診療報酬改定 「病院依存」から転換できるか

The Yomiuri Shimbun February 13, 2014
Steer patients toward home-based care through revision of medical fees list
診療報酬改定　「病院依存」から転換できるか（2月13日付・読売社説）

Will the latest proposal from a key health ministry panel trigger a retreat from excessive reliance on hospital-based treatment and attach greater importance to home health-care services?
　病院偏重の医療から、在宅ケア重視に転換する契機となるだろうか。

On Wednesday, the Central Social Insurance Medical Council adopted a set of recommendations for revising the list of medical treatment fees. These medical service payments constitute a portion of the income earned by medical institutions.
　医療機関の収入となる診療報酬の改定内容が、中央社会保険医療協議会（中医協）で決まった。

The advisory panel’s proposal calls for tightening requirements for medical care involving the use of beds designated as equipment for patients in the acute stage, a practice that can incur higher bills for seriously ill patients. Meanwhile, the proposal would pay higher fees for services involving beds that are used to place greater emphasis on rehabilitation so patients can leave the hospital at an early date.
　重症者を受け入れる急性期病床の要件を厳しくする一方で、早期退院のためにリハビリを重点的に行う病床の報酬を手厚くする。

The average number of days spent in hospitals by patients in this country is greater than in the United States and Europe. This has contributed to an enormous increase in national medical care expenditures.
　日本の病院は、患者の平均入院日数が欧米に比べて長い。それが医療費の膨張も招いている。

The graying of Japanese society is expected to accelerate. A number of older people suffer from chronic diseases that can be managed with home-based treatment. In light of this situation, it was a sound decision for the advisory panel to call for a reduction in the number of beds for acute stage treatments and for efforts to encourage patients to leave the hospital at an early date.
　高齢化はさらに加速する。高齢者の多くが、在宅医療で対応できる慢性病を患っている現状を考えれば、急性期病床を減らし、早期退院を促す狙いは理解できる。

The question is how to move forward in consolidating hospital beds that are classified by curative purpose.
　問題は、いかに病床の再編を効率的に進めるかだ。

Previous revisions to the schedule of medical treatment fees by the health ministry have caused significant confusion among medical institutions.
　厚生労働省のこれまでの診療報酬改定は、少なからず医療現場に混乱をもたらしてきた。

Revisions made to fees involving beds used to treat acutely ill patients in fiscal 2006 exacerbated this potential for confusion. The revisions set fees for medical services involving acute treatment beds at a higher level, which encouraged many hospitals to set up more of these beds than necessary and contributed to a surplus of them.
　急性期病床についても、２００６年の診療報酬改定を機に過剰になった。報酬を高く設定したため、多くの病院が必要以上に急性期病床を設けた結果だ。

This resulted in medical institutions scrambling for nurses, because the use of such beds requires more nurses to provide appropriate care for acutely ill patients. The situation also fostered a tendency among nurses to prefer to work in urban areas, leading to an uneven distribution of such medical workers.
　看護師を多く配置する必要があるため、医療機関の間で奪い合いが生じた。都会に看護師が偏在する傾向も強まった。

Negative impact clear

The adverse impact of the 2006 revisions was also evident in the many hospitals providing elderly people with treatments using beds designated for critically ill patients. However, the fact is that many of them are placed in such beds despite improvements in their conditions.
　急性期病床なのに、入院しているのは病状の落ち着いた高齢者が大半という病院も少なくない。

The ministry needs to acknowledge that it should have been more thorough in designing a new system for medical treatment fees in 2006.
　厚労省は、制度設計が甘かったことを反省すべきである。

There also is cause for apprehension about the latest proposed revisions. If fees for services involving beds for patients undergoing rehabilitation are set at a higher compensation level, it could create a spike in the number of hospitals seeking to take advantage of that. It seems likely that an excessive number of rehabilitation-designated beds could encourage patients to stay in the hospital, despite their ailments being treatable through home-based health services.
　今回の改定でも、同様の懸念は拭えない。リハビリ用病床の報酬を高くすれば、これに転換を図る病院が急増するだろう。リハビリ用病床が多過ぎると、本来は在宅ケアで済む患者が、病院にとどまることにつながらないか。

It is essential that the ministry take adequate measures to prevent a large surplus in beds for rehabilitation treatments.
　リハビリ用病床が過剰にならないよう、厚労省はしっかりとした対策を講じることが肝要だ。

The latest proposal would expand the pricing schedule to include fees for practicing doctors’ management of patients receiving home-based care. The plan is intended to ensure stability in the conditions of older patients receiving home-based treatment. However, because there is a perceived preference among older patients for large hospitals, it is unclear whether they would desire treatment from outpatient doctors as their regular physicians.
　今回の改定では、在宅ケアの患者の主治医となる開業医への報酬も新設される。在宅療養する高齢者の病状を安定させることが目的だが、大病院志向が強いとされる患者が、開業医をかかりつけ医とするかどうかは不透明だ。

Consolidating purpose-classified hospital beds requires more than revisions to the fee schedule. It will also be necessary to accurately determine the number of beds needed in each region for acutely ill patients and patients in rehabilitation.
　病床再編には、診療報酬改定だけでなく、地域ごとに必要な急性期病床やリハビリ用病床数を正確に算出することが大切である。

In fiscal 2015 or later, the national government intends to require Tokyo and all prefectural governments to put together new community-based health care plans that must include the number of rehabilitation beds needed by each community. The move is aimed at improving the quality of current community-based care schemes, which were prepared by the local governments. The national government is seeking to establish relevant legislation during the current Diet session.
　政府は、現在の地域医療計画を充実させるために、必要なリハビリ用病床数を盛り込んだ「地域医療ビジョン」を１５年度以降、都道府県に策定させる方針だ。関連法案の今国会成立を目指す。

Given the authority possessed by each municipality to supervise medical institutions in its area, Tokyo and all prefectural governments have a significant role to play in achieving a good balance in the consolidation of hospital beds.
　医療機関への指導権限を持つ都道府県が、均衡の取れた病床再編に果たすべき役割は大きい。

(From The Yomiuri Shimbun, Feb. 13, 2014)
（2014年2月13日01時15分 読売新聞）