Article ID: JE20250285
Background: In April 2016, Japan mandated higher-level hospitals (i.e., Special Functioning Hospitals [SFHs] and Regional Medical Care Support Hospitals [RMCSHs] with ≥ 500 beds) to charge additional fees for non-referral first visits to facilitate hospital function differentiation. The mandate expanded to RMCSHs with 400–499 beds and 200–399 beds in April 2018 and April 2020, respectively. We investigated changes in referral rates (proportion of referred to first-visit patients) before and after the fee’s implementation.
Methods: Using a community-based insurance claims database from a single prefecture in Japan, we extracted claims for first visits to hospitals with ≥ 200 beds between April 2014 and March 2022 and calculated monthly referral rates to five hospital groups (SFHs, RMCSHs with ≥ 500, 400–499, and 200–399 beds, and non-designated hospitals with ≥ 200 beds). We conducted a controlled interrupted time-series analysis by hospital category, treating non-designated hospitals as controls.
Results: Of 405,087 first-visit patients (mean age 54.9 years [standard deviation 20.2]; 53.2% female), 157,734 (38.9%) had a referral. The average referral rate to SFHs was high pre-mandate and did not increase. With the mandate, referral rates to RMSCHs with ≥ 500 beds and 400–499 beds rose by 5.10% (95% confidence interval: 1.84–8.35) in 2016 and 4.49% (0.28–8.70) in 2018, respectively, and stabilized afterward. Referral rates to RMCSHs with 200–399 beds remained unchanged.
Conclusions: Average referral rates increased when the additional fee was mandated for RMCSHs with ≥ 400 beds, although the influence on health outcomes remains unclear.
