POINT OF VIEW/ Joe Kurosu: Insurance caps on drug dosages harm patients

I run a medical practice in Tokyo. Due to my experience as a clinical physician in the United States, many of my patients are European or North American, and I accept national health insurance (NHI), as it generally covers care at reasonable prices. I often face a dilemma, however, when it comes to prescribing medications.

Similar to other countries, Japanese prescription drugs come with a "package insert" that details the recommended dosages, including a maximum daily dose. For reasons that are unclear, however, the indicated maximum dose is often significantly lower than that which is standard in other parts of the world. Differences in physical frame and incidence of side effects are some of the purported reasons, but a scientifically convincing basis is lacking.

A significant number of resident foreign nationals currently receive health care through the Japanese national health insurance system, but are ill-served because of these dosage standards.

The maximum daily dosages indicated on package inserts of standard medications for high blood pressure, diabetes and depression, for example, are one-quarter to one-half of the standard doses used in other countries for the identical drug. If I submit a claim for prescribing a medication at the same dosage that a foreign patient had been taking in his or her home country and that amount happens to exceed the local package insert limit, the Social Insurance Medical Fee Payment Fund will reject the claim, labeling it "excessive."

I am left with two options in such cases. One is to continue treatment at a lower dose, risking an inadequate clinical effect. The other equally unpalatable option is to proceed with treatment outside the national health insurance system, in which case the patient would be responsible for 100 percent of the total cost.

This is a result of the "all-or-nothing" principle, wherein patients cannot be billed for the portions of medical services not covered by NHI during their treatment for a given condition. They must stay completely within the insurance limits, or pay out of pocket for the entire cost of treatment if they opt to go beyond the limits.

I recently received a notice from the payment fund denying a claim for a prescription provided to one of my patients as it was deemed "excessive." This patient had been taking two-and-a-half tablets of a medication prior to his move to Japan, which had stabilized his condition and allowed him to return to work. Although the maximum recommended dose is four tablets in most other countries, the local package insert indicates 2 tablets as the maximum.

I cannot explain to my patients why I must ignore pharmacokinetic and pharmacodynamic principles in addition to clinical judgment in favor of some baseless package insert. The responsibility for this explanation rests with the insurers, payment funds and the government, but I am not holding my breath.

Foreign nationals living in Japan for one year or longer are obligated to join the NHI scheme. At one point, a proposal to require proof of coverage by NHI when applying for an extension of stay or change in residential status was also proposed.

In any case, if the government requires foreign nationals to join the system, it must be willing to provide services appropriate to that population. If this is not possible, then buying in to the system should be voluntary, or the authorities should explain to the potential insured that they may not be able to obtain adequate treatment if they sign up.

At the root of this problem is the fact that despite an official notice issued in 1980 by the health ministry stating that medications should be prescribed based on pharmacologic principles (and not the package insert), the insurers and the payment fund continue to process and reject claims by mechanically applying the dosage levels indicated on the package inserts. Japan's physicians are also complicit, failing to apply their knowledge and training while meekly complying with such rules to the detriment of their patients.

If Japan is going to accept foreign nationals as members of society and require them to join the public health insurance system, it must be prepared to deliver adequate care. I urge the government and relevant authorities to return autonomy to the physicians so that medications can be prescribed appropriately for the patient, whether foreign or Japanese, based on science and clinical judgment, rather than a piece of paper.

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Joe Kurosu is a medical doctor who runs a clinic in Shimokitazawa, Tokyo.