In the past few years, dozens of large hospitals across Japan have increased the after-hours copayment for their emergency services to discourage the patients with non-urgent conditions and focus on the care of patients with urgent conditions. We studied the effect of the copayment at the emergency department of a large suburban hospital by examining the number of patients before and after the increase in the copayment in April 2008.

We collected data on patients who visited its emergency department before （April and October 2007） and after （April and October 2008） the increase in the copayment. The copayment was set at the minimum of ¥850 to the maximum of ¥4800 according to the time of the visit, but it was waived if the visit was deemed necessary by a physician （e.g., hospitalized after the visit, referred to the emergency department, and visit after a traffic or industrial accident）, the patient was 6 years old or younger, or the patient received public medical assistance. We classified patients by their presumed urgency status into two groups: patients who arrived by ambulances （urgent） versus by other means （non-urgent）; and patients who were hospitalized after the visit （urgent） versus those who were sent home （non-urgent）. We employed Poisson regression analysis to model the number of patients of each status as dependent variables, with the amount of copayment, age, sex, and time of visit as independent variables and person-hours as control variables. Models were selected by Akaike information criteria.

After the increase in the copayment, emergency department use declined by approximately 35% among patients with non-urgent conditions but remained unchanged among patients with urgent conditions. The change was almost consistent across subgroups. Our results suggest that the number of patients with non-urgent conditions could be selectively reduced by increasing the size of copayment.

Further research to examine the possible adverse health effects among the discouraged patients is warranted.

This study investigates the employment preferences of individuals with diplomas in nursing using an online survey. We conducted the survey in two stages: in the first stage, we extracted individuals with diplomas in nursing from the pooled samples of a web service company using simple questions on employment and diploma in nursing. In the second stage, we asked the selected individuals the questions about nursing jobs, the hypothetical questions in our choice experiment, and questions about socioeconomic characteristics. Regarding the questions on nursing jobs, we asked everyone a common set of questions, but a different set of questions depending on if one is currently working as a nurse or not. In the statistical analysis, we divided the surveyed individuals into three groups: those who are nurses, those who were nurses and want to return to a nursing job, and those who were nurses and do not want to return to a nursing job.

With respect to questions about nursing jobs, women who want to return to a nursing job reported such obligations to take care of parents, babies, and themselves as problems preventing them from returning to the job. However, the salary that they need to return to the job is lower than the salary of women who are presently nurses and do not want to return to a nursing job. In contrast, regression results of the choice experiment indicates that women who want to return to a nursing job are most willing to accept a lower salary in exchange for working “the day shifts only and having 2-day weekends”. Additionally, married people in this group are more likely to accept a lower salary in exchange for these two working conditions than unmarried women. These results imply that providing “day shifts and 2-day weekends” for women who want to return to the job will increase the number of nurses working and solve the shortage of nurses.

However, satisfying women who want to return to the job with their preference for working day shifts only and having 2-day weekends off increases the strain on the present nurses. To avoid such an unfair work environment, managers in hospitals need to balance employment opportunities between present nurses and women who want to return to a nursing job. Because both groups want these two working conditions, it is effective to increase the frequencies of night shifts and 2-day weekends for present nurses instead of reducing the frequencies of night shifts and 2-day weekends off for women who want to return to a nursing job.

We identified the factors contributing to the non-payment of Japan’s National Health Insurance premiums, by taking into account the counterfactual willingness to pay if the insurance was made voluntary.

We found that, in general, income had little effect but low financial assets weakened the willingness of people to pay premiums. Also, unemployed and irregularly employed persons often fell into arrears with their health insurance premiums despite their high counterfactual willingness to pay. Thus unstable employment appears to increase the arrears by increasing the individual’s economic uncertainty. In addition, adverse selection was observed with respect to the subjective health and BMI; poor subjective health encourages the actual payment behaviors, by increasing the hypothetical willingness to pay. Finally, arrears in payment were found to be less for those who have the knowledge of the “Upper-Limit of the Individual Out-of-Pocket Payment in the National Health Insurance,” even though their hypothetical willingness to pay is low. Thus, it is expected that arrears in payment will decline when people are informed of the benefits of the upper-limits system in spite of the compulsory participation in Japan’s National Health Insurance.

There are established methodological frameworks for economic evaluation, but because healthcare systems are different among countries and have long histories, economic evaluation has to evolve and adapt to the current healthcare system or situation in each country. We surveyed health technology assessment organizations and studied the application of economic evaluation to decision-making in seven countries that utilize economic evaluation in their healthcare systems（the United Kingdom, Sweden, the Netherlands, Canada, Australia, Korea, and Thailand）. We used a common questionnaire for semi-structured interviews in every country. In these seven countries, the healthcare system is tax-based in some countries and funded by social insurance fees in others. Many countries use economic evaluation for reimbursement decision-making. While many countries target all drugs or all innovative drugs for evaluation, the United Kingdom and Thailand only evaluate selected drugs. Some countries are re-evaluating listed drugs. In many countries, reimbursement of expensive anti-cancer drugs （such as sunitinib） and drugs influential on the budget （such as long-acting insulin） is restricted. Although the experiences in countries already using economic evaluation cannot be applied directly to other countries, comparison of their challenges is valuable for countries considering the use of economic evaluation.