Nishio Municipal Hospital, what does it mean to "focus on acute care"?
In my notes from observing the "Nishio Municipal Hospital Future Planning Committee," I wrote about the deficit situation facing the municipal hospital. As a continuation of that, I would like to write about regional cooperation with the neighboring city of Hekinan.
Hekinan Municipal Hospital, like Nishio Municipal Hospital, continues to suffer from severe deficit-ridden management. As long as hospitals facing the same issues exist side-by-side in the neighborhood, there is a limit to how each can find solutions on its own. However, I should state in advance that I do not have enough expertise to say that they "should merge (or remain independent)." Rather, I want to deepen my understanding of regional cooperation, not just the choice between "integration" or "independence."
Although it is a paid article from Nikkei, I would like to introduce it because I thought the content was good for broadening one's perspective. It introduced a case in Kaga City, Ishikawa Prefecture, where two public hospitals, Kaga Municipal Hospital and Yamanaka Onsen Medical Center, were integrated in 2016.
In Kaga City before the integration, both hospitals had bed occupancy rates of only 60-70%, and they were forced to rely on a single doctor on duty for emergency care at night and outside of regular hours. As they downsized, with the suspension of the obstetrics and gynecology department and the cancellation of pediatric services, the acceptance rate for emergency transport also fell to less than 40% at Kaga Municipal Hospital and less than 30% at Yamanaka Onsen Medical Center. This was a situation where one in three emergency patients was being transported outside the city. It means that it had become realistically impossible to continue staffing both hospitals with doctors and nurses.
Ten years after the integration, the emergency response rate at Kaga Medical Center has improved to over 95%, and the number of doctors has increased from 37 before the integration to 57. The actual example of Kaga City shows that by consolidating personnel and assets into one, they were able to raise the quality of acute care.
Another thing that left an impression in the article was the scale of the construction costs. In 2016, the project cost for developing the Kaga Medical Center was about 10.7 billion yen. However, it is estimated that if one were to build a hospital of the same scale today, it would cost around 30 billion yen. That is nearly three times the level in about 10 years. The Future Planning Committee also expressed the opinion that building a new hospital is essential, but we must also consider whether the 36-year-old Nishio Municipal Hospital can afford construction costs of this scale.
Nishio and Hekinan are also at a similar level
At this committee meeting, I looked at the bed function report data for fiscal year 2025. It is a comparison of hospitals in the Nishi-Mikawa Southern West medical area by bed occupancy rate.
The bed occupancy rate of Nishio Municipal Hospital is 70.1%, and Hekinan Municipal Hospital is 75.6%. These figures almost overlap with the levels of both hospitals before Kaga City decided to integrate (60-70% range). On the other hand, Anjo Kosei Hospital in the north of the same medical area is at 94.2%, Kariya Toyota General Hospital is at 89.1%, and Fujita Health University Okazaki Medical Center is at 102.4%, all of which are operating at high occupancy. Since the large hospitals in the north have little capacity to act as a safety net for acute care patients, the role played by Nishio Municipal Hospital and Hekinan Municipal Hospital in the south is unlikely to become lighter, even if it becomes heavier in the future.
However, a point that cannot be treated the same as Kaga City is that while Kaga City originally had a structure that was almost completed by three hospitals within the city, the Nishi-Mikawa Southern West medical area has a structure where patients flow out to large hospitals in the north. It does not seem to be a simple matter of just making two hospitals into one.
The reason Kaga City decided to integrate was that two hospitals were each thinly maintaining the same functions. As a result of both hospitals trying to maintain obstetrics, gynecology, and pediatrics, they both lacked personnel, and the emergency response rate collapsed in a way that was close to mutual destruction.
Therefore, the idea of "not having adjacent hospitals redundantly hold the same functions" emerged, leading to thoughts of regional cooperation. This is a functional division where Nishio Municipal Hospital and Hekinan Municipal Hospital, while remaining under separate management, consolidate specific clinical departments (such as obstetrics, gynecology, pediatrics, or surgery) into one or the other, while the other takes on a greater role in recovery and community-based care. Since this can be started without going through the consensus-building for integration (resident explanations, construction of a new hospital, changes in staff status, etc.), the hurdle seems to be considerably lower.
What it means to focus on acute care
However, there seem to be difficult constraints on functional division as well. The Japanese medical system has a mechanism where each hospital reports the functions it performs to the prefecture, such as "we are a hospital that handles acute care" or "we are a hospital that handles rehabilitation and convalescence." The more a hospital strengthens its position as an "acute care hospital" in this report, the more difficult it tends to be to officially recognize the coexistence of functions such as rehabilitation and elderly care within the same hospital.
In other words, the more Nishio Municipal Hospital focuses on acute care, the more likely it is that the elderly care and rehabilitation functions it has handled so far will need to be entrusted to other hospitals or facilities. If the policy is to strengthen acute care, then we must also think about who will take on the role of the community-based care safety net. This is an area I have not yet been able to study, but if Nishio City is to focus on acute care, it seems necessary to organize this.
Another point is that if the management entities remain separate, coordination on how one will accept patients for functions that the other has downsized might take even longer than integration. It seems that how good a relationship can be built at the structural level will be important.
What the committee's "summary" indicated
The summary of the first meeting on "bed functions and the state of cooperation" was presented as follows.
・The bed occupancy rate of Nishio Municipal Hospital is on an upward trend, and acute care beds in particular are approaching their limit, leaving little room for accepting more acute care patients.
・Changes in the medical system are being made at the neighboring Hekinan Municipal Hospital, and the impact of this is expected to reach Nishio Municipal Hospital.
・While the total population of both Nishio City and Hekinan City is decreasing, the population aged 75 and over, which has high medical needs, continues to increase, and the demand for hospitalization is expected to increase.
・If the supply capacity of surrounding medical institutions remains at its current level, the medical supply for the entire region could become insufficient.
・Based on these factors, "increasing acute care beds" was cited as a direction for response.
"Increasing beds" gives the image of creating and adding new beds, but among the 321 beds at Nishio Municipal Hospital, the occupancy rate of acute care beds (230 beds) is tight at 78.4%, while the occupancy rate of community-based care beds (91 beds) is only 49.4%, with nearly half being empty. In the committee's discussion, it was pointed out that the term "conversion/relocation of beds" is closer to the reality than the expression "increasing beds." In other words, I understand this as a story of shifting the use of existing beds to the acute care side in accordance with actual medical demand, rather than increasing the framework of 321 beds itself.
The important thing is not to narrow down the options
I am not aware of the intentions of Hekinan Municipal Hospital. However, given that large hospitals in the north are operating at high capacity and are struggling to serve as a safety net, it is understandable, based on the aforementioned occupancy rate figures, that changes to the medical care system in the south would impact Nishio Municipal Hospital. If this situation continues, the discussion will likely need to move beyond just reviewing how beds are used within Nishio Municipal Hospital to include specific points regarding the division of functions with Hekinan Municipal Hospital.
While this topic is often discussed as a binary choice between integration or maintaining the status quo, there is actually a range of options, including integration, division of functions, and maintaining the status quo. Regardless of which path is chosen, the limitations of having two neighboring hospitals each thinly maintaining the same functions are clear, as demonstrated by the case in Kaga City. I hope that intermediate options, such as the division of functions, will be discussed among the expert committee members.