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診療報酬「大幅なプラス改定は難しい」―日本病院事務研究会長

日本病院事務研究会(会長=中林梓・ASK梓診療報酬研究所長)はこのほど、東京都内で定例の勉強会を開催し、中林会長が講演の中で来年度の診療報酬改定の方向性を占った。中林氏は、当初はプラス改定が既定路線になりかけていたものの、行政刷新会議による「事業仕分け」が始まってからは、長妻昭厚生労働相らの発言が「トーンダウンした」と指摘。これらから、来年度の大幅なプラス改定は「難しい」と予想した。

　講演で中林氏は、来年度の診療報酬改定では、今年4月の介護報酬改定との整合性を取るための対応が図られる可能性が高いとの見通しを示した。
　今年度の介護報酬改定では、通所リハビリテーションに短時間・個別のリハビリテーションを評価する「1時間以上2時間未満」の区分が新設されたほか、医療保険の疾患別リハビリテーションのうち、「脳血管疾患等リハビリテーション」と「運動器リハビリテーション」の算定医療機関に対する通所リハビリテーションの「見なし指定」が認められた。
　
　一方、2006年度の診療報酬改定で疾患別リハビリテーションが導入された当初は、算定上限日数が設けられていたが、08年度改定では算定上限日数を超える場合、「1か月当たり13単位」までは算定可能になった。
　今年度の介護報酬改定までは、「1か月当たり13単位」の上限を超えた患者にリハビリテーションを提供するため、介護施設に長時間、患者を受け入れてもらわなければならなかった。

　中林氏は、医療保険上のリハビリを提供する医療機関に通所リハの「見なし指定」が認められたのは、リハビリが必要な患者の受け皿としての機能を促す狙いがあったとの見方を示した。また「見なし指定」により、介護保険でリハビリを行うことが可能になったため、次の診療報酬改定では、算定上限日数を超えた場合の「1か月当たり13単位」までの算定ができなくなると予想した。

　中林氏は、行政刷新会議による事業仕分けが始まるまでは、足立信也厚生労働政務官らがプラス改定に意欲的な発言をしていたのに対し、仕分けの開始後に長妻厚労相が上昇率を抑えたいとの意向を示すなど、トーンダウンが目立つ点を指摘。大幅なプラス改定は難しいとの見方を示した。その上で、大幅なプラス改定が見送られた場合に勤務医対策などの財源を確保するため、診療所の再診料引き下げにも踏み込む可能性があると予想した。

　前回の診療報酬改定で外来管理加算に加わった「5分要件」については、廃止される可能性が高いとの見方を示した。さらに、5分要件の見直しに伴い増加する医療費分を捻出するため、簡単な処置の基本診療料への包括化が前回から引き続き進むと予想した。

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