{"id":4794,"date":"2026-07-13T05:30:54","date_gmt":"2026-07-13T04:30:54","guid":{"rendered":"https:\/\/blogs.bmj.com\/medical-ethics\/?p=4794"},"modified":"2026-07-13T05:30:54","modified_gmt":"2026-07-13T04:30:54","slug":"a-right-that-exists-only-as-a-billing-rule-is-not-yet-a-right","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/medical-ethics\/2026\/07\/13\/a-right-that-exists-only-as-a-billing-rule-is-not-yet-a-right\/","title":{"rendered":"A right that exists only as a billing rule is not yet a right"},"content":{"rendered":"

By George Kujo, Kazuya Iwai and Shunsuke Takagi<\/em><\/p>\n

Suppose a hospital lets you sit with your dying mother only because, if it refuses, it loses a payment. Has it honoured her right to your company \u2014 or merely met a condition on its invoice? This is not a thought experiment. It is, in effect, the model Japan adopted this year.<\/p>\n

In June 2026, Japan\u2019s revised national medical fee schedule<\/a> took effect \u2014 the schedule setting hospital payments under universal public insurance. For the first time, the rules expect hospitals to write, publicise and periodically review their visiting policies, and not to bar family visits without legitimate reason, such as infection control, keeping any restriction no stricter than necessary. Hospitals falling short cannot claim the associated payments. Against the pandemic-era routine of arbitrary bans, this is real progress \u2014 and we welcome it.<\/p>\n

But notice what kind of progress it is. The reform tries to curb a permission-based model \u2014 one in which the hospital decides a patient\u2019s contacts \u2014 by making cleverer use of that very model. The instrument is the billing system; the aim is to limit hospital discretion. Yet a rule enforced through payment leaves the hospital as the discretionary authority, answerable to a payer, not the patient.<\/p>\n

The patient appears nowhere as a rights-holder. No statement entitles patients to keep company with people of their choosing, no burden on the hospital to justify a limit, and no route lets a patient or family ask why a restriction is necessary, when it will be reviewed, and how it might be challenged. If a hospital restricts anyway, the patient\u2019s only remedy is a civil suit after the fact \u2014 a route effectively closed to someone who is hospitalised now, or dying now.<\/p>\n

This is not abstract. Separation harms patients. For older people and those with cognitive impairment, the absence of familiar faces deepens confusion; in a Japanese study, visitation restriction was associated with a more than threefold increase in the odds of delirium<\/a> among emergency admissions. At the end of life, and in maternity care, exclusion compounds distress exactly when company matters most.<\/p>\n

How thin the new rule is became visible at once. This spring two Tokyo hospitals faced the same measles epidemiology, in the same weeks, and reached opposite conclusions. In late May, one lifted its measles-related restrictions<\/a>, citing falling case numbers. On 27 May, the other announced<\/a> that from 1 June \u2014 the day the new requirements entered into force \u2014 young children would be barred from visiting shared maternity rooms, with no stated review date and no end condition.<\/p>\n

We do not suggest either judgement was inherently wrong \u2014 infection control is a serious responsibility, and hospitals may legitimately differ. Whether that restriction is in fact \u201cno stricter than necessary\u201d is precisely the question the rule ought to make answerable \u2014 and it is a genuinely contestable one. But the rule provides no forum in which anyone, least of all the patient, can put it. A rule grounded in the patient\u2019s right would require each hospital to say why a restriction is necessary, when it will be reviewed, and what would end it. A billing standard requires only a policy document on file \u2014 and in a payer\u2019s audit, compliance collapses to precisely that: whether it exists.<\/p>\n

Other systems begin from the other end. In the United States, the federal conditions for Medicare and Medicaid payment start from the patient\u2019s visitation rights<\/a>: written policies, a clinical reason for any restriction, and each patient told of their rights. Those rules, also enforced through payment, did not prevent harsh pandemic restrictions either; a rights-based rule guarantees nothing on its own. But the two designs differ on three functional points, not merely in drafting style: who may complain \u2014 there, the patient, through a grievance process the hospital must operate; who bears the burden of justification \u2014 the hospital, which must show a clinical reason; and what remedy exists short of a lawsuit \u2014 complaint, investigation, corrective action. Japan\u2019s new rule provides none of the three. The difference is not whether payment is the lever \u2014 it is, in both systems \u2014 but whether the rule equips the patient or merely instructs the biller.<\/p>\n

None of this needs to wait for new legislation. Within the fee schedule it controls, the ministry could require that any restriction state, in writing, its review date, its end condition, and a patient contact for reconsideration \u2014 the same documentary logic the reform already uses, pointed, for once, at the patient. The deeper gap, though, only a statute can close: Japan still has no patient rights law. One of us has argued in this journal<\/a> that restrictions outlasting an emergency demand proportionality review and genuine sunset mechanisms. Japan\u2019s 2026 reform is a real step against arbitrary restriction. But a right that exists only as someone else\u2019s reimbursement condition is not yet a right. Visiting is not a benefit a hospital grants. It is part of what lets a patient remain a person while they are ill \u2014 and that is not something to be found, or lost, in a billing file.<\/p>\n

 <\/p>\n

Authors and affiliations:<\/strong><\/p>\n

George Kujo \u2014 Independent researcher, Japan. ORCID: 0009-0006-6864-0145<\/p>\n

Kazuya Iwai, MD PhD \u2014 Department of Infection Control, Shizuoka City Shizuoka Hospital, Japan. ORCID: 0009-0003-4834-8807<\/p>\n

Shunsuke Takagi, MD \u2014 Takagi Clinic, Japan. ORCID: 0009-0007-0338-706X<\/p>\n

Corresponding author: <\/strong>George Kujo \u2014 George.kujo.irjp@gmail.com<\/p>\n

Competing interests: <\/strong>None declared.<\/p>\n","protected":false},"excerpt":{"rendered":"

By George Kujo, Kazuya Iwai and Shunsuke Takagi Suppose a hospital lets you sit with your dying mother only because, if it refuses, it loses a payment. Has it honoured her right to your company \u2014 or merely met a condition on its invoice? This is not a thought experiment. It is, in effect, the […]<\/p>\n

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