Hayashida Kenshi, Imanaka Yuichi
Department of Healthcare Economics and Quality Management, School of Public Health, Kyoto University Graduate School of Medicine, Yoshida Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan.
Health Policy. 2005 Sep 28;74(1):24-38. doi: 10.1016/j.healthpol.2004.12.005. Epub 2005 Jan 21.
A rational payment system is being sought in Japanese health care-one that accurately reflects the required time and the level of technical difficulty when valuing physician activity. The objective of this study is to examine the current surgical payment system in Japan by clarifying the hourly values allocated to physician activity.
This study focused on the 22 surgical procedures most frequently registered in our study database of administrative data gathered from 11 teaching hospitals in Japan. The current fee-for-service reimbursement system does not formally define which cost components surgical fees cover. It was therefore necessary for us to examine directly each reimbursement item to determine which component it represented. Next we examined the current system from the following viewpoints: (1) variation in the hourly values allocated to physician activity, for an individual surgeon or a surgical team, among types of surgery by using the actual data; (2) the association between the hourly values and the operation time or the level of technical difficulty.
The hourly values allocated to physician activity were low (US dollars 61.0 and 121.5 per surgeon: means of case 1 and case 2 estimations). The hourly values varied inequitably among types of surgery (from US dollars -28 to 237 and from US dollars 6 to 328: ranges in the case 1 and case 2 estimations). When long surgeries were excluded, shorter surgeries tended to have higher hourly values. The association between the hourly values and the difficulty level was less clear and their variation was large even at the same difficulty level.
In the current payment system, the surgical fee is deemed to include fee for physician activity as well as materials, equipment and so on. To develop a rational payment system, first, the scope of the surgical fee and that of the physician activity fee should be separated and clearly defined. Second, the latter should be modeled to reflect the manpower volume and the level of technical difficulty needed for each surgical procedure. Third, fees should be set by utilizing the cost estimates with empirical data.
日本医疗保健领域正在寻求一种合理的支付系统，即一种在评估医生工作时能准确反映所需时间和技术难度水平的系统。本研究的目的是通过明确分配给医生工作的小时价值来审视日本当前的外科手术支付系统。
本研究聚焦于从日本11家教学医院收集的行政数据研究数据库中最常登记的22种外科手术。当前的按服务收费报销系统并未正式界定手术费用涵盖哪些成本组成部分。因此，我们有必要直接审查每个报销项目，以确定它代表哪个组成部分。接下来，我们从以下角度审视当前系统：（1）利用实际数据，针对个体外科医生或手术团队，在不同手术类型中分配给医生工作的小时价值的差异；（2）小时价值与手术时间或技术难度水平之间的关联。
分配给医生工作的小时价值较低（每位外科医生分别为61.0美元和121.5美元：病例1和病例2估计的均值）。不同手术类型之间的小时价值分配不均衡（病例1估计范围为-28美元至237美元，病例2估计范围为6美元至328美元）。排除长时间手术后，较短的手术往往具有较高的小时价值。小时价值与难度水平之间的关联不太明确，即使在相同难度水平下其差异也很大。
在当前的支付系统中，手术费用被认为既包括医生工作费用，也包括材料、设备等费用。为了建立一个合理的支付系统，首先，应将手术费用的范围与医生工作费用的范围分开并明确界定。其次，应构建后者以反映每种外科手术所需的人力数量和技术难度水平。第三，应利用基于实证数据的成本估计来设定费用。
