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Sunday, Feb. 6, 2011
The bitter pill of Japan's high-cost medical treatment
When NHK's in-depth news program, "Closeup Gendai," addresses a pressing social issue, it usually offers possible solutions articulated by experts. Two weeks ago, however, the show covered a problem that seems to have no solution. The subject of the opening segment was a middle-aged man who was diagnosed with leukemia 10 years ago. His doctor estimated he had four or five years left to live. Then the anti-cancer drug Glivec was approved by the health ministry. Glivec attacks cancerous cells without destroying healthy cells. It is not a cure, but rather a treatment that prevents the leukemia from worsening.
Glivec is expensive. One pill costs ¥3,128, and a patient needs to take four a day. That adds up to over ¥4.5 million a year. Since Glivec is covered by national health insurance, the patient would pay 30 percent, or around ¥1.35 million a year, but the government also subsidizes approved treatment that is deemed too expensive for some people. Under this kogaku iryo seido (high-cost medical system), the man's out-of-pocket payments for Glivec was reduced to ¥500,000 a year.
For a drug that was keeping him alive that sounds like a bargain, but the man stopped taking it. He owns a restaurant whose business suffered as a result of competition and the economic downturn. His income dropped from ¥400,000 to ¥250,000 a month, which barely paid for his house loan and medicine. He had nothing left to live off of, and decided to stop taking Glivec, thus saving him ¥40,000 a month. When his wife found out she convinced him to start taking it again, but in the meantime his condition had deteriorated. Once a leukemia patient has reached a certain stage of the illness, Glivec is less effective. He died shortly thereafter.
Though it sounds like an exceptional case, NHK used it as an example of what Japan's national health-care system is up against. New drugs and treatments are being developed every day, and they cost a lot. On top of Japan's national health-insurance system, which is universal only in the sense that everyone has to contribute, the government spends ¥1.2 trillion a year to subsidize care that people can't pay for even with insurance. In the end, the people pay for it anyway, since that money comes from taxes. But the point NHK was making is that these costs will only increase, and the system as it stands can't absorb it; which means patients will have to pay more for these treatments even if they have insurance. According to Tokyo Shimbun, 4.45 million households, or 22 percent of all subscribers, do not pay their mandatory national health insurance premiums, which means they lose their coverage, regardless of how many years previously they paid in full and on time.
The main cause of the health insurance crisis is the rapidly aging society, and a good portion of the medication that is contributing to the high cost is used to treat cancer, which has become — no pun intended — a growth industry. The media constantly repeats the statistic that half of all Japanese people will one day develop cancer. For this reason local governments and health-care professionals promote regular cancer screenings for early detection, which can result in surgery or therapeutic treatments, or both. Pharmaceutical companies invest huge resources in the development of cancer drugs. It's what drives the industry.
Because cancer can be deadly, few people question the practicality of such an aggressive approach. One person who does is Dr. Makoto Kondo, a radiologist at Keio University School of Medicine. Kondo believes chemotherapy doesn't work on most "solid tumor" cancers. If anything, it is more likely to shorten a patient's life. After 30 years of studying the literature, he has found no credible evidence that anticancer drugs for anything other than leukemia and testicular or uterine cancers prolongs the lives of cancer patients in any meaningful way.
Unsurprisingly, Kondo is a pariah in the medical community (he remains only a lecturer at Keio after 40 years on the faculty), but his controversial stance makes him a media magnet. Last fall he wrote an article in the monthly Bungei Shunju stating that "anticancer drugs don't work" and in a subsequent issue discussed the matter with veteran journalist Takashi Tachibana, who has also written skeptically about cancer treatment, having undergone such treatment himself. He says he has talked to doctors who prescribe chemotherapy simply because they feel they have to do something.
The discussion sparked a debate in Shukan Bunshun last month between Kondo and some doctors who called his pronouncements "dangerous." They said his reasoning is flawed, and Kondo categorically rebutted their arguments, which he said were a matter of splitting hairs. Kondo's underlying point, pertinent to the health cost crisis, is that people are living longer, and the older they get the greater their chance of developing cancer, which is incurable. Rather than expend money, time and resources on annual screenings he thinks are pointless (though cancer is being "detected" earlier, the number of cancer deaths remains unchanged), and then on treatments whose effectiveness is unprovable, he advocates better palliative care for cancer sufferers.
Most people won't accept Kondo's viewpoint, but it seems obvious that sometimes "treatment" is another way of saying business-as-usual. A physician recently wrote to the Asahi Shimbun about feeding tubes for patients who can't eat on their own. These tubes are easy to administer and at any given moment are keeping 400,000 people alive, 30 percent of whom are in a vegetative state. In any case, the majority are not expected to recover from the condition that prompted the administering of the tube in the first place. Just to maintain a feeding tube costs ¥5 million on a yearly basis, which means many patients qualify for subsidies, thus costing the government ¥600 billion a year that could have been spent on certifiably treatable problems.
Philip Brasor blogs at philipbrasor.com