ASOURCE Navi

Japan's medical fee system is an important mechanism that forms the basis of the national health insurance system, and plays a role in determining the quality and efficiency of medical care. Its history began with the enforcement of the Health Insurance Act in 1927, and has undergone several changes to reach the present day. This time, we will summarize the history of medical fee revisions.

Various medical procedures are performed in the medical field, and the medical fee system is a mechanism for paying fair compensation for these medical services and the goods used. Medical fees are the remuneration that insurance medical institutions and insurance pharmacies receive from the insurer in return for insurance medical services. The contents of medical fees are evaluation of the technology and service and the price evaluation of the goods (the price of medicines is determined by the drug price standard). These evaluation standards are set by the Ministry of Health, Labor and Welfare within the scope of public medical insurance. After the actual treatment, the points of the medical procedures performed by the medical institution are added up and the total amount is calculated with 1 point being 10 yen. The patient pays a portion of the amount (10-30%), but the remaining amount is paid by the insurer to the medical institution through the examination and payment agency. Medical fee points are usually reviewed every two years based on medical advances, economic conditions, actual market prices, etc. These are also a means of guiding medical institutions to the national medical policy.

The medical fee system originated from the official price regulation following the implementation of the Health Insurance Act in 1927, and the New Medical Fee System, which is the basis of the current medical fee system, was introduced in 1958. Then, due to the advancement of medical technology and the increase in the rate of consultations during the period of high economic growth, medical expenses increased approximately 5.8 times in the 10 years from 1965 to 1975. For this reason, since the 1980s, efforts have been made to curb medical expenses by restricting the rate of revision of medical fees and promoting the introduction of a lump-sum payment system (DPC/PDPS) for hospitalization medical expenses.

In the 1990s, medical system reform was considered to respond to the aging of the population, and the Long-Term Care Insurance Act was enacted in 1997. When the long-term care insurance system was implemented in 2000, the medical fee system was also promoted to be more comprehensive, with a new "basic hospitalization fee" that integrated the previous hospitalization fee. In addition, a system for evaluating the quality of medical care was introduced, such as the functional differentiation of medical institutions based on regional medical plans and the setting of hospitalization fees according to the severity and nursing needs. In 2006, based on the government's "Basic Policy for Economic and Fiscal Management and Reform," medical fees were significantly revised downward with the aim of optimizing medical expenses. In 2012, efforts were made to strengthen cooperation between medical institutions in order to build a regional comprehensive care system, a system for providing medical and long-term care services that is self-contained in the community. In 2020, in response to the spread of COVID-19, evaluation of online medical consultations was newly established to respond to infectious disease countermeasures.

The 2024 medical fee revision will see an increase in the "initial consultation fee," "re-examination fee," and "basic hospitalization fee." These increases will increase the base pay of nurses, nursing assistants, and technicians, as well as raise wages for doctors under the age of 40 and administrative staff. In addition, a new comprehensive community medical ward will be established to accommodate the rapidly increasing number of elderly people who are rushed to hospital, providing early discharge with thorough rehabilitation and nutritional management. A surcharge has been set for medical institutions that work with long-term care insurance facilities on a daily basis and make house calls or admit residents when their condition worsens. Meanwhile, in order to curb medical expenses, the restructuring of compensation for lifestyle-related diseases will see lifestyle-related disease management fees billed only once a month, as well as a reduction in prescription fees and an expansion of the surcharge to encourage the issuance of "refill prescriptions," which can be used repeatedly within a certain period set by the doctor, even if the patient does not visit the hospital.

The issues facing future revisions to medical fees are how to respond to the increasing demand for medical care due to the aging population and how to make efficient use of limited medical resources. It will be necessary to consider the medical system from around 2025, when the baby boomer generation will start to turn 75 years old or older. Other important issues include clarifying the division of roles among medical institutions, improving indicators to accurately evaluate the quality of medical care, utilizing ICT technology, and training and securing medical professionals and improving their working environment.