In April 2016, Japan introduced a fixed extra fee at large hospitals for patients who come for a first visit without a shōkaijō, a letter of introduction from another doctor. Advanced treatment hospitals and regional medical support hospitals with 500 or more general beds were obliged to collect it.
When the rule was introduced, the Ministry of Health, Labour and Welfare set the fee for a first visit at 5,000 yen, or 3,000 yen at a dentist. The amounts have since been revised.