Sepehri Ardeshir, Chernomas Robert, Akram-Lodhi Haroon
Department of Economics, University of Manitoba, Winnipeg, Manitoba, Canada, R3T 5V5.
Health Policy Plan. 2005 Mar;20(2):90-9. doi: 10.1093/heapol/czi011.
The introduction of a comprehensive system of user charges in 1995 provided public health facilities in Vietnam, especially hospitals, with a growing source of revenue. By 1998 revenues from user charges accounted for 30% of public hospital revenues. Increasingly, provider incomes have relied on fee revenues and provision-based bonuses, the effect of which is that a poorly regulated fee-for-service system has replaced a salary system based upon a centrally determined global budget. This paper examines the potential influence of providers' on the use of publicly provided health services. Using facility-based data over the period 1996-98, the relative contribution of treatment intensity is compared and contrasted under the two sources of hospital revenues from patients, namely a user charge system and a third party payment system based on fee-for-services. The primary focus of the comparison is on the treatment intensity for all hospital contacts, hospital admissions and the length of hospital stays, decisions normally taken by the providers and over which patients have little or no influence. The results indicate that growth in patient revenues was associated with large increases in intensity. The growth in intensity was more pronounced in the case of inpatient contacts. Moreover, both the admission rate and the length of hospital stay were far higher for better off individuals than for the poor, and greater for the insured than the uninsured. The increase in the intensity of hospital care for both health insurance enrollees and the uninsured can be seen as, among other things, an attempt on the part of providers to increase revenue from health insurance premiums and user charges in the face of a shrinking share of public resources allocated to hospitals, and low wages and salaries.
1995年引入的全面用户收费系统为越南的公共卫生设施，尤其是医院，带来了日益增长的收入来源。到1998年，用户收费收入占公立医院收入的30%。医疗机构的收入越来越依赖收费收入和按服务量发放的奖金，其结果是，一个监管不力的按服务收费系统取代了基于中央确定的整体预算的薪资系统。本文研究了医疗机构对公共提供的卫生服务使用情况的潜在影响。利用1996 - 1998年期间基于机构的数据，比较并对比了医院从患者获得的两种收入来源（即用户收费系统和基于按服务收费的第三方支付系统）下治疗强度的相对贡献。比较的主要重点是所有医院就诊、住院和住院时间的治疗强度，这些通常是由医疗机构做出的决定，患者对此几乎没有或没有影响力。结果表明，患者收入的增长与治疗强度的大幅增加相关。住院就诊情况下治疗强度的增长更为明显。此外，富裕人群的住院率和住院时间远高于贫困人群，参保者的住院率和住院时间也高于未参保者。医疗保险参保者和未参保者的住院治疗强度增加，除其他因素外，可以被视为医疗机构在分配给医院的公共资源份额不断减少以及工资水平较低的情况下，试图增加医疗保险费收入和用户收费收入的一种尝试。
