اندازه گیری تاثیر اصلاحات بیمارستان دولتی محلی ژاپن بر هزینه های پزشکی ملی از طریق رگرسیون داده های پانل  Measuring the impact of Japanese local public hospital reform on national medical expenditure via panel data  regression

1. Introduction Finance strategy and delivery system are two major essential aspects for improving the health care quality and its system in Japan. The success of Japanese health care system is considered as a result of an appropriate balance of these two aspects (Hashimoto et al., 2011; Ikegami et al., 2011; Shibuya et al., 2011). Namely, Japanese hospitals have been struggling to deliver qualified care while dealing with financial challenges. On the one hand, the publicly financed universal health coverage has been established since 1961 (Ikegami et al., 2011). In 2011, the whole population was covered by 5 major health insurance schemes and approximately 3500 insurers which share the same co-payment structure (MHLW, 2013). All prices of medicine, devices and medical care services are tightly regulated by the government using a nationwide unified fee schedule. All providers, both private and public, deliver the same services at the same prices under the fee schedule. Furthermore, the high-cost medical care program was established to mitigate the medial cost burden of household when its expenditure exceeds certain limit (KEMPOREN, 2013). This system guarantees all residents have access to necessary and adequate medical services (Jeong and Hurst, 2001; Jones, 2009) Budget constraints for patients are substantially reduced when they look for health care. On the other hand, the Local Public Hospitals (LPH) were constituted to ensure that health care could be equally delivered to residents in need. In Japan, the private sector dominates the health care system, accounting for N80% of hospitals and 70% of beds nationwide. The nature of the private sector leads private medical facilities to pursue “profit” rather than public functions (Jones, 2009; Zhang and Oyama, 2016). The Japanese government considers LPH system as an important countermeasure against increasing regional disparity in health resources by providing the government subsidized policy-based medical services (PBMS). The PBMS includes high-tech medical care, emergency services, health care in less densely populated and remote areas and other non-profitable medical care services, services which private medical facilities are either unwilling or unable to provide. The LPHs have been playing an important role such as promoting technology innovation and more advanced technologies in order to attain higher health care quality for the system. During the first decade of the 21st century, the soundness of the Japanese health care system was challenged by the recession of economy (Takeda, 1995) and a number of problems in the LPH system high operating costs, huge debt, unfavorable management and substantial brain drain (Matsuda, 2008). Some local governments had to reorganize, downsize or even close LPHs to reduce their financial burden. This situation aggravated regional imbalances in health care resources and impaired equal access of the health care system. In late 2007, a LPH reform was implemented by the Ministry of Internal Affairs and Communications (MIC). From technological viewpoints we can say that the LPH reform has been an LPH innovation. Multiple measures were included in the reform, aiming to tackle not only the management problems of LPHs but also imbalances in health care resources.