Tokyo, of course, has many modern hospitals, but it is unknown to the mass market of medical travellers or tourists, such as it exists. This may be from a lack of awareness of the competence and quality of Japanese hospitals or it may be because of the perception of Japan as very expensive country. In addition, Japanese hospitals do not advertise domestically, let alone internationally, although the World Health Organization gives Japan’s healthcare system high marks.
ACCREDITATION
For foreigners, and in particular Americans, some assurance that the standards in overseas destinations are evaluated and that organisations are accredited is an important factor.
The Joint Commission International (JCI) has accredited more than 100 hospitals in 25 countries, but Japan is not among the countries listed as having any JCI-accredited organisations. To Japan’s credit, however, there is mandatory accreditation of hospitals in Japan that are reimbursed by a bundled payment mechanism called DPC by the Japan Council for Health Care Quality, but this represents less than 20 percent of hospitals in Japan, and the more than 80,000 medical clinics (many of which have 19 beds or less and often act as mini hospitals) are quite isolated from any accreditation oversight. For hospitals not reimbursed by the DPC payment method, accreditation by the Japan Council for Health Care Quality is voluntary.
Obstacles to obtaining JCI accreditation for hospitals in Japan are significant. Although JCI accreditation manuals and standards are translated into several languages, there is no current plan to publish them in Japanese. Without a comprehension of the standards by all staff within an organisation, it is difficult, if not impossible, to influence and improve corporate culture. Most hospitals in Japan, unlike those in Singapore, for example, do not have international staff, and other than physicians, have poor to non-existent English-language skills.
In Singapore, again as an example, foreign trained physicians can obtain medical licensure to practice there. In Japan, this is not possible. Patient confidence is much enhanced by being able to communicate in their native language, particularly when undergoing medical treatment and almost all patient care staff in Singaporean hospitals can speak English. Therefore, the lack of internationally accredited hospitals in Japan, as well as few multilingual healthcare providers, combined with no possibility of practice privileges for foreign-trained physicians, are major obstacles to choosing Japan as a health tourism destination.
ADVERTISING PROHIBITIONS
Japanese hospitals have others barriers as well. Since advertising is prohibited, those few hospitals maintaining an interactive website are unable to use the full potential of the internet to attract foreign patients. Most websites are only in Japanese and, when in English, are only generally descriptive and not useful in patient decision making. Costs are never revealed, nor are any quality criteria or outcomes data presented.
If one looks at the Bumrungrad or Apollo websites, the differences are readily apparent. Americans, in particular, are always interested in the qualifications of the physicians treating them. Many know that in Japan, physicians are licensed for life without a renewal mechanism and that continuing medical education is not mandatory to maintain an active medical license. Although the concept of credentialing and privileging of physicians is known here, in actual practice, in most hospitals in Japan, these programmes do not exist. Although the DPC reimbursed hospitals have a shorter average length of hospital stay than the national average of over 30 days, it is still more than twice the average in hospitals in the US and in those with JCI accreditation, which concerns patients who may be contemplating care in Japan.
PAYMENTS
While costs in Japan are lower than in the US, few hospitals have considered a fee structure for medical tourists. Japanese citizens pay a portion of their salary monthly, matched by an almost equal amount from their employer, under the mandatory national health insurance scheme. For many here, offering the same charge for healthcare to those who have not been paying into national healthcare programmes seems unfair. Therefore, a fee schedule for foreigners not covered by some form of national healthcare scheme presents a problem and fees are often arbitrarily set at a percentage of the national health insurance charges including bundled DPC charges.
Whereas those hospitals actively attracting medical tourism outside Japan can quote specific charges for procedures, the answer from most Japanese hospitals will probably be “it depends”, which is not precise enough for patient decision-making.
Accepting and processing foreign insurance claims is equally problematic for Japanese hospitals. Many foreign health insurers want copies of the medical record in English, which is not a problem in Singapore, Hong Kong and the Philippines and in internationally accredited hospitals such as Bumrungrad. Preparing medical records in English, processing claims forms in English, justifying lengths of stay two to three times longer than an insurer is willing to pay for, currency conversion issues, patient deductibles and co-payment collection and negotiating with international insurers is often extremely difficult and time consuming for Japanese hospitals.
Many physicians in Japan have adequate English-language skills, but for inpatients, the majority of hospital staff contact with the foreign patient is usually not the attending physician. These contacts are mainly nurses and also lab technicians, x-ray technicians, pharmacists and other paramedical personnel. Significant multilingual support staff can be required to maintain adequate communication with the patient and their family during the in patient stay (and outpatient encounters) to not only to ensure a high level of explanation and informed consent, but also to have a high level of patient satisfaction. This often means the hiring of translators and interpreters at additional hospital expense.
TECHNOLOGY
Another seemingly insurmountable obstacle in Japan is a technology lag. The medical-device approval process in Japan is expensive and slow and for some newer technologies, there are often delays of several years after approval in Europe and the US. Many pharmaceuticals long available outside of Japan are still not approved for use in Japan and are delayed in their introduction. This frustrates Japanese physicians trained outside of Japan in these new technologies and prevents them from offering some of these procedures to their Japanese patients here and in providing them with new pharmaceuticals.
A physician I know at Juntendo University Hospital in Tokyo practices one week a month in the US, treating Japanese patients (who can afford it) with the latest cutting-edge, life-saving procedures, using technology not yet approved for use in Japan.
Same-day surgery is common outside of Japan. It is not so common here in comparison, which contributes to long hospital stays compared to other developed countries. Organ transplants are exceedingly rare in Japan and are routine in many other countries. Thus, foreign patients are often not accepted because in many instances, cutting-edge treatment cannot be provided.
Today, many companies have been created to work with hospitals outside the US to minimise the cost, offer discounted air travel, hotel stays for families and even optional tour programs, when appropriate. Airport pick up, assistance with visa applications and VIP treatment are all part of the marketing package.
CONCLUSION
Japan seems currently incapable of providing world-class medical care as a medical travel destination because of the aforementioned obstacles and it is unlikely to be able to remove enough of them to compete in this very attractive and growing market in the foreseeable future.
In private conversations with some within the Japan Council for Health Care Quality, there appears to be no interest in cooperating with the JCI to jointly accredit hospitals in Japan, a success factor in other countries benefiting from this cooperation. The restrictions on advertising are unlikely to be relaxed anytime soon, and even provisional or limited medical license reciprocity for physicians and nurses is very unlikely.
Japan’s healthcare system is, therefore, predicted to remain a domestic endeavour providing an acceptable level of quality at a low cost to Japanese citizens and hospitals in Japan will continue to suffer from severe financial difficulties.
Medical travel would be an added revenue stream for hospitals here struggling with the bottom line, and some private hospitals on their own may attempt to access this market. Without some support from the regulatory environment, this will be a most difficult challenge even for the most proactive of Japanese hospitals.
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