Waseda Frontline Research Vol. 21: How should healthcare resources be used? A challenge of health economics (Part 2 of 2)Fri, Apr 19, 2019
Professor Haruko Noguchi, Faculty of Political Science and Economics
Part 2: Aiming to evidence-based policy making
Since the 1990’s, “Evidence-Based Medicine (EBM)” Has been emphasized in medical science. This concept is now not only taking precedence in medical science but also in the system design of the nation, policy making and evaluation. Lately, Professor Haruko Noguchi of the Faculty of Political Science and Economics has also been trying to figure out how to implement “Evidence-Based Policy Making (EBPM)” to the real world. This time, we cover the recent efforts and outcomes of her projects as well as the overall importance of EBPM. (Date of interview: July 17, 2018)
Exploring the idea of “cost effectiveness” through doctoral dissertation research
While completing my doctoral course at the Graduate Center of the City University of New York (CUNY), I worked on writing my doctoral dissertation under the guidance of three researchers including Professor Michael Grossman, who I introduced in the first section and who was a contributor to the establishment of the theoretical framework in health economics. Looking back now, I believe the research I conducted for my doctoral thesis was the cornerstone of all my research from then on.
The theme of my doctoral thesis was “Effects of State Medicaid Policies on the Likelihood of Nursing Home Admission and Length of Stay: an Application of the Competing-Risks Models.” “Medicaid” is a public healthcare and long-term care insurance for low-income and disabled people in the United States, which at the time was administered by the state government. The purpose of my doctoral thesis was to clarify how the demand for facility long-term care would be affected by the Medicaid policy.
At the time, there were two factors that influenced my decision to research “aging” issues in the United States. The first was meeting Dr. Robert Butler at the hospital where I worked as a research assistant. Dr. Butler is said to be “the father of gerontology,” and he was keen on employing systematic research for gerontology. The second was the rapid aging of Japan’s population. While conducting my research, Professor Grossman suggested I apply for the federal scholarship for $20,000USD that is offered every year to roughly 10 doctoral students across the United States. So I applied and fortunately I was selected as one of the scholarship recipients, giving me the funds I needed to proceed with my research.
Through my research for this doctoral thesis, I learned the kinds of viewpoints and approaches I could take when studying aging issues, as well as the kinds of analytical methods that can be employed. As the expenses of long-term care and medical care increased, I was able to figure out what kind of policies were most effective for containing the costs, that is, I learned the fundamental thinking required to achieve cost effectiveness.
Engaged in the original research of “evidence-based medicine”
After acquiring my Doctoral Degree from the CUNY, on the recommendations of Professor Grossman, I got the opportunity to continue my research at Stanford University under Professor Mark McClellan for around four years. Professor McClellan was Director of the Food and Drug Administration (FDA) under the administration of George W. Bush and served as Deputy Assistant Secretary of the Treasury for Economic Policy under the Bill Clinton administration. Through the use of what is called Big Data today, Professor McClellan’s research team analyzed the extent to which medical costs increased and decreased, as well as how much the treatment of patients improved by looking at the mortality and re-hospitalization rates according to drugs and innovations in medical technology for diseases such as acute myocardial infarction, renal failure, and cancer. I was in the team of acute myocardial infarction.
We conducted this research in the 1990s and since then it has become the origin of “Evidence-Based Medicine (EBM)” that is now regarded to be of high importance in the United States and Japan. Furthermore, “evidence-based” became a major concept that many thought should be applied not only in the medical science but also in systematic design and policy making, especially in the United States. The idea now referred to as EBPM: Evidence Based Policy Making. Today, even in Japan, the significance of EBPM has been emphasizing little by little.
“Evidence-based” should also by applied to the Japanese healthcare systems and policies
In 2000, I returned to Japan and I wanted to make the most of the skills I learned in the United States by applying them to healthcare policies in Japan. However, at the time, Japan did not have enough data to allow for evidence-based decision-making. To be honest, I was shocked. Japan was far behind the United States having collected Medicare claims (medical fee invoices for public healthcare insurance which covers those who are 65 years old and older) since 1984, with researchers already using the information for creating scientific evidence for policy making and evaluation.
Under these circumstances, I got the opportunity to meet the late Professor Shigekoto Kaihara (1937-2011), a leader of the field of medical informatics and Director of Central Medical Information at the University of Tokyo Hospital. Professor Kaihara and I shared the thought that “medical claims must be collected in Japan as well and used in policy making.” So in 2001, together with Professor Kaihara and Professor McClellan, “Discussion on how to use universal health data by researchers: learning from case of the United States how to manage and adminisrate claims data for Medicare (in Japanese)” was publicized in the “Social Security Review (Shakai Hoken Junpo).”
As a result, the importance of collecting claims gradually came to be featured more in Japan. With further efforts from Professor Kaihara, who served as chairman at investigative commission on the use of claims data to improve the quality of medical care held by the Ministry of Health, Labour and Welfare, it was finally made possible for claim data to be collected and organized by Japanese government and supplied to researchers for public interests. The provision of this data to researchers was achieved in 2013, about 30 years after that of the United States.
Policies determined by the “inclinations,” that is the preferences or perceptions, of politicians and administrators can often lead to great mistakes. You cannot move forward if you don’t acknowledge the reality that is “fact” and only focus on how something “should be.” There is no guarantee that the current policy will change dramatically. For example, regarding the discussion advocating for the “preservation of National Health Insurance,” there is no discussion from an objective perspective on the current situation of this system or what needs to be done to maintain it so that it can become a sustainable system in future. For this to happen, it may be necessary for us to look at the “price” of our life and health in an unemotional, realistic way. In order to ensure the system remains sustainable, we have to establish a political process that develops along with the different ideals of how policies “should be,” by making full use of scientific evidence, that is, to objectively accept “fact.”
Feeling the “changes” at Waseda University
I studied at Waseda University for both undergrad and graduate school of economics and have been involved in education and research at Waseda University since 2012. Lately though, I feel the University has gone through some changes. One change is the overall increase in quality of researchers. At the Faculty of Political Science and Economy there is a “The Center for Positive Political Economy,” of which I am a member. I believe more and more talented young researchers have been applying to Waseda University, even from abroad, especially in the last few years. As a background of this, globalization also has also been progressing in research, and so young researchers have been facing with world-wide fierce competition to get an academic job and so they have to show a good performance in research.
The attitude of the students has changed greatly. In the past, I felt that Waseda University students were quite strongly motivated to “struggle and grow individually.” These days however, I feel that the number of singularly stand-out students is decreasing, which can be seen as both positive and negative. The university as a whole, along with each faculty member, has achieved an educational style considered to be of global standards, and lectures and seminars are conducted with enthusiasm in that style. Students can succeed by obediently following this curriculum. Though I do miss the old days on the campus once in a while, these changes may be inevitable for the university itself and the researchers to survive in a globally competitive society. In order for Waseda University to take the next leap forward, we must rid ourselves of nostalgia for the past as there is a long and grueling path ahead. In terms of education, we need to do our utmost to teach students how to have a valuable life and become someone who can contribute to society. In terms of research, we must spare no effort to support healthy competition among researchers so that their achievements can be internationally recognized. These are the philosophy established at the time of Waseda’s foundation to which we must once again return, as this will set us on the right path to take on these new challenges.
Professor Haruko Noguchi graduated from Waseda University Graduate School of Economics and received her Ph.D. in economics from the Graduate Center of the City University of New York in 1997. After working as a researcher at Stanford University and the National Bureau of Economic Research (NBER), she returned to Japan in 2000 and worked at Toyo Eiwa University and the National Institute of Population and Social Security Research. She has been professor at Waseda University’s Faculty of Political Science and Economics since 2012. Currently, Professor Noguchi is a member of the Metropolitan Hospital Management Committee of the Office of Tokyo Metropolitan Hospital Accounting; a public member of the Central Social Insurance Medical Council of the Ministry of Health, Labour and Welfare Health Insurance Bureau; a member of the Expenditure Reform Working Group of the Cabinet Office Administrative Reform Promotion Council; and dean of the Adachi Ward Children’s Facility Administrator Selection Board of the Adachi Ward Education Committee. She is also Director of the Waseda Institute of Social & Human Capital Studies (WISH) and a member of Waseda University’s Center for Positive Political Economy (CPPE).
Major research achievements
- Rong Fu, Haruko Noguchi, Akira Kawamura, Hideto Takahashi, Nanako Tamiya. “Spillover Effect of Japanese Long-Term Care Insurance as an Employment Promotion Policy for Family Caregivers”. Journal of Health Economics, 56: pp 103-112. 2017.12.
- Atsushi Miyawaki, Haruko Noguchi, Yasuki Kobayashi.(2017.10)“Impact of Medical Subsidy Disqualification on Children’s Healthcare Utilization: A Difference-in-Differences Analysis from Japan”. Social Science & Medicine,191: pp89-98. 2017.10.
- Rong Fu, Harkuo Noguchi, Hirokazu Tachikawa, Miyuki Aiba, Shin Nakamine, Akira Kawamura, Hideto Takahashi, Nanako Tamiya. “Relation between social network and psychological distress among middle-aged adults in Japan: Evidence from a national longitudinal survey”. Social Science & Medicine, 175: pp.58-65. 17.2.
- Rong Fu, Harkuo Noguchi, Koichi Suga. “A revisit to the Grossman model with endogenous health depreciation”. Economics Bulletin, 36(4): pp. 2405-2412. 2016.12.
- Nanako Tamiya (co-lead author), Haruko Noguchi (co-lead author), Akihiro Nishi, Michael R Reich, Naoki Ikegami, Hideki Hashimoto, Kenji Shibuya, Ichiro Kawachi, John Creighton Campbell.“Population ageing and wellbeing: lessons from Japan’s long-term care insurance policy”. The Lancet, 378(9797): pp.1183-1192. 2011.9.
- Michael G. Shlipak, Paul A. Heidenreich, Haruko Noguchi, Glenn M. Chertow, Warren S. Browner, Mark B. McClellan. “Associations of renal insufficiency with treatment and outcomes after myocardial infarction in the elderly”. Annals of International Medicine, 137: pp.555-562. 2002.10.
- Mark B McCellan, Haruko Noguchi. “Technological change in heart disease treatment : Does high tech mean low value?”.American Economics Review, 88(2): pp.90-96. 1998.5.
- 野口晴子.日本における行政データの活用を模索する：介護レセプトデータを中心に」. 井伊雅子・原千秋・細野薫・松島斉『現代経済学の潮流2017』第4章.東洋経済新報社, 2017.8.
- ヨシュア・アングリスト, ヨーン・シュテファン・ピスケ著 ; 大森義明、小原美紀、田中隆一、 野口晴子（訳）. 『「ほとんど無害」な計量経済学：応用経済学のための実証分析ガイド』 NTT出版,2013.6.
- 井堀利宏・金子能宏・野口晴子編.「新たなリスクと社会保障：生涯を通じた支援策の構築」.東京大学出版会, 2012.10.
- 清水谷諭・ 野口晴子. 「介護・保育サービス市場の経済分析：ミクロデータによる実態解明と政策提言」. 東洋経済新報社, 2004.6. ISBN : 4492313419.
Editorial and lecture materials for the general public
- 野口晴子.『時事評論 就労促進策としての公的介護保険』週刊社会保障 71(2947), pp.26-27, (2017.11)
- 野口晴子.『時事評論 統計で見るがん患者の就労状況』週刊社会保障, 71(2926), pp.32-33. (2017.6)
- 野口晴子.『時事評論 ソーシャルネットワークと健康』週刊社会保障, 71(2916), pp.32-33. (2017.3)
- 野口晴子. 『時事評論 何がエビデンスか？－「根拠」に対する合意形成の必要性－』週刊社会保障， 69(2855): pp.30-31. 2015.12.
- 野口晴子. 『時事評論 NDBの現状と課題－「科学的根拠に基づく政策」をめざして－』 週刊社会保障 ， 69(2845): p.p40-41, 2015.10.
- 野口晴子・金子能宏・開原成充・Jeffery Geppert・Mark B McClellan.「公的に収集された医療情報への研究者への提供に関する一考：米国での個票データ管理と運営の事例から学ぶこと」 社会保険旬報， 2097: pp.6-17. 2001.5.