Current trends in Japanese health care: establishing a system for board-certificated GPs

BACKGROUND

The Japanese healthcare system provides universal health coverage through both a fee-for-service system under governmental control and a free-access system.¹ The free-access system allows private facilities to establish hospitals or clinics if they meet the requirements of the Medical Care Act, a Japanese law covering the healthcare system.¹ Patients can seek treatment at whatever public or private medical facility they prefer, with no difference in cost.¹ There is no strict gatekeeper system by primary care physicians¹ so patients are not always required to have a regular primary care doctor.¹

Under this system, Japan has maintained top-class global health indicators, including life expectancy at birth and infant mortality.¹ However, the debt-to-gross domestic product (GDP) ratio of the government currently exceeds 200%, and is expected to continue rising.² Japan’s debt-to-GDP ratio is the highest among the Organisation for Economic Co-operation and Development (OECD) countries,³ and a large proportion of that debt comes from social security expenditures.²

As a result, the costs associated with social security need to be reduced.² Healthcare expenditures increased by 3.1% in 2011, about one-third of which was attributed to the ageing population and about two-thirds to the costs of advanced medical care.² As expenditures per capita on national health care have been increasing annually, this raises the question of whether Japanese people are receiving appropriate care.

The World Health Organization and the Ministry of Health, Labour and Welfare (MHLW) in Japan point out that the lack of gatekeepers to advanced medical facilities is associated with an increased number of inpatients, a disproportionate burden on healthcare workers, and a reduction in efficiency and quality of care.¹

They also add that the lack of primary care doctors leads to an insufficient supply in providing appropriate medical care.¹ Considering these circumstances, the MHLW has indicated the importance of primary care physicians for dealing with the rapidly ageing population and reduce healthcare expenditures.⁴

THE NEW CATEGORY OF SPECIALIST

In Japan, physicians trained in an internal medicine-based residency programme have continued to play a principal role in the primary care setting.⁵ The Japan Primary Care Association (established in 2010) provides continuous professional development and has become the recognised certifying body for primary care physicians.⁶ It had 11 401 members as of 31 May 2014, including 10 227 physicians, 65 dentists, 627 pharmacists, 336 other health professionals, and 146 medical students.⁶ Moreover, as of 30 September 2015, there were 500 certified family physicians, 3386 certified instructors, 310 residency programmes, and 126 board-certified primary care pharmacists.⁶

From 2017, the system of an independent third-party organisation will be established and ‘board-certified GPs’ will become the new category of specialist.⁴ The GP board will include the following six competencies: Person-centered care — Comprehensive care, Integrated care; Interprofessional work; Community orientation; Professionalism; and System-based practice.⁷

LOOKING AHEAD

A final decision has yet to be reached on the formal English-language term for board-certified GPs. The Japanese board-certified GP consists of a combination of ‘hospitalist’ — a doctor primarily engaged in inpatient care at hospitals — and ‘family physician’ — a doctor specialising in outpatient care as a regular primary care doctor at a clinic.⁷ Thus, the concept of a board-certified GP in Japan is not necessarily synonymous with that of a GP in the UK. For example, hospitalists need to see many patients without advanced or serious disease due to the free-access system mentioned previously (that is, hospitalists are also doing the job of a family physician).

The MHLW promotes differentiation of function in outpatient care by increasing medical remuneration to those who play a role as a consistent primary care doctor to strengthen the primary care system. The MHLW also imposes the special charge for patients who visit hospitals containing over 500 beds or advanced treatment hospitals without a referral letter from a primary care physician.⁸

Whether the new system and board will lead to improvements in the Japanese healthcare system has become the subject of considerable discussion.