Since National Health Insurance (NHI) was practiced in 1995,its public satisfaction was nearly 70% in the first year while the financial status got worse and worse years by years (15.3 billion of deficit in 1999,27.8 B deficits in Y2000, and around 37.7 B in Y2001). Therefore, Bureau of National Health Insurance (BNHI) had to not only care about cost saving, social fairness but also maintain medical care quality. In order to balance the worse finance, BNHI enforced many strategies, such as case payment (1997), outpatient and inpatient co-payment, high rejection rate of requested medical cases, global budget (Dental clinic in 1998, Chinese ambulatory in 2000, primary-cared clinics in 2001/07, hospital in 2002/07), drug price reduction from November of 1996 to December of 2002 to save about 14.65 billion, rationalization of OPD service, increase insurer fee (2002/09)¡K.etc. Those implemented strategies incurred the impacts on patients, medical provider, pharmaceutical industry, and government. Therefore, the aims of this study is to explore balancing strategic variables for finding out optimal solutions among heavy financial loading from insurers, profit loss and arguments of so-called ¡§Drug price Black-Hole¡¨ from pharmaceutical industry, and quality of medical care from hospitals. This study was through the ways of two-phase interview. The first one phase is to have in-depth interview with legislators, MNHI ministers, hospital administratives, scholars who are specialized at public health, and managers of consumer society; this phase was aimed at validity for all variables that were identified from the study. Until the second phase, we would focus on validated variables from phase one to design questionnaires for telephone interviewing with all stakeholders such as common people, phsicians from hospitals, managers from pharmaceutical industry, officials from BNHI. The study will try to reveal the strategic variables from different dimensions to find out concrete balancing strategies and suggestions to stakeholders in order for coping with the inevitable impacts under system thinkings in the future.

ABSTRACT From August 1, 1999, ¡§Co-payment For the Frequent-Visit Outpatients¡¨ has gone into effect. Frequent visit outpatients have to pay more medical expenses out of their own pocket. How did the new co-payment scheme affect the medical expenditure and utilization of the outpatients, especially frequent-visit outpatients? Can this new co-payment scheme work efficiently and reach its goal: reduce the unnecessary waste of the medical resources? At Taiwan, Central Healthcare and Medical Service (CHMS) has a large outpatient database, which contains the basic information of the outpatients. This study chose the database about the ¡§Frequent Outpatients¡¨ from August-December 1998, and August-December, 1999 as population. Such data included the 157,613 cases from 1998 and 160,870 cases from 1999. By analyzing the 1998 and 1999 data provided by the Central Healthcare and Medical Service, this study found the followings have been changed since new scheme took effect: 1. Co-payment had broad and deep effect on the patients¡¦ medical care utilization. Due to the additional High Medical Utilization Co-payment Fee, NT 50 or NT 100, outpatients would be more cautious before they go to see the doctors. At the same time, trying to get more for what they pay, outpatients would rather go to the major regional hospitals or centers in the medical system than small hospitals or clinics. As for the prescribed drug, outpatients were inclined to ask doctors for prescription drugs that can be taken for more days, so they can reduce their visits and therefore save some co-payment fees. This study also found prescribed drug expenses per patient dramatically increase when the average drug expenses per day decrease. Apparently, the increased drug expenses were form the more prescribed-drug days per visit. With the drug expenditures going up, average outpatient expenses per visit increased and the detailed and combination of medical bill varies. 2. Male and female had different responses to this new co-payment scheme. The gender-oriental differences were found in the following areas: ¡]1¡^Regional hospitals (centers) or small clinics. ¡]2¡^The average prescribed-drug days for each visit. ¡]3¡^Drug expenditure per day per patient.¡]4¡^Total expenses per outpatient visit. ¡]5¡^The detailed breakdown of each outpatient visit¡¦s expenses. 3. No effect on the following outpatient age segments:¡¨ age 6-14 teenager¡¨,¡¨ age 15-24 young people¡¨, and ¡§age 25-44 adults¡¨. The new co-payment system had no effect on the above-mentioned age groups, but it did have big and deep influence on the ¡§age 45-64 mid-age adult¡¨ and ¡§age 65 + elderly¡¨, especially on the elderly. The elderly were the major medical service user, and a lot of them lived on their retire and lived on their pensions, so they got hit badly by the high co-payment. 4. In general the higher co-payment had big effect on following three groups: ¡]1¡^¡§Media-utilization Outpatient Group¡¨, ¡]2¡^¡§High- utilization Outpatient Group¡¨ ¡]3¡^¡§Extremely- utilization Outpatient Group¡¨ To save money, outpatients, whatever group they belong to, would reduce their doctor visit. After analyzing all of the above-mentioned aspects, impacts, differences, changes and effects this high co-payment have had on the different age and gender groups since August 1999, this study concluded that the new co-payment regulation had significantly reduced the medical service demands, especially from female or male age 45+.

Objective: The purpose of the study was to determine if a co-payment resulted in a differential preference for general anesthesia (GA) or oral sedation (OS) and, if so, to examine whether age, the number of appointments, perceived risks of treatment, child's awareness during treatment, or insurance type appeared to play a role in this preference.Methods: Using a cross-sectional survey design, questionnaires were distributed to caregivers of patients in the waiting room of the Virginia Commonwealth University Pediatric Dental Clinic. Two different questionnaires were distributed randomly. Both surveys described a scenario with the need for dental treatment under general anesthesia (GA) or oral conscious sedation (OS). Seventy five surveys required a $50 co-payment for treatment completed under general anesthesia and the other 75 required the same co-payment for treatment completed under oral conscious sedation. Caregivers were asked to choose treatment modalities as well as to rate factors in their decision making including perceived risks and the number of dental visits. Results: Seventy seven survey respondents selected GA as their preferred treatment option for the described scenario. The other sixty six respondents chose OS sedation. For the insured population, the GA/OS odds ratio for the OS-co-payment group versus the GA-co-payment group was OR=2.21 (95% CI = 1.06, 4.60). In terms of the uninsured, the GA/OS odds ratio for the OS-co-payment group versus the GA-co-payment group was OR=17.5 (95% CI = 1.60, 191). The child's age, awareness during treatment, and type of insurance (public versus private) were not significantly related to treatment choice. The importance of the number of appointments was found to be significant (p-value = 0.0170) and outweighed the effect of the co-payment (p-value = 0.1757). The importance of associated risks was found to be significant (p-value = 0.0171) and this outweighed the effect of the co-payment (p-value = 0.8157).Conclusions: The presence of a co-payment does not as significantly impact the GA versus OS preference while the number of appointments and perceived risks associated with the treatment remain significant.

為了「減輕家庭負擔，使3歲以下兒童獲得適切的健康照顧，促進其身心正常發展」，內政部兒童局自2002年起實施「三歲以下兒童醫療補助計畫」，並且已有研究證實此政策確實有效以免除部分負擔的方式降低兒童就醫門檻，增加兒童的醫療利用。然而，在我國面臨醫療資源分布不均與貧富差距逐漸擴大的同時，政策效果的分配是否公平有待商榷。由於兒童一旦滿三歲即不再受政策補助，本研究使用2004年至2009年健保資料庫中就醫年紀滿三歲前後二十週的兒童為樣本，依其居住地區與在固定居住地區下依其家庭所得條件分組，觀察各組兒童滿三歲前後醫療利用的變化並比較組間差別，使用RDD (regression discontinuity design) 分析政策在兒童滿三歲時造成的斷點是否顯著。 實證結果顯示，在依居住地區分組下，兒童滿三歲不受補助後，西醫門診以醫療資源不足區醫療利用的下降最為顯著；西醫急診以醫療資源過剩區醫療利用下降最為顯著，而不論西醫門診或西醫急診，皆以醫療資源不足區的價格彈性最大，其中西醫門診與急診間的替代關係對估計結果有一定的影響。在固定居住地區下依家庭所得條件分組下，各居住地區均以低所得組受政策效果較顯著，醫療資源不足區的低所得組以西醫門診政策效果最為顯著；過剩區的低所得組則以西醫急診政策效果最為顯著。兩種分組依據下的結果均顯示，醫療資源分布不均造成的低落醫療可近性無法以兒童醫療補助計畫消弭。

Darbo tikslas. Išanalizuoti išlaidų kompensuojamiesiems iš privalomojo sveikatos draudimo fondo (PSDF) biudžeto vaistams pokyčius, tendencijas, bei jų įtaką gyventojams Panevėžio apskrityje per 2003 – 2005 metus. Uždaviniai: • Išanalizuoti PSDF biudžeto išlaidų kompensuojamiesiems vaistams pokyčius Panevėžio apskrities asmens sveikatos priežiūros įstaigose (ASPĮ); • Išanalizuoti pacientų priemokas, įsigyjant kompensuojamuosius iš PSDF biudžeto vaistus, bei įvertinti kompensuojamųjų vaistų prieinamumo dinamiką. • Palyginti Panevėžio apskrities išlaidas kompensuojamiesiems iš PSDF biudžeto vaistams su bendrais Lietuvos rodikliais. Tyrimo metodika. Duomenys apie kompensuojamuosius iš PSDF biudžeto vaistus per 2003 – 2005 metus buvo renkami ir vertinami iš Valstybinės ligonių kasos (Panevėžio teritorinės ligonių kasos serveris) informacinės sistemos „SVEIDRA“ duomenų bazės. Rezultatai. Išlaidos kompensuojamiems vaistams kiekvienais metais augo po 10 – 18 %. Brangiausi medikamentai buvo išrašomi darbingo amžiaus pacientams, o pigiausi vaistai tekdavo vaikams iki 18 metų. Pacientų priemokos nuolat augo ir nuo visos vaistų kainos sudarydavo vidutiniškai 20 %. Pacientų priemokos sudarė nuo 12 % (vaikams) iki 23 % (vyresniems nei 65 metai pacientams) nuo vaisto pardavimo kainos. Išvados. 2003-2005 m. išlaidos kompensuojamiems vaistams augo sparčiau, nei bendras pacientų ir išrašomų receptų skaičius. Ypač išlaidos pastebimai augo 2005 metais, kai buvo į kompensuojamųjų vaistų kainyną... [toliau žr. visą tekstą] / The aim of the final thesis. To analyze the changes, tendencies and the influence for people out of pocket payments in expenditure for medicines that are reimbursed from the Compulsory Health Insurance Fund in Panevėžys county during the period from 2003 to 2005 years. Objectives: • To analyze the changes of expenditure for compensative medicines, that are financed from CHIF budget in health care institutions in Panevėžys county; • To analyze the patients out of pocket payments acquiring medicines that are reimbursed from the Compulsory Health Insurance Fund and to evaluate the dynamics of accessibility of the reimbursed medicines; • To compare expenditure for medicines that are compensated from the Compulsory Health Insurance Fund in Panevėžys county with general index of Lithuania Research methods. Statistical data concerning medicines that are reimbursed from the Compulsory Health Insurance Fund during the period from 2003 to 2005 was collected and estimated from the state information system “SVEIDRA”. Results. Expenditure for reimbursed medicines was increasing for 10-18 percent each year. The most expensive medicines were mostly assigned for a capable of working patients. The cheapest medicines were mostly assigned for children under 18 years. The patients co-payments for medicines was increasing average 20 percent each year. Co-payment was about 12 percent for children and about 23 percent for adults. Conclusions. During the period from 2003 to 2005 expenditure... [to full text]