My Role in This Article
This article was written by Hideki Hino. I participated as a research contributor, primarily responsible for interviewing medical professionals — physicians, pharmacists, and home-visit nurses — and providing structural analysis of systemic issues within Japan’s public health insurance system.
What Didn’t Make It Into the Article
The published piece presents frontline testimonies about wasteful medical spending, but the structural picture that emerged through reporting runs deeper.
First, the issue of unnecessary prescriptions. This is not a question of individual physicians’ ethics. Under the point-based reimbursement system for insurance-covered care, a clinic must limit consultations to five minutes and see forty to fifty patients a day just to stay solvent. If a doctor tells a patient “you don’t need this medication,” the patient simply switches to another clinic. Physicians don’t profit from prescriptions per se, but they dispense them as a form of service patients have come to expect. The incentive structure makes over-prescription rational.
Second, the pharmacist’s dilemma. Pharmacists are legally obligated to query physicians when they spot questionable prescriptions. In practice, however, challenging a doctor over duplicate medications with identical effects is socially and professionally difficult. The article includes a case where a pharmacist who raised a query was shouted down by the patient. The reimbursement bonus for proposing dose reductions is too low to justify the effort. The system effectively punishes the most conscientious pharmacists.
Third, the reality of healthcare digitization. The government is pushing data-sharing through the My Number insurance card system, but prescription records take a full month to update — rendering the system nearly useless for preventing duplicate prescriptions in real time. More critically, the capital investment required for digitization is crushing small pharmacies. Even with government subsidies, many cannot cover the remaining costs and are forced to close. What is framed as healthcare modernization is functioning, in practice, as consolidation that eliminates small operators.
None of these are stories about bad actors. They are contradictions produced by the design of the system itself.