January 18, 2019

Japanese Hospitals

After crashing in Okayama and then being hospitalized for surgery, I've learned a lot about hospitals in Japan and the local healthcare system.

If you’re not humble, life will visit humbleness upon you.

–Mike Tyson
A patient checks into a Japanese hospital in Tokyo

Looking back over things, it was entirely my fault. Just a few days before, I had been violently thrown from my bicycle in Okayama Prefecture. The result was a grievously broken collarbone and elbow. As I lay in my hospital bed post reconstructive surgery, I found myself unable to sleep due to the throbbing pain in my shoulder. Strangely though, my thoughts were surprisingly clear in a way that only true agony lends itself to. Mulling over what had transpired, it was clear that my ego had gotten the better of me yet again. Unable to merely sit around and wait while the others selected their rides, my impatient and idiotic self somehow thought it would be a good idea to cruise around the dirt parking lot. Not realizing the strength of the front brakes, all it took was a slight grasp to send me flying. Truth be told, I’m honestly lucky to be alive. The ordeal could have been much, much worse.

Now one thing I’ve come to realize during my reflections on my calamity is that I’ve been turning a blind eye to silent risks almost on a daily basis. I’ve jaywalked in front of oncoming traffic while mindlessly replying to comments on Instagram. I’ve darted between cars while bicycling around the streets of Tokyo. Hell, I’ve even squatted heavily in the gym without even taking a second to think about warming up. Talk about the perfect recipe for disaster! In fact, it’s surprising I haven’t encountered some sort of catastrophe sooner given my out of control ego. Meditating deeply on the quote above by Mike Tyson, it became clear that I would need to make some major lifestyle changes and that my lengthy path to recovery would be my instructor in the discipline of humility.

So, long winded introduction aside, what the hell does any of this have to do with traveling to Japan? Quite a lot it turns out. Since my accident, I’ve been to the hospital at least twice per week following my initial three-day internment for surgery. As such, I’ve come to intimately fathom the minute workings of the Japanese health care system in a way that I had once been oblivious to before. Prior to eating literal dirt, I had never once in my adult life had to schedule a doctor’s appointment in Japan so much of this was as new to me as it would be for any of you. Moreover, throughout my humbling experience, I’ve realized a deep-seated appreciation for matters like health insurance. Just thinking about the numerous times I’ve ventured overseas for work without ever once applying for traveler’s insurance is enough to send shivers down my spine.

In the remainder of this article, I’ll try to articulate what I’ve learned from my trials of being hospitalized in Japan. Hopefully, you will never have to use this information but let this be a solemn reminder that it’s better to be safe than sorry when exploring a foreign land.

Using Health Insurance at Hospitals in Japan

A patient in Tokyo pays for their percription at a pharmacy inside of a Japanese hospital

Compared to the dreaded and overpriced American healthcare system, Japan’s is much more affordable. Contrary to popular belief though, the Japanese National Health Insurance (NHI) scheme does not offer comprehensive universal coverage. Instead, patients bear 30% of the financial costs while the remainder is covered by one’s insurance. While nearly one-third of the total fees still seem high enough to warrant the sale of a spare kidney, you needn’t fret. Medical care in Japan is far less than expensive than other countries. For example, the final tally for the entirety of my three-day hospitalization was only 84,000 yen or around USD 800. Back home in the United States, I doubt I would even be allowed to speak with a surgeon for that paltry sum!

In addition to the NHI scheme, there are also many options for private insurance. In fact, many employees and their dependents in Japan (yours truly included) are on just such a plan. Whether or not the private insurance is better than NHI greatly depends on the plan in question. There are some truly great options out there on the market and many have noticeably better coverage than the default standard. What’s more, some plans may even cover hospitals that do not accept NHI, of which there are a few. Note that strangely, yearly check-ups, normal pregnancy-related costs, preventative medicine, and cosmetic procedures, including dental care, are not covered by insurance plans in Japan.

Unfortunately, all of this is of little concern to you, the reader, as visitors to Japan who are staying for less than 90 days cannot enroll in NHI. That said, there are still some incidental ways from which tourists can benefit from the existing Japanese medical system. Should you have a health concern or be planning to engage in any outdoor activity (I’m looking at you, skiers and snowboarders!), I highly suggest that you purchase travel insurance ahead of time. While in many cases you’ll still need to cover the expenses for your care up front, this will allow you to file for a reimbursement at a later date once you’ve made the journey back home. As mentioned, I used to eschew completing the additional paperwork but I’ve since come to embrace the mindset that it’s better to be safe than sorry.

Making Payment at Hospitals in Japan

Someone pays for their hospital bill in Japan with a stack of 10,000 yen notes

Many tourists who visit Japan often bemoan the country’s lack of cashless payment methods. You see, even today, Japan is still very much a cash based society. Throughout many of the rural and off the beaten path areas that I frequent, there’s an inherent distrust of anything that isn’t a clean, crisp bill. Now, as absurd as this may seem, the cash-only practice remarkably often extends to hospital and clinic fees. Hell, you’ll be shocked to learn that there are ATMs right there in the hospital lobby so that patients can withdraw cash payments. While there are certainly facilities that accept credit cards, they are exceptions to the rule and definitely not the norm. To be safe, I’d suggest that you assume that only cash payments will be feasible.

In addition to the cash-only practice, one of the other things that I was surprised to learn is that most of the procedures and prescriptions have designated prices set by NHI. Because of this, there is little (if any) discrepancy in prices across the various hospitals and clinics. This means those without health insurance will not be charged an arm and a leg because the fees are already fixed. If you’re concerned about the costs associated with a procedure or prescription, just ask your doctor. They can easily look up the price for you in advance. Need to know how much an x-ray will cost you? Your doctor can easily reference the huge directory on his desk to estimate the damages. Just remember that this does not apply to hospitals and clinics which are not covered by NHI.

Now, what does all of this means for visitors to Japan? Well for starters, if you’re not in a financial position to cover the expenses and are fit enough to make the trip back home, it might be wise to consider doing so. Recently, there have been many cases of tourists abusing the medical system and then departing the country without paying, leaving the hospitals to foot the bill. This not only reflects negatively on non-Japanese residents but more so is causing many hospitals to reconsider caring for foreign patients at all (yes, Japanese hospitals have the right to refuse care if they want). I know that I state this many times throughout this article but do yourself a favor and apply for travel insurance before leaving your home country!

Lastly, let’s also talk about what to expect in the event of an emergency. Here, you’ll be surprised to learn that ambulance transports are entirely free in Japan. That’s right, there’s no need to worry about getting slapped with an inordinately expensive bill for a short, express ride. This is because, in Japan, the ambulances are actually dispatched from the fire department. The only downside to this is that, purportedly, some elderly folk have been using emergency services as free transportation to the hospital. Still, I would argue that a few old folks abusing the system is less of an evil than having extortionate ambulance charges. Since you need not worry about the cost, do not hesitate to call for help if you have a medical emergency.

What’s Different about Japanese Doctors

A Japanese doctor poses with his arms crossed at a hospital in Japan

Contrary to your experiences in the west, the power dynamics within the doctor-patient relationship are somewhat different in Japan. Here, medical professionals are simply just not used to having patients questioning their diagnoses or ask for additional explanations. In fact, doctors, like lawyers, are referred to by the honorific title of sensei in Japanese and their directions are taken as gospel. While this top-down approach may seem rigid, there’s little you can do about it. Attempts questioning your doctor’s protocol will ultimately lead to upsetting the hierarchical nature of the relationship; in fact, your caretaker may interpret your inquiries as challenges to his authority. Here, you’re not going to be treated as a special little snowflake. If you need additional information, I’d suggest that you do some digging on your own rather than prying details from the hands of your doctor.

On a similar note, one of the most frequent complains that I hear from foreigners in Japan is that doctors often prescribe a ton of medications. It’s not uncommon to leave your doctor’s office with a goody bag full of pills for treating a single condition. You might be prescribed antibiotics and a cough suppressant but also a stomach medication that you didn’t request. Often times, the doctor will inform you that these additional dosages address the side effects caused by the other medications. If you feel at odds about taking these prescriptions, you can simply opt out of taking it later. That said, I’d avoid openly confronting your doctor about the matter. As I mentioned, Japanese doctors are are not accustomed to being questioned by their patients; consequently, their fragile egos may not take your inquiry well.

Speaking of questioning people, you may also be worried about how you’ll communicate in the event of an emergency. Luckily, while other languages are widely not spoken in Japan, many medical professionals actually do possess some rudimentary language skills. In fact, most older doctors actually speak German as Japan’s medical education was previously based on the system utilized in Germany. These days though, many younger doctors tend to be somewhat well versed in English, albeit their reading is probably of a much higher level than their listening. Should you be struggling to communicate, try writing out your thoughts. Otherwise, stick to clear, concise, and slowly spoken sentences while also acknowledging the fact that some dialogue will be lost due to language barriers.

Note that if you require medical services in English, there are a few hospitals within Tokyo that are able to accommodate you. As Japan becomes more and more internationalized, the number of these facilities is bound to increase. Rather than provide you with a list that will soon become outdated, here I’ll direct you to a quick Google query instead. Just remember, in the event of an emergency, the hospital of your choosing might not have the available manpower scheduled on that day to treat you. In these cases, it’s best to be flexible rather than risk long term consequences. Yes, the language barrier will mean that you’ll miss out on some details but that is going to happen regardless of where you go, including hospitals with English staff on hand.

Before moving on, I should also note that Japanese hospitals are organized quite differently than their western counterparts. While it is common for doctors to visit patients in an examining room in other countries, in Japan, the system is actually reversed. Rather than making the rounds, here the doctors remain in their office areas and the patients do the visiting. Generally, the whole process is overseen by the nursing staff so all you really need to do is follow their directions. Still, the robotic in-and-out efficiency of the process can seem rather strange to those who are familiar with other medical systems. Case in point, I think I’ve spoken less than ten minutes in total with my surgeon throughout the entirety of my care. While I definitely do trust the guy, he certainly is a terse one!

Expect to Wait at Hospitals in Japan

The waiting room of a Japanese hospital in Tokyo

One of the most peculiar things about Japanese hospitals and clinics is that they serve patients on a first-come, first-serve system outside of emergencies. Moreover, the locals will often visit a doctor for minor ailments that many westerners would simply weather at home. Because of this, the queues can be excruciatingly long. Typically, waiting rooms open around 7:00 or 8:00 AM and many patients will actually arrive before-hand to ensure they are treated in a timely manner. Those poor souls who arrive later will often need to wait hours on end to be seen. Moreover, most doctors will not take appointments unless you’ve already consulted with another doctor and were requested to come for additional follow-up. Even in these cases, the early bird is the one who gets the worm. For my weekly check-ins with my surgeon, I’ve only been able to see him in between his new patients for the day.

One of the down sides of this walk-in system is that hospitals and clinics are apt to get crowded in the mornings with elderly folk seeking to refill prescriptions. Unlike in the west, Japanese doctors generally do not prescribe long-term, refillable prescriptions. Instead, patients are expected to come in for a follow-up visit if additional medication is necessary. Some claim this process is a means for the Japanese medical system to turn an additional profit as the facilities can bill for yet another visit. Regardless of the validity of this statement, the practice ensures that patients take their medications responsibly and do not abuse it. If you’re going to be leaving the country soon and don’t have time for a follow up visit, be sure to tell your doctor. You might just luck out and be given a few extra days worth of meds.

Now if you’re in a bit of rush but you’re visit isn’t going to be considered an “emergency,” there are a few tricks that you can employ to avoid waiting. The first of these comes right from the playbook of the morning prescription fillers; simply show up right when the hospitals open. Failing this, another busy time you’ll likely want to avoid is the mid-day. You see, outside of the biggest of hospitals, many facilities close down for a few hours around lunch time. As you might surmise, this means that the slots before and after can get quite busy. To avoid the midday rush, it would behoove you to try going in the late afternoon. By then, most of the morning prescription fillers are gone meaning that you can be seen more easily. Even then though, expect to wait!