Challenging the Appropriateness of Medical Fee for the Japanese Percutaneous Coronary Intervention: Is the Value of the Cardiologist’s Hard Work Properly Assessed? – Systematic Review and Field Research –

Challenging the Appropriateness of Medical Fee for the Japanese Percutaneous Coronary Intervention: Is the Value of the Cardiologist’s Hard Work Properly Assessed? – Systematic Review and Field Research – | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Challenging the Appropriateness of Medical Fee for the Japanese Percutaneous Coronary Intervention: Is the Value of the Cardiologist’s Hard Work Properly Assessed? – Systematic Review and Field Research – Satoru Hashimoto, Yoshihiro Motozawa, Burt Cohen, Toshiki Mano This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2232053/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background In Japan, technical fees in reimbursement are considered not to reflect in actual medical costs, and medical procedures may often result in a deficit of the hospital. This systematic review and field research aimed to investigate the appropriateness of the reimbursement for percutaneous coronary intervention (PCI) as an example of the controversial issue associated with medical expenses in Japan. Methods We investigated the validity of the medical fee for PCI from two perspectives: the total cost of PCI in Japan compared with those in other countries, such as the United Kingdom, the United States of America, and Australia, and the appropriate cost of PCI calculated using 1) the costing calculation, 2) book-building, and 3) lost profit methods to investigate the technical fee, which is part of the medical fees. Results To compare the PCI cost between other countries and Japan, we searched PubMed and Google Scholar to extract articles that demonstrated PCI cost in the target countries from January 2018 to August 2022. Research reports as well as government-provided sources in each country were also searched using the Google search engine, which finally led to the extraction of eight abstracts. The results indicated that the total cost of PCI for acute myocardial infarction (AMI) was higher in Japan than in other countries; however, no difference was observed for unstable angina (UA). The average costs of technical fees calculated according to three methods were \772,186 for AMI-PCI and \566,688 for UA-PCI, which were higher than the existing reimbursement prices of \343,800 and \243,800, respectively. Conclusions Although the total PCI cost in Japan was not different from those in other countries, the technical fees of PCI reimbursed in FY2022 did not even come close to covering the cost. percutaneous coronary intervention reimbursement technical fee special treatment materials Figures Figure 1 Figure 2 Figure 3 Background More than 40 years have passed since the first percutaneous coronary intervention (PCI) was performed in Zurich, Switzerland [ 1 ]. This revolutionary treatment developed by Andreas Gruentzig was introduced to Japan in the 1980s [ 2 ]. During the introduction of this treatment, Japan was in the midst of deregulation [ 3 ] and at the height of the bubble economy [ 4 ], social structural changes [ 5 ], and technological innovations that created a favorable external environment. As a result, medical device manufacturers and suppliers, and cardiovascular hospitals in the community entered the market, creating a new industry. During this time, Japan was beginning an aging society, and to confront the ever-increasing prevalence of cardiac disease as one of the nation’s three major diseases, the government set a high reimbursement price for special treatment materials (STMs) to widespread of PCI [ 6 ] and welcomed new players in the market. Thus, from the late 1990s, cardiovascular hospitals and hospitals with cardiology as their backbone emerged one after another across the country. This newly created market was supported by marginal gains from the difference between high reimbursement prices and actual prices of STMs and was profitable for about 20 years after its birth. Among the players in the community, cardiovascular hospitals were especially relied on the marginal gain, despite the fact that the technical fee, which is the main income, was far less than the actual value [ 7 , 8 ]. Furthermore, there were few occasions when the low technical fee, the main part of reimbursement, was pointed out as a problem. However, beginning in the late 1990s, the prefectural purchase price system for PCI-related STMs was abolished [ 6 ] and replaced with an official price, and a review of device prices was conducted every 2 years; moreover, the price of PCI-related STMs continued to decline. This study aimed to examine the appropriateness of the reimbursement of medical fees from two perspectives: the total cost of PCI in Japan compared with those in other countries and the technical fee, which is part of the medical fees for PCI, investigated based on the market principle. By definition, medical fees consist of technical and drug fees as well as STM fees. Details of these three components are presented in Fig. 1. Methods Trial Design A systematic review was conducted to compare the total cost of PCI in the United Kingdom (UK), the United States of America (USA), Australia, and Japan. The total cost was defined as the sum of hospital and doctor fees per case. Data were collected from PubMed and Google Scholar using the keywords “PCI,” “tariffs,” “reimbursement,” and/or “cost-effectiveness” plus the name of each country to search for matching articles. In addition, we obtained the price lists from the websites of insurance bureaus in each country and identified the price per case for PCI from previous studies. The Google search engine was used to obtain information that could not be supplemented by the English-language literature. Subsequently, reasonable technical fees of PCI in Japan were calculated based on market principles using the costing calculation, book-building, and lost profit methods. In Japan, the Diagnosis Procedure Combination (DPC) reimbursement system is the main system for acute-care hospitals, and the doctor fee component, including STMs, is evaluated on a piecework basis; thus, we hypothesized that the technical fee of the reimbursement deviates from the prices calculated using the three aforementioned methods. The costing calculation method The costing calculation method is the calculation of the cost of PCI with the direct costs, and here, we refer to the Gaihoren Draft Proposal (GDP) 9.3 version calculated by the Japanese Health Insurance Federation for Surgery (known as Gaihoren) [ 9 ]. In this proposal, the technical fees include direct costs, such as costs of labor, basic set, STMs, partially reimbursable medical materials, nonreimbursable materials, special sutures, and drugs. It should be noted that the GDP does not include indirect costs, such as depreciation, costs of medical equipment repair and building maintenance, taxes and dues, and interest expenses. The book-building method The book-building method is generally employed to determine the initial public offering price. In determining the offer price for an initial public offering, the security company that underwrites the initial public offering sets provisional terms based on the opinions of institutional investors considered to be highly capable of calculating stock prices; then, it presents those terms to investors to evaluate demand and determine the offer price in line with the market trends. The fairness and appropriateness of this method have already been reported [ 10 , 11 ]. Using the book-building method, we conducted a survey on reasonable technical fees using a specialized cardiovascular website. The lost profit method Lost profits are earnings that should have been earned but were not due to an accident. Lost profit calculation is mainly used in the life insurance industry, where the amount to be claimed is the amount of lifetime income that the patient did not earn as a result of the death. In this study, the value of a life that could not have been saved had the cardiologist not performed PCI on the spot would be calculated. It should be noted that the application of lost profits is based on the patient’s situation and is theoretically derived, not on that costs that exist as a matter of fact [ 12 ]. Statistical analysis In the book-building method, a weighted average was taken from the survey results shown in Fig. 2. The lower (¥300,000 [US $ 2,142]) and upper (¥1,500,000 [US $ 10,714]) limits were used as they were; if a range was specified for the PCI cost, the average of the lower and upper limits was utilized. For example, if the range was ¥300,000 [US $ 2,142]–¥500,000 [US $ 3,571], we calculated (¥300,000 [US $ 2,142] + ¥500,000 [US $ 3,571]) / 2, which was ¥400,000 (US $ 2,857). Subsequently, the average prices of ¥500,000 [US $ 3,571]–¥750,000 [US $ 5,357], ¥750,000 [US $ 5,357]–¥1,000,000 [US $ 7,142], and ¥1,000,000[US $ 7,142]–¥1,500,000 [US $ 10,714] were calculated as ¥625,000 (US $ 4,464), ¥875,000 (US $ 6,250), and ¥1,250,000 (US $ 8,929), respectively. A weighted average was taken based on the percentages derived from the questionnaire to calculate the prices of PCI for unstable angina (UA-PCI) and PCI for acute myocardial infarction (AMI-PCI). The lost profit calculation is based on the subject’s age and annual income and can be carried out using the following formula: Lost profits = basic annual income × (1 − cost of living deduction rate) × Leibniz coefficient for the period of loss of working capacity The basic annual income was extracted from the National Tax Agency (NTA) website as the national average salary for each age group [ 13 ]. The cost-of-living deduction percentage represents the cost-of-living expenses to income ratio, and the percentage varies from 30–50%, depending on patient attributes, such as marital status and age. Because 50% is generally used for single men and 30% for those who are the breadwinners of a family with two dependents, 30% was adopted in the present study for convenience. The amount of tax that the patient returns to the government is calculated by multiplying the lost profits, calculated using the above formula, by the income tax estimated to be paid by the patient. (The income tax rate was obtained from the NTA’s website) [ 14 ]. From there, the fair price of PCI was multiplied by the percentage of spending on cardiovascular disease in the national healthcare spending in FY2018 [ 15 ]. Note that in this model, the age at which income could be earned was set to 67 years [ 16 ]. The technical fee of AMI-PCI = Lost profits × annual income tax rate × (the national spending for the cardiovascular disease/the total national healthcare spending) In calculating the technical fee of UA-PCI from the lost profit method, the current reimbursement of percutaneous coronary stenting (K549-2: UA) in the technical fee was divided by the current reimbursement of percutaneous coronary stenting (K549-1: AMI) to calculate its ratio, and then multiplied by the cost of AMI-PCI calculated by the loss profit method. The technical fee of PCI for UA = Price of AMI-PCI × (UA/AMI) Results The PubMed search period was from January 2018 to August 6, 2022, and the keyword search yielded 16 prior studies and research reports from the USA, 1 from the UK, and 1 from Australia (18 abstracts). In the Google Scholar search, 2037 articles were retrieved from the USA, 88 from the UK, and 436 from Australia, totaling 2561 articles. Subsequently, two articles were selected as references for the total costs of PCI in the target countries [ 17 , 18 ]. We then accessed the websites of the insurance bureaus (Medicare for the USA) in each of these countries to obtain data regarding tariffs, which could not be supplemented by previous studies [ 19 – 21 ]. Finally, we used the Google search engine to extract research reports from the Japanese government or private sectors that we deemed appropriate for the analysis [ 22 – 24 ] (Fig. 3). Situation in other countries We investigated the total costs of PCI in the USA, the UK, and Australia. Before discussing each country, we would like to gain insight into the hospital and doctor fees, both of which have recently been discussed in Japan. Hospital fees are the basic costs required for inpatient care and considered as hospital usage fees rather than fees for doctors’ practice. Doctor fees, on the other hand, are the remuneration required for the treatment provided by the doctor and include initial consultation, surgical, and various instructional fees [ 7 ]. Differences in reimbursement Total costs of PCI in the USA In the USA, the public medical insurance system is available only to the low-income groups, elderly, and disabled; those who do not meet the enrollment conditions must, in principle, purchase private medical insurance. Most of the population is covered by private insurance provided by companies, and hospitals within the networks of those insurance companies are selected [ 22 ]. Prices are calculated based on market principles, and the cost of diagnosis and treatment varies from hospital to hospital [ 23 ]. For the sake of fairness, this study refers to the total cost of PCI covered by Medicare, the public health insurance in the USA. The PCI cost for a patient who is not expected to need treatment for more than 24 h at an Ambulatory Surgical Center (nonhospital facility) (A), where the specific procedure can be performed, is $ 6,707, consisting of $ 6,110 for hospital fee and $ 597 for doctor fee. On the other hand, the PCI cost at a hospital with outpatient services (B), such as an observation room, surgery center, or pain clinic, is $ 10,855, consisting of $ 10,258 for hospital fee and $ 597 for doctor fee [ 21 ]. In the USA, Medicare also lists different fees for procedures using drug-eluting stents and for more complex procedures, but for the sake of simplicity, a general procedure was employed in this study (Code: 92928). Total costs of PCI in the UK In the UK, the National Health Service (NHS), the government’s public health service enterprise, manages health care in the country and operates on the principle that citizens have fair and free access to healthcare services regardless of their health status or ability to pay. In the UK, the distinction between doctor and hospital fees is unclear, and since 2004, a “payment by results” system has been used, whereby the official price set in the national tariff is multiplied by the number of cases treated [ 24 ]. The national tariff can be downloaded from the NHS website, and EY40 and EY41 are used as the categories for PCI [ 19 ]: EY40A–EY40D as complex PCI and EY41A–EY41D as standard PCI. Categories A–D are priced according to the presence or absence of comorbidities, such as diabetes and hypertension. For the sake of simplicity, we calculated the average price of EY40–EY41 in the NHS. We also used some other source to validate our findings [ 25 ]. As a result, we determined that £4,485 (US $ 5,303) is reimbursed per PCI performed in the UK. Total costs of PCI in Australia In Australia, the Medicare Benefits Schedule (MBS) is the equivalent of a doctor fee, and the price is set by the government [ 7 ]. The doctor fees are also published on the Internet [ 20 ]. AU $ 2,156.20 (US $ 1,489) is paid for the placement of one or more stents in two vascular regions and AU $ 1,874 (US $ 1,294) for the placement of one or more stents in one vascular region. For the sake of simplicity, we used the average value for doctor fees (AU $ 2015[US $ 1,391]). Hospital fees, on the other hand, are divided by condition: AU $ 15,930 (US $ 10,998) for ST-segment elevation myocardial infarction (STEMI), AU $ 12,677 (US $ 8,756) for non-STEMI, and AU $ 9,872 (US $ 6,818) for UA. In Australia, hospital fees are referred to as procedure costs per patient and include all costs incurred by the hospital during the patient’s stay, including costs of the PCI procedure itself, hospital stay, critical care provision, and medications [ 18 ]. The total costs of PCI in the UK, the USA, and Australia as well as in Japan are summarized in Table 1. The prices of PCI in Japan were calculated by selecting a number of hospitals that adopt the DPC and disclose the PCI prices on their websites; the range from the minimum to the maximum is presented in Table 1 [ 26 – 28 ]. The result showed that the hospital fee component of the comprehensive evaluation was lower in Japan than in the targeted countries, whereas the volume component, which is more like a doctor fee, was higher in Japan. Although there is no evidence suggesting that the total cost per case of PCI is higher in Japan than in the other countries, the medical fee of AMI-PCI was higher in Japan. It should be noted that STMs are paid on a piecework basis, which in Japan is considered a doctor fee and therefore varies from hospital to hospital. Appropriate price to calculate the technical fee of PCI Costing calculation method In the revision of technical fees in Japan, the Cabinet decides the total amount of medical expenses (revision rate) on which the premise is based. The specific individual revision items, etc., are deliberated and decided by the “Central Social Insurance Medical Council” based on the basic policy formulated by the national council, and it has been pointed out that they do not reflect the actual costs at the actual sites [ 8 ]. In 2022, Gaihoren, a general incorporated association consisting of 113 member societies, stated that “reimbursement for technical fees should be built on scientific and academic analysis” and has prepared GDP based on a survey involving related societies in the same organization. The Japanese Association of Cardiovascular Intervention and Therapeutics, the largest catheter intervention-based organization in Japan, is also a member of Gaihoren and has requested for an increase in reimbursement from the national government. Gaihoren calculated the total cost by scrutinizing the difficulty of the technique, staff required, and time required to calculate the labor cost. Based on the costing calculation method, appropriate AMI-PCI and UA-PCI prices were proposed, as presented in Table 2 [ 9 ]. After calculating the total cost of individual procedures from the price list, it was found that the technical fee based on existing reimbursement would result in a loss for each case. Book-building method We conducted a survey between July 27 and August 19, 2022, using TCROSS NEWS, a website dedicated to the field of cardiology. Of the 7188 doctor members, 3300 of whom had given permission to receive e-newsletters were asked to answer the questionnaire, which is presented in Fig. 2. Of the 185 participants who responded within the time period, we validated 161 respondents. The survey results were calculated for UA-PCI and AMI-PCI via weighted averaging as described above, resulting in the technical fees of ¥554,825 (US $ 3,963) and ¥814,600 ( $ 5,819), respectively, as presented in Table 3. Calculation based on lost profits Table 4 presents the results of the calculation using the lost profit method. The results indicated that the value of the life of a patient who dies of AMI is high, and the loss to the country if the cardiologist did not perform PCI on the patient was greater than the compensation obtained from the reimbursement. As a result, a mean of \773,961 (US $ 5,528) and a median of \812,210 (US $ 5,802) were recorded for possible technical fees for the patients aged between 31 and 67 years. Assuming that the price of UA was 70.9% of the PCI’s price with reference to existing reimbursement prices, the mean and median prices of UA-PCI were \548,841 (US $ 3,920) and \575,856 (US $ 4,113), respectively. Discussion This study challenged the appropriateness of the total costs and technical fees for PCI in terms of reimbursement in FY2022 in Japan by comparing them with those in other countries and using the costing calculation, book-building, and lost profit methods. No difference was observed in the total costs of PCI between Japan and other countries, namely, the UK, the USA, and Australia. However, it should be noted that although there was no difference in the total costs of PCI, the healthcare systems in each country are different. In the UK, medical care is a public health service program of the British government, and NHS doctors belong to the NHS as if they were national civil servants. In the USA, majority of the population is covered by private health insurances, and hospital and medical fees significantly vary from hospital to hospital. Therefore, a patient with a good insurance coverage can receive better medical care. Australia operates under the same system as the UK, and public hospitals are free of charge; thus, they are under the protection of the government. In Japan, however, there are many private hospitals, and cardiovascular hospitals play an important role, especially with regard to PCI; losses can even jeopardize the survival of the hospitals. In fact, there have been reports of cardiovascular hospitals going out of business since mid-2000 [ 29 , 30 ], and to the best of our knowledge, no cardiovascular hospitals have been confirmed to have opened since 2019. In the GDP, when labor and nonreimbursable costs are combined, the difference from the reimbursed procedure fee is even larger, and a deficit of \380,000 (US $ 2,714) for stenting for AMI-PCI and \350,000 (US $ 2,500) for stenting for UA-PCI is thought to have occurred (Table 2). In the past, this was compensated for by the difference between the actual price of STMs and the reimbursement price; however, at present, the reimbursement prices of STM continues to fall, and the difference continues to decline; thus, the more PCI procedures are performed, the larger the deficit unless the hospital negotiates the delivered price of STMs and purchases them at a lower price. However, purchasing at a lower price will further discourage hospitals from performing PCI, as the reimbursement price of STMs at the time of the next revision is reduced. For AMI-PCI with stenting and UA-PCI with stenting in FY2022, the GDP calculated that the total labor and nonreimbursable costs would be \727,997 (US $ 5,200) and \596,397 (US $ 4,260) (Table 2), respectively. The technical fees of AMI-PCI and UA-PCI calculated using the book-building method were found to be \814,600 (US $ 5,819) and \554,825 (US $ 3,963), respectively. On the other hand, the average prices of AMI-PCI and UA-PCI calculated using the lost profit method were \773,961 (US $ 5,528) and \548,841 (US $ 3,920), respectively. Furthermore, the average costs of UA-PCI and AMI-PCI calculated using the three methods were \566,688 (US $ 4,048) and \772,186 (US $ 5,516), respectively. Public hospitals have been stuck in a loss-making exodus, and mergers and acquisitions have been taking place in recent years. Because medical care is provided under the government intervention, the failure of a hospital is a failure of the government. If the reimbursement price of STMs continues to fall, the reimbursement price of the technical fee must also be revised. Otherwise, small and medium-sized hospitals as well as cardiovascular hospitals, which are less subject to the government protection, will not be able to survive. It would not be long until Japan’s world-class medical system will collapse; thus, a review of the medical fees is an urgent issue. Limitations This study has several limitations that need to be acknowledged. First, with regard to the evaluation of the countries covered by the total cost of PCI, data was extracted from previous studies and general government price lists for those countries; it is also a constant guide and may not represent the current actual price [ 19 – 21 ]. Second, the technical fees calculated in this study are direct costs, such as labor costs; indirect costs were not included. The lost profit method was employed to calculate technical fees based on annual income and age. While we accept the criticism that a person’s life depends on income and age, this study used the mean and median values as the PCI costs for all patients. The important aspect of the calculation of lost profits was the income tax that would be paid to the country if the individual were alive, and what is then used as a coefficient was not considered important [ 15 ]. Despite those limitations, the aim of the present study was to challenge the significance of the existing medical fees, especially focusing on the technical fees, and to show that based on market principles, the hospital could not operate with the existing technical fees. Conclusions The results of the present study confirm that although the overall cost of PCI in Japan was not different from those in other countries, the technical fee of the reimbursement price of PCI did not even come close to covering the cost, resulting in a loss per PCI, excluding the margins earned from STMs. Abbreviations AMI Acute myocardial infarction DPC Diagnosis Procedure Combination GDP Gaihoren Draft Proposal MBS Medicare Benefits Schedule NHS National Health Service NTA National Tax Agency PCI Percutaneous coronary intervention STEMI ST-segment elevation myocardial infarction STMs Special treatment materials UA Unstable angina UK United Kingdom USA the United States of America. Declarations Ethics approval and consent to participate: Not applicable. Consent for publication (from patients/participants): Not applicable. Availability of data and material: Available on request. Competing interests: Not applicable. Funding: Not applicable. Authors’ contributions: All authors contributed to the study. Hashimoto made a concept, research, design, and writing of the article. Motozawa provided his clinical perspective and information required for the article. Cohen provided information regarding the reimbursement systems in the western world and supported writing the article. Mano approved the final decision to submit the article. Acknowledgements: The authors thank Ms. Rie Arai for her excellent technical support and Ms. Keiko Takahashi and Mr. Shuhei Odagiri for the arrangement of all tables and figures in the article. Author details: 1 Department of Healthcare Management, TCROSS Co., Ltd., Tokyo, Japan. 2 Tama University Institute for Healthcare and Long-Term Care Solution, Tokyo, Japan. 3 Department of Internal Medicine, Sanikukai Hospital, Tokyo, Japan. 4 Department of Medical Communication, Angioplsty.Org, Sag Harbor, NY USA. 5 Chuo Graduate School of Strategic Management, Tokyo, Japan References Barton M, Gruntzig J, Husmann M, Rosch J. Balloon angioplasty – The legacy of Andreas Gruntzig, M.D. (1939-1985). Front Cardiovasc Med . 2014;1:15. Noguchi H, Shimizuya S, Chino M. Quantitative validation of treatment selection and outcomes for patients with acute myocardial infarction after percutaneous coronary angioplasty (PTCA) [in Japanese]. J Jpn Econ Res 2004;49:86–116. Doi O. Market oriented sector-selective talks [in Japanese]. Pharm Med Devices Regul Sc. 2011;42:712–713. https://www.pmrj.jp/publications/02/pmdrs_column/pmdrs_column_20-42_08.pdf . Accessed 15 Aug 2022. Ravina MJ. 1985-1990: Japan’s bubble economy. 24 May. 2022. https://www.wondriumdaily.com/1985-1990-japans-bubble-economy/ . Accessed 15 Aug 2022. Nakamura S. Japan’s welfare for the elder – past, present, and future. Asia Health and Wellbeing Initiative. Dec. 2018. https://www.ahwin.org/japans-welfare-for-the-elderly-past-present-and-future/ . Accessed 15 Aug 2022. Yoshida S. (2006). Actual situation of price difference between domestic and foreign prices of specific insured medical materials. (Report No. 119) [in Japanese]. Japan Medical Association Research Institute. http://www.jmari.med.or.jp/download/15_yoshida.pdf . Accessed 12 Aug 2022. The state of hospital fees. (2010). All Japan Hospital Association: Research report. May 2010 [in Japanese]. https://www.ajha.or.jp/about_us/thinktank/pdf/100611.pdf . Accessed 12 Aug 2022. Chino M. Cost analysis of procedure fee for percutaneous transluminal coronary angioplasty at six Japanese Hospitals. J Cardiol. 2001;37:83–90. The price list of percutaneous coronary intervention and related procedure [in Japanese]. Gaihoren draft (2022). Tokyo. Igakutushin Publishing. Tatsumi K. Why bookbuilding in IPO is dominant? – A survey and critical comments-. Gakushuin University [in Japanese]. Economic Report. 2011;48:23–44. https://core.ac.uk/download/pdf/292905605.pdf . Accessed 13 Aug 2022. Iwai K. Emerging markets and initial public offerings. - Review of existing internal and external studies and implications for institutional design-[in Japanese]. FSA Res Rev . 2010;6:39–112. https://www.fsa.go.jp/frtc/nenpou/2009/05-1.pdf . Accessed 13 Aug 2022. Niki Y. (2010). Research for lost profit [in Japanese]. Tokyo. Chisen Sho Kan. Average Japanese income. National Tax Agency [in Japanese]. https://www.nta.go.jp/publication/statistics/kokuzeicho/minkan1997/menu/05.htm . Accessed 13 Aug 2022. Income tax No. 2260 [in Japanese]. https://www.nta.go.jp/taxes/shiraberu/taxanswer/shotoku/2260.htm . Accessed 12 Aug 2022. The National Healthcare Expenditure in 2018 [in Japanese]. The Ministry of Health, Labor, and Welfare. https://www.mhlw.go.jp/toukei/saikin/hw/k-iryohi/18/dl/data.pdf . Accessed 12 Aug 2022. Tanigawa S. What is lost profits from traffic accidents? Explanation of calculation methods and points to receive a fair amount [in Japanese]. ALG ＆Associates. https://www.avance-lg.com/customer_contents/koutsujiko/issitsurieki/ . Accessed 15 Aug 2022. McCreanor V, Nowbar A, Rajkumar C, Barnet AG, Francis D, Graves N, et al. Cost-effectiveness analysis of percutaneous coronary intervention for single-vessel coronary artery disease: and economic evaluation of the ORBITA trial. BMJ Open . 2021;11:e044054. Lee P, Brennan AL, Stub D, Dinh DT, Lefkovits J, Reid CM, et al. Estimating the economic impacts of percutaneous coronary intervention in Australia: a registry-based cost burden study. BMJ Open . 2021;11:e053305. 2020/21 National tariff payment system – NHS England. https://www.england.nhs.uk/wp-content/uploads/2021/02/20-21NT_Annex_A_National_tariff_workbook.xlsx . Accessed 16 Aug 2022. Medicare Benefits Schedule – Item 38307. http://www9.health.gov.au/mbs/fullDisplay.cfm?type=item&q=38307&qt=ItemID . Accessed 12 Aug 2022. Percutaneous transcatheter placement of intracoronary stent (s), with coronary angioplasty when performed; single major coronary artery or branch. Medicare. Gov. https://www.medicare.gov/procedure-price-lookup/cost/92928/ . Accessed 20 Aug 2022. Kono K. The American Health Care System from outside the hospital: The origins and current status of hospitals, insurance, and services 2006 [in Japanese]. Tokyo: Shinkoh Igaku Shuppansha Co., Ltd. Overview of the health insurance system in the US. (2021). Japan External Trade Organization (JETRO) [in Japanese]. June 2021. https://www.jetro.go.jp/ext_images/_Reports/01/01168598c658e4b0/20210019.pdf . Accessed 20 Aug 2022. Mori K, Hosaka C. Medical fees in other countries (UK, France, Germany, US): Are medical costs and doctor fees clarified? [in Japanese]. Japan Medical Association Research Institute. (2010-11-9) No. 224. Available from: https://www.jmari.med.or.jp/download/WP224.pdf. Accessed August 13, 2022. Elguindy M, Stables R, Nicholas Z, Kemp I, Curzen N. Design and rationale of the RIPCORD 2 trial (does routine pressure wire assessment influence management strategy at coronary angiography for diagnosis of chest pain? Circ Cardiovasc Qual Outcomes . 2018; 11(2): e004191. Hakuhokai Osaka Central Hospital. Estimated inpatient prices based upon diagnosis and treatment [in Japanese]. http://www.osaka-centralhp.jp/nyuuin/gaisan.htm . Accessed 10 Aug 2022. Chuden Hospital. Estimated list of surgical expenses [in Japanese]. https://www.energia.co.jp/hospital/nyuuin/surgical-costs.html . Accessed 21 Aug 2022. Saint Maria Hospital. The application of diagnosis procedure combination [in Japanese]. https://www.st-mary-med.or.jp/patient/hospitalization/dpc.html . Accessed 23 Aug 2022. Client Brain News. Hokuto Cardiovascular Hospital goes bankrupt [in Japanese]. http://news.locumtenens.jp/?p=20 . Accessed 22 Aug 2022. Tokyo Keizai News. Gunma Cardiovascular Hospital filed for Civil Rehabilitation Procedure [in Japanese]. https://www.tokyo-keizai.com/archives/31700 . Accessed 22 Aug 2022. Tables Tables 1-4 are available in the supplementary files section. Supplementary Files Table1.xlsx Table2.xlsx Table3.xlsx Table4.xlsx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2232053","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":149357009,"identity":"bb2a5b41-71f1-4f47-bf12-7b8c0bbebca4","order_by":0,"name":"Satoru Hashimoto","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8UlEQVRIie3RPQrCMBiA4a8UMqW6pgj2CgFBBI/ikiK4VQQXwSIBoWtXnbxCR8cUIZMHqIt4AIc4drMREQdT7CaSd/oIeSA/ADbbT4YBHE705FzeltEXBIFLRQPy2IOIqNn3KuBefiv3g1E7WMulis/dIBWOUtCamggVrXHHO5Jom6BJIeS8Rwvm+htAcyMJrrTjJCTKJO4XOWdhRgC5GFDIjQfDvbJ8kpkmu1TUExC4T7wnAU24YPWEVmSoyTaZjMlRsuou4drfUPNd9MFOZbKKUveQq0XMqherBrWQxhf7lP4mKlkT8ihuTmw2m+1fuwO6NlLACRqlkgAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0002-6233-9451","institution":"Tama University: Tama Daigaku","correspondingAuthor":true,"prefix":"","firstName":"Satoru","middleName":"","lastName":"Hashimoto","suffix":""},{"id":149357010,"identity":"40d4b0f4-8864-4922-90b8-ff616bf3ec94","order_by":1,"name":"Yoshihiro Motozawa","email":"","orcid":"","institution":"TCROSS","correspondingAuthor":false,"prefix":"","firstName":"Yoshihiro","middleName":"","lastName":"Motozawa","suffix":""},{"id":149357011,"identity":"9cf7dc38-8846-44e5-abb5-647bf6354e99","order_by":2,"name":"Burt Cohen","email":"","orcid":"","institution":"Angioplasty.org","correspondingAuthor":false,"prefix":"","firstName":"Burt","middleName":"","lastName":"Cohen","suffix":""},{"id":149357012,"identity":"7df4f97b-06cd-4f07-bfcc-8c143c7690c7","order_by":3,"name":"Toshiki Mano","email":"","orcid":"","institution":"Chuo University: Chuo Daigaku","correspondingAuthor":false,"prefix":"","firstName":"Toshiki","middleName":"","lastName":"Mano","suffix":""}],"badges":[],"createdAt":"2022-11-03 01:52:55","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2232053/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2232053/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":28827851,"identity":"e7a227fa-6f34-458f-8b99-971c27f77367","added_by":"auto","created_at":"2022-11-08 21:29:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":15267,"visible":true,"origin":"","legend":"\u003cp\u003eSee above image for figure legend.\u003c/p\u003e","description":"","filename":"OnlineFigure1.png","url":"https://assets-eu.researchsquare.com/files/rs-2232053/v1/83daf03ecd7d0f5dc49f5dac.png"},{"id":28827848,"identity":"d52d64f9-8892-43d7-a68c-f1851e0663bc","added_by":"auto","created_at":"2022-11-08 21:29:24","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":22174,"visible":true,"origin":"","legend":"\u003cp\u003eSee above image for figure legend.\u003c/p\u003e","description":"","filename":"OnlineFigure2.png","url":"https://assets-eu.researchsquare.com/files/rs-2232053/v1/e4536a0d1a9469c382fa40c7.png"},{"id":28827978,"identity":"e1d8ac0d-044a-435c-b67b-364a63ba0cea","added_by":"auto","created_at":"2022-11-08 21:37:25","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":20436,"visible":true,"origin":"","legend":"\u003cp\u003eSee above image for figure legend.\u003c/p\u003e","description":"","filename":"OnlineFigure3.png","url":"https://assets-eu.researchsquare.com/files/rs-2232053/v1/1e02ef31dd688eb015ce7c14.png"},{"id":35845879,"identity":"d4718930-60d3-4fbc-a109-82c1784c650b","added_by":"auto","created_at":"2023-04-17 05:25:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":672318,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2232053/v1/4c8cc95c-458f-4356-8d61-348beef6ccc2.pdf"},{"id":28827849,"identity":"ffd71873-6048-4d30-9f72-bd62a6748038","added_by":"auto","created_at":"2022-11-08 21:29:24","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":13783,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-2232053/v1/1414f5acfdfb77d5d63305f6.xlsx"},{"id":28827979,"identity":"be4bb27c-0147-405f-8936-953722b94b57","added_by":"auto","created_at":"2022-11-08 21:37:25","extension":"xlsx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":14345,"visible":true,"origin":"","legend":"","description":"","filename":"Table2.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-2232053/v1/368beb45a910e6513ec54f2c.xlsx"},{"id":28828137,"identity":"461e8175-9072-4ee1-8015-8c749948ab2b","added_by":"auto","created_at":"2022-11-08 21:45:25","extension":"xlsx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":13495,"visible":true,"origin":"","legend":"","description":"","filename":"Table3.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-2232053/v1/2c01e311e877541b0f92f8d8.xlsx"},{"id":28827981,"identity":"f6b4a85b-7749-4401-92b5-be23984d0493","added_by":"auto","created_at":"2022-11-08 21:37:25","extension":"xlsx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":19195,"visible":true,"origin":"","legend":"","description":"","filename":"Table4.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-2232053/v1/f51ada8d6eec8e0adf66e13c.xlsx"}],"financialInterests":"","formattedTitle":"Challenging the Appropriateness of Medical Fee for the Japanese Percutaneous Coronary Intervention: Is the Value of the Cardiologist’s Hard Work Properly Assessed? – Systematic Review and Field Research –","fulltext":[{"header":"Background","content":"\u003cp\u003eMore than 40 years have passed since the first percutaneous coronary intervention (PCI) was performed in Zurich, Switzerland [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This revolutionary treatment developed by Andreas Gruentzig was introduced to Japan in the 1980s [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. During the introduction of this treatment, Japan was in the midst of deregulation [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] and at the height of the bubble economy [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], social structural changes [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], and technological innovations that created a favorable external environment. As a result, medical device manufacturers and suppliers, and cardiovascular hospitals in the community entered the market, creating a new industry. During this time, Japan was beginning an aging society, and to confront the ever-increasing prevalence of cardiac disease as one of the nation\u0026rsquo;s three major diseases, the government set a high reimbursement price for special treatment materials (STMs) to widespread of PCI [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and welcomed new players in the market. Thus, from the late 1990s, cardiovascular hospitals and hospitals with cardiology as their backbone emerged one after another across the country.\u003c/p\u003e \u003cp\u003eThis newly created market was supported by marginal gains from the difference between high reimbursement prices and actual prices of STMs and was profitable for about 20 years after its birth. Among the players in the community, cardiovascular hospitals were especially relied on the marginal gain, despite the fact that the technical fee, which is the main income, was far less than the actual value [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Furthermore, there were few occasions when the low technical fee, the main part of reimbursement, was pointed out as a problem. However, beginning in the late 1990s, the prefectural purchase price system for PCI-related STMs was abolished [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and replaced with an official price, and a review of device prices was conducted every 2 years; moreover, the price of PCI-related STMs continued to decline.\u003c/p\u003e \u003cp\u003eThis study aimed to examine the appropriateness of the reimbursement of medical fees from two perspectives: the total cost of PCI in Japan compared with those in other countries and the technical fee, which is part of the medical fees for PCI, investigated based on the market principle. By definition, medical fees consist of technical and drug fees as well as STM fees. Details of these three components are presented in Fig.\u0026nbsp;1.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eTrial Design\u003c/h2\u003e \u003cp\u003eA systematic review was conducted to compare the total cost of PCI in the United Kingdom (UK), the United States of America (USA), Australia, and Japan. The total cost was defined as the sum of hospital and doctor fees per case. Data were collected from PubMed and Google Scholar using the keywords \u0026ldquo;PCI,\u0026rdquo; \u0026ldquo;tariffs,\u0026rdquo; \u0026ldquo;reimbursement,\u0026rdquo; and/or \u0026ldquo;cost-effectiveness\u0026rdquo; plus the name of each country to search for matching articles. In addition, we obtained the price lists from the websites of insurance bureaus in each country and identified the price per case for PCI from previous studies. The Google search engine was used to obtain information that could not be supplemented by the English-language literature.\u003c/p\u003e \u003cp\u003eSubsequently, reasonable technical fees of PCI in Japan were calculated based on market principles using the costing calculation, book-building, and lost profit methods. In Japan, the Diagnosis Procedure Combination (DPC) reimbursement system is the main system for acute-care hospitals, and the doctor fee component, including STMs, is evaluated on a piecework basis; thus, we hypothesized that the technical fee of the reimbursement deviates from the prices calculated using the three aforementioned methods.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eThe costing calculation method\u003c/h2\u003e \u003cp\u003eThe costing calculation method is the calculation of the cost of PCI with the direct costs, and here, we refer to the Gaihoren Draft Proposal (GDP) 9.3 version calculated by the Japanese Health Insurance Federation for Surgery (known as Gaihoren) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In this proposal, the technical fees include direct costs, such as costs of labor, basic set, STMs, partially reimbursable medical materials, nonreimbursable materials, special sutures, and drugs. It should be noted that the GDP does not include indirect costs, such as depreciation, costs of medical equipment repair and building maintenance, taxes and dues, and interest expenses.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eThe book-building method\u003c/h2\u003e \u003cp\u003eThe book-building method is generally employed to determine the initial public offering price. In determining the offer price for an initial public offering, the security company that underwrites the initial public offering sets provisional terms based on the opinions of institutional investors considered to be highly capable of calculating stock prices; then, it presents those terms to investors to evaluate demand and determine the offer price in line with the market trends. The fairness and appropriateness of this method have already been reported [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Using the book-building method, we conducted a survey on reasonable technical fees using a specialized cardiovascular website.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eThe lost profit method\u003c/h2\u003e \u003cp\u003eLost profits are earnings that should have been earned but were not due to an accident. Lost profit calculation is mainly used in the life insurance industry, where the amount to be claimed is the amount of lifetime income that the patient did not earn as a result of the death. In this study, the value of a life that could not have been saved had the cardiologist not performed PCI on the spot would be calculated. It should be noted that the application of lost profits is based on the patient\u0026rsquo;s situation and is theoretically derived, not on that costs that exist as a matter of fact [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003e In the book-building method, a weighted average was taken from the survey results shown in Fig.\u0026nbsp;2. The lower (\u0026yen;300,000 [US\u003cspan\u003e$\u003c/span\u003e2,142]) and upper (\u0026yen;1,500,000 [US\u003cspan\u003e$\u003c/span\u003e10,714]) limits were used as they were; if a range was specified for the PCI cost, the average of the lower and upper limits was utilized. For example, if the range was \u0026yen;300,000 [US\u003cspan\u003e$\u003c/span\u003e2,142]\u0026ndash;\u0026yen;500,000 [US\u003cspan\u003e$\u003c/span\u003e3,571], we calculated (\u0026yen;300,000 [US\u003cspan\u003e$\u003c/span\u003e2,142] + \u0026yen;500,000 [US\u003cspan\u003e$\u003c/span\u003e3,571]) / 2, which was \u0026yen;400,000 (US\u003cspan\u003e$\u003c/span\u003e2,857). Subsequently, the average prices of \u0026yen;500,000 [US\u003cspan\u003e$\u003c/span\u003e3,571]\u0026ndash;\u0026yen;750,000 [US\u003cspan\u003e$\u003c/span\u003e5,357], \u0026yen;750,000 [US\u003cspan\u003e$\u003c/span\u003e5,357]\u0026ndash;\u0026yen;1,000,000 [US\u003cspan\u003e$\u003c/span\u003e7,142], and \u0026yen;1,000,000[US\u003cspan\u003e$\u003c/span\u003e7,142]\u0026ndash;\u0026yen;1,500,000 [US\u003cspan\u003e$\u003c/span\u003e10,714] were calculated as \u0026yen;625,000 (US\u003cspan\u003e$\u003c/span\u003e4,464), \u0026yen;875,000 (US\u003cspan\u003e$\u003c/span\u003e6,250), and \u0026yen;1,250,000 (US\u003cspan\u003e$\u003c/span\u003e8,929), respectively. A weighted average was taken based on the percentages derived from the questionnaire to calculate the prices of PCI for unstable angina (UA-PCI) and PCI for acute myocardial infarction (AMI-PCI).\u003c/p\u003e \u003cp\u003eThe lost profit calculation is based on the subject\u0026rsquo;s age and annual income and can be carried out using the following formula:\u003c/p\u003e \u003cp\u003eLost profits\u0026thinsp;=\u0026thinsp;basic annual income \u0026times; (1\u0026thinsp;\u0026minus;\u0026thinsp;cost of living deduction rate) \u0026times; Leibniz coefficient for the period of loss of working capacity\u003c/p\u003e \u003cp\u003eThe basic annual income was extracted from the National Tax Agency (NTA) website as the national average salary for each age group [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The cost-of-living deduction percentage represents the cost-of-living expenses to income ratio, and the percentage varies from 30\u0026ndash;50%, depending on patient attributes, such as marital status and age. Because 50% is generally used for single men and 30% for those who are the breadwinners of a family with two dependents, 30% was adopted in the present study for convenience. The amount of tax that the patient returns to the government is calculated by multiplying the lost profits, calculated using the above formula, by the income tax estimated to be paid by the patient. (The income tax rate was obtained from the NTA\u0026rsquo;s website) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. From there, the fair price of PCI was multiplied by the percentage of spending on cardiovascular disease in the national healthcare spending in FY2018 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Note that in this model, the age at which income could be earned was set to 67 years [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe technical fee of AMI-PCI\u0026thinsp;=\u0026thinsp;Lost profits \u0026times; annual income tax rate \u0026times; (the national spending for the cardiovascular disease/the total national healthcare spending)\u003c/p\u003e \u003cp\u003eIn calculating the technical fee of UA-PCI from the lost profit method, the current reimbursement of percutaneous coronary stenting (K549-2: UA) in the technical fee was divided by the current reimbursement of percutaneous coronary stenting (K549-1: AMI) to calculate its ratio, and then multiplied by the cost of AMI-PCI calculated by the loss profit method.\u003c/p\u003e \u003cp\u003eThe technical fee of PCI for UA\u0026thinsp;=\u0026thinsp;Price of AMI-PCI \u0026times; (UA/AMI)\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe PubMed search period was from January 2018 to August 6, 2022, and the keyword search yielded 16 prior studies and research reports from the USA, 1 from the UK, and 1 from Australia (18 abstracts). In the Google Scholar search, 2037 articles were retrieved from the USA, 88 from the UK, and 436 from Australia, totaling 2561 articles. Subsequently, two articles were selected as references for the total costs of PCI in the target countries [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. We then accessed the websites of the insurance bureaus (Medicare for the USA) in each of these countries to obtain data regarding tariffs, which could not be supplemented by previous studies [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Finally, we used the Google search engine to extract research reports from the Japanese government or private sectors that we deemed appropriate for the analysis [\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] (Fig.\u0026nbsp;3).\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eSituation in other countries\u003c/h2\u003e \u003cp\u003eWe investigated the total costs of PCI in the USA, the UK, and Australia. Before discussing each country, we would like to gain insight into the hospital and doctor fees, both of which have recently been discussed in Japan. Hospital fees are the basic costs required for inpatient care and considered as hospital usage fees rather than fees for doctors\u0026rsquo; practice. Doctor fees, on the other hand, are the remuneration required for the treatment provided by the doctor and include initial consultation, surgical, and various instructional fees [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eDifferences in reimbursement\u003c/h2\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003eTotal costs of PCI in the USA\u003c/h2\u003e \u003cp\u003eIn the USA, the public medical insurance system is available only to the low-income groups, elderly, and disabled; those who do not meet the enrollment conditions must, in principle, purchase private medical insurance. Most of the population is covered by private insurance provided by companies, and hospitals within the networks of those insurance companies are selected [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Prices are calculated based on market principles, and the cost of diagnosis and treatment varies from hospital to hospital [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor the sake of fairness, this study refers to the total cost of PCI covered by Medicare, the public health insurance in the USA. The PCI cost for a patient who is not expected to need treatment for more than 24 h at an Ambulatory Surgical Center (nonhospital facility) (A), where the specific procedure can be performed, is \u003cspan\u003e$\u003c/span\u003e6,707, consisting of \u003cspan\u003e$\u003c/span\u003e6,110 for hospital fee and \u003cspan\u003e$\u003c/span\u003e597 for doctor fee. On the other hand, the PCI cost at a hospital with outpatient services (B), such as an observation room, surgery center, or pain clinic, is \u003cspan\u003e$\u003c/span\u003e10,855, consisting of \u003cspan\u003e$\u003c/span\u003e10,258 for hospital fee and \u003cspan\u003e$\u003c/span\u003e597 for doctor fee [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In the USA, Medicare also lists different fees for procedures using drug-eluting stents and for more complex procedures, but for the sake of simplicity, a general procedure was employed in this study (Code: 92928).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eTotal costs of PCI in the UK\u003c/h2\u003e \u003cp\u003eIn the UK, the National Health Service (NHS), the government\u0026rsquo;s public health service enterprise, manages health care in the country and operates on the principle that citizens have fair and free access to healthcare services regardless of their health status or ability to pay. In the UK, the distinction between doctor and hospital fees is unclear, and since 2004, a \u0026ldquo;payment by results\u0026rdquo; system has been used, whereby the official price set in the national tariff is multiplied by the number of cases treated [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The national tariff can be downloaded from the NHS website, and EY40 and EY41 are used as the categories for PCI [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]: EY40A\u0026ndash;EY40D as complex PCI and EY41A\u0026ndash;EY41D as standard PCI. Categories A\u0026ndash;D are priced according to the presence or absence of comorbidities, such as diabetes and hypertension. For the sake of simplicity, we calculated the average price of EY40\u0026ndash;EY41 in the NHS. We also used some other source to validate our findings [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. As a result, we determined that \u0026pound;4,485 (US\u003cspan\u003e$\u003c/span\u003e5,303) is reimbursed per PCI performed in the UK.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eTotal costs of PCI in Australia\u003c/h2\u003e \u003cp\u003eIn Australia, the Medicare Benefits Schedule (MBS) is the equivalent of a doctor fee, and the price is set by the government [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The doctor fees are also published on the Internet [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. AU\u003cspan\u003e$\u003c/span\u003e2,156.20 (US\u003cspan\u003e$\u003c/span\u003e1,489) is paid for the placement of one or more stents in two vascular regions and AU\u003cspan\u003e$\u003c/span\u003e1,874 (US\u003cspan\u003e$\u003c/span\u003e1,294) for the placement of one or more stents in one vascular region. For the sake of simplicity, we used the average value for doctor fees (AU\u003cspan\u003e$\u003c/span\u003e2015[US\u003cspan\u003e$\u003c/span\u003e1,391]). Hospital fees, on the other hand, are divided by condition: AU\u003cspan\u003e$\u003c/span\u003e15,930 (US\u003cspan\u003e$\u003c/span\u003e 10,998) for ST-segment elevation myocardial infarction (STEMI), AU\u003cspan\u003e$\u003c/span\u003e12,677 (US\u003cspan\u003e$\u003c/span\u003e8,756) for non-STEMI, and AU\u003cspan\u003e$\u003c/span\u003e9,872 (US\u003cspan\u003e$\u003c/span\u003e6,818) for UA. In Australia, hospital fees are referred to as procedure costs per patient and include all costs incurred by the hospital during the patient\u0026rsquo;s stay, including costs of the PCI procedure itself, hospital stay, critical care provision, and medications [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe total costs of PCI in the UK, the USA, and Australia as well as in Japan are summarized in Table\u0026nbsp;1. The prices of PCI in Japan were calculated by selecting a number of hospitals that adopt the DPC and disclose the PCI prices on their websites; the range from the minimum to the maximum is presented in Table\u0026nbsp;1 [\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The result showed that the hospital fee component of the comprehensive evaluation was lower in Japan than in the targeted countries, whereas the volume component, which is more like a doctor fee, was higher in Japan. Although there is no evidence suggesting that the total cost per case of PCI is higher in Japan than in the other countries, the medical fee of AMI-PCI was higher in Japan. It should be noted that STMs are paid on a piecework basis, which in Japan is considered a doctor fee and therefore varies from hospital to hospital.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eAppropriate price to calculate the technical fee of PCI\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003eCosting calculation method\u003c/h2\u003e \u003cp\u003eIn the revision of technical fees in Japan, the Cabinet decides the total amount of medical expenses (revision rate) on which the premise is based. The specific individual revision items, etc., are deliberated and decided by the \u0026ldquo;Central Social Insurance Medical Council\u0026rdquo; based on the basic policy formulated by the national council, and it has been pointed out that they do not reflect the actual costs at the actual sites [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn 2022, Gaihoren, a general incorporated association consisting of 113 member societies, stated that \u0026ldquo;reimbursement for technical fees should be built on scientific and academic analysis\u0026rdquo; and has prepared GDP based on a survey involving related societies in the same organization. The Japanese Association of Cardiovascular Intervention and Therapeutics, the largest catheter intervention-based organization in Japan, is also a member of Gaihoren and has requested for an increase in reimbursement from the national government.\u003c/p\u003e \u003cp\u003eGaihoren calculated the total cost by scrutinizing the difficulty of the technique, staff required, and time required to calculate the labor cost. Based on the costing calculation method, appropriate AMI-PCI and UA-PCI prices were proposed, as presented in Table\u0026nbsp;2 [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. After calculating the total cost of individual procedures from the price list, it was found that the technical fee based on existing reimbursement would result in a loss for each case.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eBook-building method\u003c/h2\u003e \u003cp\u003e We conducted a survey between July 27 and August 19, 2022, using TCROSS NEWS, a website dedicated to the field of cardiology. Of the 7188 doctor members, 3300 of whom had given permission to receive e-newsletters were asked to answer the questionnaire, which is presented in Fig.\u0026nbsp;2. Of the 185 participants who responded within the time period, we validated 161 respondents. The survey results were calculated for UA-PCI and AMI-PCI \u003cem\u003evia\u003c/em\u003e weighted averaging as described above, resulting in the technical fees of \u0026yen;554,825 (US\u003cspan\u003e$\u003c/span\u003e3,963) and \u0026yen;814,600 (\u003cspan\u003e$\u003c/span\u003e5,819), respectively, as presented in Table\u0026nbsp;3.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eCalculation based on lost profits\u003c/h2\u003e \u003cp\u003e Table\u0026nbsp;4 presents the results of the calculation using the lost profit method. The results indicated that the value of the life of a patient who dies of AMI is high, and the loss to the country if the cardiologist did not perform PCI on the patient was greater than the compensation obtained from the reimbursement. As a result, a mean of \\773,961 (US\u003cspan\u003e$\u003c/span\u003e5,528) and a median of \\812,210 (US\u003cspan\u003e$\u003c/span\u003e5,802) were recorded for possible technical fees for the patients aged between 31 and 67 years. Assuming that the price of UA was 70.9% of the PCI\u0026rsquo;s price with reference to existing reimbursement prices, the mean and median prices of UA-PCI were \\548,841 (US\u003cspan\u003e$\u003c/span\u003e3,920) and \\575,856 (US\u003cspan\u003e$\u003c/span\u003e4,113), respectively.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study challenged the appropriateness of the total costs and technical fees for PCI in terms of reimbursement in FY2022 in Japan by comparing them with those in other countries and using the costing calculation, book-building, and lost profit methods.\u003c/p\u003e \u003cp\u003eNo difference was observed in the total costs of PCI between Japan and other countries, namely, the UK, the USA, and Australia. However, it should be noted that although there was no difference in the total costs of PCI, the healthcare systems in each country are different. In the UK, medical care is a public health service program of the British government, and NHS doctors belong to the NHS as if they were national civil servants. In the USA, majority of the population is covered by private health insurances, and hospital and medical fees significantly vary from hospital to hospital. Therefore, a patient with a good insurance coverage can receive better medical care. Australia operates under the same system as the UK, and public hospitals are free of charge; thus, they are under the protection of the government. In Japan, however, there are many private hospitals, and cardiovascular hospitals play an important role, especially with regard to PCI; losses can even jeopardize the survival of the hospitals. In fact, there have been reports of cardiovascular hospitals going out of business since mid-2000 [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], and to the best of our knowledge, no cardiovascular hospitals have been confirmed to have opened since 2019.\u003c/p\u003e \u003cp\u003eIn the GDP, when labor and nonreimbursable costs are combined, the difference from the reimbursed procedure fee is even larger, and a deficit of \\380,000 (US\u003cspan\u003e$\u003c/span\u003e2,714) for stenting for AMI-PCI and \\350,000 (US\u003cspan\u003e$\u003c/span\u003e2,500) for stenting for UA-PCI is thought to have occurred (Table\u0026nbsp;2). In the past, this was compensated for by the difference between the actual price of STMs and the reimbursement price; however, at present, the reimbursement prices of STM continues to fall, and the difference continues to decline; thus, the more PCI procedures are performed, the larger the deficit unless the hospital negotiates the delivered price of STMs and purchases them at a lower price. However, purchasing at a lower price will further discourage hospitals from performing PCI, as the reimbursement price of STMs at the time of the next revision is reduced.\u003c/p\u003e \u003cp\u003eFor AMI-PCI with stenting and UA-PCI with stenting in FY2022, the GDP calculated that the total labor and nonreimbursable costs would be \\727,997 (US\u003cspan\u003e$\u003c/span\u003e5,200) and \\596,397 (US\u003cspan\u003e$\u003c/span\u003e4,260) (Table\u0026nbsp;2), respectively. The technical fees of AMI-PCI and UA-PCI calculated using the book-building method were found to be \\814,600 (US\u003cspan\u003e$\u003c/span\u003e5,819) and \\554,825 (US\u003cspan\u003e$\u003c/span\u003e3,963), respectively. On the other hand, the average prices of AMI-PCI and UA-PCI calculated using the lost profit method were \\773,961 (US\u003cspan\u003e$\u003c/span\u003e5,528) and \\548,841 (US\u003cspan\u003e$\u003c/span\u003e3,920), respectively. Furthermore, the average costs of UA-PCI and AMI-PCI calculated using the three methods were \\566,688 (US\u003cspan\u003e$\u003c/span\u003e4,048) and \\772,186 (US\u003cspan\u003e$\u003c/span\u003e5,516), respectively.\u003c/p\u003e \u003cp\u003ePublic hospitals have been stuck in a loss-making exodus, and mergers and acquisitions have been taking place in recent years. Because medical care is provided under the government intervention, the failure of a hospital is a failure of the government. If the reimbursement price of STMs continues to fall, the reimbursement price of the technical fee must also be revised. Otherwise, small and medium-sized hospitals as well as cardiovascular hospitals, which are less subject to the government protection, will not be able to survive. It would not be long until Japan\u0026rsquo;s world-class medical system will collapse; thus, a review of the medical fees is an urgent issue.\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eThis study has several limitations that need to be acknowledged. First, with regard to the evaluation of the countries covered by the total cost of PCI, data was extracted from previous studies and general government price lists for those countries; it is also a constant guide and may not represent the current actual price [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Second, the technical fees calculated in this study are direct costs, such as labor costs; indirect costs were not included. The lost profit method was employed to calculate technical fees based on annual income and age. While we accept the criticism that a person\u0026rsquo;s life depends on income and age, this study used the mean and median values as the PCI costs for all patients. The important aspect of the calculation of lost profits was the income tax that would be paid to the country if the individual were alive, and what is then used as a coefficient was not considered important [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Despite those limitations, the aim of the present study was to challenge the significance of the existing medical fees, especially focusing on the technical fees, and to show that based on market principles, the hospital could not operate with the existing technical fees.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe results of the present study confirm that although the overall cost of PCI in Japan was not different from those in other countries, the technical fee of the reimbursement price of PCI did not even come close to covering the cost, resulting in a loss per PCI, excluding the margins earned from STMs.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAcute myocardial infarction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDPC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDiagnosis Procedure Combination\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGDP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGaihoren Draft Proposal\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMBS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMedicare Benefits Schedule\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNHS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Health Service\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNTA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Tax Agency\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePercutaneous coronary intervention\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSTEMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eST-segment elevation myocardial infarction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSTMs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSpecial treatment materials\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUnstable angina\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUK\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUnited Kingdom\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUSA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e\u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ethe United States of America.\u003c/div\u003e \u003cdiv class=\"Description\"\u003e\u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication (from patients/participants):\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material:\u0026nbsp;\u003c/strong\u003eAvailable on request.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u0026nbsp;\u003c/strong\u003eAll authors contributed to the study. Hashimoto\u0026nbsp;made a concept, research, design, and writing of the article. Motozawa provided his clinical perspective and information required for the article. Cohen provided information regarding the reimbursement systems in the western world and supported writing the article. Mano approved the final decision to submit the article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eThe authors thank Ms. Rie Arai for her excellent technical support and Ms. Keiko Takahashi and Mr. Shuhei Odagiri for the arrangement of all tables and figures in the article.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details:\u003c/strong\u003e \u003csup\u003e1\u003c/sup\u003eDepartment of Healthcare Management, TCROSS Co., Ltd., Tokyo, Japan. \u003csup\u003e2\u003c/sup\u003eTama University Institute for Healthcare and Long-Term Care Solution, Tokyo, Japan. \u003csup\u003e3\u003c/sup\u003eDepartment of Internal Medicine, Sanikukai Hospital, Tokyo, Japan. \u003csup\u003e4\u003c/sup\u003eDepartment of Medical Communication, Angioplsty.Org, Sag Harbor, NY USA. \u003csup\u003e5\u003c/sup\u003eChuo Graduate School of Strategic Management, Tokyo, Japan\u003c/p\u003e"},{"header":"References","content":"\u003col class=\"decimal_type\"\u003e\n \u003cli\u003eBarton M, Gruntzig J, Husmann M, Rosch J. Balloon angioplasty \u0026ndash; The legacy of Andreas Gruntzig, M.D. (1939-1985). \u003cem\u003eFront Cardiovasc Med\u003c/em\u003e. 2014;1:15.\u003c/li\u003e\n \u003cli\u003eNoguchi H, Shimizuya S, Chino M. Quantitative validation of treatment selection and outcomes for patients with acute myocardial infarction after percutaneous coronary angioplasty (PTCA) [in Japanese]. \u003cem\u003eJ Jpn Econ Res\u0026nbsp;\u003c/em\u003e2004;49:86\u0026ndash;116.\u003c/li\u003e\n \u003cli\u003eDoi O. Market oriented sector-selective talks [in Japanese]. Pharm Med Devices Regul Sc. 2011;42:712\u0026ndash;713.\u0026nbsp;\u003ca href=\"https://www.pmrj.jp/publications/02/pmdrs_column/pmdrs_column_20-42_08.pdf\"\u003ehttps://www.pmrj.jp/publications/02/pmdrs_column/pmdrs_column_20-42_08.pdf\u003c/a\u003e.\u0026nbsp;Accessed 15 Aug 2022.\u003c/li\u003e\n \u003cli\u003eRavina MJ. 1985-1990: Japan\u0026rsquo;s bubble economy. 24 May. 2022.\u0026nbsp;\u003ca href=\"https://www.wondriumdaily.com/1985-1990-japans-bubble-economy/\"\u003ehttps://www.wondriumdaily.com/1985-1990-japans-bubble-economy/\u003c/a\u003e. Accessed 15 Aug 2022.\u003c/li\u003e\n \u003cli\u003eNakamura S. Japan\u0026rsquo;s welfare for the elder \u0026ndash; past, present, and future. Asia Health and Wellbeing Initiative. Dec. 2018.\u0026nbsp;\u003ca href=\"https://www.ahwin.org/japans-welfare-for-the-elderly-past-present-and-future/\"\u003ehttps://www.ahwin.org/japans-welfare-for-the-elderly-past-present-and-future/\u003c/a\u003e.\u0026nbsp;Accessed 15 Aug 2022.\u003c/li\u003e\n \u003cli\u003eYoshida S. (2006). Actual situation of price difference between domestic and foreign prices of specific insured medical materials. (Report No. 119) [in Japanese]. Japan Medical Association Research Institute.\u0026nbsp;\u003ca href=\"http://www.jmari.med.or.jp/download/15_yoshida.pdf\"\u003ehttp://www.jmari.med.or.jp/download/15_yoshida.pdf\u003c/a\u003e. Accessed 12 Aug 2022.\u003c/li\u003e\n \u003cli\u003eThe state of hospital fees. (2010). All Japan Hospital Association: Research report. May 2010 [in Japanese].\u0026nbsp;\u003ca href=\"https://www.ajha.or.jp/about_us/thinktank/pdf/100611.pdf\"\u003ehttps://www.ajha.or.jp/about_us/thinktank/pdf/100611.pdf\u003c/a\u003e. Accessed 12 Aug 2022.\u003c/li\u003e\n \u003cli\u003eChino M. Cost analysis of procedure fee for percutaneous transluminal coronary angioplasty at six Japanese Hospitals. J Cardiol. 2001;37:83\u0026ndash;90.\u003c/li\u003e\n \u003cli\u003eThe price list of percutaneous coronary intervention and related procedure [in Japanese]. Gaihoren draft (2022). Tokyo. Igakutushin Publishing.\u003c/li\u003e\n \u003cli\u003eTatsumi K. Why bookbuilding in IPO is dominant? \u0026ndash; A survey and critical comments-. Gakushuin University [in Japanese]. Economic Report. 2011;48:23\u0026ndash;44.\u0026nbsp;\u003ca href=\"https://core.ac.uk/download/pdf/292905605.pdf\"\u003ehttps://core.ac.uk/download/pdf/292905605.pdf\u003c/a\u003e.\u0026nbsp;Accessed 13 Aug 2022.\u003c/li\u003e\n \u003cli\u003eIwai K. Emerging markets and initial public offerings. - Review of existing internal and external studies and implications for institutional design-[in Japanese]. \u003cem\u003eFSA Res Rev\u003c/em\u003e. 2010;6:39\u0026ndash;112.\u0026nbsp;\u003ca href=\"https://www.fsa.go.jp/frtc/nenpou/2009/05-1.pdf\"\u003ehttps://www.fsa.go.jp/frtc/nenpou/2009/05-1.pdf\u003c/a\u003e.\u0026nbsp;Accessed 13 Aug 2022.\u003c/li\u003e\n \u003cli\u003eNiki Y. (2010). Research for lost profit\u0026nbsp;[in Japanese]. Tokyo. Chisen Sho Kan.\u003c/li\u003e\n \u003cli\u003eAverage Japanese income. National Tax Agency\u0026nbsp;[in Japanese].\u0026nbsp;\u003ca href=\"https://www.nta.go.jp/publication/statistics/kokuzeicho/minkan1997/menu/05.htm\"\u003ehttps://www.nta.go.jp/publication/statistics/kokuzeicho/minkan1997/menu/05.htm\u003c/a\u003e.\u0026nbsp;Accessed 13 Aug 2022.\u003c/li\u003e\n \u003cli\u003eIncome tax No. 2260\u0026nbsp;[in Japanese].\u0026nbsp;\u003ca href=\"https://www.nta.go.jp/taxes/shiraberu/taxanswer/shotoku/2260.htm\"\u003ehttps://www.nta.go.jp/taxes/shiraberu/taxanswer/shotoku/2260.htm\u003c/a\u003e.\u0026nbsp;Accessed 12 Aug 2022.\u003c/li\u003e\n \u003cli\u003eThe National Healthcare Expenditure in 2018\u0026nbsp;[in Japanese]. The Ministry of Health, Labor, and Welfare.\u0026nbsp;\u003ca href=\"https://www.mhlw.go.jp/toukei/saikin/hw/k-iryohi/18/dl/data.pdf\"\u003ehttps://www.mhlw.go.jp/toukei/saikin/hw/k-iryohi/18/dl/data.pdf\u003c/a\u003e.\u0026nbsp;Accessed 12 Aug 2022.\u003c/li\u003e\n \u003cli\u003eTanigawa S. What is lost profits from traffic accidents? Explanation of calculation methods and points to receive a fair amount\u0026nbsp;[in Japanese]. ALG\u0026nbsp;＆Associates.\u0026nbsp;\u003ca href=\"https://www.avance-lg.com/customer_contents/koutsujiko/issitsurieki/\"\u003ehttps://www.avance-lg.com/customer_contents/koutsujiko/issitsurieki/\u003c/a\u003e.\u0026nbsp;Accessed 15 Aug 2022.\u003c/li\u003e\n \u003cli\u003eMcCreanor V, Nowbar A, Rajkumar C, Barnet AG, Francis D, Graves N, et al. Cost-effectiveness analysis of percutaneous coronary intervention for single-vessel coronary artery disease: and economic evaluation of the ORBITA trial. \u003cem\u003eBMJ Open\u003c/em\u003e. 2021;11:e044054.\u003c/li\u003e\n \u003cli\u003eLee P, Brennan AL, Stub D, Dinh DT, Lefkovits J, Reid CM, et al. Estimating the economic impacts of percutaneous coronary intervention in Australia: a registry-based cost burden study. \u003cem\u003eBMJ Open\u003c/em\u003e. 2021;11:e053305.\u003c/li\u003e\n \u003cli\u003e2020/21 National tariff payment system \u0026ndash; NHS England.\u0026nbsp;\u003ca href=\"https://www.england.nhs.uk/wp-content/uploads/2021/02/20-21NT_Annex_A_National_tariff_workbook.xlsx\"\u003ehttps://www.england.nhs.uk/wp-content/uploads/2021/02/20-21NT_Annex_A_National_tariff_workbook.xlsx\u003c/a\u003e.\u0026nbsp;Accessed 16 Aug 2022.\u003c/li\u003e\n \u003cli\u003eMedicare Benefits Schedule \u0026ndash; Item 38307.\u0026nbsp;\u003ca href=\"http://www9.health.gov.au/mbs/fullDisplay.cfm?type=item\u0026q=38307\u0026qt=ItemID\"\u003ehttp://www9.health.gov.au/mbs/fullDisplay.cfm?type=item\u0026amp;q=38307\u0026amp;qt=ItemID\u003c/a\u003e.\u0026nbsp;Accessed 12 Aug 2022.\u003c/li\u003e\n \u003cli\u003ePercutaneous transcatheter placement of intracoronary stent (s), with coronary angioplasty when performed; single major coronary artery or branch. Medicare. Gov.\u0026nbsp;\u003ca href=\"https://www.medicare.gov/procedure-price-lookup/cost/92928/\"\u003ehttps://www.medicare.gov/procedure-price-lookup/cost/92928/\u003c/a\u003e.\u0026nbsp;Accessed 20 Aug 2022.\u003c/li\u003e\n \u003cli\u003eKono K. The American Health Care System from outside the hospital: The origins and current status of hospitals, insurance, and services 2006\u0026nbsp;[in Japanese]. Tokyo:\u0026nbsp;Shinkoh Igaku Shuppansha Co., Ltd.\u003c/li\u003e\n \u003cli\u003eOverview of the health insurance system in the US. (2021). Japan External Trade Organization (JETRO)\u0026nbsp;[in Japanese]. June 2021.\u0026nbsp;\u003ca href=\"https://www.jetro.go.jp/ext_images/_Reports/01/01168598c658e4b0/20210019.pdf\"\u003ehttps://www.jetro.go.jp/ext_images/_Reports/01/01168598c658e4b0/20210019.pdf\u003c/a\u003e.\u0026nbsp;Accessed 20 Aug 2022.\u003c/li\u003e\n \u003cli\u003eMori K, Hosaka C. Medical fees in other countries (UK, France, Germany, US): Are medical costs and doctor fees clarified? [in Japanese]. Japan Medical Association Research Institute. (2010-11-9) No. 224. Available from:\u0026nbsp;https://www.jmari.med.or.jp/download/WP224.pdf. Accessed August 13, 2022.\u003c/li\u003e\n \u003cli\u003eElguindy M, Stables R, Nicholas Z, Kemp I, Curzen N. Design and rationale of the RIPCORD 2 trial (does routine pressure wire assessment influence management strategy at coronary angiography for diagnosis of chest pain? \u003cem\u003eCirc Cardiovasc Qual Outcomes\u003c/em\u003e. 2018; 11(2): e004191.\u003c/li\u003e\n \u003cli\u003eHakuhokai Osaka Central Hospital. Estimated inpatient prices based upon diagnosis and treatment [in Japanese].\u0026nbsp;\u003ca href=\"http://www.osaka-centralhp.jp/nyuuin/gaisan.htm\"\u003ehttp://www.osaka-centralhp.jp/nyuuin/gaisan.htm\u003c/a\u003e.\u0026nbsp;Accessed 10 Aug 2022.\u003c/li\u003e\n \u003cli\u003eChuden Hospital. Estimated list of surgical expenses [in Japanese].\u0026nbsp;\u003ca href=\"https://www.energia.co.jp/hospital/nyuuin/surgical-costs.html\"\u003ehttps://www.energia.co.jp/hospital/nyuuin/surgical-costs.html\u003c/a\u003e.\u0026nbsp;Accessed 21 Aug 2022.\u003c/li\u003e\n \u003cli\u003eSaint Maria Hospital. The application of diagnosis procedure combination [in Japanese].\u0026nbsp;\u003ca href=\"https://www.st-mary-med.or.jp/patient/hospitalization/dpc.html\"\u003ehttps://www.st-mary-med.or.jp/patient/hospitalization/dpc.html\u003c/a\u003e.\u0026nbsp;Accessed 23 Aug 2022.\u003c/li\u003e\n \u003cli\u003eClient Brain News. Hokuto Cardiovascular Hospital goes bankrupt [in Japanese].\u0026nbsp;\u003ca href=\"http://news.locumtenens.jp/?p=20\"\u003ehttp://news.locumtenens.jp/?p=20\u003c/a\u003e.\u0026nbsp;Accessed 22 Aug 2022.\u003c/li\u003e\n \u003cli\u003eTokyo Keizai News. Gunma Cardiovascular Hospital filed for Civil Rehabilitation Procedure [in Japanese].\u0026nbsp;\u003ca href=\"https://www.tokyo-keizai.com/archives/31700\"\u003ehttps://www.tokyo-keizai.com/archives/31700\u003c/a\u003e. Accessed 22 Aug 2022.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"Tables 1-4 are available in the supplementary files section."}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"percutaneous coronary intervention, reimbursement, technical fee, special treatment materials","lastPublishedDoi":"10.21203/rs.3.rs-2232053/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2232053/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIn Japan, technical fees in reimbursement are considered not to reflect in actual medical costs, and medical procedures may often result in a deficit of the hospital. This systematic review and field research aimed to investigate the appropriateness of the reimbursement for percutaneous coronary intervention (PCI) as an example of the controversial issue associated with medical expenses in Japan.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe investigated the validity of the medical fee for PCI from two perspectives: the total cost of PCI in Japan compared with those in other countries, such as the United Kingdom, the United States of America, and Australia, and the appropriate cost of PCI calculated using 1) the costing calculation, 2) book-building, and 3) lost profit methods to investigate the technical fee, which is part of the medical fees.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTo compare the PCI cost between other countries and Japan, we searched PubMed and Google Scholar to extract articles that demonstrated PCI cost in the target countries from January 2018 to August 2022. Research reports as well as government-provided sources in each country were also searched using the Google search engine, which finally led to the extraction of eight abstracts. The results indicated that the total cost of PCI for acute myocardial infarction (AMI) was higher in Japan than in other countries; however, no difference was observed for unstable angina (UA). The average costs of technical fees calculated according to three methods were \\772,186 for AMI-PCI and \\566,688 for UA-PCI, which were higher than the existing reimbursement prices of \\343,800 and \\243,800, respectively.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAlthough the total PCI cost in Japan was not different from those in other countries, the technical fees of PCI reimbursed in FY2022 did not even come close to covering the cost.\u003c/p\u003e","manuscriptTitle":"Challenging the Appropriateness of Medical Fee for the Japanese Percutaneous Coronary Intervention: Is the Value of the Cardiologist’s Hard Work Properly Assessed? – Systematic Review and Field Research –","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-11-08 21:29:19","doi":"10.21203/rs.3.rs-2232053/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2cc41e1e-643b-489c-9f10-03ea425e95a1","owner":[],"postedDate":"November 8th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-04-17T05:24:59+00:00","versionOfRecord":[],"versionCreatedAt":"2022-11-08 21:29:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2232053","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2232053","identity":"rs-2232053","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}