Over- and Under-provision of Diabetes Screening: Making More Efficient Use of Healthcare Resources

National medical care expenditure in Japan exceeded 43 trillion yen in FY2018, with over 1.2 trillion yen of this total being spent on diabetes care. The sales of diabetes drugs continue to increase by several percent every year, and in FY2020 were second only to anti-cancer drugs. Even with such huge healthcare and drug expenditure on the treatment of diabetes, the number of patients undergoing dialysis due to diabetes continues to increase, and the number of chronic dialysis patients in Japan per capita was shown to be by far the largest in an international comparison. At the end of 2020, there were 275.4 dialysis patients per 100,000 people in Japan, of which 39.5% of chronic dialysis patients had diabetic nephropathy, in which the kidneys are damaged due to diabetes.

A previous analysis of the length of hospitalization for diabetes patients in Japan showed that the average number of days spent in hospital was extremely long, with a cost-benefit analysis indicating that this is difficult to justify. The results of the data analysis carried out in this paper suggest that many people suffering from severe diabetics may not actually be receiving treatment. In contrast with the major diabetes screening programs overseas, it is clear that the Japanese program (1) does not evaluate the risk of developing diabetes, although it does include an age limit; (2) carries out annual screening regardless of the risk and/or blood sugar level; and (3) is not updated by the best available evidence from the latest clinical research.

Many stakeholders, including local governments, health insurance associations, and the Ministry of Health, Labour and Welfare, have already pointed out the importance of preventing diabetes aggravation. In this paper, we explore the reasons why Japan’s efforts to encourage people at high risk to receive preventive medical care are failing, and propose necessary measures to achieve organic cooperation between screening programs and healthcare provision.

Keywords: diabetes, educational hospitalization, screening

JEL Classification: C13, H51, I18

Top of the page

---

Reducing Over- and Under-Provision of Health Care: The Roles of Evidence-Based Medical Education and the Patient-Centered Clinical Method

In order to reduce ever-increasing social security expenditure, the Government of Japan is attempting to improve the efficiency of healthcare services. The premise of these efforts is that there exists a high degree of waste in the present system. However, the problem lies not only in over-provision of health care, but also extends to under-provision. To redress over- and under-provision of healthcare services and promote the right care, it is necessary to gain the awareness of and secure action from healthcare providers, users, and government officials. Because this is an area that involves human cognition and the modification of behavior, it is not a simple task. However, many other countries have been tackling this problem of low-value care through trial and error. Three forces that govern the de-adoption of low-value care have been previously described: evidence that a current practice provides little or no value, eminence that comes from professional societies issuing practice guidelines or recommendations against a low-value service, and financial incentives (economics) that can be used to catalyze de-adoption. In addition, education for primary health care professionals is important to enable them to fully understand the Patient-Centered Clinical Method and to implement it within their healthcare practice by taking users’ emotions and the cost-effectiveness of care into consideration.

By following the examples of other countries’ efforts to reduce over- and under-provision in their respective healthcare systems, considerable fiscal effects can be expected in Japan. This paper revisits the definitions of medical screening, examines over- and under-provision of health care by taking lung cancer screening as an example, introduces overseas attempts to de-adopt low-value care, and outlines the Patient-Centered Clinical Method.

Keywords: over-provision, under-provision, right care, low-value care, medical screening, primary health care, Evidence-Based Medicine (EBM), Patient-Centered Clinical Method

JEL Classification：H51, I18, I19

Top of the page

---

Quality Indicators for Treatment Outcomes of Regional Medical Institutions

This paper outlines what information can be utilized to compare the treatment outcomes of the acute care hospitals in regions (secondary medical-care area). Specifically, we point out existing limitations in the use of data. In addition, this paper describes leading quality indicators overseas. Some overseas public institutions publish quality indicators (QI) for each medical institution. They thus make treatment outcomes more visible to the public and improve the quality of treatment at each medical institution. One example is the Quality and Outcomes Framework (QOF) for examination and evaluation used for primary care in the UK. This paper states lessons we can learn from the QOF. In Japan, there is no evaluation of quality of care for each clinic, and the only public data are the treatment results since FY2006 of selected hospitals which adopt the payment system known as the Diagnosis Procedure Combination/Per-Diem Payment System (DPC/PDPS). Even this information is limited, as statistics for minor diseases and for small cases are dropped. In addition, the reporting quality of the personal data is diffused, as there are no uniform standards for the seriousness of the disease and complications. We conclude that the mandatory disclosure of fully unmasked set of aggregate information is vital as regional healthcare indicators. To ensure the quality of the data, we also need to impose unified reporting rules of personal treatment data.

Keywords: Quality Indicator (QI), Quality and Outcomes Framework (QOF), Diagnosis Procedure Combination/Per-Diem Payment System (DPC/PDPS), Personal Data

JEL Classification：H51, I10

Top of the page

---

Comparison of Treatment Outcomes of Acute Care Hospitals in Okitama Secondary Medical-care Area of Yamagata Prefecture

This paper compares the treatment outcomes of the three major acute care hospitals in Okitama secondary medical-care area of Yamagata prefecture. At present, each prefecture is adjusting the supply of hospital beds so that the supply plans meet the estimated demand of each region in 2025, basically reflecting changes in demography. At the national level, currently there are too many acute care beds and too few convalescence (recovery) care beds compared to the estimates. Such qualitative and quantitative shift in each region is one of the most challenging issues facing regional hospitals. To evaluate the current situation of the regional acute care, this paper compares among the three hospitals mortality rates, length of hospital stays, Barthel Index (BI) of activities of daily living (ADL) at discharge, and changes of BI per day of hospitalization. Specifically, statistical differences in hospital acute care in heart failure, myocardial infarction, stroke, pneumonia, and femoral fracture are discussed. Though there was no statistical difference in mortality rate across the three hospitals in the region, we observed several differences in length of hospital stay and ADL at discharge. The results suggest the difficulty in consistently achieving the efficient length of hospital stays on one hand and ensuring the effective functional recovery of patients on the other hand. Furthermore, we point out some inadequate reports of personal data when comparing treatment outcomes, which lead to some biased and unclear measurements for regional hospital performances.

Keywords: Barthel Index, activities of daily living (ADL), length of hospital stay

JEL Classification：H51, I10

Top of the page

---

Patient Behavior During the COVID-19 Pandemic and Impacts on Medical Institution Revenue

We analyzed patient behavior before and during the COVID-19 pandemic (from February 2019 to September 2021) using a combination of data sources, including claims data from the national health insurance and over-75s healthcare insurance systems, and outpatient and inpatient data (so-called “DPC data”) from a large, nationally distributed group of Japanese hospitals. We identified that COVID-19-related hygiene measures and behavioral changes significantly reduced medical consultations and hospitalizations for non-COVID-19 infectious diseases. Medical consultations relating to chronic diseases, such as hypertension, diabetes, back pain, and knee pain, greatly decreased. The prolonged interval of drug prescriptions appears to be a major factor behind the decrease in follow-up visits. In addition, medical consultations at acute care hospitals for minor illnesses and casual use of ambulance services also greatly decreased. It also appears possible that certain medical investigations and interventions, such as for cancer and angina pectoris, were postponed or cancelled.

The significant changes that we identified in patient behavior during the COVID-19 pandemic, namely a major reduction in non-COVID-19 patients’ propensity to seek medical care, present major challenges to the management of medical institutions in Japan. This is because the vast majority of hospitals and clinics operate on a fee-for-service basis—or a prospective, per-diem basis in the case of inpatient services (except for surgical procedures, which are fee-for-service) at hospitals operating under the “DPC/PDPS” system—and therefore rely on long-term hospitalizations and frequent consultations for revenue. With Japan’s population continuing to decline rapidly, it is essential to construct a medical care provision system that does not depend on these factors. To achieve this, consolidation of medical institutions, a review of the remuneration system, and the introduction of medical care quality evaluations will be inevitable.

In addition to improving the transparency of medical services through the use of DPC and health insurance claims data, it is also necessary to improve transparency and verify the effectiveness of the various COVID-19 subsidies received by medical institutions, such as through the mandated electronic disclosure of business reports. All medical institutions should have to prepare and publish annual financial statements under accounting standards equivalent to those imposed on companies.

Keywords: COVID-19, strain on healthcare, doctor-to-bed ratio, nurse-to-bed ratio, DPC patient data, health insurance claims (national health insurance and over-75s healthcare insurance systems), patient behavior, medical institution revenue, COVID-19 subsidies

JEL Classification：H51, I10, I18

Top of the page

---