Health insurance systems in Japan: a neurosurgeon's view.
Health insurance systems in Japan: a neurosurgeon's view.
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日本的健康保险体系：神经外科医生的观点。
DOI：
10.2176/nmc.44.617
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发表时间：
2004
影响因子：
1.9
通讯作者：
Masanori Ito
中科院分区：
文献类型：
--
作者：
Masanori Ito
从神经外科医生的角度比较日本和美国的健康保险制度。日本全体人口都参加了强制性的健康保险，没有选择的基础上就业和居住，称为“健康保险为所有人。“为70岁或70岁以上的老年人提供的老年人健康保险是在每个卫生组织内制定的。由于各医疗保险机构的财务状况各不相同，因此需要进行财务调整。医疗费用是由医疗保险支付的所有程序和产品的价格。同样的收费表适用于私人执业医生和医院。在美国的医疗体系中，有许多收费表，包括医生费和住院费。严格禁止对费用表中未列出的程序或材料收取任何额外费用（余额计费）。有一个例外条款，被称为指定医疗费制度（日语中的“Tokutei Ryoyohi”）。某些指定项目可以例外地通过健康保险费用表支付。许多日本神经外科医生对在其他国家已经安全使用的医疗材料缺乏批准表示不满。追溯性索赔审查过程包括中介机构、充当供应商付款人的准公共组织和索赔审查委员会。同行评议委员会由大约8,000名医生组成。使用相同的统一收费表的计费过程本身非常简单，有助于减少对训练有素和高薪管理人员的需求，并控制日本的行政成本。大部分医疗费用被少数接受高成本医疗的患者消耗。老年人医疗支出已占全国卫生支出的1/3，预计到2025年将占全国卫生支出的1/2。对高成本护理有灾难性的覆盖，或者对每月共同支付的支出有上限（高价医疗费制度：Kogaku Ryoyohi Seido）。为了在21世纪少子老龄化社会中保持可靠稳定的医疗保险制度，必须对所有制度进行根本性改革。
The health insurance system in Japan is compared to the U.S. system from a neurosurgeon's perspective. The Japanese entire population is enrolled in mandatory health insurance without choice based on employment and residence, called "Health-insurance-for-all." Elderly Health Insurance for senior people aged 70 years or older is set within each health organization. As the relative financial conditions are variable among health insurance organizations, financial adjustment is done. The medical fee is set for all the procedures and products that are paid by health insurance which sets the prices. The same fee schedule applies to both private-practice physicians and hospitals. In the U.S. system, there are numerous fee schedules including both doctor fees and hospital fees. Any extra charges (balance billing) for procedures or materials that are not listed in the fee schedule are strictly prohibited. There is an escape clause that is called the specified medical fee system ("Tokutei Ryoyohi" in Japanese). Some designated items can be exceptionally paid by health insurance fee schedule. Many Japanese neurosurgeons express dissatisfaction with the lack of approval for medical materials which have already been used safely in other countries. The retrospective claim review process includes intermediaries, quasi-public organizations that act as payment makers to providers and claim review boards. Peer-review boards consist of about 8,000 physicians. The billing process itself using the same, uniform fee schedule is very uncomplicated, and has helped to diminish the need for well-trained and well-paid managers, and controlled administrative costs in Japan. Most medical expenses were consumed by a few patients who underwent high-cost medical care. Medical expenditure for the elderly is already taking 1/3 of national health expenditure, and is projected to reach 1/2 of national health expenditure by the year 2025. There is catastrophic coverage for high-cost care or a cap on monthly co-payment spending (High-Priced Medical Fee system: Kogaku Ryoyohi Seido). To maintain reliable and stable medical insurance systems in the aging society with fewer children in the 21st century, it is essential that fundamental reform is introduced across all systems.