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National Health Insurance in Taiwan – Part III

National Health Insurance in Taiwan – Part III. Topics : Is the National Health Insurance (NHI) system effective ? Are the NHI improvement measures effective?. Group members: Jodie KWONG (04427778G) Lawrence CHAN (04703452G) Phiona SO (04726717G) Remus Au (04726219G)

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National Health Insurance in Taiwan – Part III

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  1. National Health Insurance in Taiwan – Part III Topics : Is the National Health Insurance (NHI) system effective ? Are the NHI improvement measures effective? Group members: Jodie KWONG (04427778G) Lawrence CHAN (04703452G) Phiona SO (04726717G) Remus Au (04726219G) Vicky LAM (04727185G)

  2. Presentation Outline • Different elements in the NHI system analyzed based on Evaluation Model – • Equity and Capacity • Cost effectiveness • Cost containment • Quality • Risk pooling • Sustainability • Evaluation of improvement measures mentioned in Part II of presentation.

  3. 1. Equity & Access

  4. By the end of 2003: • over 90 percent (17,259 in total) of medical institutions in Taiwan had joined the NHI program • 183,103 medical personnel in Taiwan • over 62,000 beneficiaries were served under health care improvement programs By the end of 2004: • 99 percent of the total population were covered by the NHI program and the public satisfaction rates of nearly 80 percent

  5. Access • After the implementation of those policies on improving short of qualified medical personnel and facilities in rural and remote areas, medical service accessibility in these areas considerably improved. • Uneven distributed geographically and by specialty. • The overall ratio of physicians per 1,000 population in 2001 was 1.37, it was only 0.33 among Taiwan’s aboriginal people and 0.8 in the mountainous areas and offshore islands. • Shortages also have been identified in psychiatric bed capacity and community rehabilitation centers. • Shortage of practitioners in certain medical specialties.

  6. 2. Cost Effectiveness

  7. Cost Effectiveness Defined as achievement of the greatest health outcome with the use of a given amount of resources Based on cross-country and self comparison of health expenditures as a share of GDP and also general health indicators

  8. Limitations • More thoughtful interpretation of cost-effectiveness needs to examine the system’s impact on health status improvements, as isolated from the impact of climate, the population’s geriatric make-up, life-style, diet, age structure, health knowledge and care seeking patterns • Some information difficult to collect and quantity

  9. Total Health Expenditures as % of GDP1983-2003 NHI Total Health Expenditures Out-of-pocket Health Insurance Government Sector

  10. Health Services Expenditure as % of GDP in Selected Countries in 2000

  11. Outcome -Life expectancy (Taiwan) In 2004 : • Average was 76.5 years • Males was 73.6 • Females was 79.41

  12. Life Expectancy in 2001 Compared with Other Countries

  13. Life Expectancy • The life expectancy was increasing from 71.9 (male) & 77.8 (female) in 1996 to 73.6 (male) & 79.41 (female) in 2004 • When compared to other developed countries, the life expectancy is still lower, but it is comparable to Korea

  14. Outcome

  15. Infant Mortality Rate at 2001 as compared to Other Countries

  16. Outcome

  17. Standard Mortality Rate per 100,000 Population As Compared with Other Countries

  18. Standard Mortality Rate • No obvious improvement in standard mortality rate after the implementation of NHI • 554.62 per 100,000 population in 1995 increased to 575.63 in 2003 • In recent years, communicable diseases receded in Taiwan, replaced with large shares by cancers, cerebral vascular diseases, geriatric diseases and accidents

  19. 3. Cost Containment

  20. A FRAMEWORK OF HEALTH-CARE FINANCING in Taiwan Organizing risk pools INSURANCE POOLS Sources of funds Paying providers of health care GOVERNMENT PROVIDERS OF CARE EMPLOYERS HOUSEHOLDS 4. Delivering health care to patients Single payer• Fee-for-services• Low consumer cost sharing• Mixed payment scheme: case payment, ,DRG, Global Budget

  21. Cost-Containment • Increase premium rate: from 4.25% to 4.55% (Sep 2003) • Increase co-payments (7 times) • Price reductions: • - Pharmaceuticals price cuts • - Payment reforms: DRGs introduced • Others: Increase claims reviews • The Ultimate tool: Global budgets

  22. THE ULTIMATE COST-CONTAINMENT TOOL:Global budgets, by sector (Taiwan Public Health Report 2004)

  23. Cost Impact of Global Budget Reform

  24. Cost Impact of Global Budget Reform

  25. Evaluation of Dental Global Budget • Per capita cost decrease: 9.1%  2.5% (-72%) • Preventive care provision (age 6-12):3%  99% (3200%) • Access (user rate):35.3%  36%(+2%) • Mean visits per user:3.15  3.08(-2.2%) • Mean cost per user :3225  3307 (+2.5%) • Repeat treatment rate(filling):2.2%0.55% (-74%) • Provision of invasive care decreased (Lee M.C. & Jones M. A. ,2002)

  26. Cost/v volume 100% 100% 100% 50% 50% 50% 0% 0% 0% -50% -50% -50% 97‘ 98‘ 99‘ 00‘ 97‘ 98‘ 99‘ 00‘ 97‘ 98‘ 99‘ 00‘ 2.4% 5.6% 2.4% -3.4% 10.5% 6.8% 2.7% 1.4% volume volume 8.0% 6.8% 3.8% -2.4% volume 1.6% 4.0% 4.2% 6.5% 3.4% 1.7% 3.6% 4.4% Cost/ v Cost/ v 0.8% 5.5% 5.3% 3.9% Cost / v Volume vs. Intensity Growth Among Different Sectors Clinic Dental Traditional medicine (Lee Y.C. 2/002)

  27. Evaluation of Quality of Care Before and After Global Budget: Patients’ Perspectives (Lee Y.C. 2/002)

  28. NHE Per GDP Growth rate of NHE >> Growth rate of cost per capita>>premium per capita

  29. Hospital Reimbursement Diagnosis-related groups (DRG’s) • 1995-now, case payment for 50 cases (22 by procedures, 28 by APDRGs) • Outpatient: only 4 case (DRGs) (Lee Y. C., 2003)

  30. Comparison of Inpatient Expenses FFS & Case Payment

  31. Co-payment • Co-payment for outpatient services: • 1999 to 2001 • Pharmaceutical co-payment max. NT $200 Freq. user co-payment max. NT $100 Physical rehab. co-payment max. NT $210 • Sept 1 2002 • Regional hospital - from NT$100 to NT$140 • Academic hospital - from NT$150 to NT$210 (Taiwan Public Health Report 2004)

  32. Review of claims (Taiwan Public Health Report 2004)

  33. Pharmaceutical • Reference Pricing 1996 • the latest round of cuts in March 2003 affected around 1,000 drugs with reductions of up to 50%. • the usage of antibiotics was decreased by 53% from the restricted reimbursement policy rolling on antibiotics. • Co-Payment • Price adjustment -7 times • Total cumulative savings: NT $25.4 billion (1996-2003)

  34. 4. Quality Patient satisfaction Technical quality Input Process Outcomes (Donabedian,1980)

  35. High Satisfaction Satisfaction survey: In 1995, 39% and 76.6% in 2004

  36. Goals of the Growth of Medical Care Resources (Source: 2004 Taiwan Public Health Report)

  37. No of physician per 10,000

  38. Population served per physician

  39. Acute bed per 10,000

  40. Process -Accreditation of hospital • Taiwan Joint Commission on Hospital Accreditation in 1999 (TJCHA) • Integrated quality system for the entire Taiwan health care system • 1st in Asia to conduct hospital accreditation • Accreditation for 3 years • 497 hospital in 2005 • 500 hospital in 2006

  41. Process - Violations • No. of contracted medical care institutions (Hospital & clinic) • 1996 15,662 • 2004 17,656

  42. Violations • The contracted medical care institutions must follow the rules and regulations from the NHI • Penalities, Suspension of Contract, Termination of Contract if violations NO. of contracted institutions violation

  43. QUALITY_BASED PAYMENT • Started on October 01, 2001 • 5 major diseases- cervical cancer, breast cancer, diabetes, tuberculosis, and asthma. • Provides extra financial rewards to providers in addition to the NHI fee schedule. • Finance of these extra rewards is not from global budgets. • 2003, include more diseases to the project (namely cancer, hypertension, chronic B and C-type hepatitis…)

  44. Preliminary Results: Asthma Before: from April 01, 2001 to June 30, 2001. After: from April 01, 2002 to June 30, 2002.

  45. Preliminary Results: TB • 9 month cure rate for TB participants: 40.69% • 9 month cure rate for all TB cases in Taiwan: 30.1% (From the Center of Disease Control in Taiwan).

  46. Cost Efficiency - National Health Insurance IC Card The issuance of IC cards can reduce waste or abuse of medical resources and provide a convenient conduit for the exchange of medical information. The cards have been in full scale usage by the Taiwanese citizens in the health care system and have witnessed a high acceptance rate.

  47. 5. Risk Pooling

  48. NHI objective • Key objective : To provide equal access to adequate healthcare for all citizens. • Approach : By risk pooling.

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