road to uhc and beyond: japan ’ s 50-year experience
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Road to UHC and Beyond: Japan ’ s 50-year Experience. 10 th Anniversary Conference Towards Universal Health Coverage: Increasing Enrolment Whilst Ensuring Sustainability Tomoko Ono OECD Health Division Accra, 5 th November, 2013. Tokyo Station. Tokyo Tower. Sky Tree. - PowerPoint PPT PresentationTRANSCRIPT
Road to UHC and Beyond: Japan’s 50-year Experience
10th Anniversary ConferenceTowards Universal Health Coverage: Increasing Enrolment Whilst Ensuring Sustainability
Tomoko Ono OECD Health DivisionAccra, 5th November, 2013
1920s: Introduction of Health Insurance Scheme1961: Achievement of Universal Health Coverage
2011:50th Year Anniversary of Achieving UHC
Tokyo Station Tokyo Tower Sky Tree
UHC helped Japan to achieve good health results with relatively low health expenditures
Outline of Presentation
• Health system of Japan at a glance
• Financing: Multiple insurances schemes
• Payment: FFS with unified fee-schedule
• Current challenges
Health System of Japan at a Glance
6
Recap historical development
1922: Health
insurance law
1956:30% not
covered
1945: End of WWII
1938: National
Insurance law
1958:National
insurance law
(mandate)
Universal Health Coverage
Population coverage: •100% achieved in 1961
Cost coverage: •82% by government or social security in 2011
Service coverage: •Outpatient, Inpatient, Dental, Pharmaceuticals
Source: WHO, World Health Report 2013
Key Feature of Health Systems
• Financing: • Multiple health insurance schemes, contribution + general
tax + co-payment (with ceiling and exemption for low-income group)
• Payment: • Managed FFS system through unified fee-schedule for all
providers/insurance schemes in Japan• Service delivery:
• Predominantly private providers (although public providers exists)
• Roles of hospitals/clinics and GPs/specialists functions are not well defined in practice
• Access: • Free choice of provider by patients (no gate keeping)
Health Insurance Schemes
4 Different Insurance Schemes
• Over 3,000 insurance plans in Japan, grouped into
• Citizens’ Health Insurance (CHI): farmers, self-employed, unemployed and elderly (later separated)
• National Health Insurance Associations (NHIA): mainly small and medium enterprise employees and their dependent
• Society Managed Health Insurance (SMHI): mainly employees of large firms and their dependent
• Mutual Aid Association (MAA): mainly public sector employees and their dependent
• Limited role for private insurance
Achieving Universal Coverage
Source: Takagi 1994, World Bank 2013 (forthcoming)
UHC in
1961
UHC: Citizen’s Health Insurance’s Role• Historical Development of CHI
• Build upon the existing community-based health insurance scheme: voluntary participation and expanded through government subsidies
• Participation was mandated in 1961 for all residents, management moved to municipalities
• Current financial sources: contribution from beneficiary, cross-subsidy from other schemes, subsidies from national and local government and copayment
Revenues for Social Health Insurance
CHI NHIA SMHI MAA
Individual
Elderly
EmployeeGovernment
cross-subsidies
Individual
Individual
Individual
Individual
Financial Sources for Health Services
UHC
Managed FFS System with Unified Fee-Schedule
Single Payment System: Fee-Schedule• Fee-schedule
• Sets prices for each services, pharmaceuticals and devices for virtually all providers
• Defines the benefits and conditions for reimbursement• Auditing for these conditions• For most providers, these are the only sources of
revenue
• Fee schedule revisions (every 2 years)• Managed by national government• Institutionalized process of negotiating benefits and
resource allocation among key stake holders• Continuous process of adaptation and adjustment
Biennial Fee-Schedule Revisions
Ministry of FinanceMinistry of
Health, Labour and Welfare
Macro: Global Revision Rate
Medical services PharmaceuticalsMedical devises
Central Social Insurance Medical Council
Micro: Fee negotiation for item-by-item
Government
Pharmaceuticals Pricing Mechanisms
• In 1982, 39% of national medical expenditure was spent on pharmaceuticals.
• It went down to 27% in 1988 and 21% in 1998, then went up again to 25% in 2009
• We set a price in fee schedule, but providers purchase products for which bigger discounts can be negotiated and earned.
• Government conduct survey of pharmaceutical prices of each products and set new fee schedule price at a certain percentile.
Cost Containment Mechanism
• Cost containment tools• Price control via negotiation, by monitoring volume• New technology - setting the initial price low,
restriction to patients with specific conditions
• Other restrictions• Balanced-billing (charging more than the fees set
in the fee schedule): banned• Extra-billing (billing services and pharmaceuticals
not listed in the fee schedule with those listed): only allowed for amenity and a few new technologies still being evaluated
Current Challenges
Slow economic growth and increasing social security expenditure
-6
-4
-2
0
2
4
6
8
10
12
14
1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010
average 4.5% in 1970-90
average 0.9% in 1990-2011
average 9.6% in 1955-70%
10
12
14
16
18
20
22
-4
-2
0
2
4
6
8
1990 1995 2000 2005 2010
Real GDP growth (left)
Social security expenditures / GDP (right)
% %
Real GDP Growth RateReal GDP Growth Rate and Social
Security Expenditures
Source: Cabinet Office of Japan
Ageing Population and Inequality between Insurance Schemes
Age structure of CHI beneficiary, 1975, 2001 and 2007
Take Home Message
UHC in Japan was achieved through...
• Long-term political commitment for UHC, supported by political groups with different ideologies
• Democratic movements and commitment to social solidarity in post-war Japan provided impetus to expand coverage
• Incremental expansion of health insurance coverage
• Harmonization of benefits and established redistribution schemes
Cost Containment despite FFS system
• Institutionalized fee-schedule revision process• Global revision rate• Item-by-item fee negotiation: mitigate
increase in expenditure, maintain appropriate solvency for providers, and reflect government priority
• Stringent and disciplined payment system • Unified fee-schedule for all health services and
conditions of its use• Ban on balanced-billing and restriction on
extra-billing
Acknowledgement:Ghana Health Insurance AuthorityProf. Naoki Ikegami, Keio University School of MedicineJapan-World Bank Partnership Program on UHC
Kagoshima, JapanNiigata, JapanKyoto, Japan
Acknowledgement for picture
• Slide 2
• Tokyo Station http://www.oldphotosjapan.com/ja/photos/78/tokyo-eki
• Tokyo Tower http://showa.mainichi.jp/photo/2008/12/post-1b55-23.html
• Sky Tree
• Slide
• Niigata, http://uonuma.biz/blog/9927
• Kyoto, http://futuretihing.net/futurething/wp-content/uploads/2013/08/63bf16f29e082d9d510aac6e4fd47ea6.jpg
Total Health Expenditure (% of GDP)
Source: OECD, Health at a Glance 2011
Total Expenditure on Health in 2011 by type of financing
Real GDP and GDP per Capita(in 1990 Geary-Khamis Dollar)
Billions of $
Attainment of Universal Health Coverage (1961) ($420B, $4291per
capita)
$ per capita
Source: Angus Maddison (2001) “ The World Economy – A Millennial Perspective”
Real GDP (left)
GDP per capita (right)
1985198019751970196519601955
30
Japan attained UHC while still a middle income country, and at the start of its rapid economic growth period
30