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.
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.
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.
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.
In Japan and the U.S., children's caregivers value doctors who can explain their rationale for opting for one treatment course over another. (Image credit: Jessica Peterson via Getty Images)Although the pressures that lead to overprescription are similar in the U.S., the countries have several big differences.
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.
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.
In contrast, reimbursement rates in the U.S. are set by a dizzying array of agencies and private companies, all with their own goals.
Dr. Erik Blutinger, emergency medicine physician for the Mount Sinai Health System
"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.
Other doctors were less open to the idea.
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.
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.
Professional groups and regulatory bodies like the Centers for Disease Control and Prevention issue protocols to help guide doctors' antibiotic prescriptions. Several U.S. clinicians told me that they'd be wary of insurers setting incentives that might conflict with those established protocols. (Image credit: Johner Images via Getty Images)
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.
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.
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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.
"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.
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.
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."
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.
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.
In the electronic medical record, in-built tools and prompts can help guide clinicians' antibiotic prescriptions. They could potentially help steer patient education around antibiotic use, too. (Image credit: Morsa Images via Getty Images)
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."
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.
Targeting caregivers
Incentives might also help by rewarding children's caregivers for educating themselves about antibiotics. That approach might be less ethically dubious than directly incentivizing doctors' prescribing habits, and the infrastructure for such incentives already exists, my reporting suggests.
The hope is that, by rewarding such healthy habits, insurers can reduce their members' medical costs. Evidence suggests that these programs can motivate people to change their behavior and improve related health measures, especially in the short term. Their long-term and systemic impacts are understudied, although some research — about quitting smoking, for example — demonstrate long-term behavioral changes.
These resources could explain that many common childhood infections are viral and resolve on their own or, similar to an app about childhood illness created in Japan, lay out the recommended care for acute viral infections and describe the signs that a bug might actually be bacterial. The creator of the app, Dr. Masahiko Sakamoto of Saku Central Hospital, has found that the platform changes how parents understand childhood illness and interact with the health system.
Dr. Shruti Gohil, infectious-disease specialist with UCI Health
"Presumably, with that kind of continuing education of patients, they would perhaps seek antibiotics less and less and understand when they're necessary," she said. "I think that [idea] is so compelling."
Beyond pediatrics
Japan's incentive program focuses on pediatricians and ENTs, because the government recognized a pattern of overprescription in those groups. In the U.S., pediatrics clinics aren't the main source of overprescription — but urgent care centers may be a significant one.
Unlike primary care pediatricians, who see children's caregivers many times and have the opportunity to build trust, urgent care providers may see them only once. In a 2026 study of pediatric urgent care providers across the country, many reported feeling pressured to satisfy parental requests for antibiotics, and over 50% admitted to altering their care plans in response to such requests.
"It does become challenging when you have a queue of patients waiting to be seen," Blutinger noted. Nonetheless, his practice aims to prioritize such education. He's found that parents are receptive to explanations about antibiotics, especially if he carefully listens to and addresses their concerns. "I've never found it helpful to make it a one-way, information-sharing conversation. It has to be two-way," he said.
In the U.S. setting, physician assistants and nurse practitioners may be logical targets for strategies to optimize antibiotic use. (Image credit: Maskot via Getty Images)
Urgent care centers are often staffed largely by PAs and NPs, with one doctor on-site along with various medical assistants. That might be relevant to their antibiotic prescribing.
The reasons for this difference aren't fully understood, although the study authors pointed out that efforts to improve antibiotic use have been aimed mostly at doctors. NP and PA education and training also tends to vary more widely than doctors' training, suggesting potential knowledge gaps.
Related stories
'Teach me! Doctor': Meet the pediatrician on a mission to boost parents' knowledge of childhood illnesses'800 seconds for a sick visit': Some factors driving antibiotic resistance have nothing to do with biology, says medical sociologist Julia Szymczak'They didn't question it': Why doctors prescribe too many antibiotics
That financial incentive didn't stand alone, though. It coincided with new educational materials for clinicians and patients about antibiotics, new guidance on antibiotics in the medical record, and the introduction of peer-to-peer comparisons of prescribing rates. Together, these strategies drove a substantial decrease in overall antibiotic use for respiratory ailments. Clinicians initially prescribed antibiotics for 48% of respiratory conditions; that fell to 33% within one year and to 26% the next.
"Antimicrobial resistance is one of the world's most urgent public health threats," Dr. Sarah Kabbani, director of the Centers for Disease Control and Prevention's Office of Antibiotic Stewardship, told me in an email. "Because outpatient prescribing is so common, even small improvements can have a large impact on patient safety and population health."
This article is for informational purposes only and is not meant to offer medical advice.
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