The reform of the health care delivery system has been one of the most important policy issues in the health care reforms in Japan scheduled in 2002. Considering the nature of strongly regulated health care service delivery, the reform is expected to have an impact on the management of medical institutions.
One of the most salient features of the Japanese health care delivery syst e m is its capital-intensive nature. The number of inpatient care beds per population and the average length of hospital stay in Japan are the highest and longest respectively among the G-7 countries. The Government reform plan considers reducing the number of hospital beds to the level in other OECD countries.
Under such circumstances, medical institutions are compelled to make difficult decisions of choice and concentration of resources. Acute care specialized hospitals and integrated service delivery complexes of medical care and health and social services are two promising ways of differentiation in the health care delivery system in Japan. The role of leadership is extremely important in the strategic decision making process and proper management is required to take consumers'needs into account and to be more responsive to them.

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Many players, such as the Ministry of Health, Labour and Welfare, the Japanese Medical Association, and the Ministry of Finance, have separate opinions about health care reform.
The important things that we should take into consideration are the characteristics of medical goods, such as universality of health needs, uncertainty, imperfectness of information, private goods, merit goods, methodological goods and non-retradable goods.
The allocative efficiency has two aspects. To improve consumptive efficiency, price mechanisms should not be used, however to improve productive efficiency, the price mechanism is effective.

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The current health care system in Japan has various problems that need to be tackled, such as improving the quality of medical services and controlling rapidly increasing health care expenditures. However, most of these problems are attributable to the issues related to the service supply system. Indeed, reforming the health care service supply system is essential for future Japanese health care policy. In this paper, enhancing payer's function, which has been discussed as a practical measure for health care reform, is examined from the viewpoint of the health care service supply system.
The primary definition of the payer's function is providing insurance coverage for its enrollees in a continuous and stable way while balancing financial results. However, this primary function will not necessarily be granted to individual payers under the public health insurance scheme due to the degree of social mission. Thus the important points of the debate regarding payer's function in Japan are i) the payer's role under the public health insurance scheme, and ii) the rationality and appropriateness of the payer's organization.
In this paper, several practical proposals, which include a) evaluating the quality of hospitals and clinics, b) directly assessing the medical bills claimed by health care institutions, and c) offering better service to the insurance enrollees, were examined from the aspect of i) reinforcing the transparency with respect to clinical information, ii) controlling health care expenditures, and iii) improving the quality of medical services. Although some of them seem to induce positive effects, I concluded that the impact would not be enough to lead to the drastic reform of our system.
As the debate regarding payer's function is one of the key factors in the health care reform discussion in Japan, further empirical studies are required to make this argument meaningful.

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Owing to the development of managed care, prices of hospital services and income from them were seriously contained in the early to the mid 1990s in the United States. Hospitals thus attempted to recover pricing initiative by increasing regional market share by way of consolidating their businesses, while reorganizing and coordinating their functions so as to be chosen not only by insurers but also consumers and patients. Based on these environmental changes, this paper describes how the Integrated Delivery System (IDS), typical of consolidated hospital service provider, has grown and what it is.
First, we focus on management of American hospitals that have been “central arena” of acute care, and try to understand in chronological order why the IDS has been developed. Next, we look into players that have played chief roles in its growth process and “methods to combine” its components, to analyze variations of the IDS. Thirdly, we discuss “carve-out,” a way of outsourcing some services in the IDS, since it provides us with an interesting perspective. While IDS is essentially a way to amalgamate fragmented healthcare functions, this carve-out is an example of removing some of them in order to improve efficiency.
Finally, as summary to the studies in 4 cases (Kaiser Permanente, Sutter Health, Catholic Healthcare West, and On Lok, all of which are not-for-profit organizations), we present history/process of growth, overall evaluation on effect of the integration and evaluation on how far the process has been consolidated.

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Many European countries are reviewing their health care systems and the suitability of their existing approaches to financing, organizing and delivering health care services. As health care reform is deeply associated with the normative, economic and organizational characteristics of each country, programs to achieve better expenditure control and greater productivity and efficiency need to be balanced with solidarity principles, such as equal access.
In order to attain this difficult goal, most western European countries have tried to adopt contract-based health care reform. Contracts define the relationships between different categories of participants in the health care system. Two approaches are used for contracting. First, contracting is used as an instrument of health care planning and management in both competitive (i. e., the UK and the Netherlands) and non-competitive environments (i. e., France and Germany). For this purpose, contracting is regarded as the formalization of the planning and management process. Second, contracting is regarded as a tool for increased choice of providers (i. e., the UK and Sweden). Although the cost-containment effect of contracting is still unclear, most European countries formalize the contracting within their health care reforms. Along with the implementation of the contracting approach, most European countries have developed a health information system that is indispensable for contracting procedures. In particular, hospital information systems based on casemix classification are widely adopted (i. e., Nord-DRG in the Nordic countries, GHM in France, AR-DRG in Germany, HRG in the UK).
In summary, policymakers in most European countries are moving away from command and control strategy and are placing greater emphasis on accountability and contestability through the development of contracting mechanisms.

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Investigation with actual trials about the bundle payment system is currently under way in Japan. The disease classification used for the investigation still plays an important role as a basis for analyzing the investigated results since the classification is closely related with other elements. Since it was our natural conclusion that failure of the disease classification to properly function made the proper preparation and operation of the intended system difficult, we investigated by re-analyzing information obtained in the DRG-related investigations and studies conducted in the past in Japan whether the disease classification used for the investigation met the intended purposes to make it suitable for the investigation, or what should be changed if the classification was not suitable. We focused our analyses on the number of days spent in hospital and their dispersion instead of the consumption quantity of resources, and confirmed that the classification in 183 categories being used for the investigation was rather small in its variation coefficient, and not inferior in comparison with AP-DRG of the United States of America and other Japanese disease classification systems. But since only a classification system having a small variation coefficient was deliberately selected to be used for the investigation, the above was the inevitable conclusion even taking into consideration the fact that no resource consumption quantity information was included in developing the disease classification system. It is possible that the good parts of the current classification system may be lost in the process of revisions, and therefore, it is suggested that careful study of how to revise the classification system and its purpose is needed.

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This article tries to analyze the efficiency of the service marketing theory in the medical services. Up to the present, academic research in medical institutions in the field of social science such as medical economics and other various fields has been studied in depth and has been outstandingly successful. However, profitable enterprises are dealing with service marketing as an academic realm, and the number of cases of actively using or conducting research on service marketing theory to adapt medical institutions must be very few. Service marketing has a different, original framework compared with conventional products marketing. In this article, as compared with other service goods, after clarifying the specific features of the medical service, on that understanding, we considered the adaptability and development of the service marketing theory for the patient. Then we practiced the experimental investigation and cited the examples and the study analysis which can be easily made use of by medical institutions themselves.

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A rapidly aging society with a low birthrate must pay serious attention to health economics. Economic evaluation is now an accepted method of appraising healthcare programmes designed to distribute health care efficiently. Although economic evaluation is widely used in the fields of medicine and pharmacy, its use in the field of dentistry is only now becoming popular worldwide. Moreover, it is no exaggeration to say that in Japan, economic evaluation in the field of dentistry is non-existent.
The purpose of this paper is to review previous studies of economic evaluation in the field of dentistry. This review reveals that these studies are of insufficient quality and have various problems. Whilst an understanding of economic evaluation in the field of dentistry is undeniably lacking, the need for it is clearly becoming more important and of increasing worldwide interest. The development of this understanding and a thorough study of economic evaluation in the field of dentistry are necessary.

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