1

National Health Insurance National Health Insurance in Taiwan – Part IIIin Taiwan – Part III

Topics :

1. Is the National Health Insurance (NHI) system effective ?

2. 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 OutlinePresentation Outline Different elements in the NHI system analyzed

based on Evaluation Model –

1. Equity and Capacity2. Cost effectiveness3. Cost containment4. Quality 5. Risk pooling 6. Sustainability

Evaluation of improvement measures mentioned in Part II of presentation.

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1. Equity & Access1. Equity & Access

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By the end of 2003:By the end of 2003: 1. over 90 percent (17,259 in total) of medical

institutions in Taiwan had joined the NHI program

2. 183,103 medical personnel in Taiwan3. over 62,000 beneficiaries were served under

health care improvement programs

By the end of 2004:By the end of 2004:1. 99 percent of the total population were covered

by the NHI program and the public satisfaction rates of nearly 80 percent

5

Access Access 1. 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.

2. Uneven distributed geographically and by specialty.

3. 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.

4. Shortages also have been identified in psychiatric bed capacity and community rehabilitation centers.

5. Shortage of practitioners in certain medical specialties.

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2. Cost 2. Cost EffectivenessEffectiveness

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Cost Cost EffectivenessEffectiveness

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

LimitationsLimitations

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 GDP 1983-2003

6.265.99

5.91

4.934.815.27

4.774.67

4.204.004.104.003.904.00

3.80

3.70

5.335.275.29 5.46 5.44

3.593.443.39

1.65

2.932.76

1.85 1.89 2.00

2.94 3.06 3.14 3.02

0.440.450.510.81 0.82 0.81 0.77 0.69 0.59 0.470.51 0.47 0.46

2.23

2.121.82 1.77

2.21 2.1 2.18 2.16

1.81.82 1.85 1.96

0.00.51.01.52.02.53.03.54.04.55.05.56.06.57.0

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

% of GDP

Out-of-pocket

Health Insurance

Government Sector

Total Health Expenditures

NHI

10

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

7.8

6.0

8.3

5.4

7.3

5.0

13.0

0

2

4

6

8

10

12

14

Taiwan Japan USA Korea UK HKSAR Australia

Age

(yr

)

11

Outcome -Life expectancy (Taiwan)Life expectancy (Taiwan)

In 2004 :In 2004 :1.1. Average was 76.5 yAverage was 76.5 y

earsears2.2. Males was 73.6Males was 73.63.3. Females was 79.41Females was 79.41

Life expectancy

68

70

72

74

76

78

80

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

year

male

female

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Life Expectancy in 2001Compared with Other Countries

72.8

76.6

75.1

77.9

72.2

78.478.5

81.981.1

84.7

78.7

84.6

646668707274767880828486

Age

(yr

)

Male

Female

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Life ExpectancyLife 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

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Outcome

Infant Mortality Rate

6.4 6.7 6.47 6.1 5.9 65.4

4.95.3

6.6

0

1

2

3

4

5

6

7

8

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Year

Mortality

15

6

3.1

7

2.7

5.5

4.5

0

1

2

3

4

5

6

7

8T

aiw

an

Japa

n

USA

Ger

man

y

UK

HK

SAR

InfantMortality Rate

Infant Mortality Rate at 2001 as compared to Other Countries

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Outcome

Crude Death Rate

5.4

5.5

5.6

5.7

5.8

5.9

6.0

6.1

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Year

Crud

e de

ath

rate

rate

17

551.8575.63

500.6475.8

342.2

531.9

378

0

100

200

300

400

500

600

700

No.

of po

pula

tion

StandardMortality rateper 100,000Population

Standard Mortality Rate per 100,000 Population

As Compared with Other Countries

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Standard Mortality RateStandard 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

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3.3. Cost Cost ContainmentContainment

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PROVIDERS

OF CARE

INSURANCE

POOLS

4. Delivering health care to patients

A FRAMEWORK OF HEALTH-CARE FINANCING in Taiwan

GOVERNMENT

EMPLOYERS

HOUSEHOLDS

Sources of funds

Organizing risk pools

Paying providers of health care

Single payer• Fee-for-services• Low consumer cost sharing• Mixed payment scheme: case payment, ,DRG, Global Budget

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Cost-ContainmentCost-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

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THE ULTIMATE COST-CONTAINMENT TOOL:THE ULTIMATE COST-CONTAINMENT TOOL:Global budgetsGlobal budgets, by sector, by sector

(Taiwan Public Health Report 2004)

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Cost Impact of Global Cost Impact of Global Budget ReformBudget Reform

1997 1998 1999 2000 2001 2002

Dental 9.15%

9.31%

6.30%

6.38%

3.32%

2.50%

Chinese medicine

3.00%

5.59%

5.53%

4.55%

4.58%

2%

Physicianclinic

8.26%

7.70%

3.30%

-3.4%

0.21%

3.93%

Western medicine

3.96%

9.48%

7.25%

0.95%

3.43%

4.01%

Hospital

2.30%

10.13%

8.6% 2.5%

4.51%

3.93%

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Cost Impact of Global Cost Impact of Global Budget ReformBudget Reform

Growth Rate of NHI-Health Expenditure per capita--by Professional Category

-6.00%-4.00%-2.00%0.00%2.00%4.00%6.00%8.00%

10.00%12.00%

1997 1998 1999 2000 2001 2002year

He

alth

Exp

en

ditu

re-g

row

thra

te/c

ap

ita

Dental

ChineseMedicinePhysicianClinicshospital

WesternMedicinetotal

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Evaluation of Dental Global Evaluation of Dental Global BudgetBudget

Per capita cost decrease: 9.1% Per capita cost decrease: 9.1% 2.5% (-72%) 2.5% (-72%) Preventive care provision (age 6-12)Preventive care provision (age 6-12)::3% 3% 99% (320 99% (320

0%)0%) Access (user rate):35.3% Access (user rate):35.3% 36%(+2%) 36%(+2%) Mean visits per user:3.15 Mean visits per user:3.15 3.08(-2.2%) 3.08(-2.2%) Mean cost per user :3225 Mean cost per user :3225 3307 (+2.5%) 3307 (+2.5%) Repeat treatment rate(filling)Repeat treatment rate(filling):2.2%:2.2%0.55% (-74%)0.55% (-74%)

Provision of invasive care decreasedProvision of invasive care decreased

(Lee M.C. & Jones M. A. ,2002)

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Volume vs. Intensity Growth Volume vs. Intensity Growth Among Different SectorsAmong Different Sectors

-50%

0%

50%

100%

volume 8.0% 6.8% 3.8% -2.4%

Cost / v 0.8% 5.5% 5.3% 3.9%

97‘ 98‘ 99‘ 00‘-50%

0%

50%

100%

volume 10.5% 6.8% 2.7% 1.4%

Cost/ v 1.6% 4.0% 4.2% 6.5%

97‘ 98‘ 99‘ 00‘-50%

0%

50%

100%

volume 2.4% 5.6% 2.4% -3.4%

Cost/ v 3.4% 1.7% 3.6% 4.4%

97‘ 98‘ 99‘ 00‘

Clinic Dental Traditional medicine

Cost/v volume(Lee Y.C. 2/002)

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Evaluation of Quality of Care Evaluation of Quality of Care Before and After Global Budget: Before and After Global Budget:

Patients’ PerspectivesPatients’ PerspectivesSatisfaction

BeforeRateAfter

DissatisfactionBefore

RateAfter

Quality of care (overall) dental care 90.66 93.58 2.01 1.41 Traditional med 78.70 82.30 1.30 0.70 Clinic 68.10 73.80 2.20 3.60

Symptom improvement dental care 87.72 91.95 3.28 2.61 Traditional med 70.20 76.10 4.00 2.60 Clinic 66.70 70.60 4.70 6.60

Out-of pocket payment dental care 64.87 81.82 8.05 5.19 Traditional med 59.70 61.10 5.60 6.10 Clinic 51.90 58.50 8.40 11.90

Thorough explanation dental care 87.72 91.10 3.32 1.90 by doctors Traditional med 76.90 81.90 2.70 1.50

Clinic 66.80 69.40 4.30 8.40

(Lee Y.C. 2/002)

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NHE Per GDPNHE Per GDP歷年平均每人NHE及NHE/GDP 比

5.485.67

6.20 6.17

5.97 6.00

5.39

5.67

4.624.87

4.96 5.05

5.49 5.40

29,351

26,37227,249

28,351

24,84423,186

21,49619,987

10,82812,548

14,05215,469

18,105

25,659

4.0

4.5

5.0

5.5

6.0

6.5

7.0

7.5

80 81 82 83 84 85 86 87 88 89 90 91 92 93 年

%

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

元

GDP占 比率 NHE平均每人 Growth Growth rate rate

Cost per capita 3.5%

Premium per capita

3.0%

NEHNEH 3.9%

Growth rate of NHE >> Growth rate of cost per capita >> premium per capita

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Hospital Reimbursement

Diagnosis-related groups (DRG’s) Diagnosis-related groups (DRG’s)

1995-now, case payment for 50 1995-now, case payment for 50 cases (22 by procedures, 28 by cases (22 by procedures, 28 by APDRGs)APDRGs)

Outpatient: only 4 case (DRGs) Outpatient: only 4 case (DRGs)

(Lee Y. C., 2003)

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Comparison of Inpatient Comparison of Inpatient Expenses FFS & Case Expenses FFS & Case

PaymentPayment

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Co-paymentCo-payment

Co-payment for outpatient services: 1999 to 2001Pharmaceutical 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$140Academic hospital - from NT$150 to NT$210

(Taiwan Public Health Report 2004)

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Review of claimsReview of claims

(Taiwan Public Health Report 2004)

34

PharmaceuticalPharmaceutical 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)

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:單位 百萬元

89年 90年 91年 92年 93年93 v.s. 89增加率( %)

224,410 218,636 228,867 233,303 237,654 5.90

199,362 203,362 209,808 213,812 216,750 8.72

18,325 18,084 18,147 18,188 18,668 1.87

119,095 126,725 132,245 130,546 133,205 11.85

牙醫一般門診費 4,679 4,709 4,930 4,698 4,630 -1.04

假牙、鑲牙矯正費 25,676 27,546 28,113 29,946 29,942 16.61

西醫門診費 44,359 48,252 49,568 46,770 46,278 4.33

中醫門診費 8,160 7,873 8,608 7,760 7,617 -6.66

生產費用 4,038 4,034 3,192 2,686 2,568 -36.41

住院費用 20,196 20,803 21,491 19,140 24,144 19.55

慢性療養院、安養院、月子中心、居家照護

7,156 8,710 11,074 15,060 13,798 92.82

檢驗院、放射院等費用 1,238 1,366 1,355 1,450 1,373 10.93

民俗醫療費用 3,423 3,239 3,733 2,861 2,669 -22.04

醫生證明書費 171 192 182 175 185 8.61

61,941 58,553 59,416 65,078 64,877 4.74

西藥 18,113 15,010 15,920 16,192 13,966 -22.89

中藥 28,375 28,136 24,584 24,140 22,413 -21.01

醫療保健用品 15,453 15,407 18,913 24,746 28,498 84.41

25,048 15,274 19,059 19,491 20,904 -16.54

873 921 972 962 960 9.97

24,175 14,353 18,087 18,529 19,944 -17.50 (1).最終消費醫療支出 (2).國內資本形成

歷年民間部門醫療保健支出統計

(1).醫療用具設備及器材 (2).醫療照護自付費用

(3).醫藥用品支出

2.民間非營利團體

總 計1.家庭最終消費醫療支出

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4. Quality4. QualityPatient satisfaction Technical quality

Input Process Outcomes

(Donabedian,1980)

37

High SatisfactionHigh SatisfactionPublic Satisfaction

0

10

20

30

40

50

60

70

80

90

Year

Per

cent

age

Satisfied

Dissatisfied

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

38

Goals of the Growth of Medical Care Goals of the Growth of Medical Care ResourcesResources

(Source: 2004 Taiwan Public Health Report)

39

No of physician per No of physician per 10,00010,000

No. of physician per 10,000

12 1213 13 13 13 13

14 1415 15

16

0

2

4

6

8

10

12

14

16

18

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Year

"physician"

40

Population served per Population served per physicianphysician

41

Acute bed per 10,000Acute bed per 10,000

42

Process -Accreditation of hospital

1.1. Taiwan Joint Commission on Hospital Accreditation in Taiwan Joint Commission on Hospital Accreditation in 1999 (TJCHA)1999 (TJCHA)

2.2. Integrated quality system for the entire Taiwan health Integrated quality system for the entire Taiwan health care systemcare system

3.3. 1st in Asia to conduct hospital accreditation1st in Asia to conduct hospital accreditation4.4. Accreditation for 3 yearsAccreditation for 3 years5.5. 497 hospital in 2005497 hospital in 20056.6. 500 hospital in 2006500 hospital in 2006

43

Process - ViolationsViolations

No. of contracted medical care institutions (Hospital & clinic)

1996 15,662 2004

17,656

No. of contracted institution violation

0

200

400

600

800

1000

1200

1400

1600

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

Year

Pena

lize

d fo

r vi

olat

ion

No.

44

ViolationsViolations

The contracted medThe contracted medical care institutions ical care institutions must follow the rulemust follow the rules and regulations frs and regulations from the NHIom the NHI

Penalities, SuspensiPenalities, Suspension of Contract, Teron of Contract, Termination of Contracmination of Contract if violationst if violations

1995 2231996 6041997 5711998 6161999 8392000 6332001 7002002 7902003 14382004 13442005 999

NO. of contracted institutions violation

45

QUALITY_BASED PAYMENTQUALITY_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…)

46

Preliminary Results: AsthmaTable 1: Medical services utilization of asthma participants in Taiwan before and after the Quality-Based Payment pilot program.

ambulatory

visits/patient

E.R. visits/patie

nt

admission/patient

Before

1.568 0.068 0.031

After 1.905 0.025 0.017

Change

0.337 -0.043 -0.014

Before: from April 01, 2001 to June 30, 2001.

After: from April 01, 2002 to June 30, 2002.

47

Preliminary Results: TBPreliminary 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).

48

Cost EfficiencyCost Efficiency - - National National Health Insurance IC CardHealth 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.

49

5.5. Risk PoolingRisk Pooling

50

NHI objectiveNHI objective

Key objective : Key objective :

To provide equal access to To provide equal access to adequate healthcare for all adequate healthcare for all citizens.citizens.

Approach : Approach :

By risk pooling.By risk pooling.

51

Chronology of Health Insurance

YearYear Description of InsuranceDescription of Insurance PopulatioPopulation n CoverageCoverage

19501950 Labor InsuranceLabor Insurance 40.12%40.12%

19581958 Government Employee Government Employee InsuranceInsurance

8.06%8.06%

19851985 Farmer InsuranceFarmer Insurance 8.21%8.21%

19901990 Low-income Household Low-income Household InsuranceInsurance

0.55%0.55%

19951995 National Health InsuranceNational Health Insurance 100%100%

20032003 National Health InsuranceNational Health Insurance 98.67%98.67%

52

Risk Pooling Risk Pooling

ArrangementArrangement 1.1. Over 98% enrollment rate for NHI Over 98% enrollment rate for NHI

scheme.scheme.

2.2. 4.55% of the monthly wage for 4.55% of the monthly wage for premium in 2003.premium in 2003.

53

Co-payment Rate – Co-payment Rate – In-patient (Year 2006)In-patient (Year 2006)

WardWard

Co-payment RateCo-payment Rate

5%5% 10%10% 20%20% 30%30%

AcuteAcute -- 30 days 30 days or lessor less

31 – 60 31 – 60 daysdays

61 days 61 days and upand up

ChronicChronic 30 days 30 days or lessor less

31 – 60 31 – 60 daysdays

61 – 180 61 – 180 daysdays

181 days 181 days and upand up

54

Exemptions from Exemptions from CopaymentCopayment

1.1. Catastrophic diseases (in-patient, Catastrophic diseases (in-patient, pharmaceuticals, laboratory and pharmaceuticals, laboratory and examinations……)examinations……)

2.2. Child deliveryChild delivery3.3. Preventive health servicesPreventive health services4.4. Medical services offered at the defined Medical services offered at the defined

mountain areas or on offshore islandsmountain areas or on offshore islands5.5. Low-income households Low-income households 6.6. VeteransVeterans7.7. Children under the age of 3Children under the age of 3

Risk pooling for catastrophic disease Risk pooling for catastrophic disease patients !patients !

55

(Source: 2004 Taiwan Public Health Report)

Catastrophic Illness Cardholders

56

6.6. SustainabilitySustainability

57

SustainabilitySustainability

58

351.8

336.8

307.6286.1

285.2

264.9

194.0

241.3 243.6260.5

352.7337.1

323.3301.8

284.2

285.9

156.8

222.9 237.6

262.0

0

40

80

120

160

200

240

280

320

360

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Insurance RevenuesInsurance Cost

Insurance Cost Average growth rate : 5.90%

Insurance Revenues Average growth rate :4.82%

Trend of NHI Financial StatusTrend of NHI Financial Status Unit: NT$bn

59

1. Universal enrollment2. Better medical personnel to patients in ratio3. Higher public satisfaction4. The NHI has accomplished its objectives and

goal • Provide equal access to healthcare for all

people• Control health service cost at socially

affordable level• Promote efficient use of health care

resources

Outcome

60

Acknowledgement Cheng, T. M. Taiwan’s new national health insurance program: genesis and experience so far, 22(3), Health Affairs. The Policy Journal of the Health Sphere.

Liu, S. L. (2005). Evaluating the efficiency of the use of medical resources in Taiwan’s medical care network: An application of data envelopment analysis, Institute of Health Care Management.

The Republic of China Yearbook – Taiwan 2002(http://www.gio.gov.tw/taiwan-website/5-gp/yearbook/2002/)

The Republic of China Yearbook – Taiwan 2003(http://www.gio.gov.tw/taiwan-website/5-gp/yearbook/2003/)

The Republic of China Yearbook – Taiwan 2004(http://www.gio.gov.tw/taiwan-website/5-gp/yearbook/2004/)

The Republic of China Yearbook – Taiwan 2005(http://www.gio.gov.tw/taiwan-website/5-gp/yearbook/)

2004 Taiwan Public Health Report, Department of Health, Taiwan, R.O.C.

61

ThankThank youyou