Part two of this article examines development and diversification of 155 private non-university hospitals with 500 beds or over (from then on, private large hospitals)in 45 years between 1951 and 1996.
The main results are as follows. (1) About 70% (107) of private large hospitals are owned by medical juridical foundation-de facto physician-owned foundation or each physician. (2) half (80) are psychiatric hospitals, one third (51) are general hospitals and 15% (24) are geriatric hospitals. (3) Distinct bi-polalization of private large hospitals to acute hospitals and chronic ones ( geriatric hospitals and psychiatric hospitals) is detected. (4) There is a strong association between type of hospital beds and set-up year of each hospital; half of geriatric hospitals are newer hospitals that were established after 1980. Two thirds of psychiatric hospitals were set up during 1950s and 1960s. (5) Number of private large hospitals increased rapidly during 1980s, at which so called“winter era of hospitals”was labeled. (6)Average period between set-up year and the year when each hospital's bed exceeded 500 is 26 years; this period is only ten years in geriatric hospitals and the third hospitals of multi-hospital systems. (7) Contrary to the conventional wisdom that majority of hospitals in Japan have their antecedent clinics, only 40% had such clinics. In psychiatric hospitals, this rate was as low as 20%. (6) Half of private large hospitals are owned by multi-hospital systems, and average hospital beds of systems is about 1,500. There are 13 multi-hospital systems with 2,000 beds or over,11 of which have large hospitals with 500 beds or over. (8) Many large hospitals have entered the health and social services market and have become the“health-care complex”; half had nursing homes or related facilities, and half had nursing schools or schools for allied health profession.

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Vol. 7 (1997) No. 3 p. 20
revised part：text

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In this paper, I discussed the issue of R&D policy in medicine, with special references to clinical research. First of all, emphasis was placed on how this issue overlaps the issue of the Japanese economy as a whole. Next I surveyed the role of private resources of the R&D in general industries and how it can be contrasted with that of medicine. Finally, I discussed the future of R&D in medicine will depend on several different views on health care in Japan.

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Health Policy of Japan has been centering on health insurance policy, but there is a growing need for the establishment of health technology policy (or biomedical research policy) with the backdrops of ageing population, advent of new technologies and increasing importance of ethical issues.
In this paper, basic models for understanding the relationship of biomedical innovation and health care costs are examined, and based on the review of policy developments in other countries, policy agenda for Japan are discussed.

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Medical expenditure is occupying larger and larger part of the national budget. The tendency is world wide. Many proposals are made for combatting this problem. None of them satisfied the people.
The progress of medical technology has opend possibility of curing hitherto incurable diseases. As a consequence, it often pushed the medical expenditure upward. As the medical expenditure cannot be allowed to increase indefinitely, the future development of the medical technology has to change acctodingly; it has to take cost-effectiveness into consideration. The biotechnology can be considered as an information-based technology, and it has a great potential for providing us inexpensive technologies. Problems arising from the future development of biotechnology will be discussed.

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As M. Crichton wrote, medicine has evolutionary advanced but its essentials has not changed in recent years. Future medicine must clarify aims and goals. The key words of future medicine as science should be brain research, embryo research and medical informatics, and as technology medical engineering, gene engineering and computer. These key words are considered to be common in the advanced societies. At the same time, the cost benefit analysis of medicine itself is becoming an unavoidable matter. The duties of medical professionals are increasing.

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Starting in the 1970s In the United States, bioethics developed mainly as an‘applied’research field aiming at; (1) a re-definition of the doctor-patient relationship, based on the concept of a persons individual self-destination; (2) the preparation of ethical guidelines for the medical profession; (3) the coordination between the medical world and other social sub-systems, especially the legal system. Intellectually, bioethic thinkling in the United States has been mainly evolving with reference to a liberalist individualism, affirming any individuals right to control knowledge and information concerning his or her own body, medical history, personal and family history, as well as his or her genes. By contrast, in a European-and especially French-context bioehics has been often interpreted synonymous to efforts at the definition of fundamental and universal bioethical principles. Increasingly, the regulation of novel medical technologies is recognized as a major issue by bioethic traditions in various countries. As a matter or fact, it is mainly this direction that bioethic thinking has developed most vigorously. The present situation in Japan, in part relating to the particular organization of the medical profession in this country, is still very much characterized by the absence of political tools for the forging of a social consensus on the appropriate use of novel technologies in medicine.

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The economics of innovation suggests that three issues are relevant in the discussion of research and development in the pharmaceutical industry. The first is the inappropriability of scientific and technological knowledge. In the pharmaceutical and biotechnological research in particular, the distance from basic research to development research is small, making the spillover from universities to the industry particularly important. As a consequence, an argument is often made that basic medical and biotechnological research should be publicly supported and the university-industry research collaboration should be fostered. The second is the importance of demand as a factor for innovation. The Japanese pharmaceutical market has a peculiar demand structure because of the government pricing policy, the national health insurance scheme, the doctors' tendency to maximize revenue from dispensation of drugs, and the imperfectness of information. It is likely that such peculiarity has been biasing the R&D of drug companies. The third is the possibility of economies of scale and of scope in R&D. Although the majority of past studies have been rather doubtful about the presence of such economies in pharmaceutical research, a recent study using detailed data of major American and European drug makers suggests that economies of scope may arise from pursuing research projects in a number of therapeutic classes.
This paper examines these three issues in detail and discusses the current problems in the pharmaceutical research in Japan.

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The increasing health care expenditure has been a problem in the Netherlands as it has been in other developed countries. They have tried to reform their health care system under the slogan of“Regulated Competition”to solve this problem. Its main purpose is to make resource allocation of health care services more efficient by introducing competition in their health care system.
In the Netherlands, they prepare both health insurance for short-term care and compulsory health insurance for long-term care. Since“Plan-Dekker”and“Plan Simmons”, the Dutch health care reform has attempted to make health care market competitive by rendering insurance corporations agents of consumers. Since 1989, they introduce policies which have aim both to make insurance corporations select health care providers and to allow consumers to be free to bind contracts with any insurance corporation. Though, after Mrs. Borst's statement in 1995, they suspend the reform for the time being, we can learn from the Netherlands many things such as an idea and a way to reform health care system because both Japan and the Netherlands adopt social insurance.

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