Chang Chao-Kai, Xirasagar Sudha, Chen Brian, Hussey James R, Wang I-Jong, Chen Jen-Chieh, Lian Ie-Bin
Yuan-pei University, Taipei City, Taiwan, Republic of China Taiwan Nobel Medical Institute, Taipei, Taiwan.
University of South Carolina, Columbia, USA
Inquiry. 2015 Aug 30;52. doi: 10.1177/0046958015601826. Print 2015.
Third-party payer systems are consistently associated with health care cost escalation. Taiwan's single-payer, universal coverage National Health Insurance (NHI) adopted global budgeting (GB) to achieve cost control. This study captures ophthalmologists' response to GB, specifically service volume changes and service substitution between low-revenue and high-revenue services following GB implementation, the subsequent Bureau of NHI policy response, and the policy impact. De-identified eye clinic claims data for the years 2000, 2005, and 2007 were analyzed to study the changes in Simple Claim Form (SCF) claims versus Special Case Claims (SCCs). The 3 study years represent the pre-GB period, post-GB but prior to region-wise service cap implementation period, and the post-service cap period, respectively. Repeated measures multilevel regression analysis was used to study the changes adjusting for clinic characteristics and competition within each health care market. SCF service volume (low-revenue, fixed-price patient visits) remained constant throughout the study period, but SCCs (covering services involving variable provider effort and resource use with flexibility for discretionary billing) increased in 2005 with no further change in 2007. The latter is attributable to a 30% cap negotiated by the NHI Bureau with the ophthalmology association and enforced by the association. This study demonstrates that GB deployed with ongoing monitoring and timely policy responses that are designed in collaboration with professional stakeholders can contain costs in a health insurance-financed health care system.
第三方支付系统一直与医疗费用的上涨相关。台湾的单一支付者全民健康保险（NHI）采用总额预算制（GB）来实现成本控制。本研究考察了眼科医生对总额预算制的反应，具体包括实施总额预算制后低收益和高收益服务之间的服务量变化及服务替代情况、随后的国民健康保险局政策反应以及政策影响。对2000年、2005年和2007年匿名的眼科诊所理赔数据进行分析，以研究简易理赔表（SCF）理赔与特殊病例理赔（SCC）的变化。这3个研究年份分别代表总额预算制实施前时期、实施总额预算制后但在地区服务上限实施前时期以及实施服务上限后时期。采用重复测量多级回归分析来研究在调整诊所特征和每个医疗市场内竞争情况后的变化。在整个研究期间，简易理赔表服务量（低收益、固定价格的患者就诊量）保持不变，但特殊病例理赔（涵盖涉及提供者不同努力程度和资源使用且计费具有灵活性的服务）在2005年有所增加，2007年没有进一步变化。后者归因于国民健康保险局与眼科协会协商并由该协会执行的30%的上限。本研究表明，通过持续监测以及与专业利益相关者合作设计的及时政策反应来实施总额预算制，可以在医疗保险资助的医疗系统中控制成本。
