A Contract-Based Healthcare Ecosystem for Depopulated Rural Communities: Residential Risk Visibility and Incentive-Linked Health Monitoring

Debates on healthcare sustainability in depopulated rural communities have focused on technological solutions — telemedicine, drone delivery, remote monitoring. This paper addresses the structural problems technology alone cannot solve: helicopter emergency medical services (HEMS) cannot fly at night or in bad weather; severe emergencies admit no alternative to physical transport; and the healthcare costs generated by rural residence remain invisible to both residents and society. We propose a "contract-based healthcare ecosystem": (a) quantifying and visualizing the relationship between residence location and medical access as individual risk; (b) making participation in continuous health monitoring a contractual condition of new residency; and (c) linking participation and risk-management attainment to basic-income-style payments. On ethical grounds the scheme applies only to new residents, with existing residents guaranteed conventional arrangements. Extending the external-balance model of our companion paper (SocArXiv, doi:10.31235/osf.io/rcsq9_v1), we estimate that if 60 high-risk residents of a 500-person community participate in monitoring and severe events fall by 15-35%, incentive payments of 2,500-11,700 yen per person per month are offset by reduced external medical expenditure alone (break-even). This range is realistic for behavior-change incentives, implying that a scheme in which health-risk management directly contributes to community economic self-sufficiency is institutionally feasible. Ethical limits concerning privacy, stigmatization, and freedom of choice are examined from a clinician's perspective. Note: The full manuscript is written in Japanese; an English abstract is provided above.