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3.4.3 Direct payment
Although most of the services are covered by national insurance, some
services, especially for non-diseases, cosmetic and luxury purposes,
are not covered by health insurance and patients have to pay the full
amount. A typical example is normal vaginal delivery, as childbirth is
not considered as a disease. Instead of providers (such as obstetric
clinics or midwiferies) claiming reimbursement from health insurance,
the government has introduced several types of one-time cash benefits
for deliveries, which are likely to offset the cost. The primary benefit
is ¥420 000 (approximately US$ 3500). Although obstetric clinics and
midwives can set the price of delivery freely because delivery is not
covered under the uniform fee schedule set by the MHLW, in most
cases, providers will set their prices somewhere within the limit of the
cash benefit. Emergency and Caesarean section deliveries are treated
as diseases covered by health insurance and providers will claim
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reimbursement from health insurance in the same manner as any other
treatment.
Other examples of direct payments include cosmetic surgery,
orthodontics, abortions and infertility treatment. In Japan, infertility
treatment (i.e. assisted reproductive treatment, ART) is proliferating due
to advancing maternal age. Such infertility treatments are not covered by
health insurance, and OOP payment for couples who wish to have children
can be heavy. To alleviate the financial burden on couples suffering from
infertility, subsidies commenced in 2004. Couples with a combined annual
income of less than ¥7.3 million (approximately $60 000) can receive a
subsidy of ¥150 000 for a treatment cycle. However, the subsidy is far
smaller than the actual charges of many clinics, which can be as high as
¥1 million and have no price control (infertility treatment is not covered
by health insurance, which means that each hospital and clinic can set
prices freely). Table. 3.13 shows the growth in subsidies for infertility
treatment, and the considerable demand for some services that are
covered only by direct payments, which means patients are required to
pay 100% of all health-care costs.
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