News Japanese hospitals burdened by unpaid medical fees from foreign patients

Japan's ever-expanding tourism industry has coincided with a growing reliance on its medical facilities for treatment and surgery. However, there is the issue of unpaid medical bills. St. Luke's International Hospital in Tokyo's Chuo Ward treats over 2,000 foreign emergency patients annually, with roughly 30 absconding without settling their debts. Foreign visitors lacking Japanese health insurance are fully responsible for medical costs, a policy St. Luke's officials believe should be reinforced by mandating appropriate insurance coverage upon entry.

The hospital implements strategies to secure payment during patient stays, but these efforts are often met with resistance: when patients have overseas insurance, the hospital engages with foreign insurers, who frequently dispute costs and seek reductions. The hospital resorts to billing their home addresses for uninsured individuals, a process rarely yielding payment. There is no mechanism for hospitals to recover these losses, leaving them to absorb the financial burden imposed by overseas visitors.

St. Luke's Hospital has introduced a payments system that handles foreign currencies and gives a range of payment options. Staff also tell patients in advance how much their medical treatment is likely to cost. A survey by the Japan Tourism Agency between October last year and February showed that nearly 30 per cent of visitors to Japan are uninsured here. Nationwide, hospitals and clinics are counting the cost. In fiscal 2022, the health ministry asked medical institutions if they had encountered problems of this kind. Nearly 30 per cent of respondents reported unpaid bills by non-Japanese patients, although the category could include foreign residents as well as tourists. In all, about 880 million yen ($5.63 million) was owed by foreigners, a significant sum although only about 1.4 per cent of the total when Japanese defaulters are included. The numbers of tourists who check in for treatment is rising. In Tokyo in 2023, a total of 3,283 foreign visitors were taken to the hospital, up more than fivefold from 624 the previous year and up from 2,620 in pre-pandemic 2019.

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travel insurance does not cost much. I wonder if any countries require it on entry.

However, not all travel insurance packages cover medical bills.

You can still sign up for medical coverage after entering Japan:

JNTO: There is travel insurance that you can purchase even after you enter Japan.

I actually didn't know you can purchase it after entering Japan, I learned something.

Any americans among that group are probably totally shocked that the bill is ready right when the visit is done.

johnnyG said:

Any americans among that group are probably totally shocked that the bill is ready right when the visit is done.

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And they'd probably be happy to pay it given the price.

We used St. Luke's once a long time ago due to pregnancy complications during a visit to Japan. I don't remember how the billing was. We probably paid out of pocket.

thomas said:

St. Luke's International Hospital in Tokyo's Chuo Ward treats over 2,000 foreign emergency patients annually, with roughly 30 absconding without settling their debts

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Honestly, 30 out of 2000 feels like a statistic that is not worthy of the attention it is getting. 1.5%? What is the percentage of local people who leave without paying? Probably the same, if not more.

Not to excuse the foreigners who don't pay - these guys are giving us all a bad name by association. But seriously...it has the feel of an anti-foreigner story disguised as a major problem. Even the nationwide number of $5.63 million in unpaid debts seems laughable. That's probably the cost of a single heart valve in the US. Or a three-month supply of insulin.

Majestic said:

Honestly, 30 out of 2000 feels like a statistic that is not worthy of the attention it is getting. 1.5%?

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I generally agree, but hospitals here do operate on very thin margins. The fees they can charge are controlled, so they cannot simply up those to offset this kind of loss.

Majestic said:

What is the percentage of local people who leave without paying? Probably the same, if not more.

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I'd guess far less (but would hesitate to add "if any"). And with the implementation of the MyNa system, and using that instead of the traditional insurance cards, maybe even less chance than a couple years ago.

Edit: I guess this part of the article addresses that: "In all, about 880 million yen ($5.63 million) was owed by foreigners, a significant sum although only about 1.4 percent of the total when Japanese defaulters are included."

It doesn't apply to outpatient visits (vs inpatient, and it'd be nice to see that split out in the above data), hopsital admission here generally requires a guarantor. Maybe exceptions are made for tourists, kind of leading to the non-payment problem?

It would be a change to the normal flow of billing, but hospitals and clinics could ask for a credit card up front, and put a hold on the card for a certain amount (similar to how car rental companies or hotels have you on the hook).

Honestly, 1.4% of the total when Japanese defaulters are included, makes this story even more of an anti-foreigner dog-whistle than I originally thought. Or, to put it another way, if 98.6% of defaults are caused by Japanese, the remaining 1.4% is barely a rounding error.

On a slight tangent here, but hopefully the board will permit this brief digression.

Now that I am out of the Japanese national insurance scheme and into the absolute bizarro world of the US health system, I am constantly astonished by how everything here is outrageous in price, complexity, and cruelty. And yet people in the US just seem numb to it, or feel powerless to effect any change in the system which seems to benefit only the healthcare providers and I guess the pharmaceutical industry.

I am in the US, and under 65, so I have to either be part of my employer's health scheme, or buy private insurance. Since I'm semi-retired I have no employer, I have to buy private insurance. It costs me about $2000 per month. There are cheaper plans, and there are more expensive plans. Mine is pretty average. It barely covers anything unless I'm seriously sick. When I had a mole removed, the insurance only covered part of it. So on top of the $2000 per month insurance, I was out another $120 or something for the mole removal. Anyway, if I need a new lung, I'm hoping my insurance will cover most of that.

But you can see its a massive expense for absolutely mediocre coverage. Healthcare is my largest expense. It is slightly subsidized by the state, but if you make over, say, $90k a year (through gig work or whatever), that subsidy goes away. So I end up paying 1/4th of my income on health care. To repeat, I can get cheaper coverage and maybe cut my healthcare cost in half ($1000/month for me and Mrs. Majestic), but that level of coverage is abysmally low, and we have to live constantly under the Sword of Damocles where any small trip to the doctor for a mole or a cavity or an ingrown toenail ends up costing thousands of dollars because the doctor is able to charge that and my insurance won't cover any of it because I'm on a cheap plan with a $15000 deductible.

So I bit the bullet and got a medium-level plan with a smaller deductible, but its still very opaque about how the doctors and dentists charge me. For example, the annual health check-up is supposed to be free, and it is, for the medical consultation with the doctor. But the blood-test that is a part of the medical consultation costs me $25. So now there is a discrepancy between the "free check up" and the $25 that I ended up being charged, but its a hell of a lot less than the $600 that the blood test normally costs. So I either shut up and pay, or I call up my insurance company to fight over this $25.

But fortunately all of this goes away when I hit 65 and can finally join the US national health care scheme called Medicare. But not so fast. Even Medicare is mediocre. How mediocre? I just watched this video yesterday of a guy who lost his aged mother to cancer, and the healthcare costs were a whopping $709,000. Partially covered by Medicare, and partially covered by a supplement to Medicare that I knew/know nothing about (because I lived in Japan so long and really never had to worry about health insurance). And like the guy says in the video, this is without any exotic drugs or anything. This concept of having to buy supplemental insurance to the national insurance, because the national insurance will only cover maybe 90% of a huge cost like that, is a massive eye-opener for me. So, even with the national scheme, I have to pay for supplemental insurance, because the national scheme isn't adequate to cover the voracious charges that healthcare providers impose on patients.

And, in the end, this guy's mother died from cancer - so she racked up $705,000 in charges (beaten down somewhat by the Medicare system), and she still died from cancer. Can you imagine paying $700k in cancer treatments and then dying within the year? What a cruel system this is.

Also drug costs are MUCH MUCH higher in the US even with insurance. Things like a pap smear also have a fee. My elderly father had a hit from influenza a few years back that put him in the hospital and still had a bill that was painful after medicare so he refuses to get any checkups. There is also the cost of "assisted living facilities" which is much higher in the US, I can get insurance for that much cheaper in Japan. In the US they want to go after your house and estate before the government steps in. When you become 65 you'll find medicare does not cover any dental care no cleanings or anything. Medicare does not cover eye exams. Many of the local Japanese community signs up for the national health insurance for their summer trips to Japan and gets every checkup in their summer trip in Japan, I cannot do this as I am not currently a resident I enter on a tourist visa. As a previous company people from other countries would go back there for surgery like Jordan or whatever. Need a sergery have nice corporate insurance? Still cheaper for them to go back to whereever to get the procedure even with the flight, it's crazy. On a lower coverage health plan in the US you can get what is called an HSA or health savings account which is tax free money you save for medical expenses you can build and keep for your life, that does not cover all risks like a 700k bill of course.
We have a system where people open gofundmes for health problems. A famous person like ex olympic Mary Lou Retton was very successful with that but not everyone is Mary Lou Retton received $459,324 in donations. She and her family won't say how it's being spent.

just recently in the Paris olympics American athletes were taking advantage of free health care

There are a few negatives here and there with the Japanese health care system like ambulances that circle looking for a hospital to take you. My family felt two elderly relatives who were in bad shape were not given the treatment they said they were, same with a friend's brotehr's wife. US also has some elder abuse but hospitals but I feel they do treatments to for certain serious conditions a bit better though in some cases they forced expensive prolonged suffering may be too much in the US so it is a delicate balance. Just looking at costs I feel the US is the cruelist system I am aware of making people potentially die due to avoiding or delaying care due to cost fears and asy ou see even if you don't go to the doctor the insurance can be a lot for many who do not have nice corporate jobs with full benefits (which is a lot of people). This week's Daily Show on Monday with John Stewart had an interview with Mark Cuban who founded cost plus drugs to help with drug costs he hopes to help with hospitals next. As you know if you have a heart attack you cannot shop around hospitals to price compare and even if you could they are not upfront about costs for things in the first place. Just living in any other developed country than the US I may live longer just due to more affordable health care. I am sure everyone knows but just to be clear often the doctor or nurses or other medical staff have no idea about costs and do not set costs they just provide the best care they can.

salyavin said:

had a bill that was painful after medicare so he refuses to get any checkups.

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I think this is a big factor in healthcare. People avoiding the doctor because they are afraid of the cost (even with insurance). So you have a population of people who won't get preventative healthcare, and instead may end up being hospitalized because of some underlying condition that went undiagnosed because the patient was afraid the check-up was going to cost them money.

And the casual cruelty is horrible. Is my visit covered? Is my treatment covered? Are the tests the doctor used to prescribe the treatment covered? Are the drugs that are a part of the treatment covered? When the insurance company says something is "covered", do they mean 100% covered, or is it only "covered" under certain conditions? Or is it only "covered" after i have paid my deductible? All of this is just horribly complicated to figure out.

I like the Japanese system, where you get your health insurance card, and that is virtually all you have to deal with. Now I never had any major surgery or health issue in Japan, so there may be some problems that I am blind to. And I know there is fraud and waste and substandard care in parts of Japan, or with some doctors (as is the case everywhere). But the simplicity of the Japanese system is magnificent.

There is limits in costs in Japan based on your income. You can get private health insurance in Japan but you don't often need it. Medical Insurance in Japan So the few foreigners skipping should pay up and be thankful even uninsured I bet it was cheaper than US (assuming Americans).

Breaking Bad is a drama that only really works in the US.

Health care is a bee in my bonnet about the USA and was an additional factor on us planning to return to Japan. I will not get medicare in Japan however I believe I am still ahead. Of course most other countries in the world have more human pricing of health care than the US.

Oh yea another pain in the US if you change companies or if your company changes insurance you may not be able to keep using your same primary care doctor or dentist, all doctors do not take the same insurance. You have to check they accept whatever insurance you have. That is not an issue in Japan.

salyavin said:

I will not get medicare in Japan however I believe I am still ahead.

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You and others probably know this already, but the insurance just continues as before--the 30%-70% split for any ongoing care**, with the amount a person pays for insurance being based on income. Since that assessment is the same as the way that residence taxes are assessed and collected, fresh retirees need to plan for higher costs in the year following retirement, but in following years (given that their retirement income is lower than their income was when they were employed), the cost for insurance will be lower.

**this can be less depending on conditions: 10-90, or even 0-100.


Another aspect of US healthcare costs is the in-network/out-of-network thing that I've read about. Even if a person goes to an in-network hospital for treatment, a doctor there (or anesthesiologist, etc) might be out-of-network. There can be a separate bill for that out-of-network 'treatment'/care, which is then not covered, or contested, by the insurer.

thomas said:

when patients have overseas insurance, the hospital engages with foreign insurers, who frequently dispute costs and seek reductions.

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For US insurers, when they get a bill from a doctor (or hospital, etc), for them, it's game on. It is never simply accepted as is, and paid. Question every single bit of it, deny the medical necessity of anything deniable, negotiate prices down, and/or simply stonewall.

And when they get a claim from a hospital in Japan, where the amount in question is likely already a deal from their US perspective, the insurers there still resort to their knee-jerk schtick for how they deal with patients and providers there.

The issue I have is getting tests outside of my doctor's office. Say I have a painful injury with my spine and am in pain. My doctor arranges for an MRI. Then the insurance company says , "Oh , you had an MRI 2 years ago and you have to wait for 3 years to pass before we pay for another one." So if you want the needed test , you have to pay out of your own pocket. If you need something done outside of what your doctor can do , you are often screwed. Also , if I have a problem that requires a quick trip to the hospital , I have to call in first to get an OK and approval for an emergency room visit. Even with Medicare , I pay about $2100 a year for my coverage.