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Page 2 of 6 Saiura. Mini-invasive Surg 2023;7:2 https://dx.doi.org/10.20517/2574-1225.2022.119

stagnation have been increasing the economic burden on the younger generation year by year, so much so
that the future sustainability of this burden is now a social problem and the topic of much debate. For
example, as a result of providing supportive medical care, hospital stays after surgery are much longer in
[2]
Japan compared with other countries .

Another element that is creating issues in Japan’s health system is its free access, with the freedom to see any
doctor at any medical institution without restrictions. From the patient’s point of view, medical care is
uniform and well-established, and safe medical care is available to all. As a result, the public’s expectation
for patient safety at medical institutions is very high. However, while moderate competition can improve
the level of medical care at each institution, it can also lead to excessive competition among institutions,
where inexperienced medical institutions are providing advanced medical care that leads to medical
accidents. In Japan, medical institutions have traditionally been free to develop new medical technologies
such as laparoscopic surgery. However, new medical technologies such as minimally invasive surgery,
involve many risks during their development. This environment likely led to a series of serious medical
accidents in HPB surgeries approximately 10 years ago, which were caused by laparoscopic surgery. Since
then, a new system has been established to safely introduce and disseminate highly advanced medical
technologies while respecting the autonomy of surgeons.

MINIMALLY INVASIVE-HPB SURGERY IN JAPAN
Yamakawa et al. performed the first minimally invasive HPB surgery in Japan in 1990 and Kaneko
[3,4]
performed the nation’s first laparoscopic hepatectomy in 1991 . Generally, public insurance
reimbursement in Japan is determined on a procedure-by-procedure basis, so new procedures are not
strictly covered. At that time, an insurance refund claim was filed against a hospital that referred to
laparoscopic cholecystectomy as open cholecystectomy, resulting in a major debate between academic
societies and the government. This led to the realization that it is essential for the widespread use of new
medical technologies such as laparoscopic surgery to be objectively evaluated for safety and effectiveness
and to be covered by insurance.

DISSEMINATION AND PUBLIC INSURANCE REIMBURSEMENT
Public insurance reimbursement is essential not only for minimally invasive surgery but also for the wide
dissemination of new medical technologies in Japan. As in other countries, new medical technologies must
be objectively demonstrated to be safe and effective before they can be approved by the government for
inclusion in insurance reimbursement. In Japan, treatments not included in public insurance are hence
performed at the patient’s own expense, placing a financial burden on the patient or the institution. To
alleviate the financial burden, the insurance covers a part of the treatment when a patient receives highly
advanced medical treatment approved by the Minister of Health, Labor and Welfare of Japan. The
Advanced Medical Care System (AMCS) is a partial insurance system for new medical technologies before
public insurance reimbursement. The system aims to cover the cost of the treatment by evaluating its
popularity, effectiveness, efficiency, safety and technological maturity based on the annual medical results.
After a period of evaluation, it is determined if the procedure is suitable for public insurance
reimbursement. In Japan, laparoscopic hepatectomy and pancreatectomy were included in AMCS in 2000
and 2004, respectively [Table 1]. Subsequently, laparoscopic hepatectomy was covered by public insurance
in 2010. Laparoscopic resection of the pancreatic body tail and pancreaticoduodenectomy were then
covered by insurance in 2012 and 2016, respectively.

SURGEON AND INSTITUTION QUALIFICATION SYSTEM FOR HIGHLY ADVANCED HPB
SURGERIES