1年生 基礎セミナー 2019年12月2日

日本の医療保険制度
健康保険？ 医療保険？

保険者、被保険者とは誰か？
あなたの保険は？

Social Security in Japan 社会保障
1. Social Insurance (from tax and premium) 社会保険
1) Medical care insurance, 2) Pension,3) Workers' accident compensation insurance4) Unemployment insurance, 5) Long term care insurance

2. Social Welfare (from tax) 社会福祉
1) For mother and baby, 2) For child, 3) For the disabled, 4) For the elderly

3. Public Assistance (from tax) 公的扶助、具体的には生活保護
1) Livelihood, 2) Education, 3) Housing, 4) Medical care, 5) Long term care,
6) Childbirth, 7) Job, 8) Funeral

4. Public Health including Medical Services (from tax) 公衆衛生（医療を含む）
1) Infection controls, 2) Food safety, 3) Water supply, 4) Waste disposal

医療保険制度の体系

出所：厚生労働省「我が国の医療保険について」

Health insurance in Japan
Uninsured

Insurance card

3,400

Insurers

Insured1.7 trillion yen
In 2013 for publicassistants.

Premium
Payment

Claim

Insurance
alliances
47 branches

Out-ofpocket
payment

Treatment

Payment

Facilities

Uncoveredservices

Claim

社会保険診療報酬支払基金

8,400 hosp. and 100,000 clinics
and 70,000 dental clinics

Regional Bureaus of Health and Welfare

Health care / medical treatment
Covered care/treatment
by insurance doctors

Uncovered care/treatment
by doctors

保険医による保険診療医師による自由診療

Fees regulated by government

Fees determined by facility

Medical Practitioners’ Act 医師法
Medical Service Act 医療法
Infectious Disease Act 感染症法
etc.

Health Insurance Act 健康保険法
Ordinance on health insurance 療養担当規則

Health care / medical treatment
Covered care/treatment
by insurance doctors

Uncovered care/treatment
by doctors

保険医による保険診療医師による自由診療

Fees regulated by government

Fees determined by facility

Health checkup, normal childbirth, cosmetic surgery etc.

Medical Practitioners’ Act 医師法
Medical Service Act 医療法
Infectious Disease Act 感染症法
etc.

Health Insurance Act 健康保険法
Ordinance on health insurance 療養担当規則

Health insurance in Japan
Insurance card

3,400

Insurers

Which rules are different?

InsuredPremium

Payment

Claim

Insurance
alliances
47 branches

Out-ofpocket
payment

Treatment

Payment

Facilities
Claim

社会保険診療報酬支払基金

9,000 hosp. and 100,000 clinics
and 70,000 dental clinics

Regional Bureaus of Health and Welfare

Health insurance in Japan
Insurance card

3,400

Insurers

InsuredPremium

Payment

Claim

Insurance
alliances
47 branches

Out-ofpocket
payment

Treatment

PaymentFacilities
Claim

社会保険診療報酬支払基金

9,000 hosp. and 100,000 clinics
and 70,000 dental clinics

Regional Bureaus of Health and Welfare

健保の料率、最高を更新 １６年度平均９．１％に９年連続上昇 2016年4月22日05時00分
大企業の会社員らが入る医療保険である健康保険組合の２０１６年度の平均保険料率は、過去最高の９・１％になった。前年度より０・０８ポイ
ント高く、上昇は９年連続。１
人当たりの年間保険料（労使合計）は平均で７８７円増え、４７万９３５４円になる。

国民健康保険の保険料
http://5kuho.com/html/keisan.html

世田谷区在住、3人家族で世帯全員が国保に加入の例
夫40歳

年収 4,000,000円→所得金額 2,660,000円→ 基準額 2,330,000円

妻39歳年収 1,000,000円→

所得金額 350,000円

→

子

12歳

年収0円

所得金額0円

基準額0円

基準額 20,000円

基準額の合計 2,350,000円「所得割額」 計算式

シミュレーション①

基準額×6.45% （医療分）

2,350,000円×6.45%＝151,575円②

基準額×1.98% （支援金分）

2,350,000円×1.98%＝46,530円③

40～64歳の方の基準額×1.50% （介護分）

2,330,000円×1.50%＝34,950円

④

①＋②＋③

151,575円＋46,530円＋34,950円＝233,055円「均等割額」 計算式

シミュレーション⑤

加入者数×33,900円 （医療分）

3名×33,900円＝101,700円⑥

加入者数×10,800円 （支援金分）

3名×10,800円＝32,400円⑦

40～64歳の加入者数×14,700円（介護分）

1名×14,700円＝14,700円⑧⑤＋⑥＋⑦101,700円＋32,400円＋14,700円＝148,800円⑨ ④所得割額＋⑧均等割額233,055円＋148,800円＝381,855円
東京23区の場合、国民健康保険料の年間上限金額は 850,000円
平成26年度の政令指定20都市の保険料で一番高のは神戸市（597,090円）、一番安いのは相模原市（346,425円）

西村圭史 2018年12月6日06時28分

国保の保険料上限、３万円増の年８０万円に 厚労省方針
厚生労働省は、国民健康保険（国保）で、高所得層が払う保険料の上限を現在の年７７万円から年８０万円に引き上げることを決めた。
加入者全体の１・９９％が対象になる見込みで、来年度からの実施を目指す。高所得層の保険料上限の引き上げは２年連続。
国保の保険料は所得が高い世帯ほど高くなるが、上限が設定されている。全国平均の状況として、現在は年間所得８４０万円以上だと保険料は年７７万円に固定される。来年度からは年間所得８８０万円以上の場合、年８０万円を払うことになる。８８０万円未満は、個々の所得に応じて８０万円未満の保険料を払う。

Health insurance in Japan
Insurance card

3,400

Insurers

InsuredPremium

Payment

Claim

Insurance
alliances
47 branches

Out-ofpocket
payment

Treatment

Payment

Facilities
Claim

社会保険診療報酬支払基金

9,000 hosp. and 100,000 clinics
and 70,000 dental clinics

Regional Bureaus of Health and Welfare

UHC in Japan①Those under public assistance (2.2 mil in 2015)②Elderly aged >75 years with a limited income③Children before elementary school④Elderly aged 70-74 years
with a limited income⑤Elderly age >70 years
with a similar income to ⑥(taxable income >1.45 mil andtotal income >3.85 min insingle family househould or>5.2 min in 2 generation
household⑥The others under healthinsurance⑦Those without support

100%
90%
80%
70%

## Free services such as
infection treatments⑦⑥⑤ ④③Health insurance②①Services
coveredPublic assistanceFees not included in health insurance
Expenses for daily life
(1) Diaper(2) Pajama(3) Rental TV(4) Haircutting(5) Landry
Documents(1) Certificate in unofficial use(2) Copy of medical chartFees paid by health insurance
In 2016, monthly payments more than 10 million yen were484 cases, and ones more than 100 million yen were 2cases.
Out-of-pocket payment was about 1.2 million yen per year atmaximum.

https://webshufu.com/thanks-for-high-cost-illness-insurance/
健康保険組合連合会（健保連）の集計によると、患者１人あたりの医療費が１カ月で1千万円以上だった例が、2016年度は484件となった。15年度に比べて件数は３割以上増え、過去最多になった。１カ月で１億円を超えた治療も２件あった。（医療費月1000万円以上、最多 １人あたり、昨年度484件 ：日本経済新聞）•高額療養費による医療費自己負担上限額（70歳未満の場合）は、せいぜい120万円程度• 区分ア（標準報酬月額83万円以上）の場合は約120万円• 区分イ（標準報酬月額53万円～79万円）の場合も約120万円• 区分ウ（標準報酬月額28万円～53万円）の場合は約110万円• 区分エ（標準報酬月額26万円以下）の場合は57,600円• 区分オ（住民税非課税者）の場合は35,400円

Ceiling of out-of-pocket payment in health insurance
Since January, 2015

AgeAnnual income
Ceiling in JY per month
年多<70 years 11.6 mil <252,600 + (Total – 842,000)×0.01 140,100
7.7-11.6 mil
167,400 + (Total – 558,000)×0.01
93,0003.7-7.7 mil
80,100 + (Total – 267,000)×0.01
44,400<3.7 mil
57,60044,400No local tax
35,40024,600Per a household
Per a member>70 years Same*
80,100 + (Total – 267,000)×0.01
44,400
Middle44,40012,000No local tax
24,6008,000
Lower
15,0008,000* Same as that before retirement.
年多： frequent payment in one year: 4th time or over in the past 12 months

JY 10,000 for those with expensive chronic disease with an exception of JY
20,000 for those aged less than 70 years with a high income

Subsidies reducing out-of-pocket payment
Subsidy for 306 designated diseases
by local/central government
http://www.mhlw.go.jp/stf/seisakunitsuite/bunya/0000084783.html

難病 Nanbyou
Difficult diseases or intractable diseases
2,500 to 30,000 yen per month
Subsidy for infectious diseases
Subsidy for psychiatric diseases

Health insurance in Japan
Insurance card

3,400

Insurers

InsuredPremium

Payment

Claim

Insurance
alliances
47 branches

Out-ofpocket
payment

Treatment

Payment

Facilities
Claim

社会保険診療報酬支払基金

8,400 hosp. and 100,000 clinics
and 70,000 dental clinics

Regional Bureaus of Health and Welfare

Regional Bureaus of MHLWRegional Bureaus ofHealth and Welfare (8)Former Regional Medical Affairs Office+Former Regional Narcotic ControlOfficesSupervision on welfare andmedical care, health insurance
societies, and employees
pensionhttps://kouseikyoku.mhlw.go.jp/tokaihokuriku/index.html 2021/1/13

Health insurance in Japan
Insurance card

3,400

Insurers

InsuredPremium

Payment

Claim

Insurance
alliances
47 branches

社会保険診療報酬支払基金

Out-ofpocket
payment

Treatment

Payment

Facilities
How to makeclaims8,400 hosp. and 100,000 clinics
and 70,000 dental clinics

* Not the formaltranslation

Ordinance to facilities and doctors
responsible for insured services* 療養担当規則
Article 1 Contents for payment
1. Medical examination and diagnosis
2. Supply of medicines and treatment materials
3. Operation and procedures
4. Home care and home nursing
5. Inpatient care/treatment
Disease prevention is not included.
The below are prohibited.
1. Treatments without examination
2. Treatments not allowed by insurance
3. Treatments combined with uncovered treatments
4. Tests for research purposes
5. Health checkup

Health care / medical treatment
Covered care/treatment
by insurance doctors

Uncovered care/treatment
by doctors

保険医による保険診療医師による自由診療

Fees regulated by government

Fees determined by facility

Health checkup, normal childbirth, cosmetic surgery etc.

Combined care/treatments are not allowed.
1. No payments from the insurance organization
2. Paying the past claims back3. Revocation of insurance facility
Exceptions for the combined care/treatment 保険外併用療養費制度
1. Patient-selected services 選定療養: extra room charge, erectile dysfunction
treatment etc.
2. Treatments to be evaluated 評価療養: treatment in a clinical trial etc.

Extra room charge
1. The price should be noticed onbulletin board in hospital.
2. The price should be informed
before the admission.
3. The agreement is required.
https://akitah.johas.go.jp/hospitalization/rooms/room4.html 2021/1/20

In case that a single room is necessary fortreatment, hospital provides a single room without
an extra charge. When the patient became
unnecessary for the single room, the patient canbe moved to an two- or four-bed room. It may
cause a problem.

Any extra charge for patient-selected
services should be reported to Regional
Bureaus of Health and Welfare

https://www.ejirihospital.or.jp/ 2021/1/13

Components of feesFirst visit
Outpatient
Basic fee 基本診療料+Re-visit
Inpatient

Medical management fee
医学管理等+Home care 在宅医療+

Home visit
No home visit

Medical skill fee 医療技術料
Laboratory test, image diagnosis, prescription, injection, rehabilitation
Operation, anesthesia, radiation therapy, pathological diagnosis, etc.

Outpatient services in 2014 version
First visit

282 points
Additional for infant, mid-night, holiday,etc.
141 points for the second department in
the same day

Re-visit

72 points for clinics and hospital with lessthan 200 beds, and 73 points for hospitalwith 200 beds or more.
Additional for infant, mid-night, holiday,etc.
36 points for the second department in
the same day

In 2014 version: 1,020 points for head CT, and 450 points for the diagnostic skill

Responsibility to issue receipt and the details
Receipt of hospital
30 %Receipt of pharmacy
140 points
1,141 points

70 points

30 %70 points

420 yen3,420 yenAugust 6, 2013https://kouseikyoku.mhlw.go.jp/tohoku/gyomu/bu_ka/shokuhin/000104612.pdf 2021/1/13

Inpatient services
Definition
Medical necessity judged by a doctor, admission to an
inpatient room, and provision of inpatient services.

Visit by an ambulance car at midnight
No necessity to admit, but no vehicle
Provision of a bed at an outpatient room

No charge from out-of-pocket payment
No payment from insurance fundInpatient services
Definition
Medical necessity judged by a doctor, admission to an
inpatient room, and provision of inpatient services.
Requirements
1. Treatment plan （入院診療計画）
Documented explanation of diagnosis, schedule,
and expected period of admission, within 7 days
with the signatures of a doctor and a nurse.
2. Infection control program (院内感染防止対策): 4 criteria
3. Safety management (医療安全管理体制): 4 criteria
4. Decubitus control（褥瘡対策）: 4 criteria
5. Nutrition management（栄養管理体制）: 6 criteria

Components of feesFirst visit
Outpatient
Basic fee 基本診療料+Re-visit
Inpatient

Medical management fee
医学管理等+Home care 在宅医療+

Home visit
No home visit

Medical skill fee 医療技術料
Laboratory test, image diagnosis, prescription, injection, rehabilitation
Operation, anesthesia, radiation therapy, pathological diagnosis, etc.

Inpatient services
Basic fee+

Addition-Reduction

e.g. Friday admission >40% or Monday discharge>40%: 8% reduction for Saturday and Sunday- for general ward mainly for acute diseases
一般病棟- for care ward
療養病棟
- for tuberculosis ward
結核病棟
- for psychiatric disease ward
精神病棟
- clinic ward (facilities with less than 20 beds) 有床診療所- clinic care ward 有床診療所療養病床 etc.

Inpatient services*P : inpatients

Basic fee

P* to Nursing % of Nurse Average Points
Employees
among NE stay
rev in 2014
7 to 1>70%< 18 days 1,591
10 to 1>70%< 21 days 1,332
13 to 1>70%< 24 days 1,121
15 to 1>70%< 60 days 960
Other cases584- for general ward mainly for acute diseases- for care ward
- for tuberculosis ward
- for psychiatric disease ward
- clinic ward (facilities with less than 20 beds)- clinic care ward etc.

Additional fee
1-14 days 450
15-30 days 192“Other cases”
1-14 days 300
15-30 days 155

Inpatients to nursing employees ratio
10 to 1 on average of 24 hours
A ward for 40 inpatients
40×30 days ×24 hours = 28,800 hours
28,800 ÷ 10 ÷160 hours/month = 18
18 nursing employees are needed.

Nursing employees are nurses, assistant nurses, andnurse assistants.

Average stay in each type of ward
A total of inpatient-days in the past three months(Admitted patients + Discharged patients) ÷ 2in the three months
Number of inpatients is that at the end of the day (24o’clock). Inpatients who discharged or died at theadmission day are counted. Inpatients who stayed 90
days or over due to a chronic condition requiring
artificial respirator, frequent sputum drainage, cancer
treatment, etc. are not counted.
The average stay in day is round up, e.g., 25.1 days isregarded to be 26 days.

Components of fees
Home care 在宅医療Home visit
No home visit

1. Self insulin subcutaneous injection: 1,230 points
2. Home peritoneal dialysis: 4,000 points
3. Home hemodialysis: 8,000 points
4. Oxygen supply: 1,300 points
5. Self urinary catheterization: 1,800 points
etc.
The points are per month.

Hemodialysis
J038 Hemodialysis in 2012
< 4 hours
４=< , but < 5 hours
5 =<2,040 points per day
2,205 points per day
2,340 points per day

22,050 yen × 12 times/ month ≒ 264,000 yen / monthOut-of-pocket payment is 10,000 yen/month under thegovernment support .
In Japan, there are 300,000 patients under hemodialysis.

Upper Gastrointestinal (UGI) Endoscopy
Table of reward points for diagnosis and treatment 2014
D308 Gastroduodenal endoscopy 1,140 points
D414 Biopsy using endoscopy 310 points
N006 Pathological diagnosis 400 points

As of 2013
scopolamine butylbromide (buscopan®)glucagon (glucagon G Novo®)(glucagon Ito®)

Price to be charged
2% 20mg/mL
58 yen1mg
2,381 yen
1 U.S.P.
1,983 yen

The price to buy the drug from company is determined by negotiation.
Contraindications for buscopan are glaucoma, urinary retention due tobenign prostatic hyperplasia, etc.

1年生 基礎セミナー 2018年12月10日

日本の医療保険制度
健康保険？
医療保険？