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Japan: On the Treadmill, Buddy

In the U.S. we’ve debated for years whether health care should be a right. Why aren’t we also having a debate about whether maintaining health is a responsibility?

Should maintaining our health also be viewed as a moral responsibility? …or take this even further — a legal responsibility?

If this sounds far fetched, consider recent legislation passed in Japan. Writing in an editorial in the International Journal of Integrated Care, Etsuji Okamoto of the National Institute of Public Health, Japan comments:

Imagine that your waist size is measured annually and your data from annual health checkups are stored in the database. A big brother keeps track of you and dictates what you should eat and how much when it exceeds a certain limit. Not a novel by George Orwell, it is an essential part of Japan‘s health care reform 2008.

Disease management programmes (DMPs) aimed at chronic diseases with a hope of controlling cost, have become popular agenda in many countries, but Japan‘s reform plan might go too far and may stir a national debate: is health a right or an obligation? According to the reform law passed by the congress in June 2006, health insurers will be required to provide annual health checkups to all beneficiaries aged 40 to 74 years starting in April 2008 and give health guidance to those who are found to be at risk of metabolic syndrome to change their unhealthy life-style or maintain good control of their diseases.

The ambitious goal is to reduce the number of metabolic syndrome patients by at least 25% between 2008 and 2015 with a hope that health care cost may be controlled consequently.

…the goal targets 100% participation and financial penalty will be imposed to insurers whose participation rate is unsatisfactory. In a sense, the beneficiaries may be collectively penalized as a form of increased premium unless the majority of them participate in the programme.

If such universal principles are applicable to health insurance, beneficiaries carry a legal obligation to avoid diseases as much as possible. Japan‘s NHI Act explicitly states that insurers shall refuse reimbursement if disease or injury are intentionally caused by the insured (article 116) or caused by grave misconduct or negligence (article 117) and may withhold reimbursement if the insured refuses to follow doctor’s directions (article 119). Doctors are required to report to the insurers when they find such patients (Practicing Rules, article 10).

In the U.S., we readily accept rights and responsibilities as going hand in hand. You have the right to free speech, but you also have the moral and legal responsibility not to yell “fire” in a crowded theater. You have the right to drive, but you have the responsibility to obey the traffic laws.

So what’s the corollary to “health care is a right”? Why don’t we talk about a moral and/or legal obligation to stay healthy? Shouldn’t this be part of our national dialogue?

 

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5 Comments

  1. Steve Hards on March 14, 2007 at 4:40 am

    What an interesting question!

    From my reading of Japanese society, compulsion to do what is ‘good for society’ is much more acceptable than in most other countries. But what interests me is the assertion that Americans perceive that they have a ‘right’ to good health. With my UK perspective, this seems quite an alien notion.

    This post got me thinking about my constructs around good health and I realised that for the past 56 years I’ve tended to live with the assumption that good health is the normal state of things and that avoiding poor health is like surviving Russian Roulette – the longer you keep playing, the more likely it is that some serious illness is going to fire off. When I was young, it seems that hardly anyone (men, particularly) expected to survive more than a few years past the retirement age of 65. Now the expectation is that most people will reach their late 70s at least. However, the evidence seems to be that without the intervention of accident or serious illness life expectancy is determined more by ones genes than anything else. If that’s the case I’m coming round to the conclusion that we (including me!) have a responsibility to ourselves – if no one else – to do whatever we reasonably can to make our older age as healthy as possible.

    The issue you raised, Vince, just shows how culturally-determined our perceptions and responses are. The deeper question in relation to healthcare provision may be whether our cultures, politics and economies are capable of changing in the face of ‘evidence’ about systems that deliver the desirable outcomes. Hey! Can we even agree on those?



  2. Ariel Linden on March 14, 2007 at 12:27 pm

    Japan was the first country to develop the concept of worksite wellness programs which actually required employee participation. I am not sure if that is still widely applied, but it certainly laid the foundation for the current concept described here.

    From a societal perspective (especially in a country that taxes individuals as a means of paying for the provision of health care to all citizens), this holds individuals accountable for their lifestyle behaviors.

    I would argue that we are moving toward a similar concept (albeit not as draconian as this) in the US. Many employers are incentivizing employees to manage their health by reducing their monthly health insurance premiums if they can demonstrate good health, or a move toward changing lifestyle behaviors to achieve better health.

    Does this make sense? I believe so. It’s all about accountability. If I exercise, eat right, and manage my stress, I will use less health services and be more productive. Shouldn’t I get rewarded for that? Conversely, if a person has a generally unhealthy lifestyle that leads to higher health care consumption and lower productivity, should their employer (or taxpayers) pay for that? This is akin to “pay-for-performance” at the individual level. I am in support of it!



  3. Julie Meek on March 18, 2007 at 3:48 pm

    In many ways, we’re getting close to this model. In our client base, we’ve moved from 10% to now 100% of our clients charging differential insurance contributions tied to participation in health management programs. I firmly believe in tying to participation, but not to biometric results…a slippery slope indeed. Behaviorally, all I want for people to do is help us find and help people earlier with their health needs. Advance predictive modeling using survey data now permits us to find people early and link them to telephonic health coaching. So like the Japanese, now view participation in a yearly survey a social responsibility in exchange for the majority of their healthcare paid for by their employer.



  4. Vince Kuraitis on March 28, 2007 at 1:49 pm

    Israeli Editorial Weighs in on Obesity Epidemic

    …A law that recognizes obesity as a chronic disease would lead to the setting of clear criteria for the Israeli health system such criteria would make it clear which cases of obesity indeed constitute a healthy problem, rather than merely an aesthetic issue.

    This way, pediatricians would be obligated to refer those who suffer from obesity to follow-up checks and treatment even before their condition worsens. Later, we should learn from global experience and set guidelines for appropriate medical treatment for those patients.

    Shula Zack
    March 25, 2007
    http://www.ynetnews.com/articles/0,7340,L-3380891,00.html



  5. Warren Todd on March 30, 2007 at 1:21 pm

    As one of the pioneers of disease management in Japan starting back in 2000… and after three lecture tours over the past 6 years and dozens of meetings with academics, government leaders, business, etc., I am very pleased to see that these modest efforts and so pro-active “planting of seeds” has resulted in such an excellent response by the Japanese government.

    What we need to understand is the very different culture in Japan. As indicated by Mr. Linden, in Japan this type of measure is not unusal. Equally important is the powerful economic forces that necessitated this type of aggressive [by our standards] policy. Japan has one of the oldest populations in the world and concurrent suffers from a rapidly declining population that has been fueled by past incentives to have small families and more recently by the growing exodus of young workers. I do not have the statistic as my finger tips but I recall that the Japanese population may be reduced by as much 40-50% over the next 10-15 years. More old people with a small work force to pay the taxes required to provide healthcare is a major crisis that would further threaten Japan’s ability to be successful in a global economy.
    We should expect to see similar mandates [either government policy or economic incentives] like the one in Japan as the realities of the global bi-modal crisis [obesity and aging/chronic disease] “sinks in.” Also note that Australia’s government has “adopted” disease management as a cost containment strategy as well. And, as mentioned about, in the last isse [March 28, 2007 at http://www.dmalliance.org] of the IDMA DM World e-Report, Israel has reclassified obesity as a disease, similar to a move in the US last year. The US insurance industry is also now working on a new round of financial strategies to “promote” more individual responsibility for lifestyles that impact healthcare costs.

    We “an’t seen nothing yet.”

    For more insights into DM in Japan, IDMA offers a free presentation by Yuji Furui, Ph.D, University of Tokyo, Tokyo, Japan entitled, “Case Study of Disease Management Program in Japan,”
    [http://www.dmalliance.org/index.php?page=home]