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The Japanese Healthcare System: Same Crisis, Different Country

Japan is completely different from the United States.  But it’s exactly the same.

I’m talking about health care, of course.

Japan is a country of about 130 million people, and one of the richest countries on Earth.  They enjoy a system of universal health care coverage, and some of the best doctors in the world.  But there are problems.

The country is is straining under the twin burdens of an aging population and rising health care costs.  At some point in the next two decades, retirees will outnumber active workers.   Medical expenses per person have almost doubled since the 1990s and continue to rise.   In a country with little immigration and low birth rates, it’s a bad combination.

The government’s response has been to try to limit what it spends on health care.  To simplify the situation, Japanese have a mandatory co-payment of 30% of all medical expenses, with some types of treatments or diagnostic testing not covered at all.  There is talk that the financial burden on individuals may increase.  It’s one of the reasons that private insurance policies that give cash payments in the event of illness are especially popular in Japan.

In terms of access to care, there have been other issues.  It can be difficult to see a specific doctor at a specific hospital because of well-meaning efforts to keep every doctor busy.  Some doctors and patients have responded by joining private, membership-only clinics where those with the ability to pay can get VIP access to the doctors they want to see.

More generally, Japan has been suffering from shortages of certain specialists, like obstetrics.  It happened because the government miscalculated the need for these specialists over the last couple of decades.  In the last year, there was a major controversy over a case in which a pregnant woman suffering from a cerebral hemorrhage was rushed to a hospital in an ambulance but was turned away by 7 successive hospitals because of the lack of OB support to help her. She was finally taken in by the 8th hospital and died there — the baby survived. There have been other stories like this, raising questions about both the government’s role in picking the right number of doctors to fund in Japanese medical schools and the way in which hospitals treat patients in need of help.

But in each of these areas – and others – the story is very familiar.  The equitable and affordable distribution of health care services is a problem across the globe.  And so the work we do at Best Doctors to help people is just as needed.  When you’re sick, no matter where you are from, you want to feel confident that you are getting the right care.  I think it’s something we are all entitled to have.  The millions of Japanese with access to Best Doctors are a testament to this.

Yesterday, I had the chance to visit with some of the Best Doctors team in Tokyo, executives and clinicians dedicated to helping people get the right care.  They do extraordinary work, and you can see some of them pictured below.  Over the next few days I’ll be seeing some of the most renowned physicians in Japan — not as a patient! — and will share some of their insights on this fascinating country and medical culture.

*This blog post was originally published at See First Blog*

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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