Healt lth h Ca Care re Refo form rm in in Japan for Un - - PowerPoint PPT Presentation

New York Pharma Forum March 4th, 2004

Councilor for Health Insurance and Health Policy Minister’s Secretariat, Ministry of Health, Labour and Welfare

Masaharu NAKAJIMA, M.D.,Ph.D.

Healt lth h Ca Care re Refo form rm in in Japan

～for Un Unpreceden cedented ed Agi ging g So Socie iety～

７．５ (1996) ９．８ (1996) １０．８ (1997) １２．０ ３１．８

Average length

• f hospital stay

５．８ ２２１ ７１．６ ３．７

U.S.A

６．１ １２０ ４０．７ ４．２

U.K

６．５ ６９．７ (1997) ３５．２ ８．５

France

６．５ ９９．８ ３７．６ ９．３

Germany

１６．０ ４３．５ １２．５ １３．１

Japan

Consultation rate of

• utpatient ( 1996 )

Number of nursing staffs per 100 beds Number of doctors per 100 beds Number of beds per 1000 persons

Country

Compar

arison of Me Medical al C Car are Se Servi vice Sy Syste tem ( ( 1 1998 )

－１－

Japanese Health Insurance Scheme

1. Universal Coverage : all national 2. Free access : all medical facilities 3. Universal Benefit: Inpatient, Outpatient, Pharmaceuticals, Devices

• 4. Fund:

・Premium (Employer 50% : Employee 50%) ・Tax ・Co-payment (30% with upper limit)

－２－

Medical Expenditure

（notes）・order is among ＯＥＣＤ countries ・”Aging Population”: the ratio of the population aged 65 years and over ・ＯＥＣＤ “ ＨＥＡＬＴＨ DATA 2002 ”

Nation Order Order 2000 2025

Japan

289,813 9 7.1 19 17.4 28.7

Germany

352,906 5 10.3 3 16.4 24.6

France

303,688 8 9.3 4 16.0 22.2

UK

216,509 17 6.8 23 15.8 21.9

USA

546,900 1 12.9 1 12.3 18.5

Aging Population（%） Per Capita ME（\） Total ME per GDP（%）

(1998) (1998)

－３－

Evaluation of Japan’s Health Care System

Japan U.S.A U.K France Germany １ １5 ９ ６ １４

Rank Country Healthy life expectancy（years） １ Japan 74.5 ２ Australia 73.2 ３ France 73.1 ４ Sweden 73.0 ５ Spain 72.8

・ Japan is ranked as No. 1 in “The World Health Report 2000” by WHO , which made comprehensive assessment of the quality and equality of health care system of 191 countries . Healthy Life Expectancy（male and female average） （The World Health Report 2000）

－４－

• 1. Current situation of Medical Care in Japan

①Evaluation by WHO

・Access（Convenience of consultation） ・Quantity ・Cost ・Quality

②Advance in medical technology

・Advanced medical technology ・Reduction of length of hospital stays

③Low co-payment ④Less number of malpractice suits

－５－

• 2. Current issues

①Medical expenditure ②Quality of medical care ③Health delivery system ④Provision of medical information ⑤Technology development

－６－

Changes in the National Medical Expenditure

11.7 11.2 11.8 10.9 10.3 9.7 8.9 8.2 7.5 6.9 6.4 5.9 4.1 8.5 8.0 5.8 6.2 5.9 6.3 6.6 6.9 7.2 7.3 7.4 7.8 8.3 5 10 15 20 25 30 35 40 85 90 91 92 93 94 95 96 97 98 99 00 01 1 2 3 4 5 6 7 8 9

16.0 21.8 23.5 24.4 25.8 27.0 28.5 29.1 29.8 30.9 20.6 Medical expenditure for the elderly Ratio of national medical expenses to national income (%)

25.4% 28.8% 29.4% 29.5% 30.6% 31.6% 33.1% 34.1% 35.4% 36.5% 38.2%

National medical expenditure FY

36.9% 37.2%

30.4 31.3

(%) （\trillion）

Notes：１）With the implementation of Long-Term Care Insurance System from April 2000,of the expenses subject to the previous national medical expenditure and medical expenditure for the elderly,the costs for long –term care insurance have been transferred. ２）Source of National Income: “National accounting” by Cabinet Office（2002.12） －７－

Breakdown of General expenditure （Budget plan for 2004 FY）

（Unit:100milionJPY, （）-％）

Social security 197,970 ( 41.6 ) Culture, education, and science promotion 61,330 ( 1 2.9 ) Public Servants’ Pensions 11,321 ( 2.4 ) Defense 49, 030 ( 10.3 ) Public works 78,159 ( 16.4 ) Stable supply of food 6,749 ( 1.4 ) Energy-related measures 5,065 ( 1.1 ) Measures for small and medium

• sized enterprises

Economic Cooperation 1,738（0.4） 7,686（1.6） Transfer to the special account for Industrial investment 988 ( 0.2 ) Miscellaneous expenses Reserve fund 3,500(0.7)

Medical care 81,445 （17.1）

Pension 58,246 ( 12.2 ) Long-term care 17,921 ( 3.8 ) Welfare 40,358 ( 8.5 ) etc. Compulsory education 25,128（5.3） Science promotion 12,841（2.7） Cultural and educational facilities 1,443（0.3） Education promotion 20,572（4.3） Educational projects 1,346（0.3） General expenditures 47,632 billion (100.0) ( 11.1 ) －８－ 52,784

Notes １.Figures for Japan are based on FY 2003buget.Figures for other countries is actual performance of calendar year ２．The ratio of financial deficit to national income for Japan and U.S.A are based on general government account excluding social security funds. Ratios for other countries are based on general government account.

20.9 26.2 41.4 31.2 39.8 54.4 15.2 9.8 9.8 25.3 25.0 22.1

11.0 1.8 1.1

10 20 30 40 50 60 70 80

Japan United States of America United Kingdom Germany France Sweden （FY2003） （1997） （2000） （2000） （2000） （2000） 37.0

Potential National Contribution Ratio

［National Contribution Ratio = Tax Burden Ratio＋Social Security Burden Ratio］

47.1 56.5 66.7

（％）

36.1 51.2 56.5 64.8 76.5

76.5 51.2

35.9

International comparison of national contribution ratio

－９－ ［Potential National Contribution Ratio = National Contribution Ratio +the Ratio of Financial Deficit to National Income]

The ratio of financial deficit to

national income Social security burden ratio Tax burden ratio

National Contribution Ratio

Changes in population composition

１９８０ ２０００ ２０２５

Sources：１９８０、２０００－“National Census” by Ministry of Public Management, Home Affairs, Posts and Telecommunications ２０２５－“Projection of Japanese Population”（Estimated January 2002）by the National Institute of Population and Social Security Research

500 1,000 1,500 2,000 2,500 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100～ 500 1,000 1,500 2,000 2,500 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100～ 500 1,000 1,500 2,000 2,500 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100～

－１０－

Medical Care Expenditure and co-payment per capita by the age bracket （average annual amount ）

（Estimated figure based on figures of undertakings for FY2000）

2.3 1.7 1.4 1.4 1.8 2.1 2.1 2.5 3.2 4.0 5.2 6.6 4.7 6.4 60.6 72.5 83.0 7.4 8.2 5.6 3.8 96.6 44.2 32.4 25.4 19.3 15.5 12.3 10.4 10.1 8.8 6.9 6.2 7.2 9.6 16.1 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0

０－４ ５－９ １０－１４ １５－１９ ２０－２４ ２５－２９ ３０－３４ ３５－３９ ４０－４４ ４５－４９ ５０－５４ ５５－５９ ６０－６４ ６５－６９ ７０－７４ ７５－７９ ８０－８４ ８５－

Co-payment Medical Expenditure

（age）

（ten thousand yen）

－１１－

Future estimation of population

101million （78.9％）

128 million FY2007 FY2025

12million （9.7％） 8,600million （71.3％） 20million （16.7％）

121 million

65 years 75 years

15million （11.4％） 14million （11.9％）

FY2007 FY2025

１２．２trillion （35.2％） １５．９trillion （45.7％） ２０．３trillion （31.0％） ３４．３trillion （52.3％）

３４．７ trillion ６５．６ trillion

65 years

Future estimation of medical expenditure (related with health insurance, in JPY）

75 years

６．６trillion （19.1％） １１．０trillion （16.7％）

－１２－

（in year）

3． Health Care Reform : What do we achieve? ①Health Promotion, Disease Prevention ②Health delivery system

（１）Improvement of the quality and efficiency of medical services （２）Promotion of information provision （３）Securing patient comfort and public confidence in medicine （４）Infrastructure development of medical services

－１３－

age

Risk factor of disease（subject to intervention）

Medical care expenditure per person

Employees Insurance

Medical Services for the Elderly

Medical Care Services for Retired Employees

Disease Threshold level

Aggravation

Accumulation of risk factors Increase in medical expenditure for the elderly National Health Insurance

Number of Lost Teeth 11teet eeth （17 teeth h remain） ６５ ７５ 17teet eeth （ 11 teeth h rem emain）

Lifestyle-related diseases with age and medical expenditure （Concept）

－１４－

Promotion measures:

○

Setting nationwide target

○

Establishment of the plan for local health promotion（Mandated to the Prefectural governments) Health Promotion Law（2002）

Concept

People should promote health by themselves. National government, local governments,

providers of health services, medical institutions and concerned parties should cooperate with each other to support such efforts.

Infrastructure development

○ Promotion of scientific research ○ Nutritional management in feeding service ○ National health and nutrition survey ○ Anti-smoking strategies

Promotion of information provision

○Measures of nutrition, labeling of foods etc. Birth Education Workplace Retirement live long in healthy condition

Health promotion to the public

Maternal and child health Industrial health service School health service Health service system For the elderly

Integrated promotion of health services throughout life

Health insurer

－1５－

○Enlightenment about lifestyle

○ Establishment of common guidelines about implementation methods

The New Physician Training System 2004 -

• 1. Mandatory Training : 2 years
• 2. Broad Rotation : Int., Surg., Emerg., Ped.,

Gyo., Psy., PH

• 3. Fundamentals of Primary Care
• 4. Training Hospitals / Facilities (standard)
• 5. Trainee salary / Funding
• 6. Recruitment : Matching System

－1６－

○ training not mandatory ○ priority on expertise ○ training at the graduating university ○ compensating for low wage by extra job

Current

Trainee doctor

Improve competence

• f new doctors

Trainee doctor

New system The expected effect

New Medical Resident Training System (2004)

－1７－

○ mandatory training ○ broad fundamental training ○ select the training hospital

• n the basis of the training

program ○ concentrate on training ○ medical practice with patient’s view in mind ○ efficient,effective medical management ○ the ability to practice broad basic medical care

Training hospital

○ 70% of trainee doctors are trained at university hospital. ○ no or limited rotation of areas ○ insufficient training, assessment ○ lower wage to trainee doctor ○ adoption of the trainee from affiliated university ○ 7 areas rotating system ○ establish training and assessment system ○ appropriate remuneration for trainee doctor ○ disclosure of training program and open recruitment of trainee doctor (matching system) ○ financial support

Improve function

• f training hospitals

○ improvement of the basic medical care ○ adoption of the newest medical knowledge ○ improvement of senior doctors and staff for teaching trainee doctors

Training hospital

Grand Design for Medical Safety

○ Clarification of the problem of medical safety ○ Direction for the solutions, clarification of the problem upon implementation

“The comprehensive measures for promoting medical safety” April 2002 Commission on the measures for medical safety ( May 2001 -)

・Medical safety ・Improvement of the quality of the medical care

Government

・Incident reporting system ・Education training ・Guidance for medical institutions ・Guidance for the industries ・Research, etc

Industries Medical institutions

Participation by the people

In order to promote the measures of medical safety, government, medical institutions, as well as related industries should cooperate with each other. ・Reporting system in hospitals ・Safe management system ・Guidance for the security measures ・Training of staff Improvement of pharmaceuticals and medical devices

－1８－

Promotio ion of f IT T in in H Heal alth Car Care

“Grand Design of Informatization in Health Care Sector” （December 2001） 〈Targets〉

・By FY 2004

At least 1 facility in all Secondary Medical Care Areas ( 363 in Japan )

・By FY 2006

60% or more of the hospitals with 400 or more beds. 60% or more of clinics

・By FY 2004

50% or more of the hospitals

・By FY 2006

70% or more of the hospitals An action plan has been prepared for the achievement of these targets. The role of the Government and private sectors are shown.

Electronic medical chart Computerized processing system for receipts ( claims for reimbursement ) Establishment of an “Action Plan”

－1９－

Reinforcement of global competitiveness of the pharmaceutical and medical device industry ○“Vision of the Pharmaceutical Industry”（August 2002）

“3-Year Plan for National Revitalization of Clinical Trials”

establishment of a large-scale clinical trial network of hospitals and increase in the number of clinical trial coordinators ・・・・

○“Vision of the Medical Device Industry”(March 2003) promotion of research and development ・・・・

－２０－

Basic Guidelines for the reform of the medical Basic Guidelines for the reform of the medical insurance system insurance system （Medical Insuran

Medical Insurance System Bil ce System Bill, 2002 l, 2002）

① The framework of medical insurance system: the merger and reorganization of insurers ② Establishment of a new medical insurance system for the elderly ③ Revising the medical reimbursement fee schedule

• 4. Heal

ealth ins insurance nce refor form

－２１－

Concept of The Reform “Basic Guideline”

○The framework of medical insurance system １．Establishment of stable and sustainable medical

insurance system ２．Equality of benefits and fairness of burden ３．Securing high quality and efficient medical care

○The medical reimbursement fee schedule １．Appropriate evaluation of medical technology ２．Appropriate evaluation reflecting the operating

costs and function of medical institutions

３．Focus on patient’s view

－２２－

Outline of the current health insurance schemes

75 years

National Health Insurance (NHI) Employee’s Insurance(EI) Medical system for the elderly Government-managed Health Insurance(GMHI) Society-managed Health Insurance(SMHI)

－２３－

The merger ger and reorg

• rganiz

anization tion of insurers urers

○Proceed with merger and reorganization in the basic unit of prefecture. ・Strengthen the financial foundation and activities of insurers

○Encouragement of the concerned bodies in the region to provide

more qualified and efficient medical services

Many small insurers

NHI

Many small associations

SMHI

Prefectures and Municipalities work together to proceed with merger and reorganization in the unit of prefecture. (premium is collected by the Municipalities). Introduce a new system of prefecture-unit-based financial management ○Enhance merger and reorganization of the small and poor associations by deregulation ○Establish the prefecture- unit-based regional health insurance societies

One insurer ( 36 million insured persons )

GMHI

Insurer rers s are financi cial ally ly managed ed in the unit of prefe fect cture re

－２４－

Health insurance system for the elderly

NME on the elderly（FY２００３） 11.6trillion（in Yen） Co-payment 1.2 trillion premium 34% (38% 2003.10~) 66% (62% 2003.10~) Public funds(Tax） Contributions from insurers

• f medical insurance

7.0 trillion Public funds Central Gov. ２／３ Prefecture １／６

Municipality

１／６ 3.4 trillion

GMHI HI MAI NHI

１０．４trillion

Contributions are calculated on the assumption that every insurer has the same portion of people

• ver 75 years

－２５－

65 years 75 years

NH EH

New health insurance scheme New adjustment scheme

○New scheme is financed with premiums paid by those 75 and over, support from the NHI and EHI, and tax. ○People ages 65-74 are covered by NHI/EHI and the unbalanced burden of medical costs caused by the difference of the population composition is adjusted.

The framework of the health insurance scheme for the elderly

○New health insurance scheme based on the self-support of the elderly ○Two schemes, ages 75 and over and ages 65-74 ○Balanced share of premium among different generations and insures

－２６－

Revision of the Medical Reimbursement Fee Schedule

☆ Patient's point of view

☆ Appropriate evaluation of medical technology (difficulty, time and technical skill) ＜Doctor fee element ＞

Clinics and small hospitals

Large hospitals Acute stage ［Inpatient care］ ［Outpatient care］ Chronic stage

Evaluation : clinical condition, ADL, nursing care needs etc. Flat Payment Schedule 特 定 機 能 病 院

Special hospitals

Evaluation : disease characteristics, severity Evaluation of functions Specialist

• utpatient

services, referrals Primary care function

☆ Evaluation appropriately reflecting the operating costs and function of medical institutions ＜Hospital fee element＞

Flat Payment Schedule

Fee-for-service Surgery etc.

・Provide information ・Patient’s choice

Convalescent rehabilitations etc. －２７－

• 5. Japan as No.1: Super-aging society

１)Aging continues for half a century

2050：Aged 65 or older（19→）36%、Aged 75 or older（8→）22%

5 10 15 20 25 30 35 40

1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050

（year）

Sources Developed nations except Japan : UN, World Population Prospects : 2000 Japan : "National Census" by the Ｍanagement and Cordination Agency and "Population Projects for Jaqpan" by the National Institute

Percentage of population of the eldely aged 65 or older in developed nations : 1950-2050 Germany U.K. Japan（Estimation in January 2002) Italy Sweden U.S.A. France

（％）

Spain

－２８－

• 5. Japan as No.1: Super-aging society

２)“the younger

er suppor

• rt the elderly

ly” → ”the elderly suppor port each other also” ①Employment of the elderly ②Change the image and physical attitude of the elderly ③Elderly as a growing market ④Ageless tolerant society ３) He Healt lth Ca Care re Re Refo form of

• f Ja

Japa pan： As

As the the Le Leade der of

• f Wor
• rld Su

Super er-agin ing Societ ety

①Po

Posi sitiv ive pre reven enti tion

• n of
• f Li

Life fest styl yle-rel elate ted di disea ease ses ②App ppro ropr pria iate ut utili liza zati tion of

• f me

medi dica cal res esour urce ces （Pat atien ents ts） ③App ppro ropr pria iate me medic ical al se serv rvic ice（Me Medi dical al ca care re pro rovid ider er） ④App ppro ropr pria iate be benef efit its and nd bu burd rden en（Mut utua ual , coo

• oper

erat ative ve hel elp ）

－２９－

This opinion belongs to myself, and it does not necessarily represent the official position of the Ministry

• f Health, Labor and Welfare…

－３０－

ＦＹ ２００４ Revision of Medical Fee Schedule

March 4, 2004

Toshihiko Takeda

Director, Office of Planning & Research, Medical Economics Division, Health Insurance Bureau, Ministry of Health, Labour and Welfare, JAPAN

Outline of the Medical Fee Revision 2004

• Overall Revision Rate

–1.0% Physician Fee 0% Dental Fee 0% Pharmacy Fee 0%

• Drug and Medical Device Reimbursement Price

Revision Rate

• 1.0%

Drugs

• 0.9%

Medical devices

• 0.1%

1984 1985 1986 1988 1989 1990

Physician Fee

2.8 3.3 2.3 4.4 0.11 3.7

Drugs

• 5.1
• 1.9
• 1.5
• 2.9

0.65

• 2.7

Total

• 2.3

1.4 0.8 1.5 0.76 1.0

1992 1994 1996 1997 1998 2000 2002 2004

5.0 4.8 3.4 1.7 1.5 1.9

• 1.3
• 2.5
• 2.12
• 2.6
• 1.32
• 2.8
• 1.7
• 1.4
• 1.0

2.5 2.7 0.8 0.38

• 1.3

0.2

• 2.7
• 1.0

Trend of the Medical Fee Revision Rate

%

Social and Economic Situation

Wage and CPI trends since last revision in 2002

• Government Employee Wage Adjustment

(Recommendation by National Personnel Authority)

• 4.9% in FY 2002 and 2003

(-2.3% in 2002, -2.6% in 2003)

• Consumer Price Index
• 0.8% in FY 2002 and 2003

(-0.6% in 2002, -0.2% in 2003)

Hospital Financial Condition

Medical Economics Actual Condition Survey (By Chuikyo, June, 2003)

Operating Profit for Private Hospitals 2.2% * *Lowest in recent 15 years. 4.6% in 2001 Operating Profit for Children’s Hospitals* 0.5% Operating Profit for Acute Care Hospitals* 0.8%

*Not including National or Local Government Hospitals

Statement of Central Social Insurance Council (Chuikyo) on Dec. 18, 2003

“As for the next medical fee schedule revision, while keeping the basic principle of “free access”, and securing the sustainability of National Health Insurance Scheme, we should aim at rational and prioritized revision on the basis that we should secure the patient-centered, quality-oriented and efficient system. While reflecting the current severe economic and social situation, next revision should put emphases on medical quality and safety, especially those items as payment with DPC, medical services for children, psychiatric care, and so on, and the revision must be understood and accepted by national people. Both members from insurers and physicians have agreed to have revision in order to proceed the reform stated above.”

Review of Medical Service Fee System

• 3. Emphasis of patient viewpoint

・ Promotion of information provision ・ Emphasis on choice by patient

1.Appropriate evaluation of medical skill (emphasizing difficulty, time, technical ability) < Doctor fee-type elements>

Clinic, Small/midsize hospital Large hospital

Acute phase [Inpatient treatment] [[Outpatient treatment]] Chronic phase

Evaluation according to condition, ADL, need for nursing, etc. Recovery phase rehabilitation, etc.

特 定 機 能 病 院

Special function hospitals Evaluation reflecting disease properties and severity Evaluation of functions

Emphasis

• n specialist
• utpatient

treatment, referral and referral back, etc. Emphasis on function of primary care physician, dentist, pharmacist, primary care function, etc.

Fee for service payment

2.Appropriate reflection of costs and functions of medical institutions

< Hospital fee-type elements>

Flat-sum payment

Surgery, etc.

Fee for service payment

Fee for service payment

Flat-sum payment

Major items of the 2004 revision (1)

1 Proper evaluation of medical/surgical procedure and services

Tentative revision of the surgical fee system based

• n performed surgical case numbers

Fee-cut system to additional fee reward system Require information disclosure Evaluation of preventive medicine PTE(Pulmonary thromboembolism) prevention medical fee (new) 305 points Introducing new technology Ultrasound-guided breast biopsy (mammotome) 3,040 points Procedure for implantable heart-assist system 30,000 points etc

From fee-cut system to reward system

Current Revised

Revision of fee qualification for institutions on surgery

30% cut 30% cut

Fee for each specified surgery

+

Numbers of surgery should be displayed Proper explanation to patients as to surgery related information (New)

Doctors with more than ten years experience

(current) Lack of surgery numbers AND Lack of doctors with 10 yrs experience Lack of surgery numbers OR Lack of doctors with 10 yrs experience Surgery numbers and doctor experience 5% addition

Certain numbers of surgery performed And Doctors with more than ten years experience

Fee for each specified surgery

Major items of the 2004 revision (2)

1 Proper evaluation of medical/surgical procedures and services (continued) Re-evaluation of existing procedures Bone marrow and cord blood stem cell transplantation evaluation Rehabilitation evaluation (increase covered services for those patients with acute cerebrovascular diseases) Evaluation of testing of sleep respiratory disturbance Evaluation of tumor marker (use of prostatic specific antigen:PSA) Evaluation of long-term dosage prescription Additional payment for specific disease prescription

prescription for 28 days and longer, 45 points (once a month)

Major items of the 2004 revision (3)

2 Appropriate reflection of medical institution’s operating costs Revision of DPC (Diagnosis-Procedure-Combination) Evaluation of high care units (new)

Patients with sub-ICU stage, patient-nurse ratio =4:1(always)

3,700 points

Hospital care for patients with chronic condition

Children are exempted from coverage limit on stays over 180 days

Evaluation of sub-acute hospital care (new)

Limited 90 days, patient-nurse ratio =2.5:1, 60% of patients to be discharged to homes, and so on.

2,050 points

Major items of the 2004 revision (4)

2 Appropriate reflection of medical institution’s costs

(continued)

Evaluation of medical care for children

Modify qualification for child high-staff hospital care Raise fee for new born infant intensive care Raise fee for off-hour care of children

Evaluation of psychiatric medicine

Proper treatment by psychiatric specialists with restraint minimize committee within hospital Additional fee for patient with specific drugs to flat-sum payment etc.

Major items of the 2004 revision (5)

－９－

2 Appropriate reflection of medical institution’s costs

(continued)

Evaluation of in-home medical care

Evaluation of multi-visits by visiting nurses for end stage cancer patients and ALS (Amyotrophic Lateral Sclerosis) Patients Evaluation of doctor’s order of drug infusion 3 times / a week to visiting nurses etc.

Major items of the 2004 revision (6)

3 Proper evaluation based on institution’s function Evaluation of physician training hospitals

Fee for university hospitals and approved doctor training hospitals with some requirements to secure high-quality care

• n the first day at hospital

30 points

Major items of the 2004 revision (7)

4 Rationalization, adjustment and revise to proper fee Fee revision of laboratory testing (based on actual cost survey) Fee revision of CT / MRI diagnostic radiology / imaging

Major items of the 2004 revision (8)

－９－

5 Others Dental:Evaluation of primary dental care, etc. Pharmacy:Review of basic pharmacy’s fee, etc.

To review the current category of basic pharmacy’s fee; from four categories to three To establish a new basic pharmacy’s fee in the case of divided preparation To deal with long-term dosage (e.g. provision of safety information) Proper evaluation of other hospital care Bedsore patient care management additional evaluation (new) 20 points, once in a hospital stay

Hospitals Subject: University hospitals, National Cancer Centers, National Cardiovascular Centers (82 hospitals) Patients Subject: Inpatients of general wards whose injury/disease, etc. falls under a diagnostic group classification (1860 classifications), excluding the following. (Patients who died within 24 hours of hospitalization, patients who are trial subjects, organ transplant patients, etc. Calculation method of comprehensive evaluation A payment arrangement will be used based on a daily comprehensive evaluation according to diagnostic group classification. However, for surgery, anesthesia, radiation therapy and guidance/supervision, fee for service payment will apply. To ensure that the level of comprehensive evaluation is actual medical expenses of the previous year at each medical institution, a medical institution coefficient shall be set for each medical institution. Daily points of each diagnostic group classification x medical institution coefficient x hospital stay (days) *Daily points set in three stages depending on hospital stay of each diagnostic group classification. In cases where the hospital stay is extremely long, calculation by fee for service. Implementation Date: April 1, 2003 However, a grace period of three months will be set for hospitals where implementation in April is difficult.

Comprehensive Coverage of Inpatient Treatment (DPC) at Special Function Hospitals

Evaluation based on length of hospital stay (Image)

A=B A

15%

B

15%

→ Fee for services DAYS I (25%tile) DAYS II(Average LOS) Specified Days

Average daily cost

• n each

DPC code

C C=D D

15% Fee For Services →

－１９－

Evaluation based on length of hospital stay(2) (Short term hospital stay for chemotherapy

(Image))

Average daily cost

• n each

DPC code

DAYS I (5%tile) DAYS II(Average LOS) Specified Days

Average LOS at each DPC Hospitals

0.0 5.0 10.0 15.0 20.0 25.0 30.0

鳥取大学医学部附属病院 熊本大学医学部附属病院 奈良県立医科大学附属病院 神戸大学医学部附属病院 宮崎医科大学医学部附属病院 東北大学医学部附属病院 長崎大学医学部附属病院 大阪大学医学部附属病院 大阪市立大学医学部附属病院 秋田大学医学部附属病院 徳島大学医学部附属病院 琉球大学医学部附属病院 鹿児島大学医学部附属病院 弘前大学医学部附属病院 三重大学医学部附属病院 筑波大学附属病院 島根医科大学医学部附属病院 広島大学医学部附属病院 名古屋市立大学病院 香川医科大学医学部附属病院 久留米大学病院 国立循環器病センター病院 九州大学医学部附属病院 愛媛大学医学部附属病院 信州大学医学部附属病院 佐賀医科大学医学部附属病院 産業医科大学病院 富山医科薬科大学附属病院 日本医科大学付属病院 札幌医科大学医学部附属病院 山形大学医学部附属病院 福井医科大学医学部附属病院 京都府立医科大学附属病院 金沢大学医学部附属病院 大阪医科大学附属病院 岩手医科大学附属病院 新潟大学医学部附属病院 和歌山県立医科大学附属病院 千葉大学医学部附属病院 福島県立医科大学医学部附属病院 北海道大学医学部附属病院 名古屋大学医学部附属病院 藤田保健衛生大学病院 高知医科大学医学部附属病院 旭川医科大学医学部附属病院 浜松医科大学医学部附属病院 山口大学医学部附属病院 大分医科大学医学部附属病院 京都大学医学部附属病院 関西医科大学附属病院 獨協医科大学病院 岡山大学医学部附属病院 山梨大学医学部附属病院 金沢医科大学病院 昭和大学病院 兵庫医科大学病院 東邦大学医学部付属大森病院 帝京大学医学部附属病院 東京大学医学部附属病院 滋賀医科大学医学部附属病院 岐阜大学医学部附属病院 聖マリアンナ医科大学病院 福岡大学病院 横浜市立大学医学部附属病院 川崎医科大学附属病院 近畿大学医学部附属病院 群馬大学医学部附属病院 杏林大学医学部付属病院 東京女子医科大学病院 日本大学医学部附属板橋病院 東京医科歯科大学医学部附属病院 愛知医科大学附属病院 埼玉医科大学附属病院 東京医科大学病院 自治医科大学附属病院 防衛医科大学校病院 北里大学病院 国立がんセンター中央病院 順天堂大学医学部附属順天堂医院 東海大学病院 東京慈恵会医科大学附属病院 慶應義塾大学病院

days Average 19.3 days (Previous year 22.4 days)

0.0 10.0 20.0 30.0 40.0 50.0

慶 應 義 塾 大 学 病 院 東 京 慈 恵 会 医 科 大 学 附 属 病 院 東 海 大 学 病 院 順 天 堂 大 学 医 学 部 附 属 順 天 堂 国 立 が ん セ ン タ ー 中 央 病 院 北 里 大 学 病 院 防 衛 医 科 大 学 校 病 院 自 治 医 科 大 学 附 属 病 院 東 京 医 科 大 学 病 院 埼 玉 医 科 大 学 附 属 病 院 愛 知 医 科 大 学 附 属 病 院 東 京 医 科 歯 科 大 学 医 学 部 附 属 日 本 大 学 医 学 部 附 属 板 橋 病 院 東 京 女 子 医 科 大 学 病 院 杏 林 大 学 医 学 部 付 属 病 院 群 馬 大 学 医 学 部 附 属 病 院 近 畿 大 学 医 学 部 附 属 病 院 川 崎 医 科 大 学 附 属 病 院 横 浜 市 立 大 学 医 学 部 附 属 病 院 福 岡 大 学 病 院 聖 マ リ ア ン ナ 医 科 大 学 病 院 岐 阜 大 学 医 学 部 附 属 病 院 滋 賀 医 科 大 学 医 学 部 附 属 病 院 東 京 大 学 医 学 部 附 属 病 院 帝 京 大 学 医 学 部 附 属 病 院 東 邦 大 学 医 学 部 付 属 大 森 病 院 兵 庫 医 科 大 学 病 院 昭 和 大 学 病 院 金 沢 医 科 大 学 病 院 平 均 山 梨 大 学 医 学 部 附 属 病 院 岡 山 大 学 医 学 部 附 属 病 院 獨 協 医 科 大 学 病 院 関 西 医 科 大 学 附 属 病 院 京 都 大 学 医 学 部 附 属 病 院 大 分 医 科 大 学 医 学 部 附 属 病 院 山 口 大 学 医 学 部 附 属 病 院 浜 松 医 科 大 学 医 学 部 附 属 病 院 旭 川 医 科 大 学 医 学 部 附 属 病 院 高 知 医 科 大 学 医 学 部 附 属 病 院 藤 田 保 健 衛 生 大 学 病 院 名 古 屋 大 学 医 学 部 附 属 病 院 北 海 道 大 学 医 学 部 附 属 病 院 福 島 県 立 医 科 大 学 医 学 部 附 属 千 葉 大 学 医 学 部 附 属 病 院 和 歌 山 県 立 医 科 大 学 附 属 病 院 新 潟 大 学 医 学 部 附 属 病 院 岩 手 医 科 大 学 附 属 病 院 大 阪 医 科 大 学 附 属 病 院 金 沢 大 学 医 学 部 附 属 病 院 京 都 府 立 医 科 大 学 附 属 病 院 福 井 医 科 大 学 医 学 部 附 属 病 院 山 形 大 学 医 学 部 附 属 病 院 札 幌 医 科 大 学 医 学 部 附 属 病 院 日 本 医 科 大 学 付 属 病 院 富 山 医 科 薬 科 大 学 附 属 病 院 産 業 医 科 大 学 病 院 佐 賀 医 科 大 学 医 学 部 附 属 病 院 信 州 大 学 医 学 部 附 属 病 院 愛 媛 大 学 医 学 部 附 属 病 院 九 州 大 学 医 学 部 附 属 病 院 国 立 循 環 器 病 セ ン タ ー 病 院 久 留 米 大 学 病 院 香 川 医 科 大 学 医 学 部 附 属 病 院 名 古 屋 市 立 大 学 病 院 広 島 大 学 医 学 部 附 属 病 院 島 根 医 科 大 学 医 学 部 附 属 病 院 筑 波 大 学 附 属 病 院 三 重 大 学 医 学 部 附 属 病 院 弘 前 大 学 医 学 部 附 属 病 院 鹿 児 島 大 学 医 学 部 附 属 病 院 琉 球 大 学 医 学 部 附 属 病 院 徳 島 大 学 医 学 部 附 属 病 院 秋 田 大 学 医 学 部 附 属 病 院 大 阪 市 立 大 学 医 学 部 附 属 病 院 大 阪 大 学 医 学 部 附 属 病 院 長 崎 大 学 医 学 部 附 属 病 院 東 北 大 学 医 学 部 附 属 病 院 宮 崎 医 科 大 学 医 学 部 附 属 病 院 神 戸 大 学 医 学 部 附 属 病 院 奈 良 県 立 医 科 大 学 附 属 病 院 熊 本 大 学 医 学 部 附 属 病 院 鳥 取 大 学 医 学 部 附 属 病 院

• 0.80
• 0.70
• 0.60
• 0.50
• 0.40
• 0.30
• 0.20
• 0.10

0.00 0.10 0.20

FY2002 FY2003 Change 2002-2003

Average LOS comparison with previous year

Specified Medical Coverage(SMC) for Drugs (From Jan. 2004)

SMC

Recognized as clinical trial exemption drug by appropriate authority

Approve NDA

evaluation Insurance coverage of newly approved efficacy Specified medical coverage for drugs has been expanded in order to cover the usage of already listed drugs for un-approved treatment (off label use) with the condition that the usage is recognized as clinical trial exemption drug by appropriate authority

Accelerated Approval process

7.5 (1996) 9.8 (1996) 10.8 (1997) 12.0 31.8 Average hospital stay 5.8 221 71.6 3.7 US 6.1 120 40.7 4.2 UK 6.5 69.7 (1997) 35.2 8.5 France 6.5 99.8 37.6 9.3 Germany 16.0 43.5 12.5 13.1 Japan Outpatient consultation rate (1996)

• No. of nursing

staff per 100 hospital beds

• No. of doctors

per 100 hospital beds

• No. of beds per

1,000 population Country

Country Comparison of Medical Service Supply System (1998)

Functional Specialization of Hospital Beds (Image)

Generous staffing, standardization, early implementation of rehabilitation, etc. Shortening of average hospital stay Concentration/prioritization of medical functions Convergence of bed numbers

Acute Phase

Recovery Phase Rehabilitation As a result of the shortening of the average hospital stay in the acute phase, rehabilitation will be implemented intensively for cerebrovascular disease patients and fracture patients within 3 months of crisis. In future, the needs will expand. Long-term Convalescence/Convalescence at Home General Beds Convalescent Beds Geriatric Health, etc. (Convalescent beds covered by medical insurance) Clarification of the function of convalescent beds covered by medical insurance Bed category notification at the end of August 2003 Switchover to care, etc. Strengthening of tie-ups with care and welfare. Provision of home-based community medical care <Convalescent beds covered by care insurance> Provision in accordance with next term care insurance business plan based on new lenient standard <Geriatric health care facilities> Proposal of convertible geriatric health care facilities Emphasis on QOL of patients, provision of a high quality convalescent environment and arrangement of caregivers, etc.

Comprehensive provision of medical/care and welfare services stressing the QOL of patients Home-oriented, not hospitalization-oriented Respond to needs for hospitalization such as pneumonia and fracture, acute deterioration, etc. Support of life at home including house calls by doctors, house calls by nurses and maintenance phase rehabilitation (Visiting nurse station, etc.)

Strengthening of home support function (switchover from hospitalization-oriented medicine)

Increase of referral rate, rate of referral back Implementation of appropriate dehospitalization plan and dehospitalization readjustment

• Securing of appropriate

convalescent lifestyle after dehospitalization

• Utilization of diverse social

services

• Continuation of high quality

care

Strengthening of community care tie-ups for acute phase beds Functional specialization taking into consideration community needs

Image of Functional Specialization of Hospital Beds

*In the above, beds besides general beds and convalescent beds (psychiatric beds, infection beds, TB beds) are omitted for simplification.

Acute phase treatment

E.g. Treatment of pneumonia, fractures, cerebral infarction, surgery on malignant tumors, etc. E.g. Treatment of diabetes, backup of treatment at home

General beds

Now Future

Long-term convalescence/Convalescence at home Convalescent wards

Long-term convalescence/Convalescence at home

Convalescent beds Home, geriatric health, etc

Wards with special functions, treatment at home, etc.

Examples of acute phase treatment

Emergency centers Intensive care, perinatal treatment, etc.

Examples from acute phase to long-term convalescence

Treatment of intractable diseases, palliative care, rehabilitation for stroke, etc.

Other beds

Acute phase treatment

E.g. Treatment of pneumonia, fractures, cerebral infarction, surgery on malignant tumors, etc. E.g. Treatment of diabetes, backup of treatment at home

General beds Convalescent beds Home, geriatric health, etc

Wards with special functions, treatment at home, etc.

Examples of acute phase treatment

Emergency centers Intensive care, perinatal treatment, etc.

Examples from acute phase to long-term convalescence

Treatment of intractable diseases, palliative care, rehabilitation for stroke, etc.

Drug Pricing System Reform 2004

Pricing rule for newly listed drugs

• Revision of similar drug comparison method (II)

(i.e. for the drugs which lack novelty)

• Introduction of a new premium system

(e.g. Co-ordination on different strength inclusions)

• Revision of pricing rule for newly listed generics

Price revision of already listed drugs

• Special rule for price revision of already listed drugs

The rule has been applied to the Japanese Pharmacopoeia drugs (which has been exceptional under 2002 overall rule) The reduction ratio has been applied on 1/2

• Modification of market expansion re-pricing rule

To relieve their ration of re-pricing on the drugs which have

• bjectively revealed their true efficacy based on the data

gathered after the marketing

The reduction ratio of the special rule

Drug category Ratio 1 The drugs approved between 1st October 1967 and 30th September 1980 4% 2 The drugs approved after 1st October 1980, and on which the previous special rule was applied in 1997 or 1998 5% 3 The drugs approved after 1st October except for the above 6%

• A half of the reduction ratio has been applied to the Japanese Pharmacopoeia drugs

listed with brand name.

• No. of products

Market Share During re-examination period

490 19%

Re-examination period terminated, but no generic products exist

1,565 32%

Re-examination period terminated, and generic products exist

1,079 28%

Generic products

4,975 7% 3,716 14%

1: No. of products and market share are based on the data of drug price survey in September 2001. 3: “Generic products” mean products other than those that were approved as original products (except for “Other products”). 4: “Other products” mean those that are listed in JP, Chinese herbal extracts, natural medicine, and those approved before 1967.

Other Products (products listed in the Japanese Pharmacopoeia, herbal medicine, etc. Original Products

2: “Re-examination” is a system during which the pharmaceutical company collects the results of post-market experience with the drug and re-examine the safety and other characteristics of the drug. A period of four to ten years is specified according to the contents of the approval.

Classification of pharmaceutical products in the drug price list (2001)

Initial revision rates for newly listed generic products

• No. of

products

• No. of products

Products listed in FY 2000 Products listed in FY2001 FY 2000 FY 2001

Arithmetic average Weighted average Arithmetic average Weighted average

Oral Use More than 10 3 ing/strs, 51 products 2 ing/strs, 27 products

• 48.2%
• 44.9%
• 53.3%
• 47.8%

10 or less 8 ing/strs, 44 products 21 ing/strs, 37 products

• 40.6%
• 34.6%
• 29.1%
• 42.8%

Injec- tion Use More than 10 NA 2 ing/strs, 31 products NA NA

• 53.5%
• 50.4%

10 or less 11 ing/strs, 20 products 10 ing/strs, 19 products

• 21.4%
• 31.0%
• 23.5%
• 31.3%

Exter- nal Use More than 10 NA 1 ing/strs, 13 products NA NA

• 25.9%
• 15.5%

10 or less 6 ing/strs 6 products 6 ing/strs, 9 products

• 18.9%
• 21.8%
• 24.1%
• 23.8%

Total More than 10 3 ing/strs, 51 products 5 ing/strs, 71 products

• 48.2%
• 44.9%
• 48.4%
• 44.1%

10 or less 25 ing/strs, 70 products 37 ing/strs, 65 products

• 33.9%
• 33.7%
• 26.8%
• 41.1%

Ing/strs: ingredients/strengths

Overview of the revision of the drug price list in FY 2004

Number of products listed Oral use 6,646 Injections 3,316 External use 1,996 Dental use 35 Total 11,993 Classification of the revision Lowered 9,645 Raised 39 Not changed 2,309 Total 11,993

(Oral use) 114 antipyretic analgesics

• 4.6%

124 antispasmodics

• 4.1%

212 antiarrhythmics

• 6.1%

214 antihypertensives

• 5.6%

217 vasodepressors

• 4.9%

218 antihyperlipidemias

• 8.6%

219

• ther cardiovascular drugs
• 3.5%

232 antiulcer drugs

• 5.7%

311 vitamin A and D

• 8.7%

313 vitamin B (except for vitamin B1)

• 2.8%

422 antimetabolites

• 3.8%

449

• ther antiallergics
• 7.1%

520 Chinese herbal medicine

• 3.8%

613 drugs that affect gram-positive/gram-negative bacteria -4.9% 624 antibacterials

• 8.0%

(Injections) 399 metabolic drugs that are not classified into other categories-7.3% 613 drugs that affect gram-positive/gram-negative bacteria -5.3% 721 X-ray contrast agents

• 5.5%

(External use) 131 ophthalmological drugs

• 2.7%

264 analgesics and antinflammatory drugs

• 4.4%

Revision rates for products in main therapeutic categories