12 - Diagnosis procedure combination: The Japanese approach to casemix

Summary

Introduction

Japan's universal health insurance system, which covers a population of 122 million people, is divided according to workplace and living place. The type of company you work for determines the insurance society to which you belong and the financial contribution you must make. Although thousands of independent societies exist, they are all integrated into a uniform framework mandated by the national government. The Japanese health system is based on fee-for-service reimbursement under a uniform national price schedule. Health insurance funds (both public and semi-public) collect premiums from their insured and reimburse the cost for medical facilities according to the type and volume of services provided (Figure 12.1). The health insurance scheme is categorized into three basic groups according to age and employment status: Employees' Medical Insurance scheme (EMI) for employees and their dependants; the National Health Insurance scheme (NHI) for the self-employed, farmers, retired and their dependants, and a special pooling fund for the elderly. Every Japanese citizen is covered by one of these schemes. Because the system is portable, Japanese residents can receive medical services at any medical facility with a modest co-payment (30 percent in general, and 10 percent for the aged).

Today the health insurance scheme is an important infrastructure supporting the Japanese people. However, while the socio-economic structure is facing large and rapid changes due to an ageing population, an increase in the numbers of working women, and a transformation in the working environment and industrial structure, the people's awareness and social values are also changing rapidly.