Appropriateness of the percutaneous coronary intervention technical fee in Japan

• Technical fees for percutaneous coronary intervention (PCI) in reimbursement are not considered to reflect actual medical costs • The fact that reimbursements do not reflect actual costs is a crisis for hospitals. • The results showed that the reimbursed technical fee is less than 50% of the ideal technical fee for PCI in Japan. • Most hospitals in Japan are running at a loss for medical profit, raising the need to review government healthcare reimbursements. In Japan, reimbursements of technical fees for percutaneous coronary intervention (PCI) are not considered to reflect actual medical costs, since medical procedures frequently cost hospitals more than they make. This study evaluated the appropriateness of PCI technical fees in Japan as part of reimbursed medical fees. We estimated the PCI technical fee’s validity from three approaches including 1) costing calculation, 2) survey-based cost estimation, and 3) lost profit methods. For the costing calculation method, we used the draft proposal that is evaluated by the Japanese Health Insurance Federation for Surgery (Gaihoren draft proposal). The proposal indicated PCI technical fees of ¥727,997 for acute myocardial infarction (AMI) and ¥596,397 for unstable angina (UA). For the SBCE method, a survey of cardiologists showed the appropriateness of ¥814,600 and ¥554,825 for AMI-PCI and UA-PCI, respectively, while the lost profit method evaluated AMI-PCI at ¥812,210 and UA-PCI at ¥773,961. The average costs of technical fees calculated according to the three approaches were ¥772,186 for AMI-PCI and ¥566,688 for UA-PCI, which are higher than the existing reimbursements of ¥343,800 and ¥243,800, respectively. The present study showed that technical fees for PCI did not reflect estimated costs in three approaches. The majority of hospitals in Japan are operating at a loss for medical profit, and these results call into question, the need for a review of the healthcare costs reimbursed by the government. In Japan, reimbursement prices of percutaneous coronary intervention (PCI) technical fees are considered to be lower than the actual cost, which can translate to losses for hospitals, especially when complex PCI procedures are performed. We estimated the appropriateness of technical fees using three approaches including 1) costing calculation, 2) survey-based cost estimation, and 3) lost profit methods. The results confirmed that technical fees, which form the core of medical fees, do not reflect estimated costs. It was suggested that this discrepancy has led to a deficit in the structure of Japanese hospitals.