Health insurance and payment systems for severe acute pancreatitis

The medical insurance system of Japan is based on the Universal Medical Care System guaranteed by the provision of the Article 25 of the Constitution of Japan, which states that “All the people shall have the right to live a healthy, cultural and minimum standard of life.” The health insurance system of Japan comprises the medical insurance system and the health care system for the long-lived. Medical care insurance includes the employees’ health insurance (Social Insurance) that covers employees of private companies and their families and community insurance (National Health Insurance) that covers the self-employed. Each medical insurance system has its own medical care system for the retired and their families. The health care system for the long-lived covers people of over 75 years of age (over 65 years in people with a certain handicap). There is also a system under which all or part of the medical expenses is reimbursed by public expenditure or the cost of medical care not covered by health insurance is paid by the government. This system is referred to collectively as the “the public payment system of medical expenses.” To support the realization of the purpose of this system, there is a treatment research enterprise for specified diseases (intractable diseases). Because of the high mortality rate, acute pancreatitis is specified as an intractable disease for the purpose of reducing its mortality rate, and treatment expenses of patients are paid in full by the government dating back to the day when the application was made for a certificate verifying that he or she has severe acute pancreatitis.     

The HELP system for the treatment of atherothrombotic disorders: a review

Given the importance of atherothrombotic disorders for the public health system, and the known limitations of conventional treatment on one hand and the compelling biochemical evidence and long-term safety of HELP (Heparin-mediated Extracorporeal LDL/Fibrinogen Precipitation) apheresis on the other hand, this approach provides a most valuable tool for further medical research and treatment of the various atherothrombotic and microcirculatory disorders. The present contribution reviews the recent developments in chronic and single application of apheresis in cardiology with particular emphasis on the newly discovered therapeutic possibilities for myocardial infarction, stroke, and after coronary artery bypass grafting.     

Current issues on ageing in Japan: A comparison with Australia

Japan's demography has changed dramatically, and with it, Japanese society and the circumstances of older people. These changes include shifts in family roles and functions, employment and social relations. Traditionally, families provided financial, physical and psychological support to their parents in the same household. While the proportion of older Japanese who live with adult children is still high in comparison to the rate in Western developed countries, patterns of care in Japan are gradually shifting towards the Western model. Public pensions supply financial support and the Long‐Term Care Insurance System (LCIS) provides substantial physical care for frail older people. This paper focuses on current issues for older people in Japan, and provides a brief comparison with the situation in Australia. Japan's LCIS provides a simpler and more consistent basis for funding long‐term care than Australia's system. On the other hand, Australia's pension system is comparatively robust.     

建立农村医疗保险使艾滋病关怀工作可持续发展

目的 在艾滋病关怀项目地区建立可行的医疗保障制度,解决艾滋病病人机会性感染治疗的费用问题。使艾滋病关怀支持工作真正落到实处。方法 分析现行的农村医疗保障制度难以运行的原因,提出新的农村医疗保障制度并分析其可行性。结果 在艾滋病关怀项目实施地区,过去曾有的合作医疗经过几起几落在很多农村县已经很难重建或发展。农民实际上完全处在无任何医疗保障状况之中。建立农村储蓄式医疗保险,是让全体农民通过医疗储蓄加入保险,保险通过透支的保险政策达到风险共担,政府按财力建立超常风险基金,从而形成适合农村的社会医疗保险。艾滋病纳入医疗保险报销范围,家庭困难的艾滋病病人及家庭进入特困户,由政府或集体代交保费,从而使艾滋病关怀工作可持续性发展。结论 在中英艾滋病关怀支持项目结束后,艾滋病病人和一般农民一样需要一种可以信赖的、能够付得起的医疗保健制度来实现疾病风险的分担。储蓄式医疗保险在中等及以上经济水平的地区具有可行性,它可以通过解决农村医疗保障制度的方式解决艾滋病病人的医疗费用负担。     

Health insurance system and payments provided to patients for the management of severe acute pancreatitis in Japan

The health insurance system in Japan is based upon the Universal Medical Care Insurance System, which gives all citizens the right to join an insurance scheme of their own choice, as guaranteed by the provisions of Article 25 of the Constitution of Japan, which states: “All people shall have the right to maintain the minimum standards of wholesome and cultured living.” The health care system in Japan includes national medical insurance, nursing care for the elderly, and government payments for the treatment of intractable diseases. Medical insurance provisions are handled by Employee’s Health Insurance (Social Insurance), which mainly covers employees of private companies and their families, and by National Health Insurance, which provides for the needs of self-employed people. Both schemes have their own medical care service programs for retired persons and their families. The health care system for the elderly covers people 75 years of age and over and bedridden people 65 years of age and over. There is also a system under which the government pays all or part of medical expenses, and/or pays medical expenses not covered by insurance. This is referred to collectively as the “medical expenses payment system” and includes the provision of medical assistance for specified intractable diseases. Because severe acute pancreatitis has a high mortality rate, it is specified as an intractable disease. In order to lower the mortality rate of various diseases, including severe acute pancreatitis, the specification system has been adopted by the government. The cost of treatment for severe acute pancreatitis is paid in full by the government from the date the application is made for a certificate verifying that the patient has an intractable disease.     

Japanese universal health coverage: evolution, achievements, and challenges

Japan shows the advantages and limitations of pursuing universal health coverage by establishment of employee-based and community-based social health insurance. On the positive side, almost everyone came to be insured in 1961; the enforcement of the same fee schedule for all plans and almost all providers has maintained equity and contained costs; and the co-payment rate has become the same for all, except for elderly people and children. This equity has been achieved by provision of subsidies from general revenues to plans that enrol people with low incomes, and enforcement of cross-subsidisation among the plans to finance the costs of health care for elderly people. On the negative side, the fragmentation of enrolment into 3500 plans has led to a more than a three-times difference in the proportion of income paid as premiums, and the emerging issue of the uninsured population. We advocate consolidation of all plans within prefectures to maintain universal and equitable coverage in view of the ageing society and changes in employment patterns. Countries planning to achieve universal coverage by social health insurance based on employment and residential status should be aware of the limitations of such plans.     

Guardianship for adults in Japan: Legal reforms and advances in practice

Major law reforms in Japan established a new system of guardianship for adults that took effect from early 2000, coinciding with the introduction of Japan's new long‐term care insurance scheme. The new legislation created a new form of advisership, alongside reforms to existing curatorship and guardianship, and introduced voluntary guardianship. Replacing the traditional system based on incompetence and quasi‐incompetence, the new system is based on respecting the autonomy of a principal as far as possible, in common with developments in other countries. After setting the context of the reforms, this paper gives with an account of the reform process and then outlines the structure of the new provisions and reports on their early operation. In concluding, some observations are made on the application of the adult guardianship to consent to medical treatment on the part of patients with dementia, an issue that remains unresolved.     

Elderly long-term care in Korea

The national mandatory elderly long-term care insurance (LTCI) was established in Korea in July 2008. One year after introduction of the LTCI, 5.2% of the elderly population aged 65 years and older were beneficiaries. The applicant's caregiver(s) submit an application form along with a statement of a doctor's medical opinion to the National Health Insurance Corporation, after which one or two National Health Insurance Corporation staff members (either a nurse or social worker) visit the applicant's house to evaluate their physical and mental status.The majority of beneficiaries are reported to have one or more chronic conditions. The problem is that national LTCI and national medical insurance are separate now in Korea. However, it is almost impossible to separate long-term care and health care. Even though long-term care facilities contract physicians or hospitals to have physicians visit care facilities regularly, the reward for these physicians is not satisfactory and sometimes they work without pay. Furthermore, contracted physicians cannot properly manage the elderly in long-term care facilities because they are not legally allowed to provide any medical services to long-term care facilities except for prescribing medicine.The efficient linkage of long-term care and health care is a big task in Korea that is under discussion by full-time physicians working for long-term care facilities.     

艾滋病病人机会性感染救治保障机制研究

目的分析中国艾滋病病人机会性感染救治保障机制的现状及存在问题,为进一步完善该机制提供建议。方法采取定量和定性调查相结合的方法。结果中国制定了＂四免一关怀＂等机会性感染医疗费用减免政策,并结合医疗体制改革要求通过医保、救助等进一步减轻费用负担。各地主要采取了医保和新农合报销补偿政策倾斜、定额医疗补助、医疗救助以及直接减免部分治疗费用等4种方式落实减免政策。目前仍存在缺乏对病种、临床路径的明确界定,医疗费用减免措施尚未覆盖所有贫困患者,医疗保障水平仍较低,救治保障资金缺口较大等问题。结论建议明确纳入医疗保障范围的常见机会性感染病种等机会性感染治疗服务体系中存在的问题;短期可通过城乡医疗救助,长期可通过将机会性感染纳入重大疾病保障;建立分级负担、多渠道的机会性感染医疗保障经费筹措机制;加强艾滋病治疗定点医疗机构的综合诊疗能力建设;进一步开展相关专题研究等。     

The impact of health insurance coverage on pediatric diabetes management

AimsTo examine the association between health insurance coverage, insulin management plans, and their impact on diabetes control in a pediatric type 1 diabetes mellitus clinic population.MethodsRetrospective cohort design drawn from the medical records of the Pediatric Endocrinology Clinic at the University of Louisville, Kentucky.ResultsOut of 701 patients, 223 had public insurance, and 478 had private insurance. 77% of publically insured used two or three injections per day vs. 40% private. Conversely, 58% of privately insured used a multiple daily injection (MDI) plan or insulin pump (vs. 21%). 84% of MDI patients had private insurance with 93% using insulin pens compared with 38% of publically insured. Mean HbA1c was 8.6% for privately insured vs. 9.8% public, p < 0.0001. Privately insured MDI and pump patients had the lowest HbA1cs.ConclusionsInsurance type had a significant effect on the insulin management plan used and was the most significant factor in overall diabetes control. Limitations on insulin pen use and number of glucose test strips may play a role in the decreased use of MDI/insulin pumps by publicly insured patients. Addressing factors related to insurance type, including availability of resources, could substantially improve diabetes control in those with public insurance.     

The basics of medical malpractice: a primer on navigating the system

Medical malpractice with its associated costs, including insurance premiums, impact on practice, consequences for career and insurability, and emotional toll, is a reality of practicing medicine in the United States. Understanding the types of claims that may be asserted, the issues to consider when securing insurance coverage, how to manage the cost of insurance, the nuances of the claims process, and the implications of the claims process are critical to the successful management of this aspect of medical practice. This article provides a guide for practicing physicians on the legal, financial, and practical considerations involved.     

The combination of "Careworks" insurance plan integrated with medical and long-term care insurance

The social security system in Japan was greatly revolutionized when the long-term care insurance plan began in April 2000. Thus, Japan began the 21st century with two great social insurance plans, that is, medical care insurance and long-term care insurance. Each delivery system is divided: the medical care insurance plan is for the acute stage, and the long-term care is for the chronic stage. Both systems can be intended to cooperate to provide continuous care throughout life. The public health and welfare system has been trying hard to efficiently integrate the medical and long-term care insurance plans. However, it is necessary to establish a new insurance plan for ensuring the integrated adequacy of both insurance systems. One's life is destined to shift from medical care to long-term care at some point. As one ages or becomes disabled, it becomes difficult to lead an independent life with self-decision, and social support become necessary from third parties, instead of from the family or from one's own means. The society imposes the responsibility of payment of the medical and long-term care plan premiums on the individual throughout life. However, the structure of these insurance foundations should be combined under an integrated system, "Careworks", in order to also combine the concepts of length of life from the medicine and the respect of living from the long-term case to improve the social security of the life.     

The burden of cirrhosis and impact of universal coverage public health care system in Thailand: Nationwide study

Background and rationale. Cirrhosis is responsible for significant health-care costs and morbidity. This study aims to evaluate the burden of illness associated with cirrhosis, its impact on the universal coverage public health care system in Thailand.Material and methods. We used data from the 2010 Nationwide Hospital Admission Data, the National Health Security Office (NHSO), Thailand. Their baseline characteristics, hospital costs, and outcomes were analyzed according to national health insurance categories including medical welfare scheme (MWFS), social security scheme (SSS) and civil servant medical benefit scheme (CSMBS).Results. 92,301 admissions were eligible for analysis. The mean age was 55 ± 12.8 years, and 63.3% of patients were above 50 years old. The majority of patients (79%) belonged to the MWFS group. The MWFS group incurred the lowest medical expense and had the shortest hospital stay compared to the SSS and CSMBS groups. Overall in-hospital mortality was 10.7%. Cirrhosis complications include bleeding esophageal varices, spontaneous bacterial peritonitis, hepatic encephalopathy, hepatorenal syndrome, and hepatocellular carcinoma. These complications significantly increased mortality rates compared to patients without complications (26 vs. 8.9%, p < 0.001). In-hospital mortality of patients with cirrhosis complications did not differ among the three national health insurance groups. Respiratory failure and septicemia were associated with the highest risk of death (HR 5.4; 95% CI: 4.8-5.9 and HR 5.2; 95% CI: 4.9-5.6 respectively; P < 0.001).Conclusions. Illness associated with cirrhosis is a significant public health problem in Thailand. Outcomes of cirrhosis complications did not differ between universal public health care coverage systems in Thailand.     

Strategic Outlook toward 2030: Japan's research for allergy and immunology – Secondary publication

Strategic Outlook toward 2030: Japan's Research for Allergy and Immunology (Strategy 2030) is the national research strategy based on Japan's Basic Law on Measures Against Allergic Diseases, a first of its kind worldwide. This strategy was established by a multi-disciplinary committee consisting of administrators of the Ministry of Health, Labour and Welfare of Japan, young and senior experts from various research societies and associations, and representatives of patient and public groups. Whereas the issues of transition, integration, and international collaboration have yet to be solved in this research realm in Japan, identification of unmet needs, digitization of information and transparent procedures, and strategic planning for complex problems (a process dubbed MIERUKA by the Toyota Way) are crucial to share and tackle the same vision and goals. The committee developed three specific actions focusing on preemptive treatment, interdisciplinarity and internationality, and life stage. The real success of Strategy 2030 is made by the spontaneous contributions of doctors, dentists, veterinarians, and other medical professionals; basic and clinical research scientists, research supporters, and pharmaceutical/medical device companies; manufacturers of food, healthcare, and home appliances; and patients, their families, and the public. The hope is to establish a stable society in which people can live long, healthy lives, as free as possible from allergic and immunological diseases, at each individual life stage. This article is based on a Japanese review first reported in Arerugi, introduces the developmental process and details of Strategy 2030.     

The medical insurance system’s weakness to provide economic protection for vulnerable citizens in China: A five-year longitudinal study

ObjectivesLittle is known about the magnitude of catastrophic health expenditure (CHE) attributable to critical disease, especially in the middle-aged and elderly population. This research aimed to exploring the key aspects of how the health insurance fails to protect the middle-aged and elderly against CHE in the past five years. And propose corresponding measures to improve.MethodsData were obtained from the 2011 to 2015 China Health and Retirement Longitudinal Study. The method was adapted from WHO to calculate the catastrophic health expenditure (CHE) and impoverishment by medical expense (IME), and use Generalized Linear Mixed Models (GLMMs) to comprehensively analyze the risk factors that cause middle-aged and elderly people to fall into CHE.ResultsThe incidence of CHE of China’s middle-aged and elderly population has been rose in the five years from 2011 (10.5 %) to 2013 (17.5 %) to 2015 (19.7 %). The CHE of richest families was almost 6 times from 2011 to 2015. Urban Employee Medical Insurance Scheme, the incidence of CHE was up 10 percentage from 2011 to 2015. According to the GLMMs, families have inpatient cares as the most important factor to CHE. The incidence of CHE increased by 2.25 times compared with those who did not use inpatient services.ConclusionsThe health system needs to control the irrational growth of health expenses and reduce residents’ overuse of health services. Government should take supplementary measures to comprehensively strengthen the advantages of health insurance. Raise residents' awareness of health care, enhance citizens' physical fitness, and avoid unnecessary waste of health resources.     

2009年全国肺结核门诊诊疗费用在不同医疗保障制度中的报销情况分析

目的 了解肺结核门诊诊疗费用在不同医疗保障制度中的报销情况。 方法 利用2010年《全国结核病防治规划（2001-2010年）》终期评估工作收集的2009年全国2631个县（区）肺结核门诊诊疗费用在3种不同的医疗保障制度（新型农村合作医疗制度、城镇居民基本医疗保险制度和城镇职工基本医疗保险制度）中报销的相关数据,对能否报销、是否制定了报销规范,以及报销比率与额度进行分析。 结果 在3种不同的医疗保障制度中,能报销的县（区）比率依次为51.1%（1324/2592）、21.8%（561/2575）和27.5%（705/2568）;制定报销规范的县（区）比率依次为83.5%（1106/1324）、70.4%（395/561）和73.9%（521/705）;报销比率的中位数依次为40%（P₂₅：30%,P₇₅：50%）、50%（P₂₅：40%,P₇₅：60%）、75%（P₂₅：65%,P₇₅：85%）;报销额度的中位数依次为490元（P₂₅：215元,P₇₅：600元）、500元（P₂₅：100元,P₇₅：800元）、825元（P₂₅：450元,P₇₅：2000元）。 结论 在我国现有的肺结核诊疗免费政策之外,基本医疗保障制度对于肺结核门诊诊疗费用报销的覆盖范围很窄,报销的比率或额度较低,并且部分能够报销的县（区）没有制定报销规范,肺结核患者的经济负担仍然很重。     

Guidelines for non‐medical care providers to manage the first steps of emergency triage of elderly evacuees

On 11 March 2011, a strong earthquake occurred off of Japan's Pacific coast and hit northeastern Japan. The earthquake was followed by huge tsunamis, which destroyed many coastal cities. As a result, the Study Group on Guidelines for the First Steps and Emergency Triage to Manage Elderly Evacuees quickly established guidelines enabling non‐medical care providers (e.g. volunteer, helpers, and family members taking care of elderly relatives), public health nurses, or certified social workers to rapidly detect illnesses in elderly evacuees, and 20 000 booklets were distributed to care providers in Iwate, Miyagi, and Fukushima prefectures. The aim of this publication is to reduce susceptibility to disaster‐related illnesses (i.e. infectious diseases, exacerbation of underlying illnesses, and mental stress) and deaths in elderly evacuees. Geriatr Gerontol Int 2011; 11: 383–394.