Health Care: Another Japanese Success : Medicine: While it has problems, the system has features that Clinton Administration reformers might hope to adopt.

They have half as big a population but consume 50% more drugs than Americans do, and thus have some of the world’s worst problems with illnesses attributable to bad mixes of prescription medicines. As patients, the Japanese often encounter long waits for care, and doctor-shopping, particularly for name practitioners, undermines equity in treatment here.

Those problems aside, Japan seems to have mastered yet another endeavor that confounds America. And it is not building best-selling cars, creating razzle-dazzle electronic devices or amassing piles of cash.

When it comes to universal health care, analysts say, there is much to the Japanese system that Clinton Administration reformers might hope for.

Consider: Japan enjoys the world’s longest life expectancy. Its infant mortality rate is less than half that of the United States. And Japan’s health bill, including an insurance system covering all but 1% of its population, costs about 8% of its gross national product.

In contrast, health costs in the United States run up a bill of 14% of the GNP and 37 million Americans have no insurance coverage.

In Japan, rich and poor alike “can receive the best treatment available at a very small burden anywhere in the country with just a single (health insurance) card,” said Dr. Eikichi Itouji, a director of the Japan Medical Assn.

“Even someone living on welfare can enter the National Cancer Center or a top university hospital,” he said.

Fees amount to about 3% of income, with matching contributions from employers. A typical salaried employee making $67,457 a year pays slightly more than $2,000 a year for health insurance covering himself, his wife and two children, plus 10% of the cost of treatments for himself and 30% of the cost for his dependents. A cap of $571 is placed on monthly out-of-pocket charges for a family.

For people with no income, the government pays the insurance fees.

One survey showed that only 0.4% of Japanese who suffer an illness refrain from going to a doctor because of the cost.

Although health costs keep rising every year (by about $9.5 billion last year), for more than a decade the increases have been held to within the rate of growth of the gross national product. In the United States, costs have been soaring out of control.

How do the Japanese do it?

The simplest element is government fiat. But social differences and an unusual intensity in primary care and preventive medicine also help explain the difference.

Every two years, doctors represented by the Japan Medical Assn. and officials of the Health and Welfare Ministry work out, line-by-line, a standard schedule of fees for all treatment, drugs and operations.

But the price-fixers are forced to keep total expected costs to within an overall increase dictated in advance by the Finance Ministry.

Itouji cited an operation to implant a pacemaker as an example of what he called an unreasonably low fee. Pacemakers cost up to $24,000 in Japan. But the fee paid to all doctors and nurses involved in an operation to implant the device--regardless of their skill and experience--is $1,143, he complained.

Writing in Health Affairs magazine, Dr. Naoki Ikegami, professor of health and public service management at Keio University, said the average cost for a day of hospitalization in Japan is $101, including physician expenses, while outpatient care costs $33 a day.

Even with low fees, Japanese doctors manage to survive.

Doctors’ earnings over a 41-year career give them an annual average income of $255,786--nearly four times that of a private company employee, the ministry reported.

An unknown number of doctors with top-notch reputations supplement their income by accepting payments of orei (gratitude) for taking cases at the patient’s request--a violation of the system’s requirement that all doctors and patients be treated equally.

Forced frugality is but one reason for the low cost of Japan’s program.

Japan has restrained its health costs, in comparison with the United States, by doing a better job of combatting illnesses in outpatient treatments and relying far less on operations, Ikegami said.

“Japan has more than twice as many outpatient consultations as the United States but only half the hospital admission rate and only a quarter the number of surgical operations,” he wrote.

American health costs are also driven up by a higher incidence of malpractice suits, alcoholism, drug abuse and AIDS, he added.

“The Japanese may also have a healthier diet: Only 25% of total calories come from fat.”

But the Japanese diet also has a high salt content, he noted. And about 60% of Japanese men older than 20 smoke.

At the end of World War II, amid poverty and hunger, Japanese life expectancy was 50 years; now it is 82.22 years for women and 76.49 years for men, the world’s longest. Japan also has one of the world’s lowest mortality rates for babies: 4.4 per 1,000, compared to 8.9 per 1,000 in the United States, within the first year after birth.

In the opinion of some doctors, a health care foundation was laid more than a century ago when the leaders of post-feudal Japan established schools even in the most remote regions of the country.

“Education is the reason,” declared Dr. Yoshio Yasuda, who runs a five-story hospital in the Omori section of Tokyo.

Japanese gain knowledge of health and sanitation as schoolchildren and keep up with developments in medicine through the mass media as literate adults, he said.

Preventive medicine is also a priority.

None of the government-guided insurance plans pay for health exams. But local governments do.

Residents, even the few who have no health insurance, receive certificates in the mail authorizing them to go to hospitals and clinics for free checkups.

Women 30 and older, for example, are entitled to free annual checkups for breast and uterine cancer.

Men and women 40 and older are examined annually free of charge for cardiovascular diseases.

Men older than 55 get free exams for stomach and lung cancer and heart disease.

Health care and checkups are provided to mothers throughout pregnancy and after birth.

The upshot, Itouji said, “is lower medical costs.”

In general, costs to the individual for a visit to a doctor are so minimal (about $1.80 for a first visit and 43 cents for subsequent visits) that patients with even the slightest illness visit hospitals and doctors--indeed, three times as often as Americans.

Even the often-criticized over-prescription of drugs plays a role in preventive treatment, Itouji said.

“Combatting a minor ailment in its early stages with drugs prevents the sickness from becoming a more serious illness,” he said. A cold nipped in the bud, for example, won’t develop into pneumonia.

Three-hour waits are common at major hospitals run by the national government and famous universities to which Japanese flock in the belief that such institutions offer the best treatment.

Doctors at such hospitals spend as little as three minutes with many patients.

Yasuda’s hospital is one alternative. It has been operating in the Omori neighborhood of Tokyo for 70 years, and Yasuda, 72, its director, like his father before him, acts as a Japanese equivalent of the American “family doctor.”

Each doctor at his hospital can see about 30 patients a day.

Another alternative is single-doctor clinics, where a patient can be in and out in 10 minutes for a simple treatment or a packet of drugs.

Clinic physicians see an average of 49 patients a day, the Welfare Ministry found in a survey.

The mass treatment methods seem particularly unfeeling.

But in the crowds in waiting rooms at hospitals, there are no arguments or signs of anger.

Kazuo Sakai, 59, one of hundreds waiting in the Kitazato Hospital one day recently, said he came to appreciate Japan’s insurance system after he had an operation for a serious case of gallstones four years ago.

Since then, he has been required to go to the hospital once a month for checkups. He said he would like more thorough examinations. “But I realize that costs money--and that other people are waiting.

“When I was young, I was never sick and just kept paying the insurance fees. I felt as if money was just being taken from me. But the insurance system really saved me when I got ill.”

Megumi Shimizu of The Times’ Tokyo Bureau contributed to this report.