doctors, if you can find them. The US - what a mess! World class health care, but my God, you get scammed for it! My friend's son had an allergic reaction at home - fire dept AND an ambulance turned up - billed cost $2500. That same friend had twins - hospital billed them $1500 for a trainee doctor they neither wanted nor needed in the OR, and who did nothing but stand and watch. Visit a doctor and ask the cost before any treatment - he won't be able or willing to tell you. Then you get the bills in - most recent one was "$99 - surgery bone / muscle" - that "surgery" was the doctor saying "Point your foot slightly downwards for me" - that was it. He charged $99 for that! On top of the $260 office visit AND $66 for the plaster cast. And this was on TOP of the $600 a month we pay for health insurance for the family. Yeah - you don't know how good you have it in Japan.

1 ( +1 / -0 )

Charging for non urgent ambulance calls would be a good start.

0 ( +0 / -0 )

I've had experience with various dentists in the US, the UK, and Japan. The easiest and lowest cost access is in Japan. As far as I can tell, the standards are quite high.

0 ( +1 / -1 )

As the government claimed that the last two increases in the consumption were for welfare, they should have a vast surplus of funds to pay for medical costs.

0 ( +0 / -0 )

You heard wrong. Go to any dentist and get it done under your normal health insurance coverage.

Thanks for clearing that up. What about braces? Very common in US, but I'm willing to go out on another limb & say not so common here. Guess I've seen lots of bad teeth here n' there in Japan.

0 ( +1 / -1 )

To be honest if everyone paid a percentage of their income as a tax to pay for their health service no-one would need health insurance. Free at the point of service. Those who wish to pay for private medical care could do so.

-1 ( +1 / -2 )

@bullfighter - who is your dentist? I have looked for 20 years for a Japanese dental assistant that can actually CLEAN teeth as well as their American counterparts. I have told by Japanese dentists that there simply is no treatment, for example, to clean the tea stains off the back of my lower teeth then I go to an American dental hygienist who gets them pearly white.

@NathalieB - agreed, the Japanese healthcare system is sensible and reasonably priced but ... I have a good friend (American) that was diagnosed with a chronic form of cancer that didn't need treatment right away. After researching options he found the gold standard around the world was a combination therapy of two common drugs but was told by a Japanese oncologist that the combination wasn't "allowed" in Japan. My friend then asked that if he, the oncologist, had the same cancer would he want to be treated in Japan or the USA. He replied that he would choose America.

-1 ( +0 / -1 )

The easiest and lowest cost access is in Japan. As far as I can tell, the standards are quite high.

In the US, people with dental coverage often get a good "teeth cleaning" annually. I heard they don't even do"teeth cleaning" appointments at all here. If true, How can can that be high standard?

And based on some peoples teeth here (crooked incisors, fangs, black stains) I'd have second thoughts on Japans dental industry.

-2 ( +1 / -3 )

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