David LeCount Report
Expenditures
Mr. Furuya gave the following information regarding the funding of psychiatric care and treatment:
- 82 Billion yen is the total mental health budget.
- 42 Billion yen is for in-patient and day services. Evidence was provided that in-patient utilization is starting to decrease, along with expenditures reduced from 80% of the total budget, to 50 percent.
- About one-tenth of the budget is for community services.
- Home Help initiative is 111 million-yen.
The information made available on the cost for in-patient treatment and the number of psychiatric hospitals in Japan continues to be unclear to me. The number of psychiatric hospitals (public and private) was between 1,000 and 1,670. The amount of funding available for psychiatric in-patient treatment was stated at 42 billion yen. I am unclear as to whether this is for all of Japan. If there are approximately 335,000 people currently hospitalized, the per diem cost would be so miniscule that it would not be realistic. While I realize that in-patient costs are considerably less in Japan than in the U.S., even at the stated cost of $60 (U.S.) a day, it would require far more than 42 billion yen. At $60 a day, it would total $21,900 per year per person. At this annual cost, times 335,000 people, it totals $7,336,500,000 in U.S. dollars, which is far more than 42 billion yen. It does not appear to me that this amount of funding (42 billion yen) could even pay for the food, clothing, shelter, and custodial care, let alone the staffing needs for treatment consideration. In Madison, for example, it would cost $578 a day for a person in our local state hospital, or $211,000 for one person annually. Further clarification is needed regarding the number of the hospitals and per diem cost, as well as the total amount of health dollars/yens being spent in Japan for this service. It seems unrealistic that Japan is able to provide such services for almost one-tenth the costs of the U.S. system.
The money for hospitalization is apparently decreasing from 80% of the mental health budget, to 50%. Even though this reduction was stated, I am not sure how the savings are being reinvested. It should present an opportunity for the funding to be realigned for community services, but is that currently happening?
Given that the hospital industry has most of the funding, staff, and influence, it is the focal point of treatment as opposed to the community. This was illustrated throughout discussions and hospital site visits. The national hospital visited in the Hokkaido Prefecture provided services typifying a community mental health center in the U.S. In addition to in-patient services, this hospital provided day services, out-patient services, outreach and consultation to the community, including case management and psychotropics post discharge, and a respite living arrangement (hostel) within the hospital setting. Many of the other hospitals performed similar functions, but I assume this is most commonly practiced through the public hospitals. I assumed public hospitals are taking care of people with the highest needs and cost. Case management services and medication monitoring for people living in the community were common functions performed by hospitals post-hospitalization. I assume emergency responses (crisis intervention for high levels of acuity) are also common functions performed by the hospitals throughout Japan in the absence of 24-hour community-based crisis intervention services.Composition of the People Hospitalized
I cannot be precise here regarding specific diagnosis, but I am assuming most of the people have major mental illnesses, such as any complex of Schizophrenia and affective disorders including major depressions. There were also in-patient settings, in which there appeared to people with a wide variety of disorders, including obvious neurological impairments. This was most evident in the private hospital visit in Nagoya. Most of the hospitals included people with Alzheimer's and dementia-related disorders. In the U.S., these people would be seldom represented in hospitals, as most of them would be treated in the community and receive shorter-term treatment in general hospitals, either for psychiatric and/or physical care, or be placed in a public hospital for a relatively short period of time before being placed in a nursing home during the most extreme latter stages. Further, in the U.S., attendant care in the home and day care services are used to reinforce community living. This latter statement is also reflective of practices throughout Japan.
Mr. Furuya stated the following stratification of the people in the hospitals.- One-third of the people in hospitals are there for social reasons.
- Another third could be released to the community through the help of psychosocial rehabilitation services. However, I was unsure if this meant these services should be provided in the hospital or in the community. (See psychosocial rehabilitation section below for further comments).
- The remaining third are the most difficult. I am assuming the later third are very institutionalized people who have been hospitalized the longest. It was stated that 29% of the people are age 65 and older, and 47% have been hospitalized for five years or longer. There was a point made here that this is an aging group of people and that many will die within the institutional settings. I am referring to this group as the "lost generation," as there appears to be little hope that anybody can do anything for them in their current state. Their families have abandoned many, and they remain in a "limbo" state, causing them to lose their sense of self. They have lost their self-identity, they are lost to their illness, and lost within an institutional bureaucracy with no way out. They know no other way of life, so there is little or no incentive from a policy or person perspective to change their circumstances. I did meet a gentleman, however, who had been hospitalized for over 35 years that appeared happily integrated into the Yadokarinosato programming and was looking forward to the future. Therefore, even this entire latter group needs to be evaluated on a person-by-person basis, and community placement not completely ruled out.
My general impression of those I observed in the hospitals is there appeared to be a large number who do not need to be there according to standards derived from the Madison experience (see section referencing community standards for hospitalization). Many of the people observed manifested institutionalized behavior, such as either indiscriminate attention seeking behaviors on one end of the continuum, to being withdrawn and apathetic on the other end. Relationship capacities have been greatly diminished for many people, along with their inability to fend for themselves and problem solve. Is this the result of their mental illness or institutionalization? The hospital visited in Nagoya seemed to represent many very institutionalized people who were devoid of spirit and had limited capacity for human relationships and general functional abilities. I have found that long hospital stays tend to impede socialization that only natural community environments can afford.
One-third of the people being hospitalized for social reasons may represent a form of social control as opposed to the need for treatment. There seems to be more of a protective approach operative throughout Japan, which has translated into policies, procedures, and practice. This is where most of the criticism enters in regarding human rights. In the U.S., the human rights movement was one of the factors leading to deinstitutionalization, and people's rights continue to be a guiding principle. It should be emphasized that I did not witness any abusive treatment, and that physical care needs and living environments within hospital settings appeared to be adequate.
Another factor related to human rights that greatly differentiates our respective systems (U.S. versus Japan) pertains to due process and the involvement of the legal system in overseeing these rights. In Japan, the family and the doctor can make decisions regarding hospitalization, and there doesn't appear to be "due process" for the person. Since 1972 in the state of Wisconsin, we have had to prove in a court of law that a given person is not only seriously mentally ill, but also must be in imminent danger (to themselves or others), before hospitalization can occur against their will. Granted, there are many family members in the U.S. who would welcome the easier access practice in Japan, especially when a son or daughter does not access involuntary treatment because dangerousness is not present. The statement has been made that "people can die with their rights on" in our country. However, being placed in a hospital setting against a person's will and for an indefinite period of time, is a daunting fact of life in Japan that begs for greater reform.
- One-third of the people in hospitals are there for social reasons.