Primary medical care in Japan is provided by individual clinics, and hospital medical services are mainly undertaken by private non-profit hospitals. However, Japan's demand for social medical services has a bottom line, and social capital is prohibited from opening private for-profit hospitals.

Primary clinics mainly appear in the form of specialized clinics, and a small number of public hospitals provide primary medical services. Japanese doctors are separated, and most hospitals and clinics are completely separated.

In the primary health care system, 1/3 doctors are employed by clinics, and the rest are doctors themselves. Clinics are usually run by individual doctors or organized by a group of doctors.

In Japan, the doctor group consists of several doctors, all of whom own a hospital or clinic.

Clinics can provide general services and specialized services. The organizational form of primary health care in Japan is usually 1 doctor+nurses. 20 1 1 Japanese clinics have an average of 7.2 full-time staff, including doctors 1.2, nurses 1.8 and front desk 2. 1.

In terms of hospital composition, in 20 13 years, 0/5% of hospitals in Japan/kloc-0 were organized by the central government or local governments, and the rest were private non-profit hospitals.

In terms of beds, 20% of beds belong to public hospitals and 80% belong to private non-profit hospitals.

Private non-profit hospitals, in particular, are considered as a part of public medical care, receiving various subsidies from the government, and are also within the payment scope of public medical insurance funds.

Japan does not allow private for-profit hospitals to open, but allows enterprise hospitals to exist to provide medical services for enterprise employees. We can simply understand for-profit and non-profit: "for-profit" means that the balance of the hospital can be used for dividends, and "non-profit" means that the balance of the hospital is considered as public funds, and the funds cannot be handled privately and can only be used for the development of the hospital. More requirements are embodied in Japanese medical law, and Taiwan Province Province of China has also learned from Japanese practices.

The boundary between public health insurance and private health insurance is clearly defined.

Japan has established a compulsory universal medical insurance system, that is, a public medical plan. Every resident or employee must join the public medical insurance plan, and legal immigrants also need to join the social insurance plan, but illegal immigrants and tourists are not included. If residents withdraw from compulsory medical insurance, they will have to pay an extra two-year premium when they rejoin, which is equivalent to a fine. About 3,400 insurance institutions are responsible for providing public medical insurance.

Except for children and the elderly, the self-payment ratio of public medical insurance is 30%. 0% for children under 3 years old, 20% for the elderly aged 70-74 years old, and 10% for the elderly aged over 75 years old.

There is no deductible line for public medical insurance, and the expenses of self-funded and some prescription drugs can be subsidized from income tax relief. In addition, it is not clear that individuals are responsible for their own profits and losses. From the perspective of the whole medical expenditure in Japan, personal expenses account for about 14%. Employers bear half of the cost of premium financing, and the premium burden accounts for 3% ~ 10% of the company's income.

The boundary between private medical insurance and public medical insurance is very clear, and the former is in a supplementary position in Japan's insurance plan. The first is the supplementary insurance of compulsory public health insurance, in which residents participate voluntarily and pay medical expenses mainly in the form of one-time payment to make up for the lack of protection of public health insurance, such as daily hospitalization expenses. The second is supplementary insurance, which covers items not covered by public health insurance, and it is a supplementary state in Japan. Finally, Japan does not allow private insurance to replace public medical insurance.

Successfully counterattack aging through long-term care insurance.

Japan quickly adjusted its layout and developed long-term care insurance before the aging crisis.

In 2000, Japan implemented long-term care insurance, which is a compulsory insurance, covering the elderly over 65 and the disabled elderly aged 40-64.

Nursing services include many contents, including home care, temporary care, home service and various auxiliary facilities needed for nursing, which also belong to the scope of public insurance. Home care service providers are mostly private organizations, of which 62.6% are for profit, 36.4% are for profit and 0.4% are sponsored by the government.

Long-term care insurance is not allowed to cover services provided by private for-profit institutions.

Nursing insurance is funded by insurance premiums and taxes. People over the age of 40 need to pay premiums, while those over the age of 65 pay premiums according to their income. In Japan, employers and employees share the long-term care premium equally, half and half. In addition, the out-of-pocket ratio of residents' long-term care insurance is 10%, and Japan will set the upper limit of the total out-of-pocket amount according to the income situation.

On the whole, Japan's compulsory public medical insurance and nursing insurance cover hospitalization expenses, emergency expenses, mental illness treatment expenses, prescription drugs within the statutory scope, home care, physiotherapy and most dental services, as well as medical services provided by clinics. People with different identities, their insurance is operated by different institutions. For example, the medical insurance for employees and civil servants is operated by independent insurance institutions, and so is the medical insurance for some professionals, such as doctors in private practice.

For China, the biggest revelation from Japan to China is that the "market" development in the medical field is not generalized, but explicitly encourages non-profit hospitals and doctors to dominate clinics, prohibits for-profit hospitals, and determines the boundaries of public medical insurance payment. In addition, China is at the crossroads of demographic changes and medical demand changes, and rapid layout adjustment may make the medical system overtake in the curve.

Extended reading:

Why is the American medical system a "bad example"?

Text | Wang Jianxiu

This article is taken from: WeChat WeChat official account "Singularity Network"

ID: geekheal_com

Seeing this topic, I believe many friends will jump up and ask: whether it is the diversity of medical service providers, the strength of health insurance companies, various technological innovations and Internet medical innovations, the United States is at the forefront of the world. In the American medical field, the free market and organizational efficiency are so high. Why is he a "bad role model"? Isn't it worth learning from China?

Don't worry, this is not to deny the American medical system, but for China, if we want to learn from the experience of a certain system, we must first look at whether the shoes fit. We can think it over. At what level is a developed country with a per capita GDP of $54,629 comparable to a developing country with a per capita GDP of $7,590? In which dimension can a country whose medical expenditure accounts for 0/7.5% of GDP and a country which has just established a universal health insurance system and whose medical expenditure accounts for 5.5% of GDP be compared?

Let's first look at the overall structure of the American medical system.

According to the data of Health Affaires, in 20 14 years, American medical expenditure was $3031300 million, accounting for 17.5% of the total GDP. In that year, the GDP of the United States was 17348 1 billion dollars, of which the out-of-pocket expenditure was 329.8 billion dollars, accounting for 658% of the total expenditure. The total population of the United States is 3180 thousand, the per capita medical expenditure is 9523 dollars, and the per capita GDP is 54502 dollars. In 20 14, the medical expenditure in the United States increased by 5.3% over the previous year, exceeding the increase of 2.9% in 20 13.

Private non-profit hospitals are the main force and the medical prevention system is weak.

As far as the medical service supply system is concerned, all primary medical care in the United States is done by private family doctors. The primary health care services of these family doctors are often included in a medical insurance network and play the role of health gatekeepers.

In terms of hospital bed resources, only 15% of beds in the United States belong to government-run public hospitals, about 70% to private non-profit hospitals, and about 15% to private for-profit hospitals. According to the data of American Hospital Association 20 16, there are 4,926 general hospitals (excluding prison hospitals and university clinics) in the United States, of which 1003 are government-run hospitals, accounting for 20.3%. 2,870 private non-profit hospitals, accounting for 58.2%; Private for-profit hospitals 1.053, accounting for 2 1.3%.

In terms of resources, the number of doctors in American society accounts for 80%, but private non-profit medical institutions dominate. The United States is open to hospital ownership, unlike Japan, which prohibits private for-profit hospitals. In a free and relaxed environment, medical service providers in the United States include hospitals, various doctor groups, individual clinics and partnership clinics.

In the United States, the concept of medical service is still based on treatment. For example, it is easy for people to have joint replacement surgery, but the United States does not do well in preventing chronic diseases.

Medical resources are gathering more and more, and private insurance companies consume too much social resources.

From the perspective of the whole insurance system, the US government undertakes medical insurance for the elderly over 65, the poor and the disabled, namely Medicare and Medicaid, and private insurance institutions cover at least 56% of the population. Before 20 12, the United States did not force people to buy insurance. 20 12 After the promulgation of the Obama ACA Act, most people are required to buy insurance, and employers are required to buy insurance for their employees. Of course, Obamacare reform is still in turmoil in the 20 16 general election, and its fate is uncertain.

There are many models of insurance network in the United States. The most typical one is HMOs, a managed medical institution, such as Caesar Group. In this insurance system, a strict grading diagnosis and treatment system has been set up, and the insurer must choose a family doctor before reimbursement can be made after referral. Outside the HMOs system, the insurance company does not bear any expenses.

Under the ecology of multi-party game among insurance companies, medical services, patients and pharmaceutical companies, the biggest winner is the insurance company. According to the data of American statistical website, the income of American life insurance and health insurance industry reached 877.9 billion US dollars in 20 14 (Figure 1). Followed by the pharmaceutical market, the US pharmaceutical market in 20 14 was US$ 374 billion (Figure 2), accounting for 40% of the world pharmaceutical market. Finally, the medical device market. In 20 14 years, the market size of American medical devices was136 billion USD (Figure 3).

Figure 1

Figure 2

Figure 3

With the increasing voice of insurance companies, there is a trend in medical service institutions in the United States: individual clinics are exhausted in the face of insurance negotiations, and many individual clinics either go to Canada to practice, or simply close their clinics and be employed by hospitals. Single hospitals tend to unite and increase bargaining chips with insurance companies. The group of doctors is also gradually moving from small scale to multidisciplinary. One of the reasons is to intensify negotiations with insurance companies.

The administrative and management costs of insurance companies have brought a heavy burden to society. According to American media reports, 2 1% of American medical expenditure is used for administrative expenses, of which 85% comes from private insurance companies (source 1).

The biggest problem is that medical input is not proportional to health output.

Health outcomes and financial sustainability are almost the most criticized goals of the American medical system (Figures 4 and 5). The United States spent 17.5% of GDP, and the average life expectancy and per capita medical expenditure were not far behind those of Cuba, which is only a fraction of the United States. From the perspective of health production, the average life expectancy of the United States is lower than that of OECD countries, especially developed countries.

Figure 4

Figure 5 (the highest item is the United States)

In 20 14, American medical expenditure increased by 5.3% over the previous year, exceeding the 2.9% increase in 20 13, and the per capita medical expenditure was $9,523. In the past 35 years, the total consumption of goods and services in the United States has increased by 7.2% annually, while the consumption growth rate of medical care has reached 9.8%.

The growth of medical expenses in the United States has been higher than that of the overall economy for a long time, so the federal government, employers and families in the United States have all suffered tremendous financial pressure. Reflection on The Bitter Fruit of Americus in America: Medical expenses are also the largest single consumption expenditure item of American families, including personal expenses and premiums paid. According to the data of the Ministry of Health, among the $3 trillion medical expenditure in 20 14 years, the financial share is as follows: households (28%), federal government (28%), private enterprises (20%) and local governments (17).

Let's summarize the characteristics of the American medical system:

First of all, the United States has invested more in medical innovation than any other country, and it also leads the world in the use of new technologies and drugs.

Second, the decentralized payers with commercial insurance as the mainstream in the United States have insufficient joint efforts in controlling the rise of medical expenses. The medical burden of employers is getting heavier and heavier. In addition, in order to increase the bargaining chip with insurance companies, hospitals tend to concentrate and unite, which leads to the concentration of suppliers and the reduction of the living space of individual clinics.

Third, the basic medical system in the United States is weak, especially the prevention-oriented medical system, which leads to many chronic diseases and senile diseases not being actively intervened, thus pushing up the overall cost.

Fourth, the operating mechanism of American commercial insurance has increased the administrative cost of the whole industry and greatly consumed social resources.

Fifth, the United States has invested a lot of money in disease treatment, but it is very passive in health interventions such as chronic diseases and senile diseases. Lifestyle diseases, including obesity, have long plagued the United States.

Seeing this, we can understand why the medical expenditure in the United States is surprisingly high. The diversified medical service system and market competition mechanism in the United States are worth learning from in China. However, we must also understand that a country's health care system must maintain a balance in medical quality, medical service efficiency, health outcomes and finance. Observing the American medical system can bring us many reflections: for example, better understanding the importance of basic medical care to China's future; Be alert to the pressure of financial sustainability brought by the expansion of medical insurance financing; Strengthen chronic disease management and health intervention.