医疗照护应如何分配ppt课件

ComparativeHealthInsuranceSystem,Chih-LiangYaungTaichungHealthcareandManagementUniversity,1,醫療照護應如何分配社會的公平個人的公平,依個人的努力與才華所獲得的財富水準即怎麼栽怎麼收獲依個人需要即各盡其能各取所需,2,醫療照護應採何種供給策略計劃經濟市場經濟,放任由個人選擇形成看不見的手強力規範政府介竹,3,醫療照護之特性,Supplyside:為高度專業病患無從瞭解所需照護之內容價格與品質提供者與利用者間資訊不對等供應誘導需求,提供可依目標收入創造需求Demandside:為正常財或luxurygoods需要的時間地點內容不可預測未能及時獲得後果常十分嚴事欠缺選擇及議價能力,4,Reportedadmissionratesforselectedprocedures:Selectedcountriesforwhichdatawerereported,1980,ProcedureCountryTonsill-CoronaryCholecyst-InguinalExploratoryectomybypassectomyhernialaparotomyrepairNumberofadmissionsper100,000populationAustralia1153214520299Canada8926219224105Denmark229-21-Ireland25649110052Japan611267-Netherlands4215131175-NewZealand102299211110Norway45133078-Sweden65-140206111Switzerland51-4911668UnitedKingdom26678154116UnitedStates2056120323841,5,ProcedureCountryProstat-Hyster-OperationAppend-ectomyectomyonlensectomyNumberofadmissionsper100,000populationAustralia183405101340Canada229479139143Denmark234255118248Ireland12412364245Japan-9035244Netherlands11638168149NewZealand19143195169Norway238-7164Sweden48145-168Switzerland-2274UnitedKingdonitedStates308557294130NOTES:Thesefiguresarenotagestandardizedandassumeequalproportionsofmenandwomen.Somearelikelytobeincomparableforartifactualreasons.SOURCE:OrganizationforEconomicCooperationandDevelopment:HealthDataFile,1989.,6,TotalHealthExpenditureasProportionofGDPandPublicHealthExpenditureasProportionofTotalHealthExpenditureamongOECDCountries,1997,*THE:TotalHealthExpenditure*PHE:PublicHealthExpenditure,7,TypeofHealthSystemsandTheirDeterminants,8,Entrepreneurial超過规定服務價格给予提供者的自付费用STC(SpecialTreatmentCharge);Out-of-pocketpaymentstoproviderbeyondstatedpriceofservice,62,家庭直接支付费用-家庭调查DirectPaymentsbyHouseholds:HouseholdSurvey,Source:YearbookofHealthInsuranceStatistics,variousyears,re-quotedfromMyungJI,1994.,63,總治療费用中自付的百分比PercentageofOut-of-PocketPaymentsoutofTotalTreatmentCosts,Note:OP=門诊服務,IP=住院服务OP=outpatientservice,IP=inpatientservicea)不包括整容手術.(Cosmeticsurgeryisnotincluded),64,衛生保健籌资HealthCareFinancing,NHE(國民衛生支出)/GDP约6%NHE(nationalhealthexp)/GDPisabout6%家庭是籌资的主要來源Householdersaremajorsourceoffinancing保險支出/NHE约25%insuranceexp./NHEisabout25%政府支出/NHE為12%governmentexp./NHEis12%直接支付/NHE為63%directpayments/NHEis63%,65,衛生预算/中央政府预算约2%左右Healthbudget/centralgovtbudgetisaround2%私立部門支配Privatesectordominates增長迅速hasbeengrowingrapidly是主要的提供者isthemajorprovider對系统的绩效影響很大muchimpactonperformanceofthesystem,66,私立提供者PrivateProviders,數量很大Largenumberof營利For-profit管制不力(Weakly)regulated按项目支付PaidbyFee-For-Service,67,公立和私立床位數PublicandPrivateBeds,Note:Numbersinparenthesisarepercentageoutoftotal.Source:1994YearbookofHealthandSocialStatistics,MinistryofHealthandsocialAffairs;andReportsbyKoreanMedicalAssociationandKoreanHospitalAssociation,68,健康保險籌资HealthInsuranceFinancing,籌资率(根據薪水)Contributionrates(salarybased)社團健康保險：3.4%(雇主和雇员平攤)CorporateHI:3.4%(sharedequallybetweenemployerandemployees)公務员健康保險：3.4%(政府和雇员平攤)CSHI:3.4%(sharedequallybetweengovernmentandemployees),-TobeContinued,69,地方健康保險保费來源PremiumbasisforRegionalHI核定收入或需纳税收入：66%(50%来自核定收入，16%来自需纳税收入)Evaluatedincomeortaxableincome:66%(50%fromevaluatedand16%fromtaxable)资產和汽車附加：34%(27%来自资產，7%来自汽車)Plusassets&automobile:34%(27%fromassets&7%fromautomobiles),70,衛生系统和保險系统的特徵FeatureswiththeHealthSystem&InsuranceSystem,公平Equity使用者支付高highusercharges無保險的服務项目昂贵expensiveuninsuredservices效率Efficiency缺乏轉診途徑(配置效率低)lackofreferralchannel(allocativeinefficiency)直到1998年，小额基金眾多，规模經濟不足(管理效率低)Upto1998,loweconomiesofscalewithlargenumberofsmallfunds(adm.inefficiency),71,特徵2(Features2),质量Quality過分依赖高成本技術highdependenceonhigh-costtechnology過度治療(如：剖腹產)excessivetreatment(C-section)大處方over-prescription對提供者不信任lowleveloftrustonproviders,-TobeContinued,72,特徵2(Features2),成本控制：成本增加迅速Costcontrol:rapidcostincrease按项目付费byFFS营利性私立提供者byfor-profitprivateproviders可持续性：资金迅速虧空Sustainability:fundsrapidlymovingintodeficits成本通货膨脹bycostinflation消费者不願支付過高的保费byconsumersreluctancetopayhigherpremiums,73,考慮衛生保健改革ReforminHealthCareAreConsidered,處方规则的變化Changeinprescriptionrule建立病人轉診渠道-家庭醫生計劃Establishingpatientreferralchannel-familydoctorprogram改革支付補償方法Reforminpayment-reimbursementmethod加强公共衛生計劃Strengtheningpublichealthprograms统一保險基金Consolidationofinsurancefunds,74,基金的统一ConsolidationofFunds,基於團结的原则Basedonthesolidarityprinciple通過健康保險加强社會公平，提高保險管理效率Tostrengthensocialequitythruhealthinsurance&toenhanceefficiencyoninsurancemanagt第一步：合併地方健康保險和公務员健康保險(共228個基金）為NMIC基金RegionalHIandCivilServantHI(totalof228funds)aremergedintofund(NMIC):1ststage第二步：合併NMIC和社團健康保險（共146個基金）為单一的NHIC基金NMICandCorporateHI(totalof146funds)willbemergedintoasinglefund(NHIC):2ndstage,75,兩階段的基金合併過程TwoStagesintheProcessofConsolidation,76,规模經濟EconomiesofScale,期待减少管理成本Reductioninadministrationcostsexpected373個基金會，每個基金會有235個支部373fundsreducedintoonefundwith235branchesLRAC预测每年可節省110億韓元的的管理成本(假設支部和基金會的成本结構相同時)LRACestimatesthat11billionWonofadministrationcostsbesavedannually(whencoststructureofbranchandfundisassumedthesame)如果將来减少支部的數量，可進一步節省成本Furthersavingsexpectedifnumberofbranchesreducedinthefuture,77,管理成本佔總支出的比例ProportionofAdministrationCostsOut-ofTotalExpenditure,社團企業保險計劃:1999年為5.6%Corporateinsuranceprogram:5.6%in1999NMIC(地區及公務员/學校员工計劃):1999年為7.2%NMIC(Regional&CivilServant/SchoolEmployeePrograms):7.2%in1999單一支付者(NHIC)2001年估計為4.7%Withsinglepayer(NHIC)in2001,estimateis4.7%,78,公平Equity,如果高風險人群是老年人或不富裕的人群，提高了公平性Gaininequityifhighriskpeopleareelderlyandthelessaffluent社會階層之間的籌资负担更公平Fairerfinancialburdenamongsocialclasses嚴格按照收入水平，而不是按照職業、地區收取保费premiumsstrictlybasedonincomelevels,butnotbasedonoccupation,geography存在的問题是：自雇人员的收入水平的確定Remainingissueistheidentificationofincomelevelsoftheself-employed,79,健康保險的其他問题OtherRemainingIssueswithHealthInsurance,覆蓋面低limitedcoverage使用者付费高highusercharges成本通货膨脹costinflation健康保險系统的破產insolvencyofhealthinsurancesystem,80,覆蓋面有限/参保自付费用高LimitedCoverage/HighUserCharges,醫療保險领域之外的高科技-激勵機制不當-低效率HightechservicesoutsidethedomainofHI-perverseincentive-inefficiency参保者自付费率超過50%(尤其针對高風險):抛棄了公平性Userchargeratesgreaterthan50%(especiallyformajorrisks):equityabandoned,-TobeContinued,81,通過擴大参保覆蓋面减少保费-增加了效率和公平Needtoloweruserchargesthruexpansionofcoverage-gaininefficiencyandequity保费水平明顯增加政治负擔Levelofcontributiontobeincreasedsubstantially-politicalburden或将覆蓋面以低風險轉向高風險-為達到收入保護，降低低MH的目標orshiftcoveragefromminorriskstomajorrisks-toachievetheobjectiveofincomeprotection,lowerMH,82,成本增加/醫療保險破產Costincrease/InsolvencyofHI,近10年來醫療保險支出增長率超过20%RateofincreaseofHIexpenditureover20%annuallyforthelast10years系统保險通货膨脹:按服務付费,私人部門利益驅動,醫療勵機制不當，政府角色不合適Thesystemisinflationarybychoice:FFS,for-profitprivatesector,perverseincentivebyHI,inappropriategovtrole,-TobeContinued,83,醫療保險的所有盈餘在幾年内耗竭ThewholesurplusinHIbedrainedinafewyears支持率降低(勞工/老人)将使醫療保險的财政状况惡化Decreasingsupportratio(workforce/elderly)willaggravatethefinancialstatusofHI宏觀（系统水平）和微觀改革都很重要Bothmacroreforms(atthesystemlevel)andmicroreformsareessential,84,醫療保險的破產InsolvencyofHI,(单位:10億韓元)(unit:billionWon)至2000年12月31日累計盈餘919億韓元AccumulatedsurplusasofDecember31,2000is919billionWon,85,政府對破產的策略GovernmentStrategiesforInsolvency,提高保險费-不易辦到Raisepremiums-noteasy提高政府對自雇主投保收益者的補贴-已考虑IncreaseGovernmentsubsidyforself-employedbeneficiaries-considered去除藥品支出的“泡沫”最近實施了新的定價政策Eliminate“bubble”indrugexpenditure-newpricingpolicyimplementedrecently,86,加强對服務提供者(醫院，診所，口腔診所，傳统醫療診所，藥房)欺詐索赔的调查-现在積極進行Strengthenedinvestigationoffraudulentclaimsbyserviceproviders(Hospitals,clinics,dentalclinics,orientalmedicineclinics,pharmacies)-activelyp