令和 6 年度診療報酬改定に関する声明

令和 6 年度診療報酬改定において、通院在宅精神療法が指定医で 330 点→315 点、非指定が 315 点→290 点と大幅な減点となった。それを補うものとして早期診療体制充実加算が新設されたものと思われたが、診療所における算定要件として、「初診における60 分以上の通院・在宅精神療法を一定期間内に所定の回数行うこと」等の厳しい基準が設けられ、当該算定要件は、長時間の精神療法を一定回数、一定期間内に求めるものであり、診療所で勤務する医師の就業時間を初診の精神療法という特定の業務に重点的に割り当てるよう誘導するものである。
しかし、診療所に勤務する医師は常態的に多数の患者を診療しており、地域によっては初診の予約に一定期間の待機を要する事態も発生しているほどである。また、自院の外来診療時間以外に国家行政・地域行政の公務等に出務する医師も多く、地域の診療ニーズに対応するだけの診療時間を確保しながら同時に公的業務への時間を捻出している現状がある。そのような中、医師の限られた就業時間を初診の精神療法という特定の業務のみに誘導することは、外来精神科診療所に通院する患者の療養環境を悪化させるだけでなく、精神科診療所に勤務する医師の公的業務への積極的貢献を阻害するものである。
また、仮に今回の診療報酬改定の意図が、外来診療ニーズへの対応ならびに公的業務への協力と、初診時精神療法の長時間化の両立を、医師の就業時間の延長によって実現しようとすること”であるとするならば、精神科診療所における医師の働き方改革をなおざりにするものと受け取らざるを得ない。医師の就業時間の適正管理が、診療の質や医療安全の確保において必要不可欠であることは言うまでもなく、それは精神科診療所においても例外ではない。精神科診療所に勤務する医師が医療の質と安全を担保するために、公的業務への協力を自粛せざるを得ないという事態も発生し得るだろう。
「早期診療体制充実加算」の算定要件は、600 万人以上と言われる我が国の精神科外来通院患者の療養環境悪化、診療所に勤務する医師の地域医療や公的業務への協力自粛、医師の働き方改革の形骸化を招くものであり、我が国の精神科医療や労働行政が目指す方向性と完全に逆行するものである。ひいては我が国全体の精神科医療の質の低下と入院から地域へという地域の保健医療福祉体制の脆弱化を招くものであり断固反対する。

公益社団法人日本精神神経科診療所協会
会長 三木和平Statement concerning FY2024 Revision of Medical Reimbursement In the 2024
revision of medical fees. Outpatient home psychotherapy was significantly
reduced from 330 to 315 points for designated physicians and from 315 to 290
points for non-designated physicians. However, the calculation requirements
for clinics were set to strict standards, such as "the prescribed number of
outpatient and in-home psychotherapy sessions of 60 minutes or more for theinitial visit within a certain period of time," etc. These calculation
requirements require that long-duration psychotherapy be provided a certain
number of times and within a finite period. This requirement is intended toinduce physicians working at clinics to allocate their working hours to a
specific task, namely, psychotherapy for initial consultations. However,physicians working at clinics routinely treat a large number of patients, andin some areas there is a situation where patients must consequently wait acertain period of time for their first appointment. In addition, manyphysicians are engaged in official duties for national and regional
governments while also fulfilling their own outpatient clinic hours, and hence
have to make time for their official duties while ensuring that they haveenough clinic hours to respond to the medical needs of the community. Under
such circumstances, directing physicians' limited working hours to a specificservice, such as initial psychotherapy, will not only worsen the medical careenvironment for patients attending outpatient psychiatric clinics, but will
also discourage physicians working at psychiatric clinics from actively
contributing to public services. If the intention of the revision of medical
fees is "to realize a balance between responding to the needs of outpatients,
cooperating with public services, and extending the length of initial
psychotherapy by extending the working hours of physicians," this would beseen as a neglect of reforming the working styles of physicians in psychiatricclinics. If this is the case, we must accept it as an attempt to neglect thereform of doctors' working hours in psychiatric clinics. It goes without
saying that proper management of physicians' working hours is essential forensuring the quality of medical care and medical safety, and psychiatricclinics are no exception. In order to ensure the quality and safety of medicalcare, doctors working in psychiatric clinics may be forced to refrain fromcooperating with public services. The "additional fee for early treatment
system" requirement will lead to the deterioration of the treatment
environment for Japan's estimated 6 million outpatients, the voluntary refusalof doctors working at clinics to cooperate in community medicine and publicservices, and the dismantling of the doctor's work style reform. This iscompletely contrary to the direction that Japan's psychiatric care and laboradministration are taking. We are firmly opposed to this policy, as it willlead to a decline in the quality of psychiatric care in Japan as a whole andthe weakening of the regional health and welfare system, which has shiftedfrom inpatient to community-based care. Japan Association of Neuropsychiatric
Clinics Chairman Kazuhira Miki