中央社会保険医療協議会における決定の構造と過程

抄録

I explain the structure and decision-making process of the Central Social Insurance Medical Council (CSIMC). The CSIMC determines the price of each medical service that the Japanese medical insurance system covers. The CSIMC has many subcommittees to investigate and examine various aspects of the medical insurance system. Although the CSIMC makes the final decision in its jurisdiction, it delegates some of its responsibilities to these subcommittees. This council comprises three groups of members: (1) the representatives of health insurance associations, (2) the representatives of medical service providers, and (3) the representatives of the public interest from universities. Discussions on this council are open to audiences and are sporadically confrontational. Every 2 years this council discusses and revises the medical pricing system following a predetermined schedule. In April of the previous year, the council starts to discuss the problems of the present situation and set agendas to reform the pricing system. In September, the council focuses on important agendas and discusses solutions to problems. In the next year, the council determines the revised plan for the medical pricing system and reports it to the Minister of Health, Labor, and Welfare. On the council, the members play three different games. The first is the game of keeping its autonomy. In this game, members belonging to the first and second groups confront the bureau of the Ministry to resist external requests to change the system. The second is a game in which the members of the first and second groups confront considerations of the financial impact of the revised plan. The first group resists plans to expand medical insurance coverage, which will deteriorate the financial prospects of their insurance system. The third is a game in which the interests of the second group contradict and each member seeks to expand the allocation of their services. In its perspective, this council will expand its function to accommodate the changing environment of medical insurance in Japan.