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TransKorea    [Video] Sick Around the World 세계의 의료보험 제도 (2/5) 일본

지난번 영국의 제도에 이어 이번에는 일본의 의료보험 및 서비스에 대해서 알아봅니다.



The next country on my tour couldn't be more different. Our family lived there twice. I was the Tokyo correspondent for The Washington Post.

Japan has 130 million people, and whenever I come to this station in Tokyo, I feel like every one of them is right here. It's a ferociously capitalist economy. They have no natural resources, but they've built the second richest country in the world. And you know, it's 130 million healthy people. They have better national health than we do. They cover everybody. And get this. They spend half as much as the United States on health care per capita. How do they do that?

One thing's for certain: Japanese health care is a bargain. For just 8 percent of GDP -- that's less than even the British spend -- the Japanese have built a system with fabulous health statistics. They have the longest healthy life expectancy in the world and the lowest infant mortality rate. Now, part of that's due to diet and lifestyle, but the health system must be doing something right.

Everybody's covered, but unlike the Brits, the Japanese don't pay for all of it through taxes. Instead, everybody has to sign up for a health insurance policy. You get it at work or through a community-based insurer. The government picks up the tab for those who are too poor. This system is known as social insurance, and it's a model that's used in many wealthy countries.

(현재 우리나라도 일본 제도와 유사한 점이 많다)

As for the health care itself, that's certainly not socialist. Eighty percent of the hospitals are private -- more than in the U.S. -- and almost every doctor's office is a private business.

Dr. Kono Hitoshi is a typical doctor. He runs a private 19-bed hospital in the Tokyo neighborhood of Soshigoya.

The best thing about the Japanese medical system is that all citizens are covered--anyone, anywhere, any time. And it's cheap.


The Japanese are prodigious consumers of health care. They go to the doctor three times as often as Americans do. And since there are no gatekeepers, they can go see any specialist they want.

Do you have to make an appointment to come?

No appointment is necessary.

Never.

Never.

How long do you see the doctor?

Three minutes.

It seems like such a short visit.

Some patients just have their blood pressure taken, receive medication, and then they leave, taking only about a minute, like a health check, very quick. So if you take the average, it's from 3 to 5 minutes.
(이것이 문제이다. 일본과 마찬가지로 우리나라도 Gatekeeper 제도가 없으니 환자들은 대형병원, 유명의사에게 몰리고, 장시간 대기해서 실제로 진찰 받는 시간은 고작 5분 내외.)

Surveys show the Japanese are highly satisfied with their health system.
(그럼에도 불구하고 일본 사람들이 자신들의 제도에 이렇게 만족한다니 놀랍다.)

You know, I -- excuse me -- she says, you know, "This annual physical is really a great idea. I think that's why I've stayed so healthy, because they really look out for me and check out all my problems."

Yeah. "Well, it's not bad, as a matter of fact. You can't call it bad because everybody has the insurance and the insurance pretty much takes care of the bills."

"So I think the Japanese health care system is really good. I know nothing about other countries. What do people in your country think about your health care system?" she says.

Here's something else that's different. Japanese patients have much longer hospital stays than Americans, and they love technology, like scans. They have nearly twice as many MRIs per capita as Americans, eight times as many as the Brits.

So how do they keep costs under control? Well, it turns out the Japanese health ministry tightly controls the price of health care, right down to the smallest detail. Every two years, the physicians and the health ministry negotiate a fixed price for every single procedure and drug. Like the items in this sushi bar, everything from open heart surgery to a routine check-up has a standard price, and this price is the same everywhere in Japan.

If a doctor tries to boost his income by increasing the number of procedures, well, then, guess what? At the next negotiation, the government lowers the price. That's what happened with MRIs, which are incredibly cheap in Japan. I asked the country's top health economist, Professor Naoki Ikegami, to tell us how that happened.

In Denver, where I live, if you get an MRI of your neck region, it's $1,200, and the doctor we visited in Japan says he gets $98 for an MRI. So how do you do that?

Well, in 2002, the government says that the MRIs, "We are paying too much. So in order to be within the total budget, we will cut them by 35 percent."

So, if I'm a doctor, why don't I say, "Well, I'm not going to do them, then. It's not enough money"?

You forgot that we have only one payment system. So if you want to do your MRIs, unless you can get private-pay patients, which is almost impossible in Japan, you go out of business.

(여기서 중요한 포인트가 제기된다. 우리나라 정부가 고려하고 있는 당연지정제 및 수가 지정과 관련이 되어 있다. 우리나라도 아직까지는 정부가 모든 수가를 관리, 지정하고 있다. 만일 이 제도를 자율화되고 경쟁이 도입되어 MRI와 같은 고가의 진단료를 병원이 자율적으로 받을 수 있게 한다면, 좋은 시설을 가지고 있는 병원들과 실력 있는 의사들은 당연히 비싸게 받을 것이고 일반인들은 이용하지 못하게 될 것이다. 과연 우리는 이걸 원하는 것일까?)

So that shafts the medical device makers and must limit innovation, right? Well, no. Japanese manufacturers of scanning equipment, like Toshiba, found ways to make inexpensive machines they could sell to doctors. And guess what? Now they're exporting those machines all over the world.

(여기서 "실용정부"의 철학이 시험대에 오르게 된다. 과연 모든 분야에서 "경쟁"을 도입하고 높은 이익을 남길 수 있는 여건을 제공해야 "선진화"를 이루게 되고 "성장"을 하는 것일까? 적어도 일본의 예를 보면 답은 "그렇지 않다"이다. 또한 뒤에 다루어질 스위스의 예를 보아도 의료 및 제약 산업이 꼭 높은 사업성을 미끼로 흔들어야 성공하는 것이 아니라는 것을 알 수 있다. 국민의 건강과 같은 중요한 문제가 관련되어 있다면 해당 기업들은 거기에 합당한 사명과 철학을 가지고 사업에 임해야 할 것이다. 이것이 너무 이상적이고 비현실적이라는 이유로 의료정책까지도 "실용"의 방향으로 바꾼다면 이는 정말로 정부의 무능함을 보여주는 것이다. 같은 어려운 여건 속에서도 다른 나라들은 하는데 우리는 왜 못하나?)

But price regulation also hits the doctors hard. Dr. Kono can't charge what he wants, he can only charge what the official price book dictates.

The treatment fee for a wound, anything under 100 square centimeters, that's 450 yen. The treatment fees are all listed here.

If somebody comes in with a cut that's less than 6 square inches, so a fairly small cut, he gets 450 yen -- $4.30 -- to sew that up. That's incredibly cheap.

It's extremely cheap.

He then told me what it costs to stay in his hospital.

OK, you're going to love this. So you know how much it costs to spend the night in a hospital here, according to this price book? If you stay in a room with four people, $10 a night. If you have a private room, $90 to spend the night in a hospital in a private room here. That's because the government sets the price.

The prices are all the same in Japan.

In Tokyo, Okinawa, anywhere?

Yes, that's true. They're all the same.

Is that fair?

It's fair.

Oh, it is.

But doctors can't get rich. [laughs]

(우리나라, 일본 그리고 뒤에 다루어질 독일 및 기타 의료제도 선진국들의 의사들의 현실을 보면, 미국의 의사들과 같이 일년에 수백만불 또는 수십억원의 수입을 올릴 수 없다는 것은 자명하다. 하지만 꼭 그러한 금전적 인센티브를 걸어야 한 나라의 인재들이 의사라는 직업을 선택하게 되는 것일까? 그렇게 의사들의 수입이 많은 미국의 현실은 의료제도 전체적으로 보면 어떠한가?)

The doctors have to live with the price book, but Japanese patients have to play their part in financing the system by paying into a social insurance fund. If you lose your job in Japan, you don't lose your health insurance. Unlike the U.S., you switch to a community insurer. And these insurance companies have very little in common with their American counterparts.

Can they turn her down if she has heart disease or something?

That is forbidden.

(당연지정제에 대한 이야기이다.)

These health care plans covering basic health care for a worker and his family, do they make a profit?

No, because they are not allowed to make a profit, and anything left over is carried over to the next year. If there's a lot carried over, then the premium rates would go down.

Insurance companies barred from making a profit, national price regulation-- that's all good news for patients. The average premium for a Japanese family is just $280 a month, with the employer paying at least half, a lot less than most Americans pay.

It's good news for Japanese employers, as well. J.R. Tokai, the company that runs this bullet train to Osaka, told me that its health care costs are about half of 1 percent of operating expenses. General Motors pays eight times as much as that.

So here's a country with the longest life expectancy, excellent health results, no waiting lists and rock-bottom costs. What's not to like?

But the president of the Nagoya Central Hospital, Professor Saito Hidero, showed me the downside.

I think our system is pretty good, pretty good, but no system is perfect. But now 50 percent of hospitals are in financial deficit now.

No, I didn't know that. In Japan?

Fifty percent in Japan. So I'm afraid hospitals may be one of the endangered species in Japan now.

Fifty percent in financial deficit? That sounds unsustainable.

So here's the weakness. While we spend too much on medicine, the Japanese seem to spend too little. In a country with $10 per night hospital stays, the prices are just not high enough to balance the books.

But the Japanese system is so popular that they're not going to rip it apart. The experts say they'll have to increase prices a little to save the hospitals from going broke. Back home, our problem is patients going broke.

(아주, 아주 중요한 부분이다. 공공부문에서는 발생할 수 밖에 없는 경제적 부담의 균형을 어느 쪽으로 기울게 할 것인가. 많은 병원들이 적자를 내기 시작하면 정부와 협의하여 수가를 조정하는 방법도 있고 개별 병원들은 상황에 따라 은행에서 대출을 받을 수도 있다. 설사 최악의 경우 병원이 문을 닫는다고 해도 거기에서 일하던 대부분의 종업원들은 의사, 간호사 등 전문직 종사자이기 때문에 (일반인들에 비해) 비교적 쉽게 다른 곳에서 일자리를 찾을 수 있을 것이다. 하지만 환자들이 파산하는 경우에는 돌이키기가 훨씬 어려워진다. 과연 어느 쪽을 택할 것인가?)

In Japan, how many people go bankrupt from medical costs?

I don't know. We never heard of it. Yeah, almost never hear of, yeah.

Before leaving Tokyo, I went to the Meiji Jingu Shrine, a deeply spiritual place. I left a prayer asking for something I think almost all of us can agree on, a health system where, as in Japan, everyone gets care and nobody goes broke paying doctor bills.

현재 우리나라 상황과 여러 면에서 비슷하죠? 그만큼 비교하고 참조할 점도 많은 것 같습니다. 다음은 독일의 이야기입니다.