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Medical care workers, communities adjusting to Japan's aging population, budgets

Physician Hiroyuki Morita, center, and his nurse Shino Nakamura, left, laugh along with patient Eiko Nakamura as they enjoy a meal together in the city of Kagoshima, on July 27, 2018. (Mainichi)

As Japan faces an aging population and a wavering social security system, some medical workers are going a step beyond government guidelines to provide tailored care with a focus on patients' overall welfare.

In late July, a doctor in the southern Japanese city of Kagoshima went to make a house call. Hiroyuki Morita, 46, and his nurse Shino Nakamura, 36, have been treating 82-year-old Eiko Nakamura at her home since April. When the examination ended, the three shared a meal together. Though Eiko had two-thirds of her stomach removed and has trouble eating, she still joined in with Morita and Nakamura, eating "futamaki" rolled sushi, an omelet, red kidney beans and other dishes.

"It's my first time to have a doctor like this," Eiko said, wiping the corner of her eye. She was moved by Morita's care not only in his examination of her physical condition, but also in checking her lifestyle.

Morita believes that the role of doctors making house calls is not only to check on the patient's health condition, but also to assess the quality of their daily life as a whole. Once he even took an elderly male patient who tended to shut himself up in his house down to the convenience store to buy some bread filled with red bean paste when the man said he liked sweets.

On the same day Morita and Nakamura visited Eiko, they also went to see a female patient in her 90s who was being cared for at a nursing care facility. Nakamura asked Morita, "Doctor, should we take a blood sample? The last time we took one was in January. It's been half a year." In general, blood tests are performed twice a year. But after giving it a little thought, Morita replied, "Let's just leave it at once a year," and ended up not drawing blood.

If they had administered the blood test, abnormalities could be discovered, and that would lead to talk of prescribing medicine or being admitted to a hospital. However, it can be toxic to the elderly to have them take several medications, and if they end up in the hospital, there is always the risk that they will become bedridden.

"I can't believe that running a test and diagnosing an illness, and then prescribing medicine or admitting them to the hospital will lead to the patient's happiness," Morita said in the car as he headed to his next destination.

Medical house calls are in principle carried out twice a month, but there are also people who are just fine with a visit only once a month. Instructions such as "visits twice a month" and "blood tests twice a year," sometimes run counter to the wishes of the patients, and merely add to their medical bills.

Morita got his start during his time working in Yubari, Hokkaido Prefecture, in northern Japan. The economy collapsed in Yubari in 2007, and the municipal general hospital went from having 171 beds to being a small treatment facility with only 19 beds. Individuals that needed a high level of medical care after being involved in a traffic accident, having a stroke or being afflicted with other serious conditions were taken to hospitals in other cities, such as the prefectural capital of Sapporo.

It was during that time that Morita, who was doing his residency in the southern Japanese prefecture of Miyazaki, started to question medical care. At the hospital where he worked, elderly patients who had become bedridden and simply stared up at the ceiling were lined up in one hospital room after another.

When Morita was considering giving up being a doctor, he learned about the situation in Yubari. Wanting to see the "town without a hospital," he headed to Hokkaido with his wife and young child in 2009. What he found there were active elderly people. Even if they had special diseases or dementia, individuals lived in their own homes in the ways that they wished.

Before becoming interested in medicine, Morita had studied economics at Hitotsubashi University. He began to research the medical treatment situation in Yubari from the prospective of economic theory. Since the number of people admitted to the hospital had dropped, medical fees had also decreased steeply. But at the same time, the death rate had remained unchanged. It was because at-home treatment and nursing care as well as mutual support among local residents were working.

Of course, the Yubari model would not necessarily work anywhere in Japan. Yubari was forced to decrease the number of its hospital beds for financial reasons. At the same time, efforts to decrease hospital bed numbers have begun around the country. Yet the medical fees paid by patients differ greatly across the country, and there tends to be more beds in regions where the medical fees are the most expensive per person.

According to a Ministry of Health, Labor and Welfare survey, during the 2015 fiscal year, the highest annual medical fees per individual were paid in Kochi Prefecture in southwestern Japan at 444,000 yen, 1.5 times higher than the lowest payment in Kanagawa Prefecture, just south of Tokyo, at 297,900 yen. Meanwhile, in a different health ministry survey, the number of hospital beds per 100,000 people in Kochi was three times that of Kanagawa during the same year.

In order to correct the imbalance, each prefectural government has set a goal for the number of available hospital beds based on the medical demand estimated for 2025. According to a health ministry summary, this will mean a 10 percent decrease from the roughly 1.35 million beds across the country in 2013. However, as the number of beds is tied to the finances of medical institutions, it is unclear how far the planned reductions will proceed.

Still, Morita says the situation in Yubari provides a message to refrain from blindly following manuals to the letter.

"Every region has a different environment," he said. "Shouldn't we consider what we can do in each of those different circumstances while getting the residents involved?"

(Japanese original by Sunao Suzuki, Medical Welfare News Department)

This is Part 1 of a series.

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