Welfare services for the elderly in Sweden and Denmark have a long history of incremental development. These countries have been moving from (1) an era of selectivism to (2) one of universalism, and, have passed through (3) an era of generalized health care and normalization. It is apparent that they are now moving towards (4) home care for the elderly, the decentralization of the welfare system into basic municipalities and the creation of service networks at various welfare area levels. Moreover, (5) they recognize the claim that to avoid increasing welfare costs and maintain their standards of welfare supply within the restraints imposed on expenditure, it is necessary to introduce“welfare mixing”, which optimally combines welfare supply depending on informal sectors such as private market household supply, volunteers and non-profit organizations in addition to the, public welfare supply.
In Japan, on the other hand, we believe that the replenishment of the public welfare supply for services to the elderly etc. is the optimal path to the best welfare mix. This is the new model for a Japanese-style welfare society (Maruo,1984)Care services for the elderly seem to be sufficiently provided through (i) welfare mixes from the supply point of view, and (ii) the combination of public funds, social insurance and individual undertaking of cost from the cost burden point of view.
Welfare mixing is necessary in Japan's case for future considerations; the ratio of the aging population to the total population in 2025 will be much larger than that of Sweden at this time. If dependence increases on public welfare supply, the national tax and social insurance system will be quickly overburdened. However, these are not the only reasons. It is imperative that the 21st century welfare society surpass the present national welfare models which utilize a combination of the government (public) sector and the private enterprise (market) sector as its foundation, and allow the informal and social (community) sectors to once aga in fulfill their considerable roles.

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The problem of how to provide long term care to the aged has become one of the most important political and social issues in Japan today. In spite of this, yet relatively little is known about the aged who are receiving long term care from family members. Recently, for example using the 1992 Basic Survey on Natio nal Life, Ogura has shown that, paradoxically, the incidence of long term care is the lowest among the aged in single households of all family types; typically, it is less than half of those in a three generation family.
In this paper, first, we try to solve this paradox, by imputing the institutional population to the general households using the 1990 Census, on the basis of sex, age and marital status. The imputed institutional population is then added to those needing longer term care in each family type, and the rate of incidence is then recomputed for each sex, age class, and family type. As a result of this imputation, for most family types, the rate of incidence has become a smooth rising curve of ages, and single households have the highest incidence of all family types.
Secondly, using these incidence rates, we compute the nu m ber of those aged needing long term care for all municipalities in 17 prefectures and compared the bases of all their municipalities of a hypothetical public insurance for long term care. Two indices are computed for this purpose; the first one being the number of those above 40 years old for each one receiving long term care, and the second one being the number of those above 20 years old for each one receiving long term care. The government is proposing public insurance for long term care operated separately by each municipality covering those above 40 years old or older. Even in terms of prefectures as a whole, our indices show, the strongest, Saitama, which is about twice the size of the weakest, Okayama, in our sample. The distribution of municipalities are quite wide within prefectures. The difference in the insurance taxes, therefore, will be even more pronounced once the regional and local differences in the incidence of long term care which have been ignored in our estimates is taken into account. K

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In April,1990, Inpatient Comprehensive Fee System (comprehensive fee in which everything from pharmaceutical, injection, and laboratory tests are included) was introduced.1,006 geriatric and convalescent hospitals (approximately 10% of all hospitals in country) have chosen the system. Although these hospitals are often observed as to give fewer and less variety of laboratry tests and pharmaceutical, the effect has not been confirmed. In the effort to grasp the actual effect, this study examined the change in the types and quantity of the pharmaceutical given, using pharmaceutical statistics from these hospitals. In addition, based on the questionnaires to the doctors of these hospitals as well as the survey of patients' ADL, elder care and pharmaceutical were reviewed for the future.
The study looked at the effect of the inpatie n t comprehensive fee system (partial fixed payment system) on the drug usage in elder care in four hospitals. In short, the findings differed considerably among the four.
Besides some exceptions, however, many hospital use less number and types of drugs since the fixed fee system was introduced. Especially, the number and types of those drugs for circulatory system (code 8), for digestive syetem (code 10), and for nerve system (code 11) have decreased significantly.

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This report is based on our survey conducted in Japan during April 1996. We collected data regarding clinical judgement of Japanese gynecologists. The data consisted of a survey with six fictional patient cases which represent common criteria for hysterectomy (e. g. endometriosis, uterine cancer). The doctors were asked if they would perform the hysterectomy under each case. If the answer was yes, we asked if they would perform the hysterectomy within one month. Besides these yes/no questions, there was space for personal comments and basic questions (e. g. age, sex, the length of experience). Surveys were sent by mail to 3,000 of the 16,500 gynecologists-chosen at random-in the Japanese Association of Gynecology. Of the 3,000, surveys sent,634 were retumed. We repeated this procedure in the United States and England in 1990.
While the real perfomance rate of hysterectomy in the U. S. and England is dramatically different (twice the rate in the U. S. as compared to England), our results showed that the clinical judgements of doctors in those two countries are quite similar. In contrast, Japanese doctors are much less likely to perform a hysterectomy than American or English doctors according to our survey. In particular, Japanese doctors are less likely to perform a hysterectomy if the situation is not life-threatening.

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In this paper we examine the supervision of registered nurses involved in care service production in hospitals. Hospitals engage registered nurses, practical nurses, and nursing aids as inputs to produce care services. According to the law, registered nurses are the only ones who can direct practical nurses and nursing aids, and with out the supervision of registered nurses, practical nurses and nursing aids are prohibited from carrying out their duties. Therefore, it is possible that the supervision is considered to be a type of transaction cost rather than an input of production. We get the following results from the cost minimizing model of hospitals in accounting for the supervision of registered nurses. To employ practical nurses and nursing aids, a part of the registered nurse labor hour should be assigned to supervision. Because it makes the labor cost of practical nurses and nursing aids for hospitals more expensive than the wage that practical nurses and nursing aids receive, hospitals will employ practical nurses and nursing aids less and registered nurses more. If the load of supervision were expanded, the employment of practical nurses and nursing aids would decrease and the employment of registered would increase. The load of supervision depends on the condition of patients, the ability levels of staff etc. These results can be applied to the choice of the regulated prices for care (Kijun Kango).

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This paper clarifies issues of medical care where patients principally determine the treatment policy, provides directions to solve the issues, and proposes a concrete solution.
1. ISSUES
1 ) In Japan patients rarely understand the medical staff's explanations completely, and in addition many patients are too embarrassed to ask the me d i cal staff questions.
2) F urthermore, the medical staff usually do not have enough time to adequately explain the patient's situation or the content of the prescribed med i c al care, thus there is a lack of information disclosed to patients resulting in a g ap between patients and the medical staff in terms of the type of the medi c a l care preferred. The ultimate result is that the patients principally det e r mine the direction of care.
2. STEPS TO HELP SOLVE THESE ISSUES
1) Frequent use of written explan a tions in addition to verbal communication which is normal in clinical settings.
2) Utilize empirical data for di sclosure under the control of the government or a related professional society.
3) Utilize research data when a difference between patients and medical staff tends to emerge in terms of the range of the medical care preferred where pati e n ts mainly determine the care protocol.
4) Encourage hospitals to show their care policies in order that patients can easily select an appropriate hospital.
5) Create public systems to support the above in addition to each hospitals' and staffs efforts.
3. A CONCRETE PROPOSAL
One possible s o lution includes the above-stated first, second and last steps. The proposal is as follows: Develop written materials which describe the effectiveness, risks and side-effects of specific medical procedures. These materials should be developed by the government or a related professional society. Establish rules which require the medical staff to show patients and explain those materials before undertaking medical care. In addition, rules may be tied to the social health insurance.
If this proposal materializes, patients' decision possibilities will be clarified in the clinical settings concerning certain medical procedures.

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Is the value of being healthy the same across all ages? The paradigm of QALY's to date have assumed this to be true, and do not discriminate between a QALY to an elderly and a QALY to a child. But on the other hand, it is possible, as has been done in DALY's (Disability Adjusted Life Years), to think of the value being different according to the age. This paper introduces a Dutch empirical study on the value of health at different ages, and reports on the results of its reproduction in Japan.
There are three hypotheses to be tested: 1. That the relative value of health will decrease with age; 2. That this negative correlation will be independent of the respondent's age; 3. That relative age values can be expressed in interval scales. In the original Dutch study, nore of the three hypotheses were rejected. In Japan, the results depended on the respondent's age. A negative age-value profile was obtained from the younger respondents but the profile from the elder respondents had a peak around age 35. The third hypothesis cannot be rejected, but it should be noted that there was a large variation in the responses.
There were many responses in the reproduction which could not be quantified, and an additional series of non parametric analyses were carried out in order not to waste the preference information collected.

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