Development of Casemix Based Evaluation System in Japan

Review Asian Pacific Journal of Disease Management 2010; 4(3), 55-66

Copyright© 2010 JSHSS. All rights reserved.

Development of Casemix Based Evaluation System in Japan

Shinya Matsuda1), Kenji Fujimori2), Kiyohide Fushimi3)

1)Department of Preventive Medicine and Community Health, University of Occupational and Environmental

Health, Japan2)Division of Medical Management, Hokkaido University Hospital3)Health Economics and Epidemiology Research, School of Public Health, University of Tokyo Medical and

Dental University

AbstractIn order to ameliorate the transparency of acute in-patient services in Japan, we have developed the Japa-nese original casemix system, so called DPC (Diagnosis Procedure Combination) after the two years’intensive researches of other countries. This casemix system has been used for payment of acute care hos-pital since 2003. As the DPC system has been organized based on the already existed Fee-for-service sys-tem, its application for payment has been smoothly conducted. The introduction of DPC system hasameliorated the transparency of clinical activities and facilitated the managerial innovation of acute carehospital both at facility level and regional level. In this article, the authors would like to introduce the over-view of Japanese casemix system.

Key words: DPC, transparency, acute care hospital, payment system, casemix, Japan

Introduction

Japan has a compulsory social health insurancescheme that is categorized into the Bismarckian typeof system. Our universal health insurance system,which covers the 120 million population, is seg-mented according to workplace and residence place.Although thousands of independent societies there-fore exist, they are all integrated into the uniformframework mandated by the national government.

Various health insurance funds, both public andsemi-public, gather the premium from their insuredand reimburse the cost for the medical facilitiesaccording to the type and volume of provided services(Figure 1).

The health insurance scheme is categorized intothree basic groups according to age and employmentstatus; Employee’s Medical Insurance scheme (EMI)for employers and their dependants, National HealthInsurance scheme (NHI) for self-employed, farmers,retired and their dependent, and a special pooling fundfor the elderly. All Japanese are covered by one ofthese schemes. Because the Japanese system is porta-ble, Japanese residents can receive medical services atany medical facilities with a modest co-payment (inprinciple, 10–30%).

Today the health insurance scheme is an impor-tant infrastructure supporting the livelihood of the cit-izen. However, while the socio-economic structure isfacing to a rapid and large changes due to ageing of thesociety, increase of working women, and transforma-tion in the working environment and industrial struc-ture, the people’s awareness and social value are alsorapidly changing. For example, solidarity principlehas been gradually eroded.

As shown in Table 1, it is an important matter how

Received: September 16, 2011Accepted: November 9, 2011Correspondence: S. Matsuda, Department of PreventiveMedicine and Community Health, University of Occupa-tional and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, Fukuoka 807-8555, Japane-mail: [email protected]

56 Asian Pacific Journal of Disease Management 2010; 4(3), 55-66


to cope with the increasing health insurance burden1).Currently the following topics are under the discus-sion; re-organization of taxation and social insurancesystem, re-evaluation of the scope of public healthinsurance benefits, to make the payment system morecost-efficient, introduction of Disease Managementscheme, to differentiate functions of medical facili-ties, and so on.

As explained above, health care system in Japanis facing serious financial difficulties due to extremelyrapid ageing and costly innovations in medical tech-nology. In order to maintain our health insurance

scheme, we need to change the system more efficientand transparent. In order to implement any program,we need objective data about the actual situation.

Financing System for Medical Services

The Japanese health financing system has longbeen based upon fee-for-service reimbursement undera uniform national price schedule. All medical facili-ties are reimbursed for medical services according tothe official fee schedule. There are separate reimburse-ment schedules for procedure and pharmaceuticals.

Figure 1 Structure of Social Medical Insurance Scheme

Note: The Japanese medical insurance system is based on the third payer scheme.

Table 1 Chronological changes of the Total Medical Expenditures in Japan

Total Medical National Income (NI) TME for the agedExpenditures (TME)

Total Increasing Per capita

Total IncreasingTME/NI

Total IncreasingPer capita TME TME for

(billion rateTME

(billion rate (%)

(billion rate for the aged the aged

yen) (%)(Thousand yen)

yen) (%) yen) (%)(Thousand yen) / TME (%)

1955 238.8 11.0 2.7 6,973.3 3.42%1965 1,122.4 19.5 11.4 26,827.0 11.5 4.18%1975 6,477.9 20.4 57.9 123,990.7 10.2 5.22% 866.6 30.3 184 13.4%1985 16,015.9 6.1 132.3 261,089.0 7.4 6.13% 4,067.3 12.7 499 25.4%1995 26,957.7 4.5 214.7 374,277.5 0.1 7.20% 8,915.2 9.3 752 33.1%2000 30,141.8 –1.8 237.5 379,065.9 1.5 7.95% 11,199.7 –5.1 758 37.2%2005 33,128.9 3.2 259.3 365,878.3 0.5 9.05% 16,890.6 3.4 656 51.0%2006 33,127.6 0.0 259.3 373,591.1 2.1 8.87% 17,123.3 1.4 644 51.7%2007 34,136.0 3.0 267.2 374,768.2 0.3 9.11% 17,743.9 3.6 646 52.0%

Source: Ministry of Health, Labor and Welfare (2010).

57Development of Casemix Based Evaluation System in Japan


Fee schedule for medical proceduresThe fee schedule of procedure is a very detailed

form of pricing control, listing more than 3,000 med-ical procedures for physicians alone. The fee scheduleis revised every two years. In order to estimate theinfluence of price revision, the Health economics sur-vey is conducted by Ministry of Health, Labor andWelfare (MHLW) one year before the revision of tar-iff table. There are two different stages of fee schedulerevision: (a) setting total medical expenditures anddetermining the distribution of funds to differentgroups (physicians, dentists, pharmacists, etc.) and (b)after determining the share for each of the players,modifying the fees for the 3,000 procedures. Althoughthe Japanese health system is based upon the fee-for-service system, it can be considered a kind of globalbudget system with a very tight bureaucratic pricingcontrol.

Fee schedule for pharmaceuticalsThere is a separate tariff schedule for the pharma-

ceuticals. The drug tariff, officially set for each brandof pharmaceuticals by MHLW, is applied for theprices paid to medical institutions and pharmaciesfrom medical insurance. The tariff lists more than13,000 drugs by brand name. It is important to be rec-ognized that these drug prices are the prices of medi-cines paid from medical insurance to medicalinstitutions, and the prices at which medicines areactually purchased by medical institutions are open tonegotiation. This gives rise to a difference between theofficial drug price and the actual purchasing price.When setting the official drug prices of existing drugs,therefore, periodical surveys are conducted on theiractual retail prices on the market, and a reasonablemargin is added to reflect differences arising fromsuch factors as the size of packages and terms of busi-ness. At present, this margin is reduced to 2%. The for-mula is as follows:

new price = the weighted average in the actual mar-ket prices + 2% of margins.

Under the severe economic situation, the publicprices for pharmaceuticals have been reduced withinthe past negotiations.

With regard to ordinary new medicines, the drugprice is determined by comparing their efficacy withthat of existing medicines closest to them and refer-ring to the price of the existing medicines. Where there

are no similar medicines already available, the officialprice is determined on the basis of the cost of produc-tion and marketing etc. In the case of extremely valu-able, innovative new medicines, the official drug priceis determined by adding a certain amount to the priceof similar existing medicines, considering how usefuland innovative they are.

Claim Data

In Japan, we have a very detailed claim data,which contains various information such as diagnosis,procedures conducted, drugs prescribed, and so on. Asthese data are registered with the date of service, wecan describe the process during the hospital days. Thehealth information companies developed the com-puter system corresponding to the FFS payment.Using the installed tariff table data, the computer pro-duces a receipt (claim sheet) of each patient for reim-bursement. Health institutions send this claim sheet tothe payers’ organization in order to receive reimburse-ment. In this computer system, all procedures, drugsand devices for reimbursement are registered for eachpatient by daily basis.

However, this claim format has not been fullystandardized nor electronized, thus these very pre-cious data had not been fully used for health policymaking before introducing the Japanese casemix sys-tem, DPC (Diagnosis Procedure Combinations). Asexplained later, one of the main purposes of the Japa-nese casemix project is to implement a standardizedelectronic claim system. The keywords are transpar-ency and accountability. Using the casemix frame-work, we can evaluate the cost and quality of medicalservices as shown in this article.

Change in Payment Scheme

The FFS payment system has a merit to enable theadequate provision of medical care for the patent asthe provider can expect enough remuneration accord-ing to the volume of provided services. However, theFFS system also entails the risk of excessive treatmentand examination. Furthermore, because Japan’s FFSsystem is based on acute illness disease structure, it isnot suited to today’s disease structure where large partof medical services is provided to chronic illness.

In order to solve this discrepancy between tariffscheme and disease structures, the bundle type of pay-



ment scheme has been gradually adopted. For exam-ple, the bundle payment for the geriatric wards wasintroduced in 1994. The effect of this reform was dras-tic. The number and volume of prescription verydecreased for drugs and lab-test, and the use of genericdrug increased2). Baring this fact in mind, the payerassociation has been insisting on introducing casemixbased payment for the acute in-patient services. Asexplained later, finally after the two years experimen-tation, the casemix based bundle payment scheme wasintroduced on April 2003.

Brief History of Casemix System Development in Japan

Since the late 90’s, MHLW and its affiliatedresearch institute (Institute of Health Economics andPolicy: IHEP) have started research on the feasibilityof casemix classification system as a tool of standard-ized medical profiling and payment. Several types ofalready existed casemix classification, such as HCFA-DRG, AP-DRG, APR-DRG, and an early version ofJapanese original casemix system were tested forvalidity.

Although the American DRGs were evaluated asapplicable for the Japanese acute-care hospitals3), thephysician’s organization criticized that the AmericanDRGs were too rough to correctly reflect their practicepatterns. But they also recognized the necessity ofcasemix profiling to improve the transparency of med-ical decision and processes to their patients and insur-ers. Thus, it was required to develop an originalclassification system that fits to the practice pattern inJapan, and at the same time, allows comparative

benchmarking across the country and with the systemof other countries.

In order to seek another way to implement thecasemix system, at first, we investigated the DRGapplication in the European countries between 1997and 1998. We have intensively investigated UK(HRG), France (GHM), Sweden (Nord DRG), Bel-gium (AP-DRG), Portugal (HCFA-DRG), Austria(LDF), Germany (FP/SE) and the Netherlands (DBC).After the two years country-study we started todevelop the new casemix system as a profiling tool ofmedical services. We have much influenced by theFrench and Austrian approach of casemix applicationfor regional health planning and Belgian and Britishapproach of incremental development process.

In 2001 the Japanese casemix research team, socalled DPC Project team, was organized in order todevelop the Japanese original casemix system. Thisteam has been playing a pivotal role for developing thecasemix based system in Japan.

The Structure of DPC

The basic idea for constructing new casemix sys-tem is not that of DRG. As the Japanese medical pro-fessionals required more process oriented system, weadapted the diagnosis dominant classificationapproach. The basis of DPC classification is definitiontable (Table 2)4). The first column is diagnosis thatcorresponds to a group of pathologies. In this case,“Malignancy, Stomach, Total gasterectomy, Chemo-therapy, No CC” contains “Malignant neoplasm ofstomach (C16$)” and “Carcinoma, in situ (D002)”. Inthe second step, a series of usually applied interven-

Table 2 The DPC definition table

Base DPC Diagnosis ICD10 Surgical JPC Adjuvant JPC Adjuvant JPC CC ICD10 SeverityProcedure therapy 1 therapy 2

Stomach, Carcinoma, C16$ Total K6572 Splenectomy K711 CVH G005 Shock R57$Malignancy Stomach gasterectomy

Carcinoma, D002 Partial K6552 chole- K672 Chemo- Cardiac I50$in situ gasterectomy cystectomy therapy failure

Brown K662 Radiation …… ……procedure

Laparoscopic K655-22 Ventilator J045$gasterectomy…… ……

JPC: Japanese Procedure Code. Source: Ministry of Health, Labor and Welfare (2010).



tions are listed up according to the opinion of special-ist’s panel. Finally other expected situation such as co-morbidities and complications are listed up by thepanel. Based on this definition table, our researchteam analyzed the actual data and constructed theDPC groups.

The structure of the DPC code composes of 8 partsas shown in Figure 2. Each part is defined by the cor-responding part of definition table. The first part isMajor Diagnosis Category (Table 3) and DPC serialnumber that corresponds to ICD10. The second indi-cates the type of admission (Current version does not

Figure 2 Structure of code of DPC version 3.4

X: not applicable; #: proc code according to level of resource consumption.

Table 3 Major Diagnosis Category

MDC Name of MDC

MDC01 Diseases and Disorders of the Nervous SystemMDC02 Diseases and Disorders of the EyeMDC03 Diseases and Disorders of the Ear, Nose, Mouse and ThroatMDC04 Diseases and Disorders of the Respiratory SystemMDC05 Diseases and Disorders of the Circulatory SystemMDC06 Diseases and Disorders of the Digestive and Hepatobiliary System and PancreasMDC07 Diseases and Disorders of the Musculoskeltal System and Connective tissuesMDC08 Diseases and Disorders of the SkinMDC09 Diseases and Disorders of the BreastMDC10 Endocrine, Nutritional and Metabolic Diseases and DisordersMDC11 Diseases and Disorders of the Kidney and Urinary TractMDC12 Diseases and Disorders of the Female Reproductive SystemMDC13 Diseases and Disorders of the Blood and Blood Forming Organs and Immunological DisordersMDC14 Pediatric Diseases and DisordersMDC15 Newborns and other Naonates with Conditions Originating in the Perinatal PeriodsMDC16 Injuries, Poisonings and BurnsMDC17 Mental Diseases and DisordersMDC18 Others



use this information for grouping). The third is code forage and birth weight. The fourth is existence and typesof surgical procedures. The fifth and sixth indicate theexistence of additional procedures and adjuvant thera-pies, i.e. chemotherapy and radiotherapy. The seventhindicates the existence of co-morbidity/complications.Finally, the eighth is the code for severity. Althoughthe eight components are the prototype of the classifi-cation structure, it should be noticed that they are forprofiling, and that all of the components are not neces-sarily used for reimbursement schedule.

Information Gathered by the DPC Project

As explained above, the principle of Japanesehealth insurance scheme has long been the FFS basedpayment. The health information companies adaptedto this scheme and developed the computer systemcorresponding to the FFS payment. In this computersystem, all procedures, drugs and devices for reim-bursement are registered for each patient by dailybasis. There is a MHLW standard code for each of allprocedures, drugs and devices.

The DPC study gathers these detailed electronicdata as E-file (cost data) and F-file (detailed proceduredata). Table 4 shows the content of E-file and F-file.E-file has information of the bundled charge of proce-dure, i.e., injection of Solita T3 in this case. F-file indi-cates the detail of bundled procedures, i.e., Solita T3500 ml 2 bottles, Chienam IV 500 mg 2 kits and Vita-

mejin IV 1 bottle. E-file and F-file is connected by IDnumber, discharge date, admission date and data cat-egory. In addition to these electronic data, a clinicaldata, so called Form 1 Minimum Data Set (Form 1) isalso gathered. Form 1 contains the following patientinformation; data ID number, birth date, sex, principaldiagnosis (ICD-10), co-morbidity and complication(ICD-10), surgical intervention (Japanese paymentcode), other major procedures (Japanese paymentcode), emergency case or not, and outcome. Further-more, there are more clinical information such asADL score (Barthel index), severity score such asNYHA and Killips score, cancer staging, UICC codeand other clinical indicators. The MHLW published astandard manual for data registration to which the par-ticipant hospital must follow.

Form 1, E-file and F-file are matched according tothe data ID number that is unique for each dischargedcase.

Reimbursement System Based on DPC

The DPC based payment for hospitals composesof two components; DPC component and Fee-For-Service component. The DPC component corre-sponds to the “so called” hospital fee, which containshotel fee, pharmaceuticals and supplies used in wards,lab-test, radiological examination, and procedurescheaper than ¥10,000. The FFS component corre-sponds to tariffs for surgical procedures and anesthe-sia, pharmaceuticals and expensive devices used in

Table 4 Structure of E-file and F-file (extracted)

Data ID number is the number of each discharge case. This ID is the same as Form 1.



operation rooms, and procedures more than ¥10,000.For the DPC component, per diem payment scheduleis set for each DPC group.

Tab l e 5 shows an exa mple fo r “DPC060020xx01x3xx: Malignancy, Stomach, Total gas-terectomy, Chemotherapy, No CC”. For each group,the standard per diem payment is defined, and threeperiods are set for reimbursement; period I, period II

and Upper limit for DPC based payment (Figure 3).The period I, II and upper limit correspond to the 25percentile-day, ALOS day and ALOS+2SD day,respectively. Up to period I, per diem payment is setfor 15% more than standard per-diem payment. Fur-thermore, the hospital coefficient is calculated foreach facility according to its function and characteris-tics. On the contrary, from period II to upper limit day,

Table 5 An example of DPC definition table for reimbursement

Source: Ministry of Health, Labor and Welfare (2010).

Figure 3 An example of DPC based payment for hospital

DPC 060020xx01x3xx (Malignancy, Stomach, Total gasterectomy, Chemotherapy, No CC)Source: Ministry of Health, Labor and Welfare (2010)

For each group, the standard per diem payment is defined, and three periods are set for reimbursement; period I, period II andUpper limit for DPC based payment as shown in this Figure. The period I, II and upper limit correspond to the 25 percentile-day, ALOS day and ALOS+2SD day, respectively. Up to period I, per diem payment is set for 15% more than standard per-diem payment. Furthermore, the hospital coefficient is calculated for each facility according to its function and characteristics.On the contrary, from period II to upper limit day, per diem payment is set for 15% less than the standard payment. Overupper-limit-day, a reduced FFS payment scheme will be applied.



per diem payment is set for 15% less than the standardpayment. Over upper-limit-day, a reduced FFS pay-ment scheme will be applied.

The calculation of DPC based payment is rathercomplicated, thus the computerization of hospitalinformation system is an indispensable requirement.In fact, the DPC based hospital computer system forreimbursement has been developed based on the for-mer FFS based tariff calculation system. Furthermorespecial computerized software for ICD coding hasbeen also developed in order to lighten the burden ofclinicians who have responsibility to complete a DPCinformation sheet (Form 1) of their patients.

Refinement Process of DPC

The first version of DPC 3.0 was developed by theDPC project team in 2001. Based on the discussionwith clinical groups and the statistical analysis ofgathered cases-data from participant’s hospitals, theclassification has been revised every two years. Thelatest classification composes of 2,658 groups underthe 18 MDCs.

During the refinement process, the evaluation ofsecondary procedures (i.e., secondary surgery, che-motherapy, radiotherapy, etc) and CCs were inten-sively reviewed. Especially it becomes a big debatingissue how to evaluate new medical technology such asnew drugs and devices.

DPC as a Tool for Transparency of Medical Services

Under the severe financial situation of govern-ment, there is a strong pressure for rationalizing thehealth expenditures. On the other hand, patientsrequire more quality and high-tech services. It is areally difficult task how to balance these require-ments. As it is not possible to ameliorate quality andefficiency of services that are not measured, it is abso-lutely necessary to equip a standard information sys-tem. One of the most important missions of DPCproject is to ameliorate the transparency of hospitalactivities, in order to make hospital services measur-able and then to prepare a common basis for discus-sion about health reform. The cost-containment is notthe first objective of DPC project. It is the first time inthe Japanese history of health policy that the datashown in this article is open for the public. With these

DPC related data, we can objectively analyze the per-formance of hospital services. Standardization, trans-parency and accountability are the keywords of DPCproject.

Using DPC data, we can describe the process ofeach in-patient treatment as shown in Figure 4. Thisfigure describes what kinds of care were given to thecase “Stenosis of bilateral common carotid artery,Female, 80 yr old, JCS on admission = 0, Not emer-gency, discharge to home”. In DPC expression, thiscase is described as “010060x001x1xx Cerebralinfarct, JCS < 30, surgery =1(angioplasty etc), proce-dure 2=3 (edarabone)”. It is very important to recog-nize that we can describe total process of in-patientservices based on the routinely collected data in eachhospital in this way.

Based on this detailed clinical data, the MHLWhas started to open various health information to thepublic. Today citizens can access the DPC based datain the website of MHLW, where the number of dis-charge cases is opened for each DPC by each hospital.For example, a patient with esophagus cancer canknow which hospital treats this disease the most fre-quently in Japan (Table 6).

Table 7 shows the top 30 regimens of chemother-apy for lung cancer among the 242 acute-care hospi-tals that had participated to the DPC based costresearch project in 20065). This project was organizedby our research team independent from the MHLWdata collection. Data was collected from 242 acutecare hospitals during July to October, 2006. Accord-ing to the results, there were 17,200 lung cancerpatients with chemotherapy and there were 659 differ-ent regimens for lung cancers. The most frequentlyapplied regimen is “carboplatin + paclitaxel” that wasused for 3,243 cases among 17,200 (18.9%) in 189 of242 hospitals (78.1%), followed by gefitinib (1,164cases and 186 hospitals, corresponding to 6.8% and76.9%, respectively), etoposide + carboplatin (1,069and 166, 6.2% and 68.6%).

Cancer has been the leading cause of deaths inJapan, with one person out of three dying of the dis-ease. More people are dying of cancer as the popula-tion gets older. The countermeasure for cancer controlis an increasingly serious issue for the health policymaker. However, it is criticized that there are widevariation of cancer care in accessibility and qualityamong the different regions and institutions. In orderto further ameliorate cancer control policy, MHLW



has established “The third term Comprehensive 10-yrStrategy for Cancer Control” in 2006. One of the mostimportant objectives of the Strategy is to assure theequal access to quality cancer treatment for all popu-lation. This requires the situation analysis of cancertreatment. The DPC framework is can be used for thispurpose. Using the summarized results such as Table7, both clinicians and patients can know what are themain streams of today’s cancer treatment, for exam-

ple. This kind of information will facilitate EBM andQuality Assurance movement in cancer care.

DPC as a Tool for Estimation of Disease Structure

The MHLW conducts the Patient Survey every 3yr. In this survey, each medical facility (hospitals andclinics) is required to report the patient’s data such as

Figure 4 Process analysis of in-patient care

Example: Stenosis of bilateral common carotid artery. Female, 80 years old, JCS on admission = 0, Not emergency,discharge to home.

Table 6 Top 10 hospitals for treatment of esophagus cancer (Discharge cases fromJuly to December 2007)

Non-surgical Surgery with Surgery without case plastic surgery plastic surgery

National cancer center hospital 314 69 76Juntendo University Hospital 73 61 34Keiyu-kai Sapporo Hospital 244 56 86Osaka City University Hospital 41 50 20Tokai University Hospital 178 46 83Kinki University Hospital 103 34 24Osaka Medical Center for Cancer and Cardiovascular Diseases 109 31 63Showa Univercity Hospital 38 31 14Akita University Hospital 56 28 16Gunma University Hospital 62 26 12Tokyo Women's Medical University Hospital 85 26 19

Total 11,068 1,320 2,087



age, sex, address (community level), main diagnosis,complication and co-morbidity, procedures deliveredfor the particular day (out-patient services) or for theone month (discharged case for in-patient services).By applying the DPC logic for this data base, we canestimate the DPC based disease structure both fornational and local levels6).

Figure 5 shows an example of disease structureestimation for Kitakyushu Health Care Region thatcovers about 1.1 million populations. Using this kindof data, the local government establishes a health pol-icy for more rational resource allocation and each hos-pital can know their position in the region.

Conclusion

The most important purpose of health policy is toassure quality care for the patient in an efficient way.The MHLW published its principles for future healthreform. This agenda composes of three main pur-poses; Respect of patient’s choice and informatiza-tion, Realization of effective and quality care deliverysystem, and Construction of reliable health system. Inorder to promote these programs we need the stan-dardized information about contents of medical ser-vices. The DPC based information system will serveas a fundamental basis for it.

In 2010, MHLW has started the National Data-base program. This database contains claim data of allkinds of public health insurance scheme. We have

Table 7 Top 30 Chemotherapy regimen for lung cancer in the Japanese hospital (2006)

Regimen Number of Percentage Number Percentage Cummlativehospitals by hospital of cases by case %

1 carboplatin + paclitaxel 189 78.1% 3,243 18.9% 18.9% 2 gefitinib 186 76.9% 1,164 6.8% 25.6% 3 etoposide + carboplatin 166 68.6% 1,069 6.2% 31.8% 4 docetaxel hydrate 148 61.2% 906 5.3% 37.1% 5 cisplatin + irinotecan 123 50.8% 652 3.8% 40.9% 6 carboplatin + gemcitabine 114 47.1% 585 3.4% 44.3% 7 etoposide + cisplatin 105 43.4% 560 3.3% 47.6% 8 cisplatin + vinorelbine 85 35.1% 544 3.2% 50.7% 9 amrubicin 117 48.3% 540 3.1% 53.9%10 carboplatin + docetaxel hydrate 79 32.6% 510 3.0% 56.8%11 vinorelbine 115 47.5% 395 2.3% 59.1%12 OK-432 137 56.6% 379 2.2% 61.3%13 gemcitabine + vinorelbine 88 36.4% 372 2.2% 63.5%14 cisplatin + docetaxel hydrate 67 27.7% 369 2.1% 65.6%15 carboplatin + irinotecan 80 33.1% 365 2.1% 67.8%16 gemcitabine 115 47.5% 358 2.1% 69.8%17 cisplatin + gemcitabine 60 24.8% 351 2.0% 71.9%18 5-fluorouracil + Levofolinate + Oxaliplatin 75 31.0% 328 1.9% 73.8%19 tegafur-gimeracil-oteracil potassium 106 43.8% 254 1.5% 75.3%20 paclitaxel 75 31.0% 249 1.4% 76.7%21 irinotecan 85 35.1% 245 1.4% 78.1%22 irinotecan + 5-fluorouracil + Levofolinate 51 21.1% 223 1.3% 79.4%23 gemcitabine + vinorelbine + nedaplatin 1 0.4% 211 1.2% 80.7%24 carboplatin + vinorelbine 42 17.4% 176 1.0% 81.7%25 cisplatin 76 31.4% 174 1.0% 82.7%26 vinorelbine + nedaplatin 4 1.7% 142 0.8% 83.5%27 cisplatin + tegafur-gimeracil-oteracil potassium 52 21.5% 140 0.8% 84.3%28 tegafur-uracil 74 30.6% 129 0.8% 85.1%29 docetaxel hydrate + gemcitabine 25 10.3% 67 0.4% 85.5%30 nogitecan 30 12.4% 64 0.4% 85.8%



developed a methodology to analyze this databaseusing DPC classification logic, which covers allranges of care, i.e., in-patient acute care, in-patientchronic care and out-patient care. In early spring of2011, we have applied the DPC logic for all range ofclaim data (acute- and chronic in-patient care as wellas out-patient care) for the first time. The main pur-pose was a medical profiling not an application forpayment. The results were very positive and thus thisprogram is determined to expand as a governmentalproject. By this program, we can assure the possibilityto estimate the disease structure at hospital level,regional level and national level more precisely.

Under the increasing consumerism and availableinformation about the “best” medical services,patients require the quality care as highest as possible.They want the best outcome, not usual one. Higher thequality of care, usually, more the resources consump-tion. Thus, it becomes a crucial issue for the govern-ment how to balance the public health expenditures

and quality of care. Patients must be offered standard-ized information about cost and quality of health ser-vices, if not, health system cannot be sustainablefacing to unlimited requirement from the patients. Infact, this is happening in Japan in some clinical ser-vices, such as obstetrics, pediatrics and general sur-gery.

Currently in Japan, most of the medical servicesare covered by public medical insurance. It is clearthat the current public financing is not enough to coverthe all services that the patient requires. This situationseems similar both for Japan and other countries. Weneed more practical discussion about how to financethe medical services. Casemix information will serveas a basis for this discussion.

References

1) Ministry of Health, Labor and Welfare: Report onnational medical expenditures 2003, 2005 (in Japa-

Figure 5 Estimation of disease structure based on DPC logic



nese).2) Takagi Y: The introduction of bundle type payment

for geriatric care and its effect. Journal of HealthCare and Society 2, 43–62 (1992) (in Japanese).

3) IHEP: Report on studies concerning the applicabil-ity of US DRG for the Japanese health system.Tokyo: IHEP, 2000 (in Japanese).

4) Ministry of Health, Labor and Welfare: Guide forDPC definition and remuneration 2010, Tokyo:

Ministry of Health, Labor and Welfare, 2010 (inJapanese).

5) Matsuda S, Ishikawa BK, Kuwabara K, Fujimori K,Fushimi K, Hashimoto H: Development and use ofthe Japanese casemix system. Eurohealth 14, 25–30(2008).

6) Fushimi K: DPC data application book (DPC datakatsuyo book). Tokyo: Jiho, 2006 (in Japanese).

Documents

Development of Casemix Based Evaluation System in Japan