Japan: Economics in Everyday Life

18. Why Do Doctors Prescribe So Many Pills?

18 Why Do Doctors Prescribe So Many Pills? Akihiko Kawaura and Sumner J. LaCroix A visit to the doctor in Japan is rarely complete until the doctor has prescribed large amounts of medicine to treat the patient’s condition. Chances are good that the patient will leave the doctor’s office with several prescriptions. It is relatively common to see a patient receiving as many as four to five kinds of pills, packets, and capsules to take three times a day. Why do Japanese doctors prescribe so many drugs? It is certainly not because Japanese patients have a peculiarly high demand for medicine. The answer is likely to be found by focusing on the behavior of doctors. We believe that the intensive use of drugs in Japan is primarily due to the incentives offered to Japanese doctors practicing under the country’s health insurance system. Share of Drug Expenditures in National Health Care Spending One distinctive feature of Japanese medical spending is that expenditures on medicine have constituted a very high percentage of total health care spending. It is estimated that in the early 131 1970s more than 40 percent of the total health care bill was accounted for by prescription and injectable drugs. Although the expenditure share of drugs had fallen to 27 percent by 1994, Japan’s per capita use of the latest generation of antibiotic drugs is greater than anywhere else in the world. In the United States, the spending on drugs amounted to about 11 percent of health care expenditures in 1993. If we adjust for differences in health care expenditures per person across the two countries, we still find that the Japanese spend a larger proportion of gross domestic product (GDP) on medicine than Americans. Screening a New Patient One of the reasons for the emphasis on prescriptions in Japan is that Japanese doctors are inundated with patients. In 1961, Japan established a health insurance system that covered its entire population (see chapter 21). There are currently three main sources of health insurance: (1) public and private insurance plans for employees and their dependents, (2) public insurance plans for self-employed persons and their dependents, and (3) a public insurance plan for senior citizens. In 1992, patients shouldered about 12 percent of health care spending, with the remainder picked up by the three insurance plans. These insurance systems have reduced the out-of-pocket cost to a patient visiting a doctor. The result is that doctors are flooded with patients. The average physician in a clinic in Japan sees three to four times more patients per day than a U.S. physician . In order to manage this flood of patients, doctors in Japan use simple medications to screen patients with more serious conditions. For example, when a doctor treats a patient with flu symptoms , he usually begins by dispensing ordinary medicines that control the fever, runny nose, and cough. At this stage, he does not spend too much time hearing about the new patient’s problem , since doing so will make it impossible to see all the other 132 Japan: Why It Works, Why It Doesn’t patients waiting for him. Physicians typically spend an average of three to five minutes with each patient. By comparison, a typical doctor in the United States spends twenty minutes with each patient. Many doctors do not give appointments to patients in Japan, so patients have to wait their turn. At major Japanese hospitals, patients sometimes wait one to three hours to see a doctor. Essentially, most patients presenting relatively routine symptoms are sent away quickly with several prescriptions. This enables the doctors to ration their large patient loads and is one of the reasons behind the extensive use of prescriptions in Japan. Not surprisingly, patients with serious health problems will return after a few days because the first set of pills was ineffective in alleviating their problems. Doctors spend more time with each patient at the second visit to determine whether the illness is serious. Government Policy toward Professional Medical Service Another factor behind the high spending on drugs in Japan is the bias in public policy against other types of medical care. Insurance funds reimburse doctors according to points (one point is worth 10 yen) specified by the Ministry of Health and Welfare (MOHW). The points have been biased in favor of drug prescription and have discouraged doctors from spending a lot of time with...