Silviase/jgov_v1.4_full_ann huggingface dataset:
In this research, in order to clarify the major problems caused by the anticipated demographic changes, we have shown how health care expenditure would grow over the next 30 years. Our scenario, however, is only one of numerous possible scenarios describing the effects of the Japanese health care system. Each scenario embodies a different set of assumptions about the shape of things to come. In this respect, we have to deal with the empirical results with caution.

We have estimated that the National Medical Expenditure in 2025 will rise to approximately 50 trillion yen in 1990 prices. Its average annual rate of growth will be 2.8 percent from 1993 to 2025. Particularly for the elderly, medical expenditures will be growing dramatically during the period. The growth rates of their in- and outpatient expenditures will both be above 4 percent per annum. Therefore, without health care reforms or restructuring of the current system, our society in 2025 will have to bear at least twice as high the National Medical Expenditure as in 1993.

The total burdens to the working-age population (the age group 15-64 in this study) are estimated to increase by 196 percent from 1993 to 2025. The burdens on behalf of other age groups, particularly the elderly, will increase by 305 percent. It will not be easy for the working generation to bear the entire burden, and this means that the government faces tough policy choices. In other words, without fundamental reforms in health care financing, a serious problem of income transfer will surface in the near future.

Moreover, the results of our second model suggest the following situation. In 2025, the share of health expenditures for those aged 70 years old and over is 58.8 percent with 45.2 percent for hospitals and 13.6 percent for clinics respectively. In contrast, their share in the population is 21.7 percent in 2025. In other words, 22 percent of the population will consume about 59 percent of the National Medical Expenditure. Reforms in the hospital sector should thus be given a high priority. The hospital sector will otherwise continue to provide services.
to many elderly inpatients who don't need medical cure but care. They are considered as the inpatients caused by social, and not medical, conditions. In the current copayment structures, there are favorable conditions which encourage the families with the elderly in need of care to hospitalization them. In addition to this, the phenomenon can also be attributed to the paucity of such care-providing facilities as nursing homes for the elderly. Thus, it is requisite to extend the reforms not only in the medical care field but also in the long-term care. Without fundamental reforms in these areas, efficiency in production could not be achieved, and the quality of life for the elderly could not be ensured.

Next, with respect to variations in medical expenditures across prefectures, there is a wide range of differences between age groups and between in- and outpatient care. Therefore, it is important to categorize medical expenditures on the basis of age and services in order to analyze the variations across prefectures. According to our empirical analysis, income, the number of doctors, the age structure, medical technology and the number of beds are the major factors that determine medical expenditures at the prefectural level. These individual factors have significantly different effects on health care expenditures between in- and outpatient care and between the elderly and non-elderly. This suggests that the government has to take account of these individual factors when it chooses policy measures to achieve certain aims (e.g., cost containment).

Finally, these results also enable us to evaluate some of health policies over the last decade in the context of efficiency in the allocation of medical resources. For example, it is so often pointed out that the per capita medical expenditure is higher in the western areas than in the eastern. Our study suggests that the number of beds is one of the dominant variables which determine medical expenditures for inpatient care. Therefore, regulations on the number of beds under the Regional Medical Care Plans may take a role in lessening the differences across prefectures and improving production efficiency in the hospital sector. Furthermore, as far as outpatient care is concerned, regulations on the number of doctors (e.g., through the imposition of a limit on enrollment in medical schools) also makes contribution to cost containment. However, the quality of care may have to be taken into account since changes in the number of doctors would influence it. Thus, it is requisite to consider not only the number of doctors but also their expertise and skills.
## Response to benefit in kind for outpatient treatment

○ A method (benefit in kind) of reducing the burden of patients paying high drug costs will be introduced for outpatient treatment in addition to conventional hospital treatment (enforced in April 2012). The method involves that when a patient receives outpatient treatment at the same medical institution and their monthly co-payment exceeds the maximum co-payment the insurer then makes the payment to the medical institution rather than the patient applying for the high-cost medical care benefits and receiving the benefits later, thus ensuring that the patient is only required to pay an amount which is capped at the maximum co-payment.

Case of general income earners (younger than 70) with medical expenses of ¥500,000 (30% co-payment)

Basic mechanism of benefit in kind

[1] Insured persons, etc. apply to insurers, etc. for a maximum payable amount certificate to be issued. (Same treatment as with inpatient treatment)

[2] Insurers issue insured persons with maximum payable amount certificates according to the income category of their household. (On an individual basis)

[3] Insured persons present the maximum payable amount certificates at the counters of medical institutions. Medical institutions calculate the amount of the co-payment of insured persons, etc. on an individual basis and do not collect the amount exceeding the maximum co-payment, etc.

$ ^{*} $ Co-payment for the 1% addition must be made even if the maximum co-payment has been exceeded.

[4] Medical institutions will require from insurers the amount of high-cost medical benefits in addition to receipts.
## Provision of Unitary High-Cost Medical/Long-Term Care Benefits (Enforced in April 2008, provision commenced gradually from August 2009)

• Conventional maximum monthly co-payment is individually set for health care insurance and long-term care insurance systems

• In addition to these limits, new maximum co-payment is also set for the total annual co-payments for both systems

* Maximum co-payment is set carefully according to age and income levels.

* Diet/residence expenses need to be paid separately.

## Reference case of the unitary high cost medical/long-term care system

Household with a husband receiving medical services and a wife receiving long-term care services, both 75 or older (exempted from residence tax)

(Medical care services)

Being hospitalized $ (*) $

(Long-term care services) Using multifunctional long-term care in a small group home

(Pension income) ¥2.11 million or less for a couple

(*) In case of being hospitalized in long-term care beds, hospital meal/living expenses and bed surcharges, etc. need to be paid separately (same as the current high cost medical care system, etc.)
Conceptual Chart of Insured Medical Treatment

Medical fees are classified into three types: medical, dental, and dispensing fees.

The medical fee is calculated by adding stipulated numbers of points for the individual medical activities provided (so-called "fee-for-service system"). The unit price for one point is ¥10. For a typhlitis hospitalization case, for example, the first visit fee, the hospitalization fee multiplied by the length of stay (days), the typhlitis surgery fee, the test fee and the drug fee are added to one another and medical care facility providing insured services will receive the total amount less the patient's co-payment from the examination and payment organization.

## Outline of the Revision of Reimbursement of Medical Fees of 2012

## Outline of the revision of reimbursement of medical fees of 2012 $ ^{[1]} $

• The first step revision toward realizing the ideal medical care in anticipation of the image of 2025 given in the “Definite Plan for the Comprehensive Reform of Social Security and Tax”.

• Prioritized distribution in areas that are needed for the development of environments in which people/patients can receive safe, reliable, and high-quality medical care

Overall revision rate

+0.004%

Medical fees (core)

+1.38%

(approx. ¥550 billion)

Medical services +1.55% (approx. ¥470 billion)

Dental services +1.70% (approx. ¥50 billion)

Dispensations +0.46% (approx. ¥30 billion)

Drug prices, etc. -1.38% (approx. ¥550 billion)
Overview Changes in Medical Care Expenditure

1985	1990	1995	2000	2001	2002	2003	2004	2005	2006	2007	2008	2009	2010
National medical care expenditure	6.1	4.5	4.5	$ \Delta $ 1.8	3.2	$ \Delta $ 0.5	1.9	1.8	3.2	$ \Delta $ 0.0	3.0	2.0	3.4	3.9
Medical expenditure for the elderly	12.7	6.6	9.3	$ \Delta $ 5.1	4.1	0.6	$ \Delta $ 0.7	$ \Delta $ 0.7	0.6	$ \Delta $ 3.3	0.1	1.2	5.2	5.5
National income	7.2	8.1	$ \Delta $ 0.3	2.0	$ \Delta $ 2.8	$ \Delta $ 1.5	0.7	1.6	0.5	2.6	0.9	$ \Delta $ 7.1	$ \Delta $ 3.6	-
GDP	7.2	8.6	1.7	0.9	$ \Delta $ 2.1	$ \Delta $ 0.8	0.8	1.0	0.9	1.5	1.0	$ \Delta $ 4.6	$ \Delta $ 3.7	-

(Note) 1. The national income and GDP are based on the national accounting announced by the Cabinet Office (December 2010). Total health and medical expenditure is the item used to compare the medical expenses among OEDC countries. It includes preventative services, etc. and has a wider range of coverage than national medical care expenditure. The average ratio of medical expenditure of OECD allies in 2009 was 9.5% of GDP.

2. The national health expenditure and health expenditure for elderly in their latter stage of life of FY2010 are estimated figures that were calculated by multiplying those of the previous fiscal year by the growth rate of approximate medical expenditure of FY2010. The figures in italics indicate the growth rate of approximate medical expenditure.
National Medical Care Expenditure of OECD Countries (2009)

Country	Total medical care expenditure in GDP (%)	Per capita medical care expenditure ($)	Remarks
U.S.A.	17.4	1	7,960
Netherlands	12.0	2	4,914
France	11.8	3	3,978
Germany	11.6	4	4,218
Denmark	11.5	5	4,348
Canada	11.4	6	4,363
Switzerland	11.4	6	5,144
Austria	11.0	8	4,289
Belgium	10.9	9	3,946
New Zealand	10.3	10	2,983
Portugal	10.1	11	2,508
Sweden	10.0	12	3,722
U.K.	9.8	13	3,487
Iceland	9.7	14	3,538
Greece	9.6	15	2,724
Norway	9.6	16	5,352
Ireland	9.5	17	3,781
Spain	9.5	17	3,067

Source: “OECD HEALTH DATA 2011”

Country	Total medical care expenditure in GDP (%)	Per capita medical care expenditure ($)	Remarks
Rank
Italy	9.5	17	3,137	18
Slovenia	9.3	20	2,579	23
Finland	9.2	21	3,226	17
Slovakia	9.1	22	2,084	27
Australia	8.7	23	3,445	16
Japan	8.5	24	2,878	21
Chile	8.4	25	1,186	32
Czech Republic	8.2	26	2,108	26
Israel	7.9	27	2,164	25
Hungary	7.4	28	1,511	29
Poland	7.4	28	1,394	30
Estonia	7.0	30	1,393	31
Korea	6.9	31	1,879	28
Luxembourg	6.8	32	4,451	5
Mexico	6.4	33	918	33
Turkey	6.1	34	902	34

OECD average	9.5	3,223

(Note) 1. The rank in this table indicates the rank among OECD member countries.

2. The figures marked with (*1) indicate the figures for 2008 (the figures for 2007 for Greece).

3. The figures marked with (*2) indicate estimates.

## Detailed Data 2 Structure of National Medical Care Expenditure (FY2009)

Breakdown of national medical care expenditure by system

National medical care expenditure ¥36,006.7 billion

Per capita medical care expenditure ¥282,400

• Insured persons' burden includes National Health Insurance premiums

Medical fee structure of medical institutions

• Estimates based on the results of Estimates of National Medical Care Expenditure FY2009 and Survey on Economic Conditions in Health Care (July 2009), etc.
## Overview

## Types of Medical Institutions

### 1. Hospitals, Clinics

The Medical Care Act restricts the sites of medical practice to hospitals and clinics. Hospitals and clinics are classified as follows: hospitals are medical institutions with 20 or more beds and clinics are those with no beds or 19 or less beds.

Hospitals (20 or more beds)

Medical institutions

Clinics (0 to 19 beds)

Clinics with beds (1 to 19 beds)

Clinics without beds (0 beds)

Hospitals are required to provide truly scientific and appropriate treatment to injured or sick people and are expected to have substantial facilities.

There is no strict regulation on facilities for clinics with 19 or less beds compared to hospitals.

### 2. Types of Hospitals

The Medical Care Act provides requirements (staff deployment standards, facility standards, responsibilities of managers, etc.) that are different from general hospitals for hospitals with special functions (special functioning hospitals, regional medical care support hospitals) and accepts hospitals that satisfy requirements to use the name.

In addition, separate staff deployment standards and facility standards are provided for some beds in consideration of differences in subjects of patients (patients with mental disorders or tuberculosis).

General hospitals

Special functioning hospitals (providing advanced medical care, etc.)

Hospitals

Regional medical care support hospitals

(supporting family doctors and family dentists who are taking roles in regional medical care, etc.)

Mental hospitals (hospitals with mental wards only) (subject: mental disorders)

Tuberculosis hospitals (hospitals with tuberculosis wards only) (subject: patients with tuberculosis)
## Special Functioning Hospitals

## Purpose

As part of efforts to systematize medical facility functions, the Minister of Health, Labour and Welfare approves individual hospitals having capabilities of providing advanced medical care, development of advanced medical technologies, and conducting advanced medical care training.

## Roles

☐ Provide advanced medical care

☐ Develop/evaluate advanced medical technologies

☐ Conduct advanced medical care training

## Requirements for Approval

○ Having capabilities of providing, developing, evaluating, and conducting training of advanced medical care

○ Providing medical care to patients who are referred to by other hospitals and clinics

○ Number of beds ..... Must have 400 or more beds

○ Staff deployment

• Doctors ..... Twice as many as ordinary hospitals, etc.

Facilities .....Must have intensive care units, sterile rooms, and drug information management rooms etc.

* The number of approved hospitals (as of September 30, 2009) ..... 83

## Detailed Data 2 Regional Medical Care Support Hospitals (from 1997)

## Purpose

Medical institutions that are approved by prefectural governors as being hospitals competent enough to secure regional medical care with the ability to support family doctors who are taking roles in providing regional medical care

## Roles

☐ Provide medical care to patients on referral (including the reverse case in which patients are referred to family doctors)

☐ Implement shared use of medical devices

☐ Provide emergency medical care

☐ Conduct training for regional medical professionals

## Requirements for Approval

## [Administrative body]

National government, prefectures, municipalities, special medical corporations, public medical institutions, medical corporations, etc., in principle

Providing medical care mainly to patients on referral

• Percentage of patients on referral shall exceed 80%, etc.

○ Being capable of providing emergency medical care

☐ Securing a system in which regional doctors, etc. can use buildings, facilities, and devices

☐ Providing education to regional medical professionals

☐ Having 200 or more beds, in principle, and facilities that are considered sufficient for a regional medical support hospital

* The number of approved hospitals (as of September 30, 2009) ..... 267
[An the beginning (from 1948)]

• Progress of aging

• Changes in disease structure

[Introduction of specially authorized geriatrics wards (1983)]

• In order to cope with the progress in aging and changes in disease structure, it was necessary to create facilities to provide medical care not only for elderly but for "patients requiring long-term care" in general.

[Creation of long-term care-type bed group system (1992)]

• The number of patients requiring long-term care increased due to changes in disease structure caused by the rapid progress in the birth rate decline and aging. Although various systems have been created, including long-term care-type bed group system, patients with various symptoms are still intermingled.

[Creation of general beds and long-term care beds (2000)]

Provide medical care that is suitable for patients' symptoms
Changes in Number of Medical Institutions (Hospitals and Clinics)

Year	Hospitals	National (included)	Public (included)	Others (included)	General clinics	Dental clinics
1877	159	12	112	35
1882	626	(330)	296
1892	576	(198)	378
1897	624	3	156	465
1902	746	4	151	591
1907	807	5	101	691
1926	3,429	(1,680)	1,749
1930	3,716	(1,683)	2,033
1935	4,625	(1,814)	2,811	35,772	18,066
1940	4,732	(1,647)	3,085	36,416	20,290
1945	645	(297)	348	6,607	3,660
1950	3,408	383	572	2,453	43,827	21,380
1955	5,119	425	1,337	3,357	51,349	24,773
1960	6,094	452	1,442	4,200	59,008	27,020
1965	7,047	448	1,466	5,133	64,524	28,602
1970	7,974	444	1,388	6,142	68,997	29,911
1975	8,294	439	1,366	6,489	73,114	32,565
1980	9,055	453	1,369	7,233	77,611	38,834
1985	9,608	411	1,369	7,828	78,927	45,540
1990	10,096	399	1,371	8,326	80,852	52,216
1995	9,606	388	1,372	7,846	87,069	58,407
1996	9,490	387	1,368	7,735	87,909	59,357
1997	9,413	380	1,369	7,664	89,292	60,579
1998	9,333	375	1,369	7,589	90,556	61,651
1999	9,286	370	1,368	7,548	91,500	62,484
2000	9,266	359	1,373	7,534	92,824	63,361
2001	9,239	349	1,375	7,515	94,019	64,297
2002	9,187	336	1,377	7,474	94,819	65,073
2003	9,122	323	1,382	7,417	96,050	65,828
2004	9,077	304	1,377	7,396	97,051	66,557
2005	9,026	294	1,362	7,370	97,442	66,732
2006	8,943	292	1,351	7,300	98,609	67,392
2007	8,862	291	1,325	7,246	99,532	67,798
2008	8,794	276	1,320	7,198	99,083	67,779
2009	8,739	275	1,296	7,168	99,635	68,097
2010	8,670	274	1,278	7,118	99,824	68,384

Source: 1875-1937: 1938-1952:

“Annual Report of Public Health”, Ministry of Internal Affairs

“Annual Report of Public Health”, Ministry of Health and Welfare

From 1953 and on: “Survey of Medical Institutions”, Statistics and Information Department, Minister's Secretariat, MHLW

(Note) The figures in parentheses indicate the total number of public sector medical institutions.

Detailed Data 1 Changes in Number of Hospitals by Establisher and by Number of Beds

2000	2001	2002	2003	2004	2005	2006	2007	2008	2009	2010
Total	9,266	9,239	9,187	9,122	9,077	9,026	8,943	8,862	8,794	8,739	8,670
National	359	349	336	323	304	294	292	291	276	275	274
Public medical institutions	1,373	1,375	1,377	1,382	1,377	1,362	1,351	1,325	1,320	1,296	1,278
Social insurance organizations	131	130	130	129	129	129	125	123	122	122	121
Medical corporations	5,387	5,445	5,533	5,588	5,644	5,695	5,694	5,702	5,728	5,726	5,719
Private	1,173	1,085	954	838	760	677	604	533	476	448	409
Others	843	855	857	862	863	869	877	888	872	872	869
20-99 beds	3,811	3,781	3,726	3,667	3,616	3,558	3,482	3,391	3,339	3,296	3,232
100-299 beds	3,848	3,851	3,862	3,860	3,855	3,865	3,862	3,875	3,876	3,875	3,882
300-499 beds	1,111	1,111	1,110	1,110	1,125	1,118	1,120	1,123	1,111	1,106	1,096
500+ beds	496	496	489	485	481	485	479	473	468	462	460

Source: “Survey of Medical Institutions”, Statistics and Information Department, Minister's Secretariat, MHLW
## Overview Number of Doctors, etc

The number of doctors and dentists are increasing every year. As of December 31, 2010, there are 295,049 doctors and 101,576 dentists.

Number of Medical Professionals

Number Of Medical Professionals
• Doctors
295,049 persons
• Dentists
101,576 persons
• Pharmacists
276,517 persons
Source: 'Survey of Physicians, Dentists and Pharmacists 2010', Statistics and Information Department, Minister's Secretariat, MHLW
• Public health nurses
54,289 persons
• Midwives
32,480 persons
• Nurses
994,639 persons
• Assistant nurses
389,013 persons
Source: Health Policy Bureau, MHLW (2010)
• Physical therapists (PT)
45,358.3 persons
• Occupational therapists (OT)
26,261.3 persons
• Orthoptists
5,603.4 persons
• Speech language hearing therapists
8,583.3 persons
• Orthotists
141.9 persons
• Dental hygienists
84,777.5 persons
• Dental technicians
11,651.3 persons
• Clinical radiologic technologists
46,115.8 persons
• Medical technicians
59,759.4 persons
• Clinical engineers
16,559.2 persons
Source: 'Survey of Medical Institutions and Hospital Report 2008', Statistics and Information Department, Minister's Secretariat, MHLW
* Full-time equivalent numbers
• Massage and finger pressure therapists
104,663 persons
• Acupuncture therapists
92,421 persons
• Moxibustion therapists
90,664 persons
• Judo therapists
50,428 persons
Source: 'Report on Public Health Administration and Services 2010', Statistics and Information Department, Minister's Secretariat, MHLW
* Figures were calculated with Miyagi Prefecture excluded due to the impact of the Great East Japan Earthquake
• Emergency medical technicians
37,567 persons
Source: Health Policy Bureau, MHLW (as of December 31, 2009)
## Conforming Rate to the Statutory Number of Doctors and Nurses Designated in the Medical Care Act and Sufficiency Status (Results of FY2009 On-Site Inspection)

Detailed Data 1 Regional Conforming Rates

(Unit: %)

Region Classification	Nationwide	Hokkaido Tohoku	Kanto	Hokuriku Koshinetsu	Tokai	Kinki	Chugoku	Shikoku	Kyushu
Doctors	90.0	77.8	94.4	86.6	92.6	95.5	89.8	87.9	91.3
Nurses	99.2	99.5	98.4	99.2	99.3	99.2	99.4	99.3	99.8

Detailed Data 2 Nationwide Achievement Status

Hospitals with sufficient number of doctors	Hospitals with insufficient number of doctors	Total
Hospitals with sufficient number of nurses	7,305 (88.9)	793 (9.7)	8,098 (98.6)
Hospitals with insufficient number of nurses	85 (1.1)	28 (0.3)	113 (1.4)
Total	7,390 (90.0)	821 (10.0)	8,211 (100.0)

(Note) Figures represent the number of hospitals (excluding dental hospitals). Figures in parentheses represent the percentage.

## (Explanation of terms)

• Numerical standards: Number of doctors and nurses to be deployed at hospitals designated by the Medical Care Law.

• Conforming rate: "Percentage of hospitals satisfying the designated number of doctors/nurses" in "hospitals for which on-site investigation are conducted".

• Sufficient/insufficient: Of hospitals for which on-site investigation are conducted, those satisfying the numerical standards are counted as "sufficient" and those not satisfying the numerical standards are counted as "insufficient".
Expansion of Matters that can be Advertised with the Revision of Advertisement Regulations (Medical Care Act)

• With regards to regulation of matters that can be advertised under advertisement regulation system, the system has been revised such that items with certain characteristics are grouped and regulated comprehensively as “matters regarding …” instead of listing individual matters one by one as conventionally done.

→ Substantial relaxation of advertisement regulation

• Revision from direct penalties to indirect penalties in case matters that are not advertisable are advertised

## [Example of relaxed advertisements]

$ ^{*} $ Imprisonment with work for a term not exceeding 6 months or a fine not exceeding ¥300,000.

• Specialities of medical professionals • Photographs and visual images of facilities and medical professionals • Treatment policies

• General name/development code of investigational drugs • Offered treatments and its contents in understandable manner

• Matters regarding medical devices, etc.

$ ^{*} $ These information, however, must be in accordance with laws, regulations, and guidelines.