What the US could learn from Japan’s responsible antibiotic use
Written by Nicoletta Lanese on . Posted in Current News
When penicillin was first introduced to the public, it earned the nickname “the wonder drug” because it cured infections that had once been deadly. It ushered in the golden era of antibiotics, during which the bacteria-killing drugs entered widespread use, driving down rates of severe disease and death from infections
Unfortunately, the sweeping adoption of these medicines also set the stage for their obsolescence. Once hailed as miracles, antibiotics are now losing their power as bacteria evolve strategies to evade them.
Today, the world is contending with a “silent pandemic” of antibiotic resistance, driven largely by the misuse and overuse of these critical medicines. Curbing resistance, then, means changing how doctors prescribe — and patients use — antibiotics.
I traveled to Japan because a government initiative aimed at correcting antibiotic misuse has helped slash unnecessary prescribing and I wondered if a similar approach could work in the U.S.
The program offers “tips” of 800 yen (about $5) to the clinics of pediatricians and ear, nose and throat doctors (ENTs) who withhold antibiotics in cases when they’re likely not needed.
My findings suggest that many of the factors that drive antibiotic misuse in outpatient clinics overlap in the U.S. and Japan. But the cultural, governmental and insurance landscape may differ too greatly between the two countries for America to copy-and-paste Japan’s approach.
Instead, here’s what I think could work to close the gaps in antibiotic overprescription in the U.S., based on my conversations with doctors.
Similar pressures, different systems
In both Japan and the U.S., sick visits are mere minutes long, so doctors must determine quickly whether an antibiotic is needed. Few rapid tests exist for bacterial infections, introducing a degree of diagnostic uncertainty.
Children’s caregivers sometimes request antibiotics when they’re not needed, and depending on the doctor, that social tension can be enough to prompt an unnecessary prescription, research has found.
I learned that children’s caregivers value doctors who can answer questions and clearly explain their reasoning. They don’t necessarily arrive at an appointment expecting a specific “solution,” such as an antibiotic prescription — even if they sometimes request one.
When faced with parents who request a prescription, doctors can often defuse the tension by explaining why antibiotics aren’t necessary, my reporting found.
On paper, Japan’s antibiotic incentive gets at both halves of this pediatrician-parent dynamic. It offers pediatricians and ENTs extra payment to avoid antibiotics for certain types of infections.
To claim that cash for their clinics, the doctors must explain their reasoning for withholding antibiotics to the child’s caregivers, to help educate them about appropriate antibiotic use.
Although the pressures that lead to overprescription are similar in the U.S., the countries have several big differences.
For one, Japan has a national insurance system in which children’s healthcare is essentially free. People in Japan report a relatively high degree of trust in their national government overall, and they specifically report being very happy with their healthcare system, with satisfaction rates far exceeding those of similarly wealthy countries.
By contrast, the U.S. has a patchwork of private, subsidized and public insurance. About 27 million people — roughly 8% of the population — are uninsured, and those with insurance frequently face issues with using their coverage and major barriers to care, such as prior authorization and claim denials.
Navigating these barriers can derail and delay medical care, spurring frustration. Meanwhile, the number of people able to cover medical care is falling as costs spike, and people worry that insurers hold too much sway over health policy.
These layers of complexity are baked into the U.S. healthcare system, whereas in Japan, the federal government can introduce an insurance policy and affect change across the whole system at once. That’s how the 800-yen incentive for pediatric clinics was implemented.
Hesitations from U.S. doctors
Japanese doctors readily accepted the notion of “tips” for withholding unneeded antibiotics, in part because those types of small-scale incentives already exist in Japanese healthcare.
Clinics earn incentives by claiming an add-on fee when they seek insurance reimbursement for a given appointment. That reimbursement rate is dictated by Japan’s federal government, which sets healthcare pricing, so it’s simple to introduce such incentives at scale.
Similar add-on fees have been used to encourage doctors to prescribe cheaper “biosimilars” over costlier drugs with the same effects and to adopt better treatment approaches for conditions like hip fractures and painful periods.
In contrast, reimbursement rates in the U.S. are set by a dizzying array of agencies and private companies, all with their own goals.
I asked U.S.-based doctors whether a similar incentive could work here. Their responses were mixed.
“I think a program like the Japanese one could work in the U.S.,” Dr. Conor Blanco, a pediatric ENT based in New Jersey, told me in an email. He noted that many physicians’ pay is determined partially by patient satisfaction scores, so there are existing financial incentives that steer their behavior. If you set up a similar incentive around proper antibiotic use, “maybe it makes a difference, it’s tough to say,” he said.
Dr. Dmitry Volfson — chief medical officer of CityMD, a large urgent care provider in New York and New Jersey — agreed that it might work. “But [it] may be difficult to implement” given America’s multitude of insurance payers, Volfson told me in an email.
Other doctors were less open to the idea.
“On first pass, it feels very unethical to me,” said Dr. Morgan Leafe, a pediatrician who worked in both inpatient and outpatient settings for 11 years. Children’s caregivers might be upset to hear that clinics get paid more when they don’t prescribe an antibiotic, given that some are already under the impression that U.S. doctors are overly motivated by money, she told me in a direct message.
Doctors already widely criticize insurers for denying what physicians deem necessary care. Dr. Jennifer Shu, a pediatrician with Children’s Medical Group in the Atlanta metro area, worries that insurers might set up the incentive in a way that restricts doctors’ prescribing patterns too aggressively or doesn’t align with current scientific evidence.
“I do not believe that financial incentives should dictate clinical practice,” said Dr. Erik Blutinger, an emergency medicine physician for the Mount Sinai Health System in New York who also works in its urgent care centers. “It should boil down to the patient’s health and ultimate well-being over finances.”
Dr. Ilan Shapiro, a community pediatrician at AltaMed Health Services in Southern California, said he could see an incentive driving down unnecessary antibiotic prescriptions, but he added that it could also overcorrect, encouraging doctors to hold back antibiotics that are actually needed.
“I’m not a believer in the carrot or the stick,” Shapiro told me.
How incentives work in the U.S.
Notably, many U.S. doctors are already financially incentivized to improve antibiotic prescribing — but those incentives apply at a high level, rather than case by case.
For example, many American health insurance plans use a tool called the Healthcare Effectiveness Data and Information Set (HEDIS) to assess patients’ quality of care at the medical centers they visit.
The tool is used by many commercial insurers, as well as by private groups that manage Medicare and Medicaid plans.
Some insurers incentivize providers to achieve higher HEDIS scores by offering higher reimbursement in exchange, “but this is not universal,” Volfson explained. There are HEDIS metrics that track how often antibiotics are used for ailments that are frequently viral, like upper respiratory infections, sore throat and bronchitis, he added.
These incentives fall under “value-based care,” which aims to reward behaviors that tend to improve patient outcomes and lower healthcare costs. That’s opposed to the more dominant “fee-for-service” model, which compensates practices for individual services provided.
Medicare has its own value-based care approach that includes metrics to track antibiotic use, including for upper respiratory infections. These metrics get factored into one composite score that can boost reimbursement (if the score is high) or lower it (if the score is low) for eligible clinicians and practices covered by the program.
Medicaid, which covers nearly half of U.S. children and is run at the state level, does not have an equivalent to this Medicare approach, but it has other ways of tying reimbursement rates to metrics like antibiotic use.
Medical practices’ participation in value-based care is growing, but fee-for-service remains dominant. Some doctors are skeptical of the alternate approach, Leafe noted, because they feel it puts them on the hook for outcomes that are not completely within a healthcare team’s control.
But Shapiro, whose healthcare system uses value-based care, sees it as a way to encourage doctors to consider the long-term trajectory of a patient’s health rather than only the acute ailment at hand.
“You have to have some sort of guardrail”
U.S. doctors were often put off by the idea of clinical decisions being steered by a potential bump in payment. “Patient-related outcomes are more important than financial incentives when it comes to shaping my clinical decision-making,” Blutinger said.
Shapiro embraces value-based care but expressed doubts about the Japanese approach to incentives. My interviews suggested that incentives awarded for individual actions — such as offering $5 to not prescribe antibiotics for a given child’s cold — might not be accepted as easily in the U.S. as they are in Japan.
As Shu expressed, that may partially come down to a lack of trust in insurance companies. There may also be a lack of trust in other doctors and practices; multiple doctors I spoke with expressed worries about underprescription.
“What if people become disincentivized to give antibiotics at all, even when they need them?” asked Dr. Shruti Gohil, an infectious-disease specialist with UCI Health who has designed antibiotic stewardship interventions for hospitals. “You have to have some sort of guardrail on that.”
Gohil noted that, in Japan’s case, the government incentive aims to promote a “culture of safety, whereas with an insurance company, it’s just about finance.” In other words, she worries that U.S. insurance companies mainly care about their bottom line, not public health. An insurer incentivizing doctors to provide less care struck her as “unsettling.”
In contrast, the pediatricians I spoke with in Japan expressed concerns about other doctors overusing antibiotics, not underusing the drugs, and they argued that some doctors still don’t take antibiotic resistance seriously.
Their salaries are also lower than those of other medical specialties, and the doctors explicitly stated that they appreciate that the antibiotic add-on boosts their practices’ profits.
Alternative approaches?
U.S. doctors may not accept a clone of Japan’s incentive program, and given America’s complex mix of insurance providers and systems, a similar incentive could be difficult to implement uniformly and at scale. But based on my research, I think that incentives that fit more comfortably within our existing infrastructure could still move the needle.
Doctors are already incentivized to record certain metrics, such as body mass index (BMI) and ongoing weight-management plans, in their notes, Shu said. For example, Medicare and HEDIS bake this documentation into quality measures that affect reimbursement, as well as other calculations that help dictate insurance payments.
Borrowing from Japan’s approach, I propose that clinicians and health systems could be paid more when they document that they’ve explained key facts about appropriate antibiotic use to patients’ caregivers.
These facts might include that childhood illnesses are often viral and that symptoms like fever or green mucus don’t necessarily mean bacteria are to blame. They could note that unnecessary antibiotics can cause side effects like diarrhea and make the medicines less effective over time.
These talking points could be added to the electronic medical record, where clinicians could easily access them.
This parent-education requirement could incorporate follow-up plans for further learning. That might include providing parents with physical materials, like pamphlets, or links to vetted websites like the American Academy of Pediatrics’ HealthyChildren.org.
Gohil’s practice regularly uses those types of patient-directed materials. “Nothing beats the conversation,” she said, “but they [the materials] give you talking points and then allow the patient to reference something.”
Various trials suggest that educating parents about appropriate treatment for respiratory infections and uses of antibiotics can help shift their expectations around the drugs, in turn reducing how often they seek antibiotics.
There’s also data to suggest that doctors’ providing parents both verbal and written information can help the knowledge stick. Some trials have found that the number of antibiotic prescriptions fell after such educational interventions.
Particularly effective trials combine parent education with efforts aimed at healthcare providers: in-office materials and presentations about antibiotics, guidelines within the electronic medical record that point doctors toward best practices, data on antibiotic resistance rates in the community, or “audit and feedback,” where clinicians get report cards comparing their prescription rates with those of others in their practice.
This approach would not specifically incentivize nonprescribing over prescribing, but it would prompt clinicians to educate patients and caregivers about appropriate antibiotic use while providing them a simple script to follow.
U.S. adults report placing more trust in health information from their own healthcare providers than from government entities, suggesting that these messages are more likely to stick when doctors deliver them.
This is taken from a long document. Read the rest here livescience.com
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