the study on japanese health care insurance and medical...

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  • 2 0 1 0 - 3

    The Study on Japanese Health Care Insurance and

    Medical Service Reimbursement System

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  • SUMMARY

    The purpose of this study aims that 1) to study the situation of the

    Japanese health insurance systems and reimbursement system, 2) to study

    the health insurance fee through translation of the Japanese health

    insurance reimbursement fee, 3) to study the situation of the revision of

    japanese health insurance fee and its implications for Korea.

    To achieve the study goal, two groups of specialist was organized. One is

    Japanese specialist of health insurance the other one is Korean specialist.

    Japanese researchers divided duties according to their specialty. Korean

    researcher translated the code book of Japanese health insurance fee. The

    results are as follows:

    In 1961 the Japanese achieved national coverage of health insurance. The

    system consists of two major pillars: The Employees' Health Insurance(EHI)

    that covers employed working population and their dependent family

    members and The National Health Insurance(NHI) that covers

    non-employed population. The Employees' Health Insurance is further

    divided into Health Insurance Societies that are established in major

    corporations and the Social Insurance Agency that covers employees and

    medium to small sized corporations.

    In 2008, the health insurance system was radically restructured. The

    elderly population aged 75 years or older was separated and covered by

    the newly created the Health Insurance System for the Old-old. The

    reimbursement is basically fee-for-service and the government sets the

    national uniform fee schedule as well as the price list of all drugs covered

    by insurance. The fee schedule is revised every two years through the

    negotiation between the government and the provider side as Japan

  • Medical Association etc. The fee schedule revision is important in health

    policy making because not only it changes the price but also it implements

    certain health policy. The implications of this study shows as follows:

    1) Treatment fee between hospital and clinic must be control to achieve

    health care delivery system.

    2) To develope preventive service items for preventing disease.

    3) Strengthen the pediatric fee for service to invigorate pediatric service for

    children.

    4) To develope the item of disease management fee for chronic disease

    patients.

  • Table of Contents

    Chapter 1. Introduction 1

    Section 1. Background and Objective 1

    Section 2. Contents and Methodology 4

    1. Contents 4

    2. Translations 5

    Section 3. Literature Review 6

    Chapter 2. Healthcare Insurance System in Japan 8

    Section 1. Healthcare System and Development in Japan 8

    1. Development of Health Insurance 8

    2. Separation of Prescribing and Dispensing Drugs 11

    3. Healthcare System for the Elderly 14

    4. Herb Medicine and Alternative Medicine 23

    5. Allied Systems of Health Insurance 25

    Section 2. Healthcare Finance and Expenditure 30

    1. Healthcare Finance and Expenditure 30

    Section 3. Healthcare Providers and Supporting Administrative System 32

    1. Ministry of Health 32

    2. Professional Associations 33

    3. Insurer Groups 36

    4. Medical Societies 37

    5. Allied Professional Groups 38

    6. Medical Service Organizations 38

    Section 4. Healthcare Insurance Society and Benefit 47

    1. Healthcare Insurance Society 47

  • 2. Non Applied Health Insurance Service 56

    Chapter 3. Healthcare Service Payment System in Japan 61

    Section 1. Healthcare Service Payment System 61

    1. Decision Rules of Healthcare Insurance Fee 61

    2. Revision of Healthcare Insurance Fee 75

    3. DPC(Disease Procedure Combination) 86

    Section 2. Healthcare Services Fee Claim, Review, Assessment and

    Related Statistics 94

    1. Claim, Review and Payment 94

    2. Review of Healthcare Services Fee Claim 100

    3. Digitalizing of Healthcare Services Fee Claim 118

    4. Assessment of Healthcare Services 126

    5. Related Statistics 130

    Chapter 4. Medical Errors and Compensation 137

    Section1. Medical Errors and Solutions 137

    Section2. Compensation of Damages from Drugs 146

    Chapter 5. Contemporary Issues of Japanese Healthcare System

    159

    1. Physician Shortage 159

    2. Criminal Liability of Medical Errors 164

    Chapter 6. Conclusions and Speculations 174

    Section 1. Characteristics of Japanese Healthcare Insurance Fee 174

    1. Characteristics of Evaluation and Management Fee and Medical

  • Management Fee 175

    Section 2. Plans for Improvement of Healthcare Insurance Fee 184

    1. Improvement of Evaluation and Management Fee 184

    2. Establishment of Medical Management Fee 187

    3. Evaluation and Management Fee Improvement for Children 189

    Section 3. Implications 190

    1. Restructuring Healthcare Delivery System 190

    2. Provision of Qualitative Healthcare Services 192

    3. Improvement of Healthcare Insurance Fee for Children 193

    Section 4. Anticipation and Application Plan 195

    Chapter 7. References 196

    Appendix 1. Japanese Health Insurance Law

    Appendix 2. Japanese National Health Insurance Law

    Appendix 3. The Index of Japanese Healthcare Insurance Fee

  • i

    1 1

    1 1

    2 4

    1. 4

    2. 5

    3 6

    2 8

    1 8

    1. 8

    2. 11

    3. 14

    4. 23

    5. 25

    2 30

    1. 30

    3 32

    1. 32

    2. 33

    3. 36

    4. 37

    5. 38

    6. 38

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    1. 47

    2. 56

    3 61

    1 61

    1. 61

    2. 75

    3. DPC 86

    2 , , 94

    1. 94

    2. 100

    3. 118

    4. 126

    5. 130

    4 137

    1 137

    2 () 146

    5 159

    1. 159

    2. 164

    6 174

    1 174

  • iii

    1. 175

    2 184

    1. 184

    2. 187

    3. 189

    3 190

    1. 190

    2. 192

    3. 193

    4 195

    7 196

    ()

  • iv

    13

    15

    15

    21

    22

    26

    29

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    35

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    10 1 40

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    3 3 45

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    2008 4 53

    () 54

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  • v

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    67

    ADL 67

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    76

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    20(2008) 78

    85

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    DPC 90

    94

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  • vi

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    [ 2] 18

    [ 3] 19

    [ 4] 22

    [ 5] 23

    [ 6] 28

    [ 7] (() ) 28

    [ 8] 30

    [ 9] 32

    [ 10] 41

    [ 11] 42

    [ 12] 100 46

    [ 13] (1996-2008) 76

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    [ 15] 89

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    [ 25] () 127

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    [ 35] (1995-2007) 165

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    2005 ()17 331,289 259.3 3,666,612 9.04

    2004 ()16 321,111 251.5 3,638,976 8.82

    2003 ()15 315,375 247.1 3,580,792 8.81

    2002 ()14 309,507 242.9 3,557,610 8.70

    2001 ()13 310,998 244.3 3,613,335 8.61

    2000 ()12 301,418 237.5 3,718,039 8.11

    1995 ()7 269,577 214.7 3,742,775 7.20

    1990 ()2 206,074 166.7 3,483,454 5.92

    1985 ()60 160,159 132.3 2,610,890 6.13

    2006(18) 2005(17)

    331,276 100 331.289 100

    121,274 36.6 120.61 36.4

    81,895 24.7 82,992 25.1

    39,379 11.9 37,618 11.4

    162,245 49 162,93 49.2

    66,923 20.2 67,082 20.2

    95,322 28.8 95,811 28.9

    47,757 14.4 47,786 14.4

    47,555 14.4 47,572 14.4

    2006(18) 2005(17)

    331,276 100 331.289 100

    250,468 75.6 249,677 75.4

    122,543 37 121,178 36.6

    127,925 38.6 128,499 38.8

    25,039 7.6 25,766 7.8

    47,061 14.2 45,608 13.8

    8,229 2.5 9,807 3

    479 0.1 431 0.1

  • 32

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  • 2 39

    (%) (%)

    2007 2006 2007 2006 2007 2006 2007 2006

    8,862 8,943 1,620,173 1,626,589 100.0 100.0 100.0 100.0

    291 292 123,208 124,191 3.3 3.3 7.6 7.6

    1,325 1,351 338,200 347,299 15.0 15.1 20.9 21.4

    123 125 36,357 36,699 1.4 1.4 2.2 2.3

    5,702 5,694 847,587 842,864 64.3 63.7 52.3 51.8

    533 604 49,061 55,161 6.0 6.8 3.0 3.4

    888 877 225,760 220,375 10.0 9.8 13.9 13.5

    99,532 98,609 155,143 159,898 100.0 100.0 100.0 100.0

    631 637 2,301 2,332 0.6 0.6 1.5 1.5

    3,827 3,896 2,931 3,003 3.8 4.0 1.9 1.9

    700 727 42 44 0.7 0.7 0.0 0.0

    34,317 32,196 95,470 94,270 34.5 32.7 61.5 59.0

    49,010 50,355 52,673 58,432 49.2 51.1 34.0 36.5

    11,047 10,798 1,726 1,817 11.1 11.0 1.1 1.1

    108,394 107,552 1,775,316 1,786,487

    : 2007

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    1988 139,542 10,034 79,752 24,598 55,154

    1989 141,849 10,081 80,572 24,372 56,200

    1990 143,164 10,096 80,852 23,589 57,263

    1991 145,817 10,066 82,118 23,369 58,749

    1992 148,359 9,963 83,394 23,151 60,243

    1993 149,878 9,844 84,128 22,383 61,745

    1994 152,532 9,731 85,588 22,082 63,506

    1995 155,082 9,606 87,069 21,764 65,305

    1996 156,756 9,490 87,909 20,452 67,457

    1997 159,284 9,413 89,292 19,796 69,496

    1998 161,540 9,333 90,556 19,397 71,159

    1999 163,270 9,286 91,500 18,487 73,013

    2000 165,451 9,266 92,824 17,853 74,971

    2001 167,555 9,239 94,019 17,218 76,801

    2002 169,079 9,187 94,819 16,178 78,641

    2003 171,000 9,122 96,050 15,371 80,679

    2004 172,685 9,077 97,051 14,765 82,286

    2005 173,200 9,026 97,442 13,477 83,965

    2006 174,944 8,943 98,609 12,858 85,751

    2007 176,192 8,862 99,532 12,399 87,133

  • 2 41

    [ 10]

    : 2007

    .

    [ 11] .

    92 127

    90 . 98

    05 36

    07 34 3,400.

    .

    2012 2011 , 15

    .

    , 22 , 3

    ()

    . 20

    4 1 .

  • 42

    [ 11] 19)

    (: )

    1987 158 35 5 0 117

    1988 163 35 5 0 122

    1989 166 36 4 0 125

    1990 168 36 4 0 126

    1991 169 36 4 0 127

    1992 169 36 4 0 127

    1993 168 36 4 0 127

    1994 168 36 4 1 126

    1995 167 36 3 2 124

    1996 166 36 3 4 122

    1997 166 36 3 6 121

    1998 166 36 3 10 116

    1999 165 36 2 17 109

    2000 165 36 2 24 102

    2001 165 36 2 27 99

    2002 164 36 2 30 97

    2003 163 35 1 34 92

    2004 163 35 1 35 91

    2005 163 35 1 36 90

    2006 163 35 1 35 91

    2007 162 35 1 34 91

    19) 2007

  • 2 43

    . 20)

    2008 ,

    ,

    " "

    .

    . , 1

    () ,

    2 (), 3 ()

    .

    .

    .

    ,

    critical

    pathway .

    critical pathway

    critical pathway .

    .

    ' ' .

    2006

    critical pathway .

    critical pathway

    . ,

    1) ( (

    20) (2007),

  • 44

    ))

    2) ( ),

    3) ( ),

    4) (() )

    ( ).

    .

    2006

    3.16% . 2006

    33 1,276 . 13.

    (') 2006 5 1 1,000

    .

    2008 8 0.38% .

    1.2%( 5.2%) 0.82%

    .

    1)

    2008

    400 .

    2008 4~6 ,

    -1.88%, () -0.31%,

    ( ) -2.64%( 15).

  • 2 45

    3 3

    )

    . N 3 (* )

    : , 2008 4~6

    (1% ), (5%

    ), ( 2%), (1% )

    .

    27%.

    90% . (

    12).

  • 46

    [ 12] 100 21)

    ) : , , ,

    : , (), 2006 6

    , , , ,

    , , IT

    , ,

    .

    21) , , 2008 1

  • 2 47

    4

    1.

    .

    .

    1927. 10 1200

    180

    .

    1938

    1961. 5,000

    .

    .

    .

    ,

    .

  • 48

    ()

    ()

    (

    )

    3,565 5

    1,700 3,012 300

    4

    19

    78 959, ,

    3,200 4,7695 , , ,

    160 393, , ,

    3,200 150

    ()

    ( ) 471,400

    75

    65~74

    ) 2006 3 , .

    1)

    ()

    . .

    ) ( )

    2008 9

    .

    . 28%

  • 2 49

    .

    ) ( )

    300

    . 1500 .

    , .

    .

    . ,

    .

    23% .

    )

    . . 7.5% .

    )

    (0.1%)

    . 2010 1

    .

    2)

    5

    . .

  • 50

    . 37% .

    , , , ,

    . 7

    .

    .

    1984

    .

    ,

    .

    .

    .

    () .

    1)

    .

    ( 8.2%)

    ( )

    (3.3%) (4.9%) 13%

  • 2 51

    .

    (: 3%~10%

    ( )

    2)

    ,

    ,

    .

    , 4, 250, 5

    A 494, B 255 .

    .

    1)

    .

  • 52

    1922 ( 11)

    , .

    1938 ( 13)

    , .

    1959 ( 34)

    .

    .

    1961 ( 36)

    ,

    .

    10 , () 5 .

    5 , () 5 .

    1963 ( 38)

    7 .

    1968( 43)

    7 .

    1973( 48) .

    70 10 .

    7 .

    1983( 58)

    70 (65 )

    . , 1 400, 2 1 300.

    2001 1 .

    1984( 59)

    8 () 7, 8 .

    , 10 () 9 ,

    1 .

    1997( 9)

    9 8 . ,

    (2001 )

    2000( 12)

    2001( 13)

    (1 )

  • 2 53

    2002( 14)

    3 7 8 .

    2003( 15)

    , ,

    7 ( 3) .

    2005( 17)

    .

    2006( 18)

    , 7 (3

    ) .

    2008( 20)

    70~74: 8 (2 ( 2010 1))

    75 : 9 (1 ), 7 (3 )

    6 3 ( )8 (2 )

    , 7 (3 )

    .

    .

    .

    2)

    2008 4

    7,

    .

    2008 4

    6 3 ( ) 20%

    6 4( ) ~69 30%

    70~74 20%2010 10%

    30%

    75 10% 30%

  • 54

    )

    .

    ) ,

    .

    .

    .

    3)

    ,

    .

    ( ).

    ()

    ()

    70

    150,000(-500,000)1%

    80,100(-267,000)1%

    35,400

    70 80,100(-267,000)1%

    62,100

    75 24,600

    15,000

    75

    80,100(-267,000)1%

    10,000

    44,400

    24,600

    15,000

  • 2 55

    4)

    ,

    .

    (

    . , 100

    50 3 35

    ).

    .

    (,

    . 100-35=65

    ).

    .

    . 1981,

    1983, 2001

    . 1998 ( ) 3,186

    2( 2237(2000.12.18) 44~45

    ).

    .

    1 3,500 . 2001 4

    2002 3 1 () 486, 368,

    68, 34, 16. 66

    63, 43 .

  • 56

    .

    (medical tourism)

    . ,

    . ,

    ,

    .

    .

    .

    .

    WHO

    .

    .

    . 1

    10 , 200 ( 210)

    . ( )

    . 200

    15%(5%10%), 1800

    50%(40%10%)

    .

    . .

    2.

    .

    .

  • 2 57

    (

    ) ,

    .

    .

    .

    All or Nothing .

    . ()

    , , ,

    ,

    . .

    ( )

    1. , .

    2. .

    3. .

    4. .

    5. , .

    6. ( .)

    (, )

    1. .

    2. evidence .

    3. .

    4. .

  • 58

    .

    . .

    2004 .

    .

    .

    .

    2007 11

    . A

    . A .

    . A

    ,

    .

    .

    .

    .

    .

  • 2 59

    .

    .

    1)

    (

    23).

    ( )

    (,investigational)

    ()

    .

    ,

    ( )

    .

    2)

    , , 200 ,

  • 60

    ( 24).

    200

    200

    180

    .

    2000

    .

    ()

    . , ,

    TV, , . , ,

    , .

    .

  • 3 61

    3

    1

    1. 22)

    ,

    , .

    , 2003 (DPC:

    Diagnosis Procedure Combination)

    .

    .

    , , .

    2

    1994 .

    18(2006) . 1 10

    .

    .

    . .

    1) 23)24)

    2 2008 , ,

    22) , , 23) 2004 , 200424) , 2008

  • 62

    .

    () , .

    2007 6 ( 25).

    (%)

    1 867 209 1,076

    1 9.8 25 131 156

    2 22.9 842 78 920

    2 6,092 31,714 37,806

    1 5.4 119 16 135

    2 2.6 235 1 236

    3 10.4 1,931 1331 3,262

    4 4.6 306 468 774

    5 11.8 19 6 25

    6 5.2 50 7 57

    7 1.8 28 0 28

    8 1.2 67 0 67

    9 7.5 502 1,912 2,414

    10 7.1 2,603 24,609 27,212

    11 1.1 141 3,364 3,505

    12 0.3 76 0 76

    13 15 0 15

    3

    2 0 2

    6,961 31,923 38,884

  • 3 63

    .

    1)

    ,

    , . 200

    .

    52

    . 5

    , ,

    5 2008 .

    .

    . 16(2004)

    19 .

    .

    ( 26).

    200 200

    6 270 270 270

    6 342 342 342

    *16 71 60 70

    6 106 95 105

  • 64

    NO

    (1 )

    /

    1 7:1 70% 1983 928 0.47

    2 7:1 70% 1923 928 0.48

    3 10: 1 70% 1728 928 0.54

    4 13: 1 70% 1520 928 0.61

    5 15: 1 70% 1394 940 0.67

    6 15: 1 40% 1382 928

    7 875 790

    8 A 1709 1695

    9 B 1320 1306

    10 C 1198 1184

    11 D 885 871

    12 E 750 736

    13 563 549

    14 7:1 70% 1847 1447

    15 7:1 70% 1787 1387

    16 10: 1 70% 1592 1192

    17 13:1 70% 1349 949

    18 15:1 70% 1298 898

    19 15:1 40% 1286 886

    20 18:1 70% 1169 769

    21 18:1 40% 1157 757

    22 20:1 70% 1125 725

    23 20:1 40% 1113 713

    2)

    1 , , ,

    ,

    .

    .

  • 3 65

    24 870 550

    25 10:1 70% 1699 1240

    26 15:1 70% 1271 812

    27 15:1 40% 1259 800

    28 18:1 70% 1183 724

    29 18:1 40% 1171 712

    30 20:1 70% 1129 670

    31 20:1 40% 1117 658

    32 850 550 0.65

    33 7:1 2267 928 0.41

    34 10:1 2012 928 0.46

    35 7:1 1777 1447 0.81

    36 10:1 1522 1192 0.78

    37 13:1 1279 949 0.74

    38 15:1 1216 886 0.73

    39 7:1 1810 1311 0.72

    40 10:1 1739 1240 0.71

    41 15:1 1338 839 0.63

    42 7:1 2067 1555 0.75

    43 7:1 2007 1525 0.76

    44 10:1 1812 1300 0.72

    45 13:1 1604 1092 0.68

    46 7:1 1867 928 0.5

    47 10:1 1612 928 0.58

    48 13:1 1404 928 0.66

    49 15:1 1266 928 0.73

    50 1 810 450 0.56

    51 2 640 280 0.44

    52 A 975 961 0.99

    53 B 871 857 0.98

    54 C 764 750 0.98

    55 D 602 588 0.98

    56 E 520 506 0.97

    57 450 436 0.97

  • 66

    ) , , , , ,

    , .

    ) 75 .

    ) . 21

    .

    ) 14

    180 60~80% .

    ) .

    3) ADL

    ( ),

    (ADL),

    15(2003) .

    (ADL)

    .

    . .

    25 1 (563/) .

  • 3 67

    3

    []

    (subacute myelo-optico-neuropathy) 24

    [ ]

    , 24 , , drain, ,

    , , ,

    2

    []

    , , , ,

    ( ), , , ,

    , , , ,

    30 ,

    [ ]

    , , , ,

    , , , , ,

    1 3, 2

    ADL . ADL

    , , 4 , (0)

    (6) .

    ADL

    ADL 1 ADL 2 ADL 3

    ADL 0~10 ADL 11~22 ADL 23~24

    ADL

    1 2 3

    ADL3 D(885/) B(1320/) A(1709/)

    ADL2 E(750/) B(1320/) A(1709/)

    ADL1 E(750/) C(1198/) A(1709/)

  • 68

    4)

    , , , ()

    , , .

    1

    . ( , , (1)

    (2), , ) 34~150.

    1

    . (1) , 5~7

    120, 8~9 130, 10 140.

    2 2

    90% .

    5)

    2008 4 .

  • 3 69

    K196

    14,000

    14,000

    9,610

    K511

    () 18,000

    (1 ) 35,900

    35,800

    (1 ) 32,700

    1 () 37,600

    K514 36,900

    1 1 41,000

    K633 () 6,000

    K634 () 20,800

    K655(

    )

    20,700

    42,600

    K655-2 30,000

    K657 32,800

    58,300

    K672 15,200

    K672-2 20,300

    K714 10,900

    K714-2 16,600

    K716 11,700

    28,000

    K718 6,210

    K719

    17,900

    25,700

    ,

    (

    )

    32,700

    K740

    (

    )27,000

    (

    )44,200

    (

    )50,100

    50,100

    .

  • 70

    .

    ,

    .

    .

    .

    . 100 .

    .

    1)

    ) 5 .

    ) .

    ) .

    ) .

    ) 1 .

    ) .

    ) ICD

    .

    ) .

    ) .

    2)

    ) 5 1 .

    ) 5

    .

  • 3 71

    3)

    ) 100

    .

    4)

    1 2

    .

    :

    1 2

    3 9,700(1) 11,200(1)

    4 7 8,775(1) 10,140(1)

    8 14 7,490(1) 8,890(1)

    ,

    .

    ( )

    .

    .

    . 2004 3 .

  • 72

    10,885

    3,205

    4,769

    35

    18,894

    .

    .

    ( )

    . ()

    . .

    5000 .

    .

    .

    . 4000

    900 , 900 , 1600

    .

    60~80% .

    .

    . ,

    .

    () .

  • 3 73

    . 10 1 ,

    1 10 .

    . 6000 , 2200

    , 1200 , 1100 , 110 ,

    1600 . 40~70% .

    . 700 .

    , , ,

    .

    .

    . , ,

    , , , 14

    .

    .

    (2008 4 )

    ()

    () 13,900,000

    4,190,000

    4) 3,300,000

    () 3,150,000

    (2) 2,810,000

    ( ,) 1,780,000

    1,630,000

    (stent-graft)( ) 1,620,000

    ( )(8) 1,460,000

    (dual chamber(4)) 1,330,000

    () 1,124,280

    ( ) 1,100,000

    1,060,000

    ( ) 1,010,000

    () 999,000

  • 74

    ()

    (sungle chamber(1)) 991,000

    ( ) 942,000

    (S) 911,000

    (S) 911,000

    ( ()) 910,000

    ( ) 866,000

    ( ) 861,000

    809,000

    ( ) 786,000

    ( ) 773,000

    ( ()) 709,000

    ( ) 693,000

    ( ) 663,000

    ( ) 660,000

    ( ) 645,000

    ( ) 624,000

    ( ) 624,000

    ( (1)) 576,000

    ( 2 ) 523,000

    ( ) 487,000

    (8) 425,000

    () 424,000

    ( (2)) 419,000

    () 419,000

    (( )) 418,000

    ( ) 382,000

    ( ) 378,000

    ( ) 377,000

    () 366,000

    (:( )) 349,000

    (, endotoxin) 347,000

    ( ) 345,000

    ((1)) 338,000

    ((2)) 334,000

    () 311,000

    ( ( )) 309,000

    atherectomy (2) 306,000

  • 3 75

    ()

    ( ) 297,000

    (stent-graft)( ) 286,000

    ( 1) 283,000

    281,000

    (()) 273,000

    (4) 269,000

    ( VDD) 262,000

    (4) 261,000

    () 258,000

    () 258,000

    (:()) 249,000

    IABP 245,000

    atherectomy 243,000

    242,000

    () 241,000

    () 239,000

    234,000

    IABP 230,000

    (: ( )) 224,000

    IABP () 222,000

    () 221,000

    220,000

    ( ) 219,000

    IABP 213,000

    (:()) 213,000

    ((1)) 210,000

    ( 1) 207,000

    2.

    .

    2 2006

  • 76

    . 12

    . ()20(2008)

    ( 35).

    20(2008) -0.82

    () 0.38%

    -1.2%

    [ 13] .

    [ 13] (1996~2008)

    . ()

    .

    .

  • 3 77

    1 , , 7

    2 , 7

    3 6

    1 2006 ( ) 1 . 2

    2 . .

    2 3, 1, 1

    .

    . 2007 10

    24 . 20(2008) 3 5

    . .

  • 78

    1100,

    400

    1500

    ,

    , , ,

    ,

    ,

    .

    71 ,

    1

    20(2008)

  • 3 79

    ()

    () 5000(

    )

    ()

    (00/50, )

    1000(1 )

    10002000(1

    )

    () 1 13

    () 1 11 1

    () 1( ) 4500

    () 300600

    () 100200

    1 300350

    2 450500

    550560

  • 80

    ,

    .

    71 ,

    1

    ()

    () 5000(

    )

    ()

    (00/50, )

    1000(1 )

    10002000(1

    )

    () 1 13

    () 1 11 1

  • 3 81

    () 1( ) 4500

    () 300600

    () 100200

    1 300350

    2 450500

    550560

    , ,

    ,

    120(14)

    105~355(

    )

    180182

    3840

    , ,

    () (IMRT) 3000(1)

    () 2 1000

    () 100

    () 1 100

  • 82

    (t-PA )

    () 12000

    () 2 2050

    ( )

    900

    600

    ,

    ()

    1 1690

    50

    2 1595

    (20 ) 6

    1

    1 1

    2 1 500, 2 400

    (1 )

    350650

    ()

    200

    () ( )

    3000

    1

    70%

    30%

    1 387/112200

    2 193/5656

  • 3 83

    ,

    ,

    () 50

    100

    () 500

    1300

    () 200

    () 900

    200

    () 2 200

    3000/1500

    ,

    1

    24

    ( )

    53005550

    530555

    24

    () 24 5400( 1)

    6000

    () 6000

  • 84

    2 , ,

    , ( )

    , ,

    .

    . .

    .

    3 5 36, 24

    8 19, 4 3 .

    , , , , ,

    .

    .

    .

    . IT

    .

    .

    .

    25).

    25) IT ,

    .

    ,

    . ,

    . . IT

    .

    ~, , 2001.12

    ~, ,

  • 3 85

    .

    .

    . 20(2008) 11

    IT

    26) .

    20027)

    . 1,000 200

    . . IT

    . .

    (2008 11)

    5 1

    .

    1 .

    .

    , . 2

    .

    , , , ,

    . .

    .

    . .

    , .

    2003.3~5

    , , 2007.9

    , , , 2008.12.21.26) , 20 11, 27) 18 IT

    200 .

  • 86

    , .

    . 2

    , .

    ,

    . .

    , .

    .

    .

    . 2 .

    . .

    .

    .

    . ()

    . Q&A

    , . .

    IT .

    .

    IT . , , ,

    . ,

    . .

    3. DPC

    . DRG DPC

    DPC

    DRG . DRG

    . ,

    DPC .

  • 3 87

    . DPC 28)

    1)

    14

    (ICD-10 ), , .

    , ,

    ,

    .

    [ 14]

    28) 2003

    DPC , ,

  • 88

    2003

    42004 4 2006 4 2008 4

    MDC 16 MDC 18 MDC

    2552

    3074 2347 2451

    1860

    1717 1438 1572

    (

    )

    MDC16 3

    2)

    DPC

    . ,

    1 3

    . .

    . 7

    .

  • 3 89

    [ 15]

    [ 16]

  • 90

    DPC

    ,

    (), ,

    1000

    3)

    , DPC

    ,

    . , DPC

    . , 24

    ,

    .

    4)

    (

    ).

    .

  • 3 91

    , .

    .

    2010 .

    . DPC ,

    DPC

    . 2003 82

    2008 28 8610 .

    91 1014 31.7% .

    : DPC DPC , 2007

    [ 17] DPC

    . DPC

    1) DPC

    DPC

  • 92

    . DPC

    .

    ,

    .

    .

    : DPC DPC (

    19(2007))

    [ 18]

    2) DPC

    . DPC

    . ,

    .

    , , ,

    . ,

    .

  • 3 93

    .

    [ 19] DPC

    . DPC

    DPC . 2

    . , ,

    , . ,

    . 1

    .

    : DPC , DPC , 2007

    [ 20] 6

  • 94

    2 , ,

    1.

    .

    . 1948

    7 (

    )

    , ( 41).

    29)

    1948 7 .

    1948 9 .

    1976 11 .

    1983 2 .

    1984 10 .

    1991 10 .

    1994 4 .

    1997 4 B5 A4 .

    1997 10 .

    1998 6

    60 .

    1999 4 .

    2000 4 .

    2002 11 .

    2003 10 .

    2006 4 .

    2007 4 .

    29)

  • 3 95

    1 13

    .

    1() 13()

    1 ()

    , , ,

    ,

    ,

    .

    13 ()

    1 .

    . 1.5 .

    . .

    . ( ) .

    . .

    .

    .

    1958 .

    45

    ( )

    .

    () .

    (

    )

    .

  • 96

    .

    [ 21] .

    [ 21]

    , , [ 22] .

    [ 22] , ,

  • 3 97

    .

    . [ 23]

    .

    6 7 8

    10 20 30 10 20 30 10 20 30

    [ 23] 6 , ,

    1) 6 7 10,

    ,

    .

    2) , .

    1 8(80)

    . 1

    .

    3) 7 20 .

    8 10

    .

    4) 8 20 8 21

    .

    5) () 1% .

  • 98

    . , 3%

    .

    6)

    . 5% .

    7)

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    , Q&A( 50 )31) http://www.ssk.or.jp/rezept/jiki_i/index.html

  • 3 101

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    A A C 2 D

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  • 3 105

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    16(2004) 7

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  • 108

    3

    100 .

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    2005 4 16 6 2 1 25

    2006 3 7 1 2 10

    2007 3 12 12

    2007 9 47 47

    2008 8 5 20 25

    40 20 6 3 3 47 119

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  • 3 109

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  • 110

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  • 3 111

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    20, 2006 10 ( 49).

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    1998 1999 2000 2001 2002 2003 2004 2005 2006

    1539 1656 1717 1688 1610 1483 1388 1139 1083

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  • 112

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    , 33~36% 2003

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  • 3 113

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    EPO erythropoietin

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  • 114

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    .

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  • 3 115

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    1999 1 13,000.

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  • 116

    . 1 . 1

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    10 .

    205 35)

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  • 3 117

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    42, 49, 75, 140, 250

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  • 118

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  • 3 119

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    1987 .

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    .

    .

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    2001 ,

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    2001 . ( 288,

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    2001 .

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    .

    .

    2011

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  • 120

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    2011 ,

    .

    400 2008

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    2009 IT ,

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    . EDI

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    36).

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    2003/3~5 http://yuhan.jp/.

  • 3 121

    5,398

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    .

    , 3 ,

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    18,604

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    (400) 166,057(3.9) 4,922(0.1) 4,073,137(96.0) 4,244,116(100.0)

    (400) 1,700,314(26.9) 1,425,466(22.6) 3,187,929(50.5) 6,313,709(100.0)

    18,410,358(61.1) 9,916,834(32.9) 1,825,209(6.1) 30,152,401(100.0)

    8,635,711(100.0) 300(0.0) 0(0.0) 8,636,011(100.0)

    482,967(2.2) 6,451,130(29.5) 14,928,348(68.3) 21,862,445(100.0)

    29,395,407(41.3) 17,798,652(25.0) 24,014,623(33.7) 71,208,682(100.0)

    .

    38). .

    37) :(2009.5.11)38) http://202.214.127.149/guest/plsql/IndexP

  • 122

    919

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    21,713

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    , .

    1,922

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    284

    92

    , , ,

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    2006 (2006 4 10 111

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  • 3 123

    . 3()

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    .

    .

    ,

    . , IT ,

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    .

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    , 8.6%

    . , , .

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    20(2008) 10

    (

    111) , 2009 1 21 .

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    2009 4 11

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  • 124

    .

    .

    . .

    ICD-10 .

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    .

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    0000999

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    .

  • 3 125

    ICD-10

    ICD-10( )

    K250 5319011

    K251 8832277

    K252

    K253 5313001

    K254 8834632

    9620001

    K255

    8830483

    8835734

    5310002

    K256

    K257 8833960

    5317003

    K259

    5319009

    8830419

    5310001

    8834146 ()

    5317002

    .

    .

    , . 1,

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  • 126

    4.

    .

    ,

    . 1976

    (), , , ,

    , , , ,

    , 1995 7 (Japan

    Council for Quality Health Care, JCQHC)39)( ) .

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    .

    1)

    2 1997

    . 1997 7 1 5 2002

    .

    2009 7 Ver. 6.0

    .

    39) http://jcqhc.or.jp/html/

  • 3 127

    [ 25] ()

    [ 25] .

    2003~04 .

    () 2002

    2005~06

    2008 11 8,832 505 5.7%

    .

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    (Structure), (Process), (Outcome) 3

    2

    .

    .

    2002 Ver. 4.0 .

    ()

    .

    100~200 1

  • 128

    . .

    .

    .

    .

    5 .

    .

    3)

    .

    2007 8 .

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    4~6 ,

    , . 2

    .

    [ 26]

  • 3 129

    4) Ver. 6.0

    2009 7 Ver. 6.0 . ,

    , , .

    , 3

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    .

    5 ,

    .

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    () .

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    , , 5

    .

    .

    .

    , Ver. 4.0, Ver. 5.0 IAP(International

    Accreditation Program, ALPHA) (International

    Principles for Healthcare Standards) . ISQua(

    International Society for Quality in Health Care)

    .

  • 130

    5.

    .

    40) 41)

    . .

    ,

    .

    , , , ,

    , , , , ,

    , , , ,

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    ,

    .

    .

    2009 5 2007 6

    . 232

    11(1) (), ()

    .

    1) : 19(2007) 6

    40) , , , ,

    .41) http://wwwdbtk.mhlw.go.jp/IPPAN/ippan/scm_k_

    Ichiran, http://wwwdbtk.mhlw. go.jp/toukei/index.html

  • 3 131

    (, ), ,

    .

    355,204 10,739 1,218

    9,521

    28,981 957

    74,544 4,501

    2) : 2008 12( )

    3) : 232

    4) 6

    .

    355,204/76,609,782= 0.00464 0.46%.

    .

    2007 6 , ,

    .

    (2007 6 )

    A 170,272,539,131

    B 76,609,782

    C 166,371,946

    D 1,656,826,956

  • 132

    12 2007 .

    2007

    2,223

    2.2

    22

    1 1,023

    1 103

    20.43

    9.1

    . , ,

    ,

    .

    , , 2007

    (%)

    16.5 59.7

    2.8 10

    DPC 1.1 4

    0.7 2.4

    3.3 12

    1.2 4.4

    2.1 7.5

    27.7 100

  • 3 133

    6 1 ()

    . DPC

    4% ,

    1.2( 4.4%)

    . () 14 . [ 27]

    14 .

    [ 27] 14 ()

    .

    4 .

    .

    .

    .

  • 134

    A100 (1454) D006 (74)

    1 7 1 1555 1 15

    2 10 1 1269 2 15

    3 13 1 1092

    4 15 1 954 23 C 260

    () ( 44)

    J038 (2266) K655 (41528)

    1 2250 1 20700

    2 1590 2 42600

    1 300 () 5000

    2 300

    3 120

    1 3(2

    ) . 1,800

    . A100 ,

    4 .

    1,454 1

    . .

    , , [ 28], [

    29], [ 30] . 1

    . .

    1, 34, 125,

    144, 144, 150 .

    , 64%

    . 3

    ( )

    .

  • 3 135

    [ 28] (: /)

    [ 29] (/)

  • 136

    [ 30] (/)

    .

    .

    .

  • 4 137

    4

    1

    1.

    1999 1

    .

    . 2

    .

    .

    2001 1 , 2003 3

    6

    .

    .

    . (

    )

    .

    1) .

    2) .

    3) .

    4) 2 .

  • 138

    .

    1) 1999

    .

    2) 2000

    .

    3) 1 6

    .

    4)

    .

    . ,

    .

    2.

    2008 226 20

    2000 .

    79 13 .

    . 1997

    99 20~40.

    1999

    .

    1999 20 4 80

    . 41 124 .

  • 4 139

    [ 31]

    , 42)

    20(2008) 1 12 1 1440.

    , 584(40.6%), 360

    (25.0%), 62(18.8%). ,

    442(30.7%), 438(30.4%), 232(16.1%)

    . , 679(47.2%), 164(11.4%) .

    193(11.0%), , ,

    .

    .

    1 29

    300 ()(43)) .

    42) 16 (21(2009) 3 24)

    43)

  • 140

    405

    12 1,440 .

    .

    236 3

    58,239 . 1 0.296

    82.26 . 278

    1 .

    .

    3.

    2 ( 32).

    [ 32]

    ,

    . .

  • 4 141

    .

    , , ,

    ( 60).

    . ,

    , ,

    .

    .

    .

    , .

    .

    .

    .

    .

    . ,

    .

    ,

    1) .

    2) .

    3) .

    4) ,

    ,

    .

    .

  • 142

    , , ,

    44) .

    .

    ,

    , , ,

    ,

    . ,

    .

    4.

    .

    13(2001) 4

    . 5

    .

    .

    2)

    12(2000)

    , ,

    ,

    , .

    44) A234 ( ) 50

  • 4 143

    3)

    .

    .

    2005 4 4

    200 .

    4)

    , , 2

    . 6 11

    ,

    .

    5.

    2004

    . 2006

    .

    2008

    .

    .

    .

  • 144

    .

    .

    1994 .

    2006

    . ,

    .

    : ,

    [ 33] ,

    6.

    .

    .

    . 2005

    8 .

    .

  • 4 145

    7.

    2009 ,

    600 20 2400,

    3000 .

    21(2009) 1

    .

    .

    , , () 98% .

    21(2009) 1 3 .

    .

    .

    .

    ,

    1)

    2)

    3)

    4) .

    8. ADR

    ADR(Alternative Dispute Resolution)(

  • 146

    1948 ,

    1949-55

    1950

    BCG

    1951

    1952

    1953

    1954

    1955

    1956 (5.15 ,

    1953~56 108 )

    1957

    ) . 2007

    (ADR) .

    10 2 .

    . 1998

    2007 ADR .

    ,

    .

    2 ( )

    1.

    .

  • 4 147

    1958-

    62,

    1961

    (11.18 )

    1962

    ( )

    ,

    (9.13)

    ()

    1963

    (6.17

    )

    1964

    SMON (5.7)

    () (

    )

    1965

    (2.16 , 5.7

    () , 1959~ 65 38

    )

    (3)( 17 , 1 )

    1966

    (

    20 3 )

    ,

    1967

    1968 (3)

    ,

    (10.4)

  • 148

    1969

    , (9.2)

    (2)

    ()

    (6)

    (12.27)

    1970

    ()

    (11.26

    )

    ( 409

    1586 )

    1970

    (11.26

    )

    ( ) (8.6 ,

    , 9.9,

    )

    (11)(1963~70 (

    ) 1000 () , 1971 11

    , 1980 )

    1971

    LSD

    (

    FDA )

    , , (

    )

    ,

    (6.30)

    (7.1)

    ,

    (9.26)

    (9, )

    ( 1, 19728 )

    IDU (, )

    , (5.28)

    , (9.16)

    , (11.20)

  • 4 149

    1972

    (3.13)

    , (7.3)

    (, )

    (20 , 11

    )

    ( , 4

    1000 )

    1973

    ( )

    ,

    (3.20)

    ()

    ,

    (6.9)

    1973

    ( ,

    )

    ,

    (12.23)

    ()

    ( ,

    )

    ( )

    ( 500?) (4)

    (10.5)

    ,

    (12.14)

    1974

    ( )

    (4.23)

    (9657, 379

    )

    ,

    (10.26), (12.11)

  • 150

    1975

    , , , ( ,

    )

    2

    ( ,

    , )

    (

    )

    (, )

    ,

    (7.31)

    ,

    (8.5)(1988~90 )

    , (10.23)

    , (12.22)

    1976

    (1970 , 1

    )

    ,

    (3.22)

    ( ,

    , )

    (X, 340

    , 5~6 )

    , 3 , 9.9

    , (6.10)

    1977

    DES()

    (2.25)

    (, )

    (10.5)

    (, )

    ,

    , (10.29)

  • 4 151

    1978

    , (3.1),

    (8.3) ,

    (3.10)

    (9.25)

    , , ,

    (12.1)

    1979 ( ,

    414 )

    (4)

    (10.15)

    ,

    ()

    1980

    ( 2)(7)

    ( 1

    , ) (9)

    1981

    (

    )

    , (2.1)

    X(1974 8 74, 19

    , 1982~88 83, 9

    )

    1982

    1983

    (4)

    ,

    1984

    (2)

    ,

    , (9)

    1985

    ( 77

    )

    767

    , 24 (,

    1/3)

    , 1 (3)

    (, 3 ,

    )(9)

    (3 17 , 7 ,

    )(11)

  • 152

    1986

    (85 51 ,

    , 90 1 17 182

    14 )(5)

    803

    , 18

    1987

    ( ,

    , ) (2)

    890

    , 19

    (

    254-T

    , 3 .)

    (2 )

    1988

    (

    4)

    (12.23)(1989.2.17 )

    ( , 88

    , 89 5

    ) (5)

    ( )(6)

    ( 5 5 ,

    )(12)

    1989

    ,

    ,

    (

    . 86 7

    )(2)

    , 13 .

    , (5.8)

    ( 11 ,

    , )(6)

    5 B

    ( ) (6)

    HIV (10.27)

    X ( 10 14

    ,

    )

    ,

    ( 2 60 )(12)

  • 4 153

    1990

    , ()

    (3 , 91 3

    2 ,

    )(4) ,

    (GC

    P) (10)

    (

    13, 3) (8)

    ,

    ( 3 5

    )(9)

    1991

    ( 4 43

    )(4

    )

    MMR ( 744 7

    , 93 4

    )(7)

    ( )

    , 3 ,

    (10)

    1992

    (4)

    ,

    (12)

    ( 1977

    16 , 76

    )(10)

    ( 3 ,

    7, 2 ,

    )(11)

    6490 6471 (

    19)

    1993

    (

    6, 20 ) ,

    , (4

    )

    1994

    (

    )

  • 154

    1995

    HIV, (7.26)

    , 4( )

    1 , 3

    ( )

    1996

    HIVHIV ,

    (3.29)

    , 92

    (2)

    CJD( )

    (11.20)

    ,

    () (7)

    , , 98

    10

    (GCP)

    1997, ( ) ,

    (3)

    ,,

    (3)

    1997

    ,

    ,

    .

    (7)

    ,

    ( )

    ,

    ( 3

    )

    1998

    , ,

    ,

    ( 8)

  • 4 155

    1999

    ,

    (TTP)

    ( 6)

    ,

    (5)

    (N IRA) ,

    (6

    )

    ,

    (8.24)

    2000

    , ()

    (8)

    , ( )

    ( 6)

    3 (2.23)

    ,

    (7), 9 , 2001 3 28.

    : http://www.mi-net.org/yakugai/

    2.

    .

    .

    .

    (Pharmaceuticals and

    Medical Devices Agency, PMDA)45) . 16(2004)

    45) http://www.pmda.go.jp/index.html

  • 156

    4 1 ,

    ,

    .

    .

    55 5

    .

    ( )

    .

    .

    .

    7 .

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    2) ( )

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    4) ( 18 )

    5) ( )

    6) ( )

    7)

    [ ]

    1) (

    )

    2)

    3)

    4)

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  • 4 157

    6)

    []

    . .

    . 2 1 .

    .

    16(2004) 4

    .

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  • 5 161

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  • 6 183

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