INTERVIEW | Sustaining Healthcare Excellence in an Aging Nation

Most would agree that Japan's healthcare system is exemplary. In 2021, the Organization for Economic Co-operation and Development (OECD) reported that Japan topped the list of total hospitals in major countries worldwide. The country boasted an impressive 8,205 facilities. Meanwhile, the United States came in second with 6,129 facilities, underscoring a substantial gap of over 2,000 facilities compared to Japan's leading count.

According to the OECD's 2021 analysis of hospital beds per 1,000 population, Japan dominated major nations, with 12.8 beds per 1,000 individuals. It had roughly four to five times more beds than the US (2.8 beds per 1,000 persons) and the United Kingdom (2.5 beds).

At the same time, the OECD report showed that Japan has fewer active physicians per 1,000 population than other OECD countries. According to the report, Japan had 2.5 active physicians per 1,000 population in 2018. That ranks it seventh lowest among OECD member countries. Compared to the abundance of hospitals and beds, doctors are spread thinly.

Another complicating factor is that the elderly demographic is steadily growing. Some government forecasts indicate that by 2060, a quarter of the population will be 75 years or older, constituting one out of every four people.

What steps can Japan take to tackle these challenges and modernize its healthcare system for the well-being of future generations? Medical expert and Japan Innovation Party member Masatoshi Ishikawa recently sat down with JAPAN Forward to discuss these issues. Ishikawa runs a clinic in Tokyo's Ota-ku and is a specially appointed professor at Tokyo Healthcare University.

Managing Hospital Beds

One latent issue within Japan's medical system is how its hospital beds are used, explains Ishikawa.

"In the UK, hospitals receive a fixed amount per hospitalization, regardless of the duration of the stay," Ishikawa says. "This system creates a financial incentive for hospitals to discharge patients sooner."

Japan, on the other hand, employs a per diem compensation system, he notes. "Here, hospitals are reimbursed based on the length of each patient's stay. Consequently, there's a financial incentive to prolong hospital stays, driving the need for expanded bed capacity."

The average length of stay for acute medical care in OECD member countries is 8.9 days in Germany, 8.8 days in France, 6.9 days in the UK, and 6.1 days in the US. In contrast, Asian members have markedly longer stays. Japan has an exceptionally long average stay of 16.0 days, ranking second after South Korea (18.0 days).

Elderly patients who find it challenging to receive home care may choose hospitalization instead of care facilities, Ishikawa opined. He suggested that they may remain in the hospital because they feel safer, even if their condition has improved.

"This phenomenon of social admissions presents a multifaceted challenge in healthcare management," Ishikawa observes. "Ideally, it might be better for patients to be discharged earlier and return home for recovery," he suggests. He also notes that it could help make the use of medical resources more efficient.

Surplus Hospitals, Scarce Resources

Hospital beds are available, but Japan's surplus of medical facilities ironically poses another significant challenge. 

"An overabundance of hospitals, coupled with Japan's low doctor and nurse per capita ratio, exacerbates the strain on healthcare resources," Ishikawa analyzes. "During the pandemic, this imbalance created difficulties in managing COVID-19 patients while maintaining essential healthcare services."

The debate over patient admission protocols "not only led to vacant beds, it also strained healthcare teams," Ishikawa explains. As a result, he added, "coordinating cohesive responses to the pandemic proved challenging."

Ishikawa emphasizes, "Japan boasts excellent healthcare access. However, despite this, too few physicians spread across too many hospitals poses a risk to quality." He further elaborates, "Consequently, there's an increasing discourse suggesting that a slight reduction in access, coupled with consolidation, might enhance overall quality." 

Highlighting the significance of this debate, he states, "This is especially pertinent in acute care hospitals." Here, reforms in areas such as physician workstyle are underway, aiming to reduce long working hours.

Despite Japan's excellent medical care, there are concerns about case volume and productivity. He emphasizes, "The crux of the issue lies in the low number of cases being handled rather than access itself." At the same time, he adds, "The overarching challenge is the shortage of doctors."  

Virtual Healthcare

Ishikawa notes that, out of necessity, Japan is considering new ways to "bolster local healthcare infrastructure and increase access to physicians."

One option under consideration is the use of online consultations. "One readily apparent benefit is enhanced accessibility," he says. "Patients no longer require in-person visits for consultations, thereby reducing wait times and allowing access from any location."

This extends beyond Tokyo, encompassing regions with fewer doctors. Virtually, individuals can receive first-rate treatment from physicians without traveling to the capital.

Online consultations also help patients obtain and share important information related to their care. Ishikawa continues. "For example, wearable devices can transmit a range of data online. Previously, patients had to visit the hospital every one or two months to measure blood pressure and maintain a log. With the ability to monitor blood pressure fluctuations daily, this information can be directly sent to the hospital," he elaborates.

"If blood pressure levels are significantly elevated, the hospital can immediately contact the patient for further action. This level of detailed monitoring allows for more precise and timely healthcare interventions, which were not feasible before," he concludes.

AI Integration

Ishikawa also imagines a significant integration of artificial intelligence into Japan's medical system in the future.

"AI may soon offer more precise responses than less experienced doctors. While this potential has yet to be fully realized, platforms like Babylon Health (now eMED) in the UK already provide AI-driven medical consultations," Ishikawa elaborates. "Given the occasional challenges in matching patients with doctors, leveraging AI to refine this process or offer diverse perspectives could become increasingly viable," he remarks. 

In 2017, the Ministry of Health, Labor, and Welfare established The Council for the Promotion of AI Utilization in Health and Medical Care. This later became the Round-Table Conference on Promoting the Use of AI in Healthcare. It identifies six priority areas for promoting the use of AI. These include: 

1. Diagnostic imaging support
2. Diagnostic and therapeutic support (including testing, disease management, and disease prevention)
3. Surgical support
4. Nursing care and dementia
5. Genomic medicine, and
6. Drug development.

"Another example of AI technology in medicine is EndoBRAIN," Ishikawa says. "EndoBRAIN employs AI to analyze endoscopic images, predicting whether detected lesions are tumors or non-neoplastic polyps. This functionality significantly aids in the early detection of tumor-forming polyps, particularly in colorectal cancer cases."

Conclusion

Amid Japan's aging population and evolving healthcare needs, Ishikawa underscores the necessity for innovation and adaptation in healthcare. From reimagining compensation models to embracing AI integration, Japan is poised to navigate these complexities and continue its legacy of excellence in healthcare delivery. 

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Author: Daniel Manning