Medical fee table revision

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

In May 21, 2003, the Central Social Insurance Medical Council agreed to the proposal by the Minister Chikara Sakaguchi on restructuring a scheme of fee degression for re-consultation. This decision made the scheme to be abolished in June, which was only one year and two months after its introduction during a normal session for fee table revision in April 2002.

Purpose of health policy or idea

This report describes the third of three items included in the Framework for Health Care Reform in Japan. The Framework consists of

1. creation of a new health care system for the elderly
2. revision of the existing system of medical fee tables
3. reorganization/integration of health insurers.

In May 21, 2003, the Central Social Insurance Medical Council (chairman: Shinyasu Hoshino) agreed to the proposal by the Minister Chikara Sakaguchi on restructuring a scheme of fee degression for re-consultation. This decision made the scheme to be abolished in June, which was only one year and two months after its introduction during a normal session for fee table revision in April 2002. This is an extraordinary incident in that (re-)revision of medical fee tables was conducted between normal sessions in every two years. 

Fees for (the first) consultation are counted for a day when the first consultation is conducted in a medical institution. On the other hand, re-consultation fees are counted for each medical practice not covered by the (first) consultation fee. (Both consultation and re-consultation fees are arranged to be higher in clinics than in hospitals, reflecting the policy in the Ministry of Health, Labour and Welfare to urge clinics to emphasize in outpatient care than hospitals.) Re-consultation fees are counted for clinics and hospitals with less than 200 beds.

In the revision of medical fee tables conducted in February 2002, a scheme of fee degression for re-consultation had been introduced, which reduces the fee points according to the number of consultations in the same month. The scheme was expected to correct cases of excessive consultations for a patient.    

The Japan Medical Association had demanded the abolition of the free degression scheme. JMA argued that

• grounds for assessing outpatient care in that way were not clear (even if evidence showed that the first outpatient consultation in a month was properly assessed),
• it was not possible to explain patients why out-of-pocket payment changes with exactly the same medical care provided to them (it became the highest in the beginning of the month),
• containment of the frequency of consultations was not observed after all with introduction of the scheme,
• the scheme did not affect patients' behavior because their out-of-pocket payment decreases in the second and subsequent consultations in the same month,
• the introduction of the scheme did not affect the behavior of doctors either, and so on.  

Main points

Main objectives

• Simplification of the medical fee system
• Correction of fee schedule revision based not on actual cost but on policy intention to differentiate functions of medical institutions

Type of incentives

• financial
• non financial

Groups affected

Provider: medical institutions, Payer: insurers, Patients: patients

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

This reform is, substantially, in line with the trend toward reduction of medical fees. As specialty had been emphasized in increasingly segmented medical practice, it would be irrational to assess the practice in the same way for all doctors across all medical institutions. It would be high time to think about (re-)consultation fees segmented for specific specialty or the years of experience. In other words, fee degression was meaningful in that it captured the characteristics of each specialty.

Political and economic background

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

Division of functions among medical institutions
The Japanese Ministry of Health, Labour and Welfare attempts to strengthen the basis of clinics, that can be defined as providing primary care services, devising a scheme in which patients are referred to large hospitals from clinic or hospitals in the neighborhood, thus preventing concentration of patients to large hospitals.

In order to achieve this, policy measures to constrain consultations to outpatient departments in large hospitals have been taken. For example, fees for outpatient care in large hospitals have been decreased as a disincentive to large hospitals attending to outpatient clients. In addition, medical fee tables have been revised to include some incentives to raise the rate of referral from other medical institutions.

The scheme of fee degression for re-consultation within a month had been also intended to lead to the same direction, but was abolished because it did not function as expected. An increasing number of patients realized that medical fees were lower in hospitals (especially those with 200 beds or more) than in clinics. This perception increased the number of patients going not to clinics but to hospitals.

Approach of idea

The approach of the idea is described as:
amended:

Innovation or pilot project

Pilot project - revision of medical fee schedule

Stakeholder positions

(Agreed to the abolition) Japan Medical Association
JMA has been requesting the abolition, arguing that the scheme would cause out-of-pocket payment of patients to automatically change monthly without any rational explanations to them. 

(Agreed to the abolition) payers/insurers
They also admitted that there was an irrational part in the degression scheme and agreed to abolish it, because evidence showed that the introduction of the degression scheme had not reduced frequency of consultations and had proved less effective than expected.
Also, payers requested, as a condition for abolishing the scheme, to revise a medical fee table for outpatient care. To be more precise, they proposed to contain fees for simple tests and procedures in the re-consultation fee. For example, fees for outpatient care in hospitals with 200 beds or more include items such as some forms of urine tests for general substances or procedures for curing of wounds. The proposal of payers is to introduce general rules for re-consultation fees in all the medical institutions. 

However, in terms of their proposal, the providers' side requested to allow exceptions for diabetes and renal diseases because there are some cases in which frequent tests are necessary for those diseases. Both sides did not reach a compromise during the session. Consequently it was decided to continue consultations toward the next session of medical fee revision, scheduled the next year.

Influences in policy making and legislation

In May 2003, the Committee for Basic Problems on Medical Fees, attached to the Central Social Insurance Medical Council, agreed on abolishing a fee degression scheme for re-consultation within a month and approved of a proposal by the Ministry of Health, Labour and Welfare on a new medical fee table. The plenary of the Central Social Insurance Medical Council approved of the Ministry's proposal on the spot based on the Committee's decision. The new fee table was decided to be implemented from June 1, 2003. The whole process was judged as extraordinary in that a (re-)revision of fee tables was conducted between normal sessions in every two years.

Legislative outcome

major changes

Monitoring and evaluation

There are no agencies or institutions with a special mandate to evaluate the result of the reform, but the results will draw attention of many researchers/scholars because they are significant matters of concern from medical perspectives.

Expected outcome

• Frequency of outpatient consultations will be contained with subsequent reduction of health care cost.
• Some medical institutions, such as clinics where average days of outpatient care for a patient is fewer, will reduce their revenues.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

It is significant that a precedent of emergency revision between normal sessions was made.

References

Sources of Information

• Journals (e.g. Shakai-hoken-junpo (in Japanese))
• Internet Homepages
• Newspapers

Author/s and/or contributors to this survey

Tetsuya Aman, Masayo Sato

Suggested citation for this online article

Tetsuya Aman, Masayo Sato. "Medical fee table revision". Health Policy Monitor, June 2004. Available at http://www.hpm.org/survey/jp/c2/2