National health insurance, which was implemented since 1995, have not only provided basic health care for our citizen, but reduced financial burden of them. This achievement was outstanding, though its financial deterioration has been a difficult issue. The authorities of national health insurance have implemented lots of intervention to reduce the increasing medical expense. Balance billing project was one of the policies to achieve both fairness and justice. The purposes of this research included understanding the relationships between balance billing and the characteristics of patients. The Andersen¡¦s health behavior model was the conceptual framework for this study. The questionnaires were collected at a medical center in Kaohsiung between February and May in 2009. 450 questionnaires were collected with 399 copies were effective (response rate 88.66%). The characteristic and the attitude towards balance billing system such as medical quality, medical care and medical expenses from patients were collected. Descriptive analysis and logistic regression were used to analyze this study. The results of this survey are summarized as follows: 1.¡yPredisposing characteristics¡z¡G a. Demographic Gender was significant related to the agreement of the policy of balance billing system. However, there were no statistical difference in age, marriage, and number of family. b. Social structure There were no statistical difference in educational level, occupation, and language. c. Health beliefs Care of health and cognition of balance billing system were significant related to the agreement of the policy of balance billing system. 2.¡yEnabling resources¡z a. Personal / Family resources Family budget and identification was significant related to the agreement of the policy of balance billing system. b. Community resources There were no statistical differences in private insurance and convenience to health care. 3.¡yNeed¡z a. Perceived Awareness and understanding of health condition were significantlyrelated to the agreement of the policy of balance billing system. b. Evaluated Frequency of using health insurance card was significant related to the agreement of the policy of balance billing system. However, there were no statistical differences in major disease care, chronic disease. 4.¡yRapport¡z Reliability to doctor and satisfaction to treatment were significant related to the agreement of the policy of balance billing system. However, there were no statistical difference in loyalty to doctor and satisfaction to doctor. Based on the results from this study, it is certain to conclude that patients of the hospital support (74.2%)the balance billing policy. 64.4% patients understood this policy. Patients who understood the new policy were more likely to support this policy. We encouraged the bureau of National Health Insurance to continue communication with the public and the providers to assure the success of new policy.

Due to the background discrepancy, the regulations of healthy insurance, and the different situation of medical service, there is different perception of balance billing between patients and physicians. The promotion of balance billing is based on the request by law, paid by the users, and medical budget control, which can lead to lower growth rate of medical fee. The purpose of this study is not only to reveal the difference of perception of balance billing between patients and physicians, but also to find out the relationship between service satisfaction and perception gap. Cross-section research method was used to investigate the opinions of admitted patients and physicians in 65 hospitals, located in southern Taiwan and affiliated with the Bureau of National Health Insurance, by questionnaire during a 2 months period. We¡¦d performed various statistical analyses in order to identify the different perception between patients and physicians, and the relationship between perception gap and medical service satisfaction. After extensive research on the related factors, including medical service situation, individual need, and past experience of patients, we can predict their expectation to balance billing. Besides, the discrepancy of expectation and perception between patients and physicians can cause the satisfaction gap, which may influences medical service satisfaction. Our results provided the related factors of satisfaction to the Bureau of National Health Insurance, in effort to help the promotion of balance billing.

Abstract After the National Health Insurance was implemented ,it provides our citizens not only the basic medical treatment but also reduce the financial burden. However, the financial difficulties is becoming worse for National Health Insurance of Taiwan. In order to reduce the medical expenses. The Health Insurance authorities implemented many different policies.Balance billing was one of these interventions. The purposes of this research included to understand the relationships between the balance billing and the characteristics of physicians and patients .Particularly, this research focused on the perceptions of balance billing form the Physicians and hospitalized patients¡¦points of view. The Andersen¡¦s health behavior model was the conceptual framework for this study. The questionnaire was sent out to 200 doctors and 1000 patients in Kaohsiung , Pingtung regional hospitals ,with 101 (response rate 50.6%) and 638 (63.8%)returned , respectively. The characteristic and the attitude towards balance billing system such as medical quality, medical care and medical expenses from both physicians and patients were collected. Descriptive analysis and logistic regression were used to analyze this study. The Results from physicians survey are summarized as follows: 1.There were no statistical significance between the physicians¡¦ characteristics (such as age, gender, and tenure) and the agreement of balance billing .Ninety-four out of 101 physicians agreed on the new policy. 2.There would be no influence of balance billingon the medical care from the perspective of physicians. 3.Physicians who agreed on the viewpoints of paying extra payments would lead to the better treatment were 12 times more likely to accept the balance billing. 4.There were no difference among medical expenditures, the level of understanding, and the policy of balance billing. The results from inpatient survey are summarized as follows: 1. Inpatients demographic characteristics, (such as education¡Boccupation and disease), were significant related to the agreement of the policy of balance billing system. However, there were no statistical difference in age, gender, language, and private insurance. 2.Most inpatients who agreed on the balance billing policy were 1.8 times more to believe that if they paid out-of-pocket, they would gain more medical attention form physicians. 3.Regarding the quality of care, inpatients whoever agreed upon the policy of balance billing would perceive that they would receive 3 to 3.8 times higher quality of care in medical materials and medicine, respectively. 4.The more the agreement of the balance billing policy, the higher the satisfactory. 5.Inpatients who understood the new policy were more likely to pay extra payment. Based on the results from this study, it is certain to conclude that both the doctors and inpatient of the region hospital are supporting the balance billing policy .The average score of the inpatient questionnaire is 3.305.And 93.1% of the surveyed. Doctors accepted the policy of balance billing. We encouraged the bureau of National Health Insurance to continuing communication with the public and the providers to assure the success of new policy.

Cette thèse est consacrée aux systèmes d'assurance maladie mixtes où la couverture publique obligatoire peut être améliorée par une complémentaire santé. Les questions abordées portent sur l'effet inflationniste de la complémentaire sur le prix des soins et sur l'impact de la tarification à l'âge sur les solidarités entre malades et bien portants et entre catégories de revenu. Les analyses empiriques sont réalisées sur données françaises. Cette base de données originale regroupe les consommations de soins de 99,878 affiliés à la MGEN sur la période 2010-2012. Le chapitre 1 estime l'effet causal d'une meilleure couverture sur la consommation de dépassements d'honoraires et démontre l'effet inflationniste de la complémentaire sur le prix des soins. Le chapitre 2 considère l’hétérogénéité de l'impact d'une meilleure couverture sur les dépassements et sa corrélation avec la demande d'assurance. De fait, l’effet inflationniste de la complémentaire est accentué par des effets de sélection. Le chapitre 3 montre que la tarification à l'âge permet de maximiser les transferts entre malades et bien portants au détriment de la solidarité entre hauts et bas revenus. / This thesis deals with two questions relative to efficiency and fairness in mixed health insurance systems with partial mandatory coverage and voluntary supplementary health insurance (SHI): (i) the inflationary effect of SHI on medical prices; (ii) the fairness of SHI premiums. We set the analysis in the French context and perform empirical analyses on original individual-level data, collected from the administrative claims of a French insurer (MGEN). The sample is made of 99,878 individuals observed from 2010 to 2012. In Chapter 1, we estimate the causal impact of a generous SHI on patients' decisions to consult physicians who balance bill their patients. We find evidence that better coverage contributes to the rise in medical prices. In Chapter 2, we specify individual heterogeneity in moral hazard and consider its possible correlation with coverage choices. We find evidence of selection on moral hazard: individuals who are more likely to ask for coverage exhibit stronger moral hazard. In Chapter 3, results show that when SHI is voluntary, age-based premiums maximize transfers between low and high healthcare users but do not guarantee vertical equity.