this is because as part of the casemix scheme a conversion factor is applied to reflect hospital historical charge an important number of acts and services are paid outside of the dpc and hospitals can further charge by a traditional feeforservice scheme if the hospitalisation is prolonged beyond a specified period taken together these arrangements might undermine hospital efforts to improve performance and provide incentives to shift costs to services paid outside of the dpc component evidence demonstrates that outpatient expenditures increased by between and in hospitals participating to the dpc payment scheme and readmission rates have also increased from to between and these figures might reflect inappropriate incentives associated with the hospital payment structure although japan compares well to other oecd countries in terms of the evenness of doctors geographical distribution available evidence suggests persisting problems of workforce supply in hospitals in for example the mhlw estimated that emergency care physicians were lacking across the health system