This is because as part of the case-mix scheme, a conversion factor is applied to reflect hospital historical charge, an important number of acts and services are paid outside of the DPC and hospitals can further charge by a traditional fee-for-service scheme if the hospitalisation is prolonged beyond a specified period. Taken together, these arrangements might undermine hospital efforts to improve performance, and provide incentives to shift costs to services paid outside of the DPC component. Evidence demonstrates that outpatient expenditures increased by 4.1% between 2002 and 2003 in hospitals participating to the DPC payment scheme, and readmission rates have also increased from 4.7% to 9.7% between 2002 and 2004. These figures might reflect inappropriate incentives associated with the hospital payment structure. Although Japan compares well to other OECD countries in terms of the evenness of doctors’ geographical distribution, available evidence suggests persisting problems of workforce supply in hospitals. In 2010 for example, the MHLW estimated that 725 emergency care physicians were lacking across the health system.