Learning from Nagano clinic’s bold experiment

Lee Young-hee
The author is a Tokyo correspondent of the JoongAng Ilbo.

It took about an hour and 10 minutes by bullet train to travel from Tokyo to Karuizawa Station in Nagano. After a 15-minute drive, a wooden building appeared through the dense forest. It looked like a vacation cottage at first glance, but it was actually a clinic. Founded in 2020, the Hotch-Lodge is creating a new medical culture in Japan.

On the morning of April 25, staffers busily walked around the facility before its opening hours. Although the clinic specializes in internal medicine, pediatrics and pain relief treatments, not a single medical worker wore a doctor’s coat or nurse’s uniform. This is because the clinic does not want patients to feel intimidated during treatment. Inside the building were a large living room and kitchen, a well-stocked library and a children’s area with toys. Consultations take place in the attic on the second floor. Patients arrived one after another by 9 a.m. Children played in the playroom and adults read books while waiting to meet doctors.

The clinic is staffed by three medical doctors and five nurses, but outpatient services are only available in the morning hours of Monday through Saturday. For the rest of the time, the clinic operates a 24-hour home visit system. It has contracts with about 150 homecare patients who live within 16 kilometers (10 miles) of the clinic; a doctor or nurse pays a visit to their homes two to three times per month to offer medical services.

The cost depends on a patient’s income. For elderly people covered by nursing care insurance, it ranges from 6,700 yen ($42.33) to 18,000 yen per month. “Most of our patients are elderly people with limited mobility,” said Satoko Fujioka, co-founder of the lodge. “The advantage of home visits is that we can give them advice after carefully observing their living environment rather than just simply discussing their symptoms,” he said.

Hotch-Lodge is named after the village of Hotch. It is not only a place for offering medical services, but also a community where patients, caregivers and residents can easily interact and communicate. In collaboration with a nearby elementary school, the facility operates after-school classes through which students and older adults can interact, and runs a day care program for disabled children. “We don’t approach patients only from the perspective of medical symptoms. Our activity is about sharing various factors and improving quality of life,” said Fujioka.

In Nagano, where the clinic is located, a culture of at-home medical care has been established for decades. Due to its mountainous terrain and scare transportation, doctors and nurses began visiting patients’ homes early on.

Toshikazu Wakatsuki, who began his medical practice at Saku Hospital in the city of Saku in 1945, is considered a pioneer of rural health care. With a belief that prevention beats cure, he introduced an integrated prevention and treatment system through proactive contact with patients in rural areas and massive medical checkups.

This inspired several hospitals in Nagano Prefecture to start offering house calls, including checkups and nursing. According to the 2020 medical facilities survey published by Japan’s Ministry of Health, Labor and Welfare in 2022, 30 percent of hospitals in the prefecture provide house calls, a proportion significantly higher than Tokyo’s 13.5 percent and Osaka’s 25 percent. In particular, 10 percent of the medical institutions in Nagano provide home palliative care for terminal cancer patients, the highest rate in the country.

Experts believe that this healthcare system has played an important role in making Nagano a “longevity prefecture.” Nagano was not included in the list of Japan’s longevity prefectures until the 1970s, but since the 1990s, it has always been at the top. As of 2020, the average lifespan in Japan was 81.49 years for men and 87.60 years for women. In Nagano, it was 82.68 years for men and 88.23 years for women. Of the 47 metropolitan regions, Nagano ranked second-highest in terms of longevity after Shiga Prefecture.

Japan has 2.6 doctors per 1,000 people, according to data from the Organisation for Economic Cooperation and Development, putting it nearly on par with Korea. To cope with the aging society, Japan has increased the medical school admissions quota by an average of 110 per year between 2008 and 2023. As the shortage of doctors in rural areas is particularly serious, Japan operates “regional quotas” that require students to practice in specific areas while local governments and universities provide scholarships to those selected for the program.

Starting last year, Ina, a city in Nagano with many mountainous areas, began a service offering online medical consultations and delivering medicines with drones to residents of remote areas. “Korea needs to actively consider the regional quota system of medical schools being operated in Japan in order to cope with the shortage of doctors in rural areas,” said Kim Myoung-jung from the NLI Research Institute. “Expanding online medical services using information technology will help solve problems associated with the aging populations in rural areas,” the expert on Japan’s aging society added.