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but could in the future.

bursement schedules. Generally, reimburse-

To date, Japan has done a fairly good job

ment is on a fee-for-service basis, although

of controlling costs without resorting to the

recently some chronic conditions have been

rationing common in many universal care

"price bundled" into a single fee. Reimburse-

systems. This is due in part to factors outside

ment schedules are set within the context of an

the health care system, such as generally

overall global budget on health spending, but

healthy lifestyles, low vehicle accident rates,

the division of resources is the subject of exten-

low crime rates, low rates of drug abuse, and

sive negotiation with providers.

other cultural factors.145 One study estimat-

The fee schedule reflects both the Japanese

style of medicine and attempts to contain

ed that 25 percent of the difference in health

costs. For example, because of a strong cultur-

care spending between the United States and

al bias against invasive procedures, surgery

Japan is attributable to a lower incidence of

tends to be reimbursed at a much lower rate

disease and 15 percent to less aggressive prac-

than nonsurgical procedures.138

tice styles.146 But rationing has also been

avoided through the management of the

The fee-setting system has had serious cor-

health care system and the imposition of sig-

ruption problems. Because the fees for each of

nificant consumer cost sharing.

more than 3,000 procedures or services are set

Rationing has

Nonetheless, spending is beginning to

individually and adjusted every two years on an

also been avoided

escalate, especially in government-managed

individual basis, it is possible to manipulate

programs such as the Roken, where there has

particular fees without attracting much atten-

through the

tion.139 In 2004, a group of dentists was indict-

been less of an attempt at cost sharing and

management of

ed for bribing the fee-setting board.140

cost containment. As one observer explained:

the health care

In addition, the reimbursement schedule

We Japanese have a tendency to go to the

for physicians creates an incentive for them to

system and the

hospital even when we have only minor

see as many patients as possible. The result is

imposition of

ailments such as the flu, headaches, or

assembly line medicine. Two-thirds of patients

stomach aches. If medical expenses are

spend less than 10 minutes with their doctor;

significant

18 percent spend less than 3 minutes.141

not high and we do not feel well, then

consumer cost

why not go see a doctor and get some

On the other hand, the Japanese, like

sharing.

medication. . . . The result, of course, is

Americans, practice a very technology-inten-

that waiting rooms of clinics and hospi-

sive style of medicine. Capital investment in

tals are full of people. Everyone is wel-

technology has been given high priority, and

come and there are, in fact, regular cus-

the Japanese have at least as much access to

tomers. Sometimes elderly people come

technology such as MRI units, CT scanners,

to see a friend and the hospital waiting

and lithotripters as patients in the United

States.142 Because the government imposes

room becomes a sort of salon.147

uniform fee schedules on hospitals, there is no

price competition. Instead, hospitals attempt

This problem is aggravated by the demo-

to lure patients by having the best technology.

graphics of a rapidly aging society. By some

While this can benefit patients, it has also led

estimates, the elderly are responsible for 90 per-

to queues at the best hospitals and a black

cent of the aggregate increase in Japan's health

care costs.148 If current trends continue, Japan

market with "under the table" payments for

faster access.143

will almost triple its government spending on

health care in the next 20 years.149 And the sit-

Some restrictions have been added in the

last few years, capping the number of diag-

uation will only grow less stable with time.

nostic imaging procedures that a hospital can

Japan is expected to lose 35 million workers by

perform in a calendar month, as well as reduc-

2050, with 35 percent of its population in

ing the fees for those services.144 These

retirement.150 This raises questions of how a

changes have not led to visible rationing yet

system that relies on payroll taxes for funding

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