What Japan’s Antibiotic-Resistance Strategy Can Teach the United States

Antibiotics transformed modern medicine. When penicillin became widely available, it was celebrated as a “wonder drug” because it treated infections that had once been life-threatening. However, decades of widespread antibiotic use have allowed bacteria to develop resistance, making some infections increasingly difficult to treat.

Today, antibiotic resistance is considered a global “silent pandemic.” The overuse and misuse of antibiotics, particularly for viral illnesses that do not respond to these medicines, are major contributors to the problem. Reducing antibiotic resistance will require changes in how healthcare providers prescribe antibiotics and how patients and caregivers understand their use.

Japan offers an intriguing example. A government program that gives pediatric and ear, nose and throat clinics a small financial incentive for avoiding unnecessary antibiotic prescriptions has helped reduce inappropriate prescribing. The approach raises an important question: Could a similar antibiotic stewardship program work in the United States?

After speaking with doctors in Japan and the U.S., I found that the pressures behind antibiotic overprescribing are similar in both countries. Doctors often have only minutes to evaluate a sick child, rapid tests for bacterial infections are limited, and caregivers may expect antibiotics even when they are not medically necessary.

However, the two countries have very different healthcare, insurance and cultural systems. Rather than copying Japan’s program exactly, the U.S. may benefit from adapting its central ideas: better patient education, stronger antibiotic-prescribing guidelines, improved documentation and carefully designed incentives.

Similar pressures, different healthcare systems

Doctors in Japan and the United States often make antibiotic decisions during short outpatient visits. Because many symptoms overlap between viral and bacterial infections, providers may have to make treatment decisions without definitive test results.

Caregivers may also ask for antibiotics when their children have symptoms such as fever, congestion, coughing or green mucus. Yet these symptoms do not necessarily indicate a bacterial infection. Research suggests that social pressure from patients and families can influence prescribing decisions, even when doctors know antibiotics are unlikely to help.

Conversations with physicians revealed that caregivers generally value clear explanations more than a specific prescription. When doctors listen carefully and explain why an antibiotic is unnecessary, parents are often willing to accept an alternative treatment plan.

Japan’s incentive program addresses both sides of this interaction. Doctors can receive an additional payment for withholding antibiotics in specific cases, but they must also explain their decision to the child’s caregivers. The goal is not simply to reduce prescriptions, but to improve understanding of appropriate antibiotic use.

The broader healthcare environments, however, are very different. Japan has a national insurance system in which children’s healthcare is largely free or highly subsidized. The central government sets healthcare prices and can introduce nationwide reimbursement policies relatively quickly.

The United States has a fragmented system involving private insurers, public programs and government-subsidized coverage. Millions of Americans remain uninsured, while many insured patients face high costs, prior authorization requirements and claim denials. These barriers can reduce trust in insurers and complicate the implementation of a uniform national incentive program.

Why U.S. doctors are cautious about financial incentives

Japanese physicians were generally familiar with small reimbursement incentives. Japan’s healthcare system already uses additional fees to encourage certain practices, such as prescribing lower-cost biosimilar medicines or following recommended treatment guidelines.

In the United States, reimbursement is controlled by numerous public agencies, commercial insurers and healthcare networks. This makes it more difficult to create a single antibiotic-prescribing incentive that applies consistently across clinics.

Some U.S. doctors believe financial rewards could help reduce inappropriate antibiotic use. Dr. Conor Blanco, a pediatric ear, nose and throat specialist, noted that physicians are already influenced by measures such as patient satisfaction scores. An incentive connected to appropriate antibiotic prescribing could potentially influence behavior as well.

Dr. Dmitry Volfson, chief medical officer of a large urgent-care provider, agreed that the concept might work but said implementation would be challenging because of the number of insurance payers involved.

Other clinicians expressed ethical concerns. They worried that caregivers might believe doctors were refusing antibiotics to increase clinic revenue rather than to protect the child’s health.

Dr. Erik Blutinger, an emergency medicine physician, said clinical decisions should be based on patient well-being rather than financial considerations. Other doctors raised the opposite concern: an incentive to avoid antibiotics could cause some clinicians to withhold them when they are genuinely needed.

These concerns highlight the importance of safeguards. Any U.S. antibiotic stewardship program would need independent clinical standards, regular monitoring and penalties or corrective measures for unsafe prescribing or underprescribing.

Existing antibiotic-prescribing incentives in the United States

Many U.S. doctors are already encouraged to improve antibiotic prescribing, although these incentives usually operate at the practice or healthcare-system level rather than during individual patient visits.

One example is the Healthcare Effectiveness Data and Information Set, commonly known as HEDIS. Commercial insurers and organizations that manage Medicare and Medicaid plans use HEDIS measures to evaluate aspects of healthcare quality.

Some HEDIS metrics track antibiotic use for conditions that are frequently viral, including upper respiratory infections, bronchitis and certain sore throats. Health plans may offer better reimbursement to providers that achieve stronger quality scores, although participation and payment structures vary.

These programs are part of “value-based care,” which rewards healthcare providers for improving patient outcomes and controlling unnecessary costs. This differs from the traditional fee-for-service model, which pays providers for individual visits, tests and treatments.

Medicare also uses quality-based payment systems that include measures related to antibiotic prescribing. Medicaid does not have one nationwide equivalent because it is administered by individual states, but many state programs use their own quality metrics and value-based payment arrangements.

Although value-based care is expanding, fee-for-service remains common. Some doctors worry that these programs hold them responsible for outcomes that may be influenced by factors outside a clinic’s control. Others say value-based care encourages providers to consider a patient’s long-term health rather than focusing only on the immediate complaint.

Why antibiotic stewardship programs need safeguards

In interviews, U.S. doctors were more comfortable with incentives that promote education and evidence-based care than with programs that directly reward doctors for not prescribing antibiotics.

One possible safeguard would be to reward providers for documenting that they explained antibiotic use to patients and caregivers. This would encourage communication without making “no prescription” the sole measure of success.

Any program should also account for legitimate bacterial infections. Clinical guidelines, diagnostic testing, prescribing audits and peer review could help ensure that financial incentives do not discourage medically appropriate treatment.

Infectious-disease specialist Dr. Shruti Gohil emphasized that a program must include a “guardrail” to prevent underprescribing. She also noted that a government-led public health initiative may inspire more confidence than an insurer-led program focused primarily on reducing costs.

This distinction is important. Antibiotic stewardship is intended to protect individual patients and public health by preserving the effectiveness of antibiotics. It should not be used simply as a tool to limit healthcare spending.

A better U.S. approach: reward antibiotic education

The United States may not be able to reproduce Japan’s program nationwide, but it could adapt the idea to existing healthcare infrastructure.

Instead of rewarding clinicians specifically for withholding antibiotics, insurers and health systems could provide incentives for documenting meaningful conversations about antibiotic stewardship. Relevant information could be built into electronic health records, allowing clinicians to access a clear, consistent explanation during a short appointment.

These conversations could explain that:

• Many common childhood illnesses are caused by viruses, not bacteria.
• Antibiotics do not treat viral infections.
• Fever, coughing, congestion and green mucus do not automatically indicate a bacterial infection.
• Unnecessary antibiotics can cause side effects, including diarrhea and allergic reactions.
• Overuse of antibiotics contributes to antibiotic-resistant bacteria.
• Some illnesses can be safely managed through observation, symptom relief and follow-up care.

Clinicians could also provide printed materials or links to trusted medical resources, such as the American Academy of Pediatrics’ HealthyChildren.org. Written information gives caregivers something to review after the appointment and reinforces the doctor’s explanation.

Research suggests that combining verbal explanations with written information can improve caregivers’ understanding of respiratory infections and reduce demand for unnecessary antibiotics. Provider education, electronic prescribing guidance and regular feedback can make these interventions even more effective.

One useful strategy is “audit and feedback,” in which clinicians receive reports comparing their prescribing patterns with those of colleagues. When combined with clear guidelines and patient education, these reports can help reduce inappropriate prescribing without encouraging doctors to avoid antibiotics in every case.

Could caregivers receive rewards for antibiotic education?

Another possibility is to provide incentives directly to patients and caregivers. This may be less ethically controversial than paying doctors based on individual prescribing decisions.

Many health insurers already offer rewards such as gift cards, cash payments or points for completing preventive health activities. Examples include annual checkups, cancer screenings, smoking-cessation programs, exercise tracking and online health courses.

The same infrastructure could support short educational programs about antibiotics. Caregivers might receive rewards for completing interactive lessons about bacterial and viral infections, watchful waiting, symptom management and the warning signs that require additional medical care.

Brief quizzes could confirm that participants understood the information and provide an opportunity to address common misconceptions. Educational programs could also include guidance about when to contact a doctor, when symptoms can be managed at home and when urgent care is needed.

These programs would not replace a medical evaluation. Instead, they could help caregivers arrive at appointments with more realistic expectations and reduce pressure on clinicians to prescribe antibiotics unnecessarily.

Dr. Gohil said ongoing patient education could help families better understand when antibiotics are appropriate. In the long term, better-informed caregivers may be less likely to seek antibiotics for illnesses that are likely to resolve without them.

For insurers, the potential benefits could include fewer unnecessary visits and prescription costs. For public health, the larger benefit could be a reduced risk of antibiotic-resistant infections.

Could antibiotic stewardship expand beyond pediatric care?

Japan’s program focuses on pediatricians and ear, nose and throat doctors because those specialties had particularly high rates of unnecessary prescribing. In the United States, urgent-care centers may be an especially important target for antibiotic stewardship efforts.

Studies suggest that urgent-care providers are more likely than some primary-care providers to prescribe antibiotics unnecessarily for acute respiratory illnesses. One analysis of millions of urgent-care visits found that antibiotics were prescribed for a notable share of bronchitis cases, even though antibiotics are rarely appropriate for uncomplicated bronchitis.

Urgent-care clinicians may see a child or caregiver only once, making it more difficult to establish trust. Providers may also face long queues and pressure to complete visits quickly. Still, research indicates that many caregivers are receptive to explanations, even when the treatment plan does not include an antibiotic.

Physician assistants and nurse practitioners could be important participants in U.S. antibiotic stewardship programs because they provide a large share of urgent-care services. Some studies have found higher rates of inappropriate antibiotic prescribing among these providers compared with physicians, particularly during visits involving children.

The reasons for these differences are not fully understood. Training pathways vary, and many antibiotic stewardship initiatives have historically focused on physicians rather than the entire clinical team. Tailored education for nurse practitioners, physician assistants and urgent-care staff could help close this gap.

Large urgent-care networks affiliated with hospitals may be well positioned to introduce these strategies. They can establish consistent prescribing guidelines, track antibiotic use and incorporate communication metrics into performance reviews.

A Utah urgent-care network used a combination of clinician education, patient materials, electronic medical-record guidance, peer comparisons and prescribing targets. Antibiotic use for respiratory conditions fell substantially after the program was introduced, demonstrating that incentives are most effective when combined with education and practical support.

The future of antibiotic stewardship

Japan’s experience shows that targeted incentives can reduce unnecessary antibiotic prescribing, at least within the country’s centralized healthcare system. The United States faces different challenges, including fragmented insurance coverage, varying reimbursement policies and lower trust in insurers.

For that reason, the U.S. should avoid relying on a single incentive. A stronger strategy would combine evidence-based prescribing guidelines, clinician education, electronic health-record prompts, prescribing audits, peer feedback and caregiver education.

Financial rewards could have a role, but they should support safe clinical practice rather than dictate it. Incentivizing providers to explain antibiotic decisions may be more acceptable than paying them simply to reject prescriptions. Rewarding caregivers for completing reliable health education could further reduce misconceptions and improve shared decision-making.

Antibiotic resistance remains one of the world’s most urgent public health threats. Because antibiotics are prescribed so frequently in outpatient settings, even modest improvements could protect patients, reduce side effects and preserve these medicines for future generations.

The goal is not to eliminate antibiotic use. It is to ensure that antibiotics are prescribed when they are truly needed—and avoided when they will not help.