Health Administration (11:30 ～12:10 Auditorium of East Building)Session chair: Prof. Takaaki Kondo

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Quality Assessment of Stroke Treatment and Pay-for- Performence in Japan and
Korea
S. Jeong1)
1) Center for Well-being and Society, Nihon Fukushi University, Nagoya, Japan

Introduction
P4P (Pay for Performance) is considered to be a tool thatcan enhance health care quality and improvement. Reports
show that P4P has been increasingly used in developed
countries such the United States1 and the United Kingdom.2
Nevertheless there is a lack of reports on formal evaluation of
hospital P4P in the literature. Systematic evaluation of hospital
P4P is needed to understand the effect and benefits of investingin P4P.3
Similar P4P programs are under way in Korea and Japan,
too. This study reviews the status and examines theperformance in the two countries.
P4P in Korea
In Korea, The cause-specific death rate by stroke andcerebrovascular diseases in recent years has been on the decline,
but stroke is still ranked the number one disease killer,
accounting for the highest percentage of the global burden of
disease such as disability combined and therefore causing
incrased medical costs. In consideration of this, an acute strokeassessment tool that has been developed to provide data to care
hospitals for promoting their voultary quality improvement
acitvities has been used since 2005. Also, the 2006 survey on
the status on the medical services for stroke patients was
conducted for the similar purpose. Based on these results, apilot P4P project for acute stroke was undertaken from 2007
throughout 2010.
Amomg the assessment criteria were Documentation ofsmoking history, Neurologic exam.rate, Screen for dysphasia
by end of hospital day two, brain scan within 24 hours ofadmission, Lipid Profile, T-PA considered, Autithrombotic
medication within 48 hours of admission, Discharged on
Antithrombotic, Patients with Atrial Fibrillation Receiving
Anticoagulation therapy.

>30% of patients under the P4P program should demonstrate an
improvement in their daily living functions or functional
recovery at the time of hospital discharge.
ResultKorea
The follow-up assessment for the two treatment periods, in2005 and October to December of 2008, in the categories of 1)
promptness in initial diagnosis, 2) responsiveness in initial
treatment, 3) secondary preventive measures, and 4) initialassessment of patient conditions, revealed that there wereoverall improvement in quality compared to the results on 2005,
but significant variations in treatment practices across types
and care hospitals were observed (Figure1 and 2).
Following this, the third assessment was conducted on thetreatment period of January to March of 2010 with a goal of
seeking for ways to reduce the discrepancies between hospitals
and ensuring enhanced medical service quality for stroke
patients. The numbers of subject hospitals were 187 for 2005,
194 for 2008, and 313 for 2010.

P4P in Japan
There have been growing concerns and requirements forhealth care quality in Japan. The introduction andimplementation of P4P (Pay for performance) programs forrehabilitation and recovery in 2008 was a significant
advancement in the area of health care service. However, there
still remains a gap involving a need for close examination ofwhat factors may critically influence the rehabilitation medical
service quality and the degree to which hospitals have made or
will make efforts in achieving best practice in rehabilitation. To
begin with, the assessment criteria for P4P set forth by theJapanese government are summarized as follows.
In Japan, P4P inpatient rehabilitation among stroke
survivors began in 2008 with a primary objective to provide theservices needed and improve post stroke patient functional
recovery. Despite concerns over the effectiveness and qualityof P4P by some stakeholders of the program in Japan,1 threestandards were developed for the P4P inpatient rehabilitation
program. They included: (1) >60% of participating stroke
survivors should be discharged to the community; (2) >15% of
newly hospitalized patients should have severe stroke; and (3)HA-1

Figure 1. Improvement in quality measures

Figure 2. Decrease in variance among hospitals in Korea
Japan
The comparison of the data before and after the
introduction of P4P showed that for FIM during hospital stay,the score after P4P (68.85) was slightly higher than that before
P4P (65.82) without any statistical significance. On the other
hand, the Rankin Scale score was found to be lower after P4P(3.28) than before P4P (3.78), showing higher scores forpatients with light disability (p<.001). With respect to FIM at
hospital discharge, the scores were not significantly different
between before (90.46) and after (91.86) P4P. Also, in the caseof patients whose actual FIM was deteriorated from estimatedFIM, the percentages were about the same with 34.8% and34.4% for before and after P4P, respectively. The home return
rate was 80.0% after P4P, compared to 73.0% before P4P,
showing an increase of 7.0% point (p<. 05) (table 1).
Also the therapeutic results were compared between
hospitals. We estimated the expected value of levels of ADL atdischarge for rehabilitation patients using regression analysis.
Furthermore, we identified the distribution of the expected
improvement levels in ADL by hospitals.
The results showed large differences between hospitals(Figure 3).
Table 1. State of patients before and after P4P in Japanof the P4P pilot project implemented in Korea. However the
judgment of the quality of medical services can vary dependingon which criteria are used or which compound values are taken
into account 4. This holds for the case of Japan.
The study in Japan focused on patients in recovery in the
rehabilitation ward using a sample of 680 patients from 12
different hospitals after adjusting for triage at admission
obtained from the databank (issued in September, 2009) inJapan and compared the therapeutic results between hospitals.
The comparison found that there were statistically significant
differences in the results of therapeutic achievement in eachhospital.
Thanks to advances in the assessment of health care quality
and wider publication of results from studies conducted in a
number of first world countries such as the US and the UK, it isexpected that health care providers will put a voluntary effort toimprove their future health care services. Nonetheless, prior tosuch efforts of medical providers, it is essential to develop
appropriate criteria for assessing health care quality andverifying the validity.
Conclusion
Donabedian (1980)5 mentions that those who have noexperience with the complicated system of medical practice,
are likely to think that assessing the quality of medical services
would be as easy as weighing a bag of potato chips, but in theactual settings the task is not so easy as it appears. In quality
assessment of medical services quality, there are not a few
elements involved. Indeed, it should be insured that indesigning the structure and process for targeted outcomes, therelevance to the therapeutic objective, the validity of thecausality, the sensibility, the appropriateness of timing, costs,
and the patient satisfaction, among others, are properly taken
into consideration. Since these requirements are also applied to
P4P, putting P4P in right place will be a rewarding but also
challenging task.
References[1]Jeong S, Kondo K, Inoue Y. Pay for performance in USA
and suggestion to Japan. Shakai Hoken Jyunpo.
2009;2397:20–25.
[2]Doran T, Fullwood C, Gravelle H, et al. Pay-forperformance programs in family practices in the United
Kingdom. N Engl J Med. 2006;355(4):375–384.
[3]Mehrotra A, Damberg CL, Sorbero ME, Teleki SS. Pay for
performance in the hospital setting: what is the state of theevidence? Am J Med Qual. 2009;24(1):19–28.
[4]S. Jeong, K. Kondo, N. Shiraishi, Y. Inoue：An evaluationof the quality of post-stroke rehabilitation in Japan. ClinicalAudit 2:59-66, 2010[5]A.Donabedian ： Exploration in Quality Assessment andMonitoring: The definition of Quality and Approaches to Its
Management.（1）．Health Administration Press, 1980.
Author address
E-Mail: k-jeong@n-fukushi.ac.jp

Figure 3. Decrease in variance among hospitals in Japan
Discussion
Many reports suggest that improvement in Korean medical
services has been confirmed over the course of the three years

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Total Health Expenditure and its structure in two Asian OECD countries, Japan and
Korea
Jeong-Woo Shin1)1) Department of Health Administration, School of Health Sciences, Yonsei University, Wonju, Rep of Korea.

Introduction
Improvement of economic and progress of aging increase
not only a personal concern but also social interest about health.
Beyond this, it is required to make a rational policy for
operating a health care system efficiently and allocating theresources at the national level. However, to fulfill those needs,
it is necessary to build a statistical infrastructure and healthspending is regarded as one of the most important statistics.
Total Health Expenditure(hereafter THE) is a core index
showing health spending and a National Health Accounts(hereafter NHA) gives us clear information of tendency of THE.
The NHA does clearly organize the flow of health spendingby tri-axial(Health care functions, Health care service provider
industries and Sources of financing health care). The NHA is
proceeding according to the SHA(System of Health Accounts,
hereafter SHA) guideline published by Organisation for
Economic Co-operation and Development (hereafter OECD) in2000. Each economy collects the data and implements SHA inorder to develop comprehensive and enhance a consistency.
Moreover, this concept is based on the consensus on what
element should be included or not, so the result is to ensure thecomparability of health care expenditure estimated by different
nation.
Those three kinds of element(Comprehensiveness,
Comparability and Consistency) could be a strength and a main
goal of SHA. Recently, OECD, EROSTAT and WHO havecollaborated in the joint OECD-EROSTAT-WHO Health
Accounts Data collection, they have also been engaged inprojects to develop a methodology. Nevertheless, there are lotsof problems harmonizing the criteria in several aspects such as
an experience, a limitation of data and a cultural difference.
The paper begins by presenting the meaning of the SHA
briefly which is used for collecting a data internationally, andexamining the structure of THE in two countries, Japan and
Korea. Additionally, this paper aims to provide a detailed
review of THE in both countries comparing with other OECDeconomies.
A concepts and development of SHA
As noted above, The System of Health Accounts(SHA)
proposes an integrated system of comprehensive andinternationally comparable accounts and provides a uniform
framework of basic accounting rules and a set of standard
tables for reporting health expenditure data(Orosz and Morgan,2004). It proposed in three dimensions, ICHA-HF, ICHA-HC
and ICHA-HP. Firstly, ICHA-HF is related to financing
sources. THE mainly comprises public financing(HF.1.) andprivate financing(HF.2.), and its composition determines thecharacteristics of health care system. Secondly, ICHA-HC is aclassification of Function (e.g. Inpatient, Outpatient) which isthe crucial element of the SHA. Consequently, health policymaking refers to it on the national level. Lastly, ICHA-HP
shows information of providers; hospitals, nursing andresidential care facilities etc.
The SHA has two major aims; one is to provide aframework for international data collection and the other is tosuggest a possible model for redesigning and complementing

NHA to aid policy-makers(Jeong, 2010). To achieve this, a lotof health accounts expert meeting have been holding since
1990s and ‘A system of Health Accounts’ (version 1.0) was
published by OECD in 2000. During the last decade, most of
the OECD economies are able to implement basic triaxial(ICHA-HF, ICHA-HC, ICHA-HP) according to thismanual. There was a demand for systemizing accounting
system among developing countries, and the World HealthOrganization(WHO) published NHA Producers Guide toresponse those needs in 2003. Since then, a number of OECDand non-OECD countries have undergone SHA framework andhave provide a data regarding health spending. In 2004, threeinternational organizations build a cooperative system forharmonizing National Health Accounts and collecting astandardized health statistics. Such interests in Health Accounts
are also spreading to across Asian-Pacific countries like Sri
Lanka, India and China etc. Recently, the 6th APNHAN (AsiaPacific National Health Account Network) expert meeting washeld in Korea in last July 2010 and more than 50 experts
participated from approximately 20 economies. As a result, theSHA manual(OECD, 2000) is used in a large and growing
number of OECD and non-OECD countries as the standard
accounting framework for statistics on health expenditure andfinancing.
A structure of THE in Japan and Korea
Prior to comparing the major findings of THE, it is required
to close look at the characteristics of the structure of healthspending and the data sources. Although many OECD and nonOECD economies are currently undertaking the OECD/SHA
manual, some countries(including Japan) continuously use
domestic standard. However, this makes lots of confusions.
In Japan, there are two types of representative index
showing health spending statistics, one is Japanese National
MedicalExpenditure(KokuminIryohi,
hereafter
NME)
publishedby‘Departmentof
Statistics
andInformation(Japanese Ministry of Health, Labor and Welfare)’,and the other is OECD’s Total Health Expenditure(THE)estimated by ‘Institute for Health Economics and Policy(Japan,
IHEP)’.(Jeong, 2001) The former is the total medical payment
limiting its scope to medical service covered by the healthinsurance scheme, while the latter includes not only NME
statistics but also other items like OTC drugs, health promotion
services, Japanese long-term insurance(Kaigo Hoken),administrative finances and capital formation etc. In otherwords, the NME is a subset of THE. In considering the healthspending to GDP ratio, there is a 2.6%p gap between
THE(8.1%) and NME(6.5%) in 2007. In the case of THE, it isbased on the number of statistics(around 40 kinds of statisticaldata) including NME statistics.(Mitsutake, 2010)
In Korea, estimation of health expenditure was attempted
since 1976. Initially, many scholars tried various methods, butOECD’s concept was accepted right after joining the OECDin the late 1996. Eventually, SHA-based health accounts havebeen reported annually by Jeong(focal point designated ofOECD-WHO-EUROSTAT) since 2004. Recently, a Health
Accounts Forum was organized to spread its concepts and toHA-2

develop a method. For calculating THE, a variety of sources
can be used individually or in combination.
A comparative analysis of THE in Japan and Korea
Total Health Expenditure accounted for 8.1% of GDP in
Japan, slightly less than the OECD average(8.6%) in 2007.
Although it increased 15.7% in the past 10 years, that is still
below the OECD level. Meanwhile, Korea increased
53.7%(annually 10.4%) at the same period and it reached to
6.3% of GDP in 2007, even though it ranks(28th) at the bottomof OECD members. The United States is the country which
spends tremendous amount of money on healthcare with 15.7%
of GDP in 2007. Besides, 6 countries like France, Switzerland,
Germany, Austria, Canada and Belgium followed with morethan 10% of their GDP. Overall, health spending as a share of
GDP has been increased during this period, but both of two
countries level is significantly lower than the OECDaverage.(Figure1)

15.7% in Japan, notably higher than Korea(1.7%) where caretend to be provided in informal sector such as family.
In terms of hospital expenditure, out-patient care is around
27.5% of current health expenditure in Korea where hospitals
maintain large out-patient department.(excluding a tablebecause of restricted paper)
Table1. Total public and private health expenditure byfunction (US$ PPP Per capita)
Japan(2006)
In-patient Ser.
Out-patient Ser.
Other Ser.
Medical goods
Prevention
Health Admin.
Etc.
Total

Korea(2008)OECD*

US$PPP(%)

US$PPP(%)

US$PPP

(%)

987
823
52
548
60
61
49
2,580

(38.3)(31.9)(2.0)(21.3)
(2.3)
(2.3)
(1.9)
(100)

530
593
10
463
42
56
107
1,801

(29.4)(32.9)(0.6)(25.7)
(2.4)
(3.1)
(5.9)
(100)

1,663
373
123
537
76
143
75
2,991

(55.6)(12.5)(4.1)(18.0)
(2.5)
(4.8)
(2.5)
(100)

1) * Source: Jeong, Lee, Shin and Song(2008) , 17 Countries average including
AUS, CAN, USA, ESP, PRT, DNK, NOR, CHE, NLD, KOR, JPN, DEU,
FRA, LUX, CZE, SVK and POL.

Figure1. Total Health Expenditure in Japan and Korea as ashare of GDP

Discussion & Conclusions
The major goal of SHA is to provide a set of international
standard aggregating NHA. Estimating THE using common
boundary such as OECD/SHA makes it possible to compare thelevel of health spending, as well as health care system. The
SHA manual(ver. 1.0) is scheduled to be revised in several year
for further development.

1) Source: OECD Health Data 2010(2010)
2) Excluding Luxembourg and Portugal.(2007 not available data)

As shown by Figure2, most of the OECD countries, there
is generally close agreement on the THE mainly financed bypublic sector with 71.2%. In Japan, 81.9% of THE is funded bypublic side in 2007 and this figure is almost similar to 10 years
ago(81.5%). On the other hand, the share of public spending in
Korea is obviously lower than that of OECD economies except
the USA and Mexico. Although Social security scheme andgovernment(public part) play an important role in Japan and
Korea, there is a big different composition in financing sources.
Figure2. Share of THE by financing agent

1) Source: OECD Health Data 2010(2010)
2) Excluding Luxembourg and Portugal.( 2007 not available data)

Table1 gives details of health spending by Function in
Japan and Korea. The allocation of health spending across thevarious service and medical goods shows the characteristics ofhealth care system. The table shows that Korea and Japan
report a relatively low proportion of expenditure for in-patient
services(29.4%, 38.3% respectively) comparing to OECDaverage level(55.6%). On the other hand, spending for Inpatient and Medical goods is high. Furthermore, large
differences remain between Korea and Japan in Long-term
nursing care. The ratio of Long-term nursing care accounted toThis paper explained about a concept of internationalclassification named OECD/SHA and examined total
health expenditure in two Asian countries. Although bothof them are based on a same prototype (NHI), it presents
the variations in terms of financing sources andallocation of resources. However, the analysis using
international data like this is expected to provide someevidence to assess health system performance and to aid
policy making.
References[1]Eva Orosz, David Morgan. SHA-Based National Health
Accounts in Thirteen OECD Countries: A Comparative
Analysis. OECD Health Working Papers No.16. Paris:
OECD. 2004.
[2]Jeong HS, Korean National Health Accounts and Total
Health Expenditure in 2008. Seoul: Ministry of Health andWelfare. 2010.(Korean)[3]Jeong HS, Jeremy Hurst. An Assessment of the performanceof the Japanese Health Care System. Labour Market andSocial Policy Occasional Papers No.56. Paris: OECD. 2001.
[4]Jeong HS, Lee JH, Shin JW, Song YM. Scale and structureof 2006 Total health expenditure in Korea constructedaccording to OECD/WHO/EUROSTAT’s SHA. The Korean
Journal of Health Economics and Policy. 2008;14(1):151169.(Korean)[5]Mitsutake Naohiro. 国際基凖としての医療費-OECD のSHA 手 法にづく総保健医療支出. 保健連海外医療保障.
2010;80:11-23.(Japanese)[6]OECD, OECD Health Data 2010. 2010.
[7]OECD. System of Health Accounts. Paris: Organization for
Economic Cooperation and Development. 2000.
Author address
E-Mail: jwshin@ymail.com

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