Richard Smith on learning from health systems in Asia

Richard Smith It depresses me that despite the spread of the internet we are still most of us stuck in our intellectual and geographical silos. Why, I wondered at a conference in California last month, do we hear in Britain so little about Asian systems when they have so much to teach us?

Japan, unlike most countries, is succeeding in containing health costs and providing comprehensive long term care despite having the world’s oldest population. And Singapore, having started as an ex-British colony, has moved right away from relying
on the state to self reliance and manages to provide high quality care to all for just 3.6% of its gross national product (in case you’ve forgotten, it’s about 9% for Britain).

Naoki Ikegami, professor of health policy and management at Keio University in Tokyo, explained how Japan has managed to contain health care costs. It spends 8% of its GDP on health care and yet has no waiting lists and rapid diffusion of new technologies.

Indeed, the spread of new technologies may be too rapid, in that the country had the highest rate of CT and MRI scans in the world. Japan’s policy makers don’t believe that it’s possible to contain demand for health care. Instead, they control the supply side and are able to do so by controlling fees to hospitals and doctors. They can do this because all “money flows through a single pipe from all payers to all providers” and extra billing is prohibited.

The Japanese are subtle in how they control fees, and they target individual items. Thus they cut the fees for CT and MRI scans by 30% in 2002. Consequently far fewer were done.

As somebody in the audience pointed out, controlling fees in the US through the payments for patients on Medicare hasn’t contained health care costs, but, answered Ikegami, Medicare is only one system among many whereas Japan has control of all fees.

We can learn also from the mistakes of Japan. In 2008 the government introduced a new insurance plan for those over 75: they had to leave their existing plan and join the new one. It had the unfortunate name of “Health insurance for the later period of life” and soon became known as “hurry up and die insurance.” The government also introduced a payment for a one hour consultation to discuss end of life issues, again giving the idea that the sooner the old died the better. This is, however, a good idea and should, suggested Professor Ikegami, have been introduced for everybody—doing so would have avoided the accusation of ageism.

The government had to retreat from its new plan, but Japan has comprehensive, government led, long term care, and Professor John Creighton Campbell from the University of Michigan, argued that experience from Japan and Germany shows that comprehensive care is “affordable, doable, and controllable.”

This is achieved in Japan in part, said Professor Ikegami, by making a “Copernican” shift from a health care system to a long term care system. Within the health care system services become medicalised, the public expects “the best available,” expensive professional staff (especially doctors) have the dominant role, and patients have limited choice. In the long term care system, in contrast, services include lots of social care, the public expects “decent care,” cheaper staff are dominant, and clients have more choice. This shift might upset some geriatricians, but Professor Creighton Campbell, showed that comprehensive long term care is not available in the US because of the dominance of medical costs.

Then how is it that Singapore manages to spend such a small proportion of its GDP on health care and yet have such good outcomes? Partly it’s that it’s a country of young people (although aging rapidly) and has a big GDP—Singapore now has one of the highest incomes per capita in the world, well ahead of Britain. But it’s also the shift to self reliance. Singaporeans have Medisave (a compulsory savings plan with the money being spent only on their care or that of their family), Medishield (a catastrophic insurance plan), and Medifund (a health endowment fund).

The proportion of public spending on health care has fallen from around 50% in 1965 to around 20% now, but importantly the whole system is underpinned by a promise from the government that nobody will go without care. In broad terms, taxes pay for public health (always a good investment), out of pocket payments for primary care, savings for acute care, and insurance for catastrophic care.

The move to self reliance is based on a philosophy that underpins all of Singapore: “Singapore believes that welfarism is not viable as it breeds dependency on government. It has adopted a policy of copayment to encourage people to assume responsibility for their own welfare, although the government does provide subsidies in vital areas like housing, health, and education.”  This is, of course, very different from the British philosophy.

Other reasons that Singapore gets so much for so little, said Kai Hong Phua from the Lee Kuan Yew of School of Public Policy, are low utilisation rates, extensive use of nurses, tight management of incentives for doctors, and low administration costs because everything is computerised. It may well be that ancient Britain is just too different from young Singapore to learn much that’s useful, but I suggest that we pay much more attention to Asia—not least because Japan and Korea will be the first countries in the world to have to cope with large numbers of elderly people relative to young people.