International Journal ofEnvironmental Researchand Public Health

ArticlePreliminary Examination of an Appropriate Price Calculation
Method and Medical Treatment Costs for Foreign Visitors
in Japan
Tomoyuki Takura *Visiting Japan †and Study Group: Research on Appropriate Medical Treatment Prices for Foreigners

Department of Healthcare Economics and Health Policy, Graduate School of Medicine, The University of Tokyo,
Tokyo 113-8655, Japan* Correspondence: ttakura@m.u-tokyo.ac.jp; Tel.: +81-35-800-9523† Special note: Study group was a committee formed as part of a government-affiliated subsidy project, and held
a number of discussions related to this research; hehp-labo@umin.ac.jp.

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Citation: Takura, T.; Study Group:
Research on Appropriate Medical
Treatment Prices for Foreigners
Visiting Japan. Preliminary
Examination of an Appropriate Price
Calculation Method and Medical
Treatment Costs for Foreign Visitors
in Japan. Int. J. Environ. Res. Public
Health 2021, 18, 5837. https://doi.org/10.3390/ijerph18115837
Academic Editor: Sunghyup
Sean Hyun

Abstract: This study proposes a method for calculating the appropriate medical treatment price levelfor foreign visitors (FVs) in Japan. Hospital management costs and foreign prices were analyzed
from a market principles perspective to determine the medical treatment price. The study involved
two stages: a preliminary survey and an extended survey, supplemented by an international survey.
Relatively frequent diseases were selected, and the costs incurred by hospitals for the treatment
of FVs were analyzed though data from three hospitals, covering 24 outpatients and 4 inpatients.
Payments made by three insurance companies for overseas medical institution services for Japanese
tourists with pharyngitis were analyzed. This study shows that the appropriate medical treatment
prices for FVs, considering profits, were 1.22–4.26 times higher compared with prices under Japan’s
public health insurance plans. Furthermore, these prices were 1.31–4.26 times higher for outpatientswith pharyngitis and external injury and 1.22–3.66 times higher for inpatients with appendicitis
and femoral fractures. The price of pharyngitis treatment in 12 countries was USD 20.32–158.75 per
patient for Japanese tourists, whereas FVs paid 60.24 dollars (1.13 times higher than Japan’s publichealthcare price) in Japan. This study shows it was appropriate to set the ideal price level for FVs
higher than that for Japanese patients.
Keywords: market price; health insurance; foreign patients; cost accounting; pharyngitis;
external injury

Received: 12 April 2021
Accepted: 27 May 2021
Published: 29 May 2021

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1. Introduction
The Japanese government has set tourism by foreign visitors (FVs) as an industrial
policy. In 2018, 31.19 million FVs visited Japan [1]; this number has since increased by
262%. Compared to 2018, the number of hospitals accepting FVs increased by 7.6% in 2019,
and the annual number of accepted FVs increased by an average of 40.3% per medical
institution [2]. The number of FVs in Japan has decreased by more than 80% due to the
COVID-19 pandemic over the last year; however, it is estimated that the inflow of FVs will
increase when the pandemic recedes due to the spread of vaccination and the acquisitionof herd immunity.
Japan is set to host the Olympic and Paralympic Games in 2021 and various international exposition events in the near future, which are expected to attract many international
travelers. Japan’s medical security scheme is characterized by the Universal Medical Care
Insurance System. For proper operation of the National Health Insurance (NHI), keeping
pricing systems under control is necessary to serve the increasing number of FVs who
require emergency medical care due to accidents [3].

4.0/).

Int. J. Environ. Res. Public Health 2021, 18, 5837. https://doi.org/10.3390/ijerph18115837

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Japanese public health insurance is largely based on a fee-for-service payment system.
This system, which is the basis of the national fee schedule for each type of medical treatment (inpatient, outpatient, and dental), applies to all Japanese citizens regardless of theiroccupation/income or gender/age group in the NHI. The fee-for-service payment system
lists all services, procedures (e.g., surgery), and products (e.g., drugs) for medical treatment.
In the NHI, regardless of the operational style of the medical facility (public/private), theamount billed by the medical institution for providing medical treatment—that is, theofficial price of healthcare services—is decided by the government.
Therefore, each medical institution has limited opportunities to independently consider the medical fee level, except for special medical services. Against this background,many medical institutions have not cultivated a system for setting prices. Owing to nonsubscription to the NHI, FVs are not entitled to use medical care services under the same
conditions as Japanese citizens. In other words, FVs are not locally insured patients. However, given the background mentioned above, it is believed that not all medical institutions
have cultivated a system of setting prices for services for FVs. Therefore, it is necessary to
determine appropriate pricing for the medical treatment of FVs in Japan.
In general, the medical treatment fee for FVs is expected to be higher than the public
fee under NHI as the following additional burdens are implied:
(1)
(2)
(3)
(4)

Employment of coordinators, medical interpreters, and nurses/assistants who speak
foreign languages.
Physical infrastructure development (e.g., multilingual websites, in-institution medical guidance, and development of remote interpretation systems).
Knowledge-oriented measures (e.g., manuals, checklists, and related education).
Decrease in treatment efficiency (e.g., increased burden on medical care explanations,dispensing prescriptions, and risk countermeasures).

Burdens 1–3 are additional expenses that are not incurred by locally insured patients,
only by FVs. These additional costs for FVs occur outside of fee-for-services payment
in the NHI and, thus, it is necessary to set an appropriate price for them. For FVs, who
are non-locally insured patients, the time requirement and resource consumption will
increase due to various reasons, such as collecting medical information and carrying out
test diagnoses, considering the risk of illness specific to their place of origin and race;
formulating treatment plans and obtaining informed consent, considering FVs’ culture
and religion; or conducting payment negotiations with an overseas insurer (burden 4:
increasing basic medical expenses).
A survey by the Ministry of Health, Labour and Welfare reported that only 4% of
the medical institutions (n = 4971) that responded had an FV billing price of JPY 20 (USD0.18), more than double the fee for Japanese patients) or more per point in medical fee [4](NHI: 1 point = JPY 10: USD 0.09). Most medical institutions are unable to consider thecost of additional treatment for an FV, which may affect their financial management andthe stability of medical service supply.
Theoretical and economic evidence of the appropriate medical treatment price level for
FVs in Japan is insufficient. The purpose of this study is to examine the medical treatment
price to secure stable hospital management—a necessity for the stable provision of medical
services to FVs. A method for calculating the medical treatment price level for FVs istherefore proposed.
2. Methods
2.1. Theories and Methods Related to Price-Setting Research
For price optimization, it is desirable to consider the behavior and motivation ofmarket economic agents as well as the pricing mechanism for goods and services, including
resource allocation and income distribution. Overall, the general economics approach islimited as there are various uncertainties related to the highly specialized technologies inmedical science. Thus, examining price setting in the medical field is generally considereddifficult due to the complex involvement of various factors.

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medical science. Thus, examining price setting in the medical field is generally considereddifficult due to the complex involvement of various factors.
The price-setting
in medical
treatment
cantreatment
be discussedof twoThe approachprice-setting
approachin medical
can inbe terms
discussed
in terms of two
major categories:“market-based”
and“input-based”[5].
The“market-based”
approachmajor categories: “market-based” and “input-based” [5]. The “market-based” approach
determines theprice leveltheby price
considering
actual market
price ofmedicaltreatment,
determines
level bythe
considering
the actual
marketpriceof medical treatment,
while the “input-based”
approach is basedon theconsumptionof goods and ofservices.
while the “input-based”
approachis basedon the consumption
goods and services.
Generally, in countries
the medical
is mature,
it isispresumed
prices arethat prices are
Generally,wherein countries
wheresystem
the medical
systemmature, itthat
is presumed
being formed being
in the formed
public medical
marketusing market
these approaches.
in the public
medicalusing these approaches.
Meanwhile, thereare
discussions
about
approaches
explain thatthe economic
Meanwhile, there are discussions aboutthat
approaches
explain thevalue
economic value ofof individual medical
technologies(services). For
example,the standpointof a med- of a medical
individual
medical technologies(services).
Forfrom
example,from the standpoint
ical provider (thesupplythe methodsof “technicaldifficulty”
and “medical
provider(theapproach),
supply approach),the methodsof “technicaldifficulty”
and “medical cost”
cost” are oftenare
selectedfrom thefrom
viewpointof quality
and business
manage- management.
often selected
the viewpoint
ofevaluation
quality evaluation
and businessment. Furthermore,from thefrom
standpointof the payer(beneficiary),
the methodsof “pa- of “patient
Furthermore,
the standpointof thepayer (beneficiary),
the methods
outcome”,“economic
performance”,
and “willingness
to arepay”often
are often
selected from thetient outcome”,“economic
performance”,
and “willingness
to pay”
selected
viewpointof market
and valueevaluationfrom the viewpointof market
and valueevaluation[6–9].[6–9].
arecertain
cases wherecertain preconditions
the use of these
Additionally, Additionally,
there are casesthere
where
preconditions
are set for theare
usesetof forthese
ForJapan’s
example,in Japan’s
universal
healthinsurancesystem,most of the prices
indicators. Forindicators.
example, inuniversal
healthinsurancesystem,most ofthe prices
chargedto public
insurersby medical
arethecenteredon the direct
charged to public
insurersby medical
institutions
areinstitutions
centered on
direct medical
cost, medical cost,based on theofconsumptionof medical
resourcesconsidering
their clinical usewhich is basedwhichon theisconsumption
medical resources
considering
theirclinical usefulfulness
andhospital
operability.
Incidentally,
technical
fees
(such
as
those
ness and hospital operability. Incidentally, technical fees (such as those from surgery),from surgery),which arethe doctors’
specialty, areconsidered
as factorsof technical difwhich are influenced
by influenced
the doctors’by
specialty,
are considered
as factorsof technicaldiffificulty.
Furthermore,
overseas(developed
countries)
marketpricesarereferred
to whenculty. Furthermore, overseas (developed countries) market prices are referred to when
determining
publicprices for pharmaceuticaland medical devices.
determining public
prices forpharmaceuticalresources andresources
medical devices.
this study,
a methodsetting
priceonlevel
onofthemedical
analysis of medical
In this study, Ina methodof setting
the ofpricelevelthebased
the based
analysisexpensesofJapanese
medicalinstitutions
for
FVs
was
examined,andinternational comexpenses of Japanese medical institutions for FVs was examined, and international comparisonsofpricelevelsforJapanese
tourists(patients)inforeigncountries
were conductedparisons of price levels for Japanese tourists (patients) in foreign countries were con(Figure
1).
ducted (Figure 1).

Figure(in(ingeneralandwithin
the
range
ofof
this
examination).
Figure1.1.Theory
Theoryofofthe
theprice-setting
price-settingapproach
approach
generalandwithin
the
range
this
examination).

2.2. Price-Setting Research Centered on Medical Expenses
2.2. Price-Setting Research
MedicalCost is Centeredclassifiedon
intoactualExpenses
and standard cost depending on the consumption and unit

Cost is classified
into actualand standard
cost
dependingtheconsumption
andprice calculation
criteria.
In addition,
cost
is dividedon
into
directand indirect
costs according
unit price calculation
criteria. In addition,
cost theis divided
into withdirectmedical
and indirect
costsBoth standard
to the consumption
method andassociation
practice.
according to theandthe association withmedicalpractice. Bothandconsumption
indirect costs method
require an
allocation/proration
process
to consolidate
the consumptionof medical
resources
into
cost units based ona specific
way of thinking.
standard and indirect
costs
require an
allocation/proration
process
to consolidate
the con- In this study,
a methodof setting
basedon theper patient
while referring
sumption of medical
resources
intoprices
cost units
basedon amedical
specific expenses
way of thinking.
In thisto the cost accounting method of the Health Economics Research and Social Insurance
Welfare Association, was adopted [10]. Specifically, the annual cost of the entire facility

J. Environ. Res. Public Health 2021, 18, x FOR PEER REVIEW

4 of 14Int. J. Environ. Res. Public Health 2021, 18, 5837

4 of 13study, a method of setting prices based on the medical expenses per patient while referring to the cost accounting method of the Health Economics Research and Social Insurance
Welfare Association, was adopted [10]. Specifically, the annual cost of the entire facility
was apportioned to one case in three stages, using the number of medical treatments, thewas apportioned to one case in three stages, using the number of medical treatments, thenumber of staff, and the occupied area as coefficients (Figure 2) [10]. The expense items
number of staff, and the occupied area as coefficients (Figure 2) [10]. The expense items
were organized according to accounting items (resource consumption provided by medical
were organized according to accounting items (resource consumption provided by medtreatments: labor costs, material costs, general expenses, depreciation costs, welfare costs).
ical treatments: labor costs, material costs, general expenses, depreciation costs, welfare
The billing items covered the medical treatments and related services.
costs). The billing items covered the medical treatments and related services.

Figure 2. Costof theentireoffacility
apportioned
to one case to
in onethree
stages(calculation
frame of medical
Figure2. Costthe entire
facility apportioned
casein threestages (calculation
frame expenses).
of

medical expenses).

In this calculation, the costs were analyzed based on socioeconomic ranges, taking
theclinicaleconomic
activities
of an FV into
consideration.
In this calculation,characteristics
the costs wereandanalyzed
based
on socioeconomic
ranges,taking Both thecosts related toandgeneralmedicalcare andin hospitalmanagement
the clinical characteristics
economic
activitiesof thean public
FV intoinvestment
consideration.
Both theandhealthcare
infrastructure
throughtheinsurancesystemandvarioustaxation
systems
costs related to general medical care and the public investment in hospital managementthat
supportJapan’s
medicalsystem,
were
taken
into
account.
For
example,thesocialand healthcare infrastructure through the insurance system and various taxation systems
insurance
burden(insurance
contributionsandsubsidies,suchasoperational
grantstothat support Japan’s medical system, were taken into account. For example, the social inmedical
institutions)andadditional
expensesforFVs(e.g.,
interpretation
costs,
coordinatorsurance burden (insurance contributions and subsidies, such as operational grants tocosts, equipment costs, and risk management costs) can be used as calculation items.
Three medical institutions with more than 400 beds were chosen as the target facilities, and their location conditions (urban or rural) were taken into consideration. In
the calculation, additional factors (such as the occupancy and profit rate of each facility)medical institutions) and additional expenses for FVs (e.g., interpretation costs, coordinator costs, equipment costs, and risk management costs) can be used as calculation items.
Int. J. Environ. Res. Public Health 2021, 18, 5837
of 13
Three medical institutions with more than 400 beds were chosen as the target 5facilities, and their location conditions (urban or rural) were taken into consideration. In thecalculation, additional factors (such as the occupancy and profit rate of each facility) werealso considered. In this study, the data collection consisted of a medical practice survey
were also considered. In this study, the data collection consisted of a medical practiceand a medical institution management survey. The medical practice survey used the timesurvey and a medical institution management survey. The medical practice survey usedstudy
(occupation
time of medical
staff andstaff
institution
equipment)
and medical
records
thetimestudy (occupation
time of medical
and institution
equipment)
and medical(electronicandmanagement
ledgers).
Some
were
self-reported
alternatives
based
prorecords (electronic and management ledgers). Some were self-reported alternativeson
based
fessional
experience.
The
medicalinstitution
management
surveycollected
financialstateon professional experience. The medical institution management survey collected financial
ments (profit
and andloss loss
balancesheets),the numberof patients
andandmedicaltreatments,
thestatements(profitbalancesheets),the numberof patients
medicaltreatments,
numberofstaff
andequipment,
unit
purchaseprice,
and
the
area
of
each
department.
the number of staff and equipment, unit purchase price, and the area of each department.
The price
price ofof medical
medical expenses
expenses forfor FVsFVs waswas broadly
broadly divided
divided into
into “additional“additional expenses
expensesTheofforeign
medicaltreatment”
and“increased
expensesofregularmedicaltreatment”
of foreign medical treatment” and “increased expenses of regular medical treatment”(Figure 3).
3). The
The following
following definitions
definitions forfor additional
additional andand increased
increased expenses
expenses were
were applied:
applied:(FigureThe additional
additional expenses
expenses were
were thethe costs
costs forfor new,
new,additional
additionalservices
services(e.g.,(e.g.,interpretationinterpretationThe
and transportation)transportation) forfor non-locally
non-locally insured
insured patients.
patients. The
The increased
increased expenses
expenses were
were forforandmedicalservices
similarly
offeredtolocally
insuredpatients,butfor
non-locallyinsuredmedical services similarly offered to locally insured patients, but for non-locally insured
patients, thethe unit
unit priceprice andand quantity
quantity were
were increased
increased (e.g.,(e.g., consultation
consultation hours
hours andand number
numberpatients,ofstaff).
Profitwas
includedin
thiscalculationasanecessary
resourceforreinvestmentof staff). Profit was included in this calculation as a necessary resource for reinvestment byby medical
institutions
to realize
sustainable
management
appropriately
respondmedical
institutions
to realize
sustainable
management
whilewhile
appropriately
respondingtoing medical
to the medical
needs
FVs. However,when determining
the margins,profit margins,
the histheneeds of
FVs.ofHowever,when determining
the profit
the historicaltorical averageof each institution
was toadoptedto avoid distortionof priceand theaverageof each institution
was adopted
avoid distortionof price levels
and levels
the expensive
expensiveburden
economic
burdenFVs due toexcessive
profits.
In otherwords,
the profits
economic
on FVsdue onto excessive
profits.
In otherwords,
the profits
gainedfromgainedfrom
FVs werebasically
the same
as fromthoseJapanese
gained fromJapanese patients.
FVs
were
basically
the sameas those
gainedpatients.

FigureFigure 3.
3. TheThe structure
structure ofof medical
medical expenses
expenses forfor foreignforeignvisitors
visitors(FVs);(FVs);calculation
calculationand
andaddition
additionfrom
fromtwo
twoperspectives.
perspectives.

Regardingof ofregularmedicaltreatment”,
the medical
fee clasRegardingthe
the“increased“increasedexpenses
expensesregularmedicaltreatment”,
the medicalfeesification
system(list)
forpublicmedicalinsurance
was
used
to
reducetheburdenof costclassification system (list) for public medical insurance was used to reduce the burdenofaccounting at each medical institution, improving the efficiency of billing operations andcost accounting at each medical institution, improving the efficiency of billing operations
utilizing data across facilities (benchmark comparison standard). For the calculation unit
and utilizing data across facilities (benchmark comparison standard). For the calculationof each medical practice, the unit price of medical treatment reward points (reimbursement
amount) of public medical insurance was applied, the “increase coefficient” as the ratio tothe medical expense for FVs calculated, and all prices were converted into multiples of the
medical treatment reward points. The “additional expenses of foreign medical treatment”
were also converted into a multiple of the medical treatment reward points. The “increasein the expense of ordinary medical treatment” and “additional expenses of foreign medical

Int. J. Environ. Res. Public Health 2021, 18, 5837

6 of 13treatment” were added together to generate a bill. Finally, the medical material expenses,
general and administrative expenses, and the institution’s average profits over two years
were added. In addition, a part of the various unit price data (electric utility expense, water
bill, wage unit price by occupation) was replaced by national designated statistics.
The above method was organized as a calculation manual (guidance), and a prototype
calculation software was developed. The manual was published on the website of the
Ministry of Health, Labour and Welfare in Japan [11]. The software was published on the
homepage of the research group’s organization [12].
2.3. Stages of the Study
This study was conducted in two stages: a preliminary survey (2017–2018) and an
extended survey (2019), supplemented by an international survey comparing medical
treatment prices of representative disease. Preliminary research examined pricing methods
and the feasibility of data collection. Based on these results, the number of cases wasincreased and an FV price analysis was validated in the extended survey. The extended
survey focused on outpatient cases, considering the frequency of cases and the feasibilityof conducting the survey.
As there were no available statistical surveys on the frequency of occurrence of FV
diseases, this study was positioned as an exploratory report that also collected epidemiological information on the status of therapy for FVs. Furthermore, this study was conductedunder the conditions of the availability of medical treatment data for FVs. Throughout
the study, more than 10 target diseases (including pharyngitis, urticaria, cystitis, severe
pneumonia, appendicitis, cholangitis, femoral fractures, asthma, external injury, and arrhythmia) frequently diagnosed for FVs in Japanese medical institutions were selected.
These diseases were nearly identical to the representative diseases of Japanese medical
treatment. Pharyngitis was the target disease in Section 2.4.
In the preliminary survey, seven target diseases (pharyngitis, urticaria, cystitis, severe
pneumonia, appendicitis, cholangitis, and femoral fractures) which are frequently diagnosed for FVs in Japanese medical institutions were selected. In this study, supplemented
by an international survey comparing medical treatment prices of representative disease,the consumption of medical resources was focused on dense equipment scale and allocationof human resources while paying attention to the balance between outpatient visits andinpatient treatments. However, statistical processing was difficult due to the sample size of
this study.
The extended survey, covering 21 outpatients, used continuous observation (registration); the first-visit and second-visit samples were analyzed. The main target conditions
were trauma and infectious diseases. Other cases included respiratory diseases, such asasthma and circulatory diseases, including arrhythmia. The inflow trends of FVs confirm
that patients primarily come from North American, European, and Asian countries.
At both stages of the study, data from the same type of injury and medical intervention
services were collected in parallel for Japanese and FV subjects. The public charges were
calculated and compared to those for FVs. A Wilcoxon signed-rank test was employed
to examine the mean population differences in this study. The statistical analysis software used was SPSS version 26.0 (IBM Corp., Armonk, NY, USA). The level of statisticalsignificance was set at 5%, and mean values were expressed as standard deviations.
The calculation of costs may vary depending on how specific the diagnosis is, howmuch time a patient requires for recovery, and the occupancy rate of the medical institution.
There were restrictions during sampling in this study. A one-dimensional sensitivity
analysis was performed to verify the robustness and representativeness of the results foran extended survey, considering their uncertainty. In the sensitivity analysis, cases werefirst classified according to the International Classification of Diseases (ICD-10) and werethen associated with clinical department.
The daily unit cost (clinic, outpatient, and Japan’s public healthcare unit price) andthe national average value related to the number of patients by clinical department as per

Int. J. Environ. Res. Public Health 2021, 18, 5837

7 of 13

the government’s official statistics were then organized [13]. The weighting coefficientof the unit cost of medical treatment and the number of patients from the contents were
determined, and the distribution of the difference between the medical cost for Japanesepatients and that of the national average was calculated. Finally, for sensitivity analysis,
the difference distribution of medical treatment costs of Japanese patients was comparedwith those of FVs when reduced by 25%, confirming the probability that the costs for FVs
would exceed those for the Japanese.
2.4. International Comparison of Representative Medical Treatment Prices
It is necessary to discuss the following aspects related to the price level: (1) the
estimation of profits for reinvestment, (2) patients’ payment ability for emergency services,and (3) subsidies for medical institution management. The risk of price negotiations andreceivables has a major impact on management for medical institutions that are unable torefuse treatment due to regulations when the patient’s payment ability is low. Therefore,
when examining the price level for FVs in Japan, it is desirable to refer to the price leveland billing methods in foreign countries.
In this study, information on medical expenses in foreign countries was collected,
focusing on high-prevalence diseases and medical departments that FVs most frequently
consult. This survey investigated the level of payment for Japanese overseas travelers(overseas FVs) in overseas countries to evaluate the validity of the calculated medical
treatment prices of FVs in Japan. The price level (representative cases), price breakdown(expenses, expense items, and ranges), and billing system (related payment systems) werealso researched. The target areas were European countries whose healthcare systems,
economic situations, and demographics are similar to those of Japan and other Asian
countries, which account for a large percentage of FVs.
The main data were obtained from the medical expenses (self-funded medical treatment) for Japanese tourists during 2017–2018 from three insurance companies (private
financial institutions and public payment agencies). Other statistical data were analyzed
using public databases (PubMed data since 2010). Data collection was performed considering the payment system (self-pay, etc.), medical treatment structure (protocol, etc.), cost
structure, and an analysis that aligned medical services and accounting expenses within acertain range. Data scrutiny was performed as much as possible, matching the periods toeach other.
In order to ensure the accuracy of data comparison while considering various points
to be noted for the target disease, pharyngitis (outpatient consultation) was selected basedon the number of cases and type of medical treatment. Pharyngitis cases have a relatively
high incidence, with little difference in medical care contents between countries (the initialdiagnosis of pharyngitis, whether viral or bacterial, is relatively standardized).
The conversion of each country’s currency to American dollars was carried out using
the exchange rate at the time of medical treatment. The average exchange rate between
the Japanese yen and US dollar was 108.73 yen per dollar from 2017 to 2019. Since theproportion of services has increased in recent years, the significance of purchasing power
parity (PPP) has decreased slightly. Regardless, there are many opportunities to use it,compared to the prevailing exchange rate. In this study, PPP-adjusted figures in US dollars
are also shown [14].
3. Results
3.1. Appropriate Medical Expenses Based on Pricing in the Preliminary Survey
As a result of the investigation, seven patients were selected: three outpatients withpharyngitis, urticaria (allergic treatment), and hemorrhagic cystitis and four inpatientswith severe pneumonia (including outpatient treatment), general surgery for appendicitis,
cholangitis treatment using endoscopy, and surgery for a fracture of the trochanteric regionof the femur (including rehabilitation). This sample included one case that transitioned
from outpatient to inpatient. The survey results are shown in Figure 4. The cost of medical

3.1. Appropriate Medical Expenses Based on Pricing in the Preliminary Survey
As a result of the investigation, seven patients were selected: three outpatients withpharyngitis, urticaria (allergic treatment), and hemorrhagic cystitis and four inpatientswith severe pneumonia (including outpatient treatment), general surgery8 offor
Int. J. Environ. Res. Public Health 2021, 18, 5837
13
appendicitis, cholangitis treatment using endoscopy, and surgery for a fracture of thetrochanteric region of the femur (including rehabilitation). This sample included one casethat transitioned from outpatient to inpatient. The survey results are shown in Figure 4.
treatment
Japanese(locally forinsured)patients
wasinsured)
the averagefor thesamein the
The cost offor
medicaltreatment
Japanese(locally
patients
wasthe cases
averageforpast
at thecases
targetthe same
inhospital.
the past at the target hospital.

FigureFigure 4.
4. Calculation
Calculation ofof price
price levels
levels forfor foreignforeign visitors
visitors (seven(seven diseases).
diseases).

Comparedwith thethemedical
medicalexpenses
expensesofof
Japanesepatients,
thoseCompared withJapanesepatients,
those
for forFVsFVswerewere
1.31
1.31
times
(1
point
0.12
dollars)
higherforpharyngitis,
1.56
times
(1
point
0.14
dollars)
times (1 point 0.12 dollars) higher for pharyngitis, 1.56 times (1 point 0.14 dollars) higher
higherfor urticariawith allergies,
2.21(1times
point
0.20 dollars)higherfor hemorrhagic
for urticariawith allergies,
2.21 times
point(10.20
dollars)
higher for
hemorrhagic
cystitis,
cystitis,
3.66
times
(1
point
0.34
dollars)
higherfor
inpatientswithseverepneumonia,
3.66 times (1 point 0.34 dollars) higher for inpatients with severe pneumonia,
1.22 times
1.22
times0.11(1 point
0.11higher
dollars)
forsurgery
generalofsurgeryof appendicitis,
2.92(1 point
dollars)
forhigher
generalappendicitis,and 2.92andtimes(1 times
point
(1
point
0.27
dollars)
higherforendoscopic
cholangitis
treatment.
The
operatingexpense0.27 dollars) higher for endoscopic cholangitis treatment. The operating expense for thefor the trochanteric fracture of the femur was 3.59 times (1 point 0.33 dollars) higher.
trochanteric fracture of the femur was 3.59 times (1 point 0.33 dollars) higher.
In summary, the medical expenses for FV patients were 1.22 to 3.66 times higher thanIn summary, the medical expenses for FV patients were 1.22 to 3.66 times higher thanthose for Japanese patients, 1.31 to 2.21 times higher for outpatients (pharyngitis, urticaria,
those for Japanese patients, 1.31 to 2.21 times higher for outpatients (pharyngitis, urticaria,
and cystitis), and 1.22 to 3.66 times higher for inpatients (severe pneumonia, appendicitis,and cystitis), and 1.22 to 3.66 times higher for inpatients (severe pneumonia, appendicitis,
cholangitis, and femoral fractures).
cholangitis, and femoral fractures).
3.2. Survey for International Comparison of Medical Expenses (Self-Funded Medical Treatment)
3.2. Survey for International Comparison of Medical Expenses (Self-Funded Medical
Figure 5 shows the amount billed when providing medical treatment to Japanese
Treatment)
overseas travelers (overseas FVs) in each country. The survey indicates that although
Figure5 shows
the amountwhen
providing
medicalJapanesethe total
numberof patientswasbilled
18 (onein eachcountryother treatment
than USA,toAustralia,
overseas
travelers(overseas
FVs)
in
each
country.
Thesurveyindicatesthat
althoughtheItaly, and China), the actual medical payment was about USD 20.32–158.75/bill (medical
total
numberofpatients
was
18
(one
in
each
country
other
than
USA,
Australia,
Italy,
andexpenditures for medical examination and drug cost) in 12 countries (Figure 5). The highest
China),
actual
was about
USD
20.32–158.75/bill(medical
pricewasthein theUnitedmedical
States, atpayment
USD 158.75/bill(medicalfee may
be partially unknown),
expenditures
for medical
examinationanddrug cost)
12 countries(Figure5).(PPP:The
followedby Austria
with USD
79.38 (PPP:
86.28)/bill,
andinBelgium
with USD
73.93
73.93)/bill. Western countries account for the top ranks of medical price levels. China has
the lowest medical price level, at USD 20.32 (PPP: 31.32)/bill in, followed by the Philippines
with USD 27.15 (PPP: 71.68)/bill and India with USD 29.52 (PPP: 95.03)/bill, since Asian
countries generally have low medical price levels.

highest price was in the United States, at USD 158.75/bill (medical fee may be partiallyunknown), followed by Austria with USD 79.38 (PPP: 86.28)/bill, and Belgium with USD
73.93 (PPP: 73.93)/bill. Western countries account for the top ranks of medical price levels.
China has the lowest medical price level, at USD 20.32 (PPP: 31.32)/bill in, followed by
theInt. J. Environ. Res. Public Health 2021, 18, 5837
9 of 13
Philippines with USD 27.15 (PPP: 71.68)/bill and India with USD 29.52 (PPP: 95.03)/bill,
since Asian countries generally have low medical price levels.

FigureFigure5.5.International
Internationalcomparison
comparisonof
ofmedical
medicalexpenses
expenses(pharyngitis(pharyngitisandandoutpatient).
outpatient).

In
Inthisthisstudy,
study,thetheresults
resultsofofthe
thecalculated
calculatedactual
actualcost
costfor
forFVsFVswerewerecompared
comparedwith
withthethepricelevelsforJapanesepatients
inforeigncountries,
andthevalidity
of
the
price
accounting
price levels for Japanese patients in foreign countries, and the validity of the pricemethodfor FVs
was confirmed.
general expenses
for Japanese
rangedaccounting
methodfor FVs wasTheconfirmed.
The general
expensespharyngitis
for Japanesecases
pharyngitis
from
USD
41.00
to
46.00
for
the
initialconsultation
andmedicationin
FY2018(theinitialcases ranged from USD 41.00 to 46.00 for the initial consultation and medication in FY2018
consultationfee
variesdependingonthecharacteristics
oftheinstitution).
However,the(the initial consultation fee varies depending on the characteristics of the institution).
medicalexpense(excludingtax)(excluding
for FVs, calculatedby theprice accounting
method,was
However,the medical
expensetax) for FVs,
calculatedby the priceaccounting
estimated
60.24
dollarsin
FY2018(1.31
times
higher
than
that
for
Japanesepatients).
method, was estimated 60.24 dollars in FY2018 (1.31 times higher than that for Japanese
The results of this survey show that the actual expenses for the investigated FV cases
patients).
were about
the sameas theactualbilling(Japanese
tourists)
the relevant FV
country
The resultsof thissurveyshow
thatamountthe actual
expenses
for theininvestigatedcases(Italy).
Inaddition,thecalculated
price
for
the
FVs
was
almosttheaverage(58.00were about the same as the actual billing amount (Japanese tourists) in the dollars)
relevantforall surveyedcountries.
country(Italy). In
addition, the calculated price for the FVs was almost the average (58.00

dollars)
for all surveyed
3.3.
Preliminary
Evaluationcountries.
of Pricing for FVs and the Difference between Calculated Price andPublic Price in the Extended Survey
3.3. Preliminary Evaluation of Pricing for FVs and the Difference between Calculated
In the extended survey, the difference between the calculated FV price and the public
Price and Public Price in the Extended Survey
price ranged between 1.95 (USD 32.83 vs. USD 64.18) and 4.26 times (USD 616.82 vs.
the extended
survey,the difference
betweenincluded
the calculated
FVthatpricewere
and thepublicUSD In2626.31)
in 23 cases(Table1). This sample
2 cases
revisitedpricerangedbetween
1.95
(USD
32.83
vs.
USD
64.18)
and
4.26
times
(USD
616.82
vs.
USD
repeatedly. This population had an average age of 51.4 ± 22.8 years and a male ratio
2626.31)
in
23
cases
(Table1).
Thissampleincluded
2
cases
that
were
revisited
repeatedly.
of 33.3%. Comparing the prices of 23 FV and 23 Japanese cases, the cost for FVs wasThis population
had anandaverageage higherof 51.4than± 22.8years
and a (USD
male 158.52
ratio of
33.3%.
statisticallysignificantly
2.31 times
for theJapanese± 156.52
Comparing
the±prices
ofp23
FV and 23 Japanese cases, the cost for FVs was statisticallyvs.
USD 445.61
573.55,= 0.029).
significantly and 2.31 times higher than for the Japanese (USD 158.52 ± 156.52 vs. USD
445.61 ± 573.55, p = 0.029).

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Table 1. Difference between calculated price of FVs and public-insurance price for Japanese nationals in the extended
survey (including re-examination).
Country of
Citizenship
IrelandUSA
USA
EnglandEnglandIsraelIsraelIsraelAustralia
Australia
Singapore
Singapore
Switzerland
Switzerland
ThailandTaiwanTaiwanTaiwanChina
China
Germany
Germany
FranceMedical Treatment Price (Dollar)
Diagnosis

Asthma (suspected)
Urinary retention
Atherosclerotic cerebral
infarction/suspected
acute phase
Pleurisy
Left knee joint pain
Arrhythmia
Head cutSciatica
Cystitis
Chief complaint:
respiratory distress (nodiagnosis)
Lumbar compression
fracture (suspected)
Swelling of the face
Forehead contusion
Forehead contusion
Insect bites/Phlebitis(suspected)
Suspected influenza
Left head bruise
Head flapping, chin cut
Croup syndrome
Pregnancy, irregular
bleeding
Acute cystitis
Acute cystitis
GoutJapanese Public
Insurance Costs 100%

Foreign Visitors (FV)
to JapanA multiple of theJapanese Medical
Treatment Price

32.83
151.4764.18
420.73

1.95
2.78

424.42863.05

2.03

66.68
62.17
74.68
84.06
61.89
51.96

133.82135.17
195.91
196.39150.67131.07

2.01
2.17
2.62
2.34
2.43
2.52

47.64

93.92

1.97

367.591309.58

3.56

224.95616.82213.73506.072626.31667.96

2.25
4.26
3.13

99.78

211.902.12

117.16249.41405.57103.92321.82654.78841.22218.62

2.75
2.63
2.07
2.10

74.68

149.54

2.00

43.04
38.81
3560

159.36129.08
7392

3.70
3.33
2.08

The smallest difference was for the diagnosis of suspected asthma (Ireland) and thelargest difference was for the treatment of forehead contusion (Switzerland). Therefore, it
can be inferred that the treatment price levels for FVs are higher by about 2 to 5 times theofficial price (outpatient cases only; ranged from 1.95 to 4.26 times).
As a result of the sensitivity analysis, the average ratio of medical treatment costs for
FVs was 1.95 times higher than those for Japanese individuals, and the case rate of medical
treatment costs for FVs exceeded those of Japanese by 60.0%. Therefore, it is speculated thatthe method of pricing for FVs adopted in this study is, to some extent, a valid approach. In
addition, it is concluded that it is reasonable for the price level for FVs to be higher thanthe public price of Japanese patients.
4. Discussion
Medical care services for FVs in Japan have long been billed at the same level (public
prices) as those of Japanese people since many medical institutions have few FVs andmedical treatments. However, after 2015, the number of medical treatments increased
sharply as the number of FVs increased [2]. As a result, the economic burden for FVs
in hospital management has also increased; thus, it has become necessary to discussappropriate FV pricing.
The medical treatment price level for FVs was identified as the sum of the “additional
expenses of foreign medical treatment”, which includes the cost of items other than regular
medical treatment and the “increased expenses on regular medical treatment”, which

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includes increases in the unit price of medical care for FVs within the range of regular
medical care. It is believed that the method of calculating multiples of the current medical
treatment reward points for Japanese individuals, based on this total expense, would beappropriate as a billing price for FVs. Profits were included in the calculation to allow for
the sustainable management of medical institutions while appropriately responding to the
medical needs of FVs in Japan. In other words, it was positioned as a necessary resource
for the reinvestment of medical institutions and considered appropriate to incorporate thepast average profit level for each facility into the calculation [15].
The contribution of the study findings would be valid only in a normal context, notconsidering the COVID-19 pandemic over the last year. It is therefore necessary to becareful in applying the results of this study to the management of hospitals under thecurrent irregular circumstances. It is anticipated that the results of this study will be used
in a meaningful way when the pandemic has subsided.
Future research should examine whether the calculation method in this study could beapplied to other cases in which the medical treatment price level is specific because medical
treatment expenses depend on the condition, age, and severity of the disease. Even if thedisease is the same, the level of accounting cost is different; this applies not just to FVs but
also to medical treatment for Japanese individuals [10]. Incidentally, the data in this study
were collected under the conditions of availability. Therefore, there was a limitation on the
representativeness of the findings. It is conceivable that the increase or decrease of more than acertain number of FV patients, that is, the productivity of medical services affects the medical
treatment price. Unfortunately, due to data limitations, it is not possible to verify the impactof the result on increasing or decreasing FVs. This issue warrants long-term consideration.
It is important to examine whether the medical treatment expenses for FVs should be
calculated individually based on the actual consumption of medical resources, treatment,
and services. The advantage of this calculation method is that billing can be made according
to the actual expenses. The disadvantage is that detailed data and calculations are required
for each medical treatment case. As such, the expected price cannot be indicated tothe patient in advance, which will hinder contract negotiations and cause accruals ofoutstanding amounts. Medical treatment expenses generally tend to be diverse dependingon age, the severity of the disease, and the individual’s condition. It should be notedthat this is not limited to FVs and can be considered the same in medical treatment forJapanese people. The regular price list is calculated based on typical treatment levels. The
medical expenses of public medical insurance (1 point = JPY 10) can be regarded as thestandard medical treatment price in Japan. This study effectively utilizes the public medical
insurance claim system (unified prices for the whole of Japan), which comprehensively
covers many medical treatments and improves the accuracy and efficiency of the pricing
approach for FVs.
When considering the price setting of an FV, it is necessary to clarify the following:
how many FVs need to receive medical treatment in Japan, what medical resources canbe used, and how the medical treatment for FVs impacts the overall medical institution
balance. Medical services, medical treatment explanations, price-contract negotiations, andplanned price explanations may be requested in advance for FVs to avoid subsequent issues,
such as receivables. In examining the medical price for FVs, it is essential to consider theoperational expenses of medical facilities. The medical institution’s balance of income andexpenditure is determined by the profit for each treatment case (difference between cost andprice). If medical institutions have a higher number of FV patients, it can be assumed that
their cost–income ratio is balanced by setting price points for standard medical treatments
and applying the points of public medical insurance (converting one point to several tensof yen). By setting this standard price, which is the appropriate price based on medical
expenses, medical institutions will increase their ability to explain price levels to FVs.
Simultaneously, medical expenses can be presented before a doctor consultation so thatproblems in receivables are reduced, the balance of medical management is stabilized, andadministrative procedures become more efficient.

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When referring to the level of medical treatment prices overseas, not only should thereal economy (economic level) of each country but also the medical system (comprisingpatient access, the composition of financial resources, and the degree of self-pay), history,
and culture require special consideration [16,17]. The price in this study is a free price(self-pay medical treatment fee). Therefore, even for the same medical service, the payment
amount generally differs depending on the solvency (economic power), cost level in thehome country (affordability), and the amount billed by the medical institution.
It is necessary to consider the economic balance at the national level as well as the
hospital level to recover public capital related to medical treatment for FVs in Japan. In
this regard, it was speculated that the public expenditure portion of medical fees (used forgeneral financial resources) would be appropriate for FVs in Japan by using the multiple
calculation methods. Specifically, in this method, the portion corresponding to the public
expenditure will also be paid by FVs who become patients (which is several times theamount that is paid by the Japanese). Regarding public infrastructure, taxes and indirectcontributions to regional medical care should be considered. Examining the medical
treatment price level for FVs also has the following benefits: (1) it ensures high returns to
the national treasury through the consumption and business tax on self-funded medical
treatment; (2) it contributes to regional medical care (residents) by strengthening the base of
medical institutions that accept FVs; and (3) it boosts the stabilization of the employment of
medical personnel related to FVs. Based on the results of this study, it is planned to develop
a larger and more extensive survey and to develop an improved calculation manual for
medical institutions.
This study was conducted based on the hypothesis that the provision of medical
services to FVs consumes more medical resources than for the Japanese, considering theactual situation (increased burden) of medical practice in Japan. To test this hypothesis, it
was also meaningful to confirm that the medical treatment price for foreigners overseas
is higher than the price for the inhabitants of that country. Based on the results of thisresearch, it is hoped that research on this subject will progress in the future.
5. Conclusions
This study identified various issues and directions regarding the setting of medical
prices for FVs in Japan. Based on trial calculations of medical expenses and an overseas
price survey, our study shows it is appropriate to set the ideal price level for FVs higher
than that for Japanese patients. Furthermore, it is necessary to set standard prices for each
medical institution and calculate the expected consumption of medical resources to control
the balance of income and expenditure in hospital management while considering thetotal inflow of FVs into Japan. Based on this information, it is essential to provide priorexplanations and follow-up measures to patients, families, and insurers.
Author Contributions: Conceptualization, T.T. and Study Group: Research on Appropriate Medical
Treatment Prices for Foreigners Visiting Japan; Methodology, T.T.; software and formal analysis, data
curation, T.T.; writing—original draft preparation, T.T.; project administration, T.T. All authors haveread and agreed to the published version of the manuscript.
Funding: This research was funded by the Ministry of Health, Labour and Welfare. Grant no.
187100001049.
Institutional Review Board Statement: This study was approved by the Ethics Committee of the
University of Tokyo Hospital (No. 2019307NI) and used an observational study design.
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: The data collected for this study are highly sensitive, and if reasonably
requested, the data supporting the findings of this study can be obtained from the project director.
Acknowledgments: This manuscript received great help from Rei Goto, Shuzo Nishimura, Yasumi
Adachi, Norihiro Nakajima, Keihiro Ota, and Taro Kondo. And I would like to thank Aya Nagahata,
Yuma Yazawa for useful discussions.

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Conflicts of Interest: The authors declare no conflict of interest. The funders had no role in the designof the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; orin the decision to publish the results.

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