從買醫療到買健康

──健保給付改革
:::

2012 / 9月

文‧張瓊方 圖‧莊坤儒


小兒科醫師林秉鴻形容台灣健保與其他國家的差異:「世界各國都在吃雞蛋,只有台灣還有雞肉吃。」

國內投保人繳了健保費,宛如拿到一張「無限卡」,可無底限地進入醫療市場消費。

為了讓民眾公平享有醫療照顧,17年來,健保局必須在有限的資源中撙節用度、合理分配。支付制度雖有效抑制醫療大餅過度擴張,卻改變了醫療生態,「醫病不如醫美」的景況,讓醫師大嘆:不如歸去!

解鈴還需繫鈴人,扭曲的醫療生態,需要更合理公平的健保支付制度來修復。


「不能要讓馬兒跑,卻只給牠吃四分飽。」

因為要一塊給五毛,健保給付左右了醫生選科別的志向,棄外科暫走醫美的洪浩雲說:「台灣不缺勞工,何以需要引進外勞?因為沒有人要做危險、骯髒的3D工作。同樣地,台灣也不缺醫生,只是沒有人要走5大科!」

前立委沈富雄指出,台灣健保雖非公醫制度,卻仍是特殊的單一保險人制度──健保局替全國人民買服務,全數的醫療提供者,受制於單一保險人,且保險人與提供者不對等,只有保險人說了算。

健保給付甚至改變了台灣的醫檢報告,造成許多疾病高盛行率的假象。洪浩雲以胃鏡報告為例,為了申請給付,現在已經找不到陰性(正常)的報告,「只要稍用技巧,都可以照到紅腫、潰瘍或陰影。」

部分艱難技術也有「失傳」的危機。沈富雄指出,現在全台灣能開胰臟癌的只剩下台大和榮總,因為手術複雜困難,得從早上8點開到晚上8點,一組團隊無法竟功,需要不同團隊接力,但因健保給付不敷所需,漸漸只剩下台大、榮總兩家責無旁貸的醫學中心繼續開,可以想見其他醫院後進的醫生若沒有機會學習,日後可能就不會了。

秀才遇到兵

「核刪、斷頭、總額…,健保局想盡一切辦法砍給付,」沈富雄指出,過度「微觀治理」,已讓醫界喪失自主性。

健保的核刪制度,常讓執業醫師為之氣結,有醫師以「秀才遇到兵」為名,在部落格上專文批判健保核刪的種種不合理現象。

由於健保支付採事後審核制,對於不當或重複的醫療處置,會逕行刪除,但刪除的標準,常讓醫師丈二金剛摸不著頭緒。

如:病患在加護病房住30天,健保局刪除10天的呼吸器費用;肺癌手術包括肺葉切除與胸腔淋巴廓清術,給付時後者被刪除。

為杜絕醫院浮報亂象,還有所謂的「放大核刪」,即健保局只要抽審到一筆不該付的費用,不只是一筆勾銷而已,而是「合理懷疑」未抽到的部分仍有許多不該給付,於是按比例放大50倍、100倍刪減給付。

而為避免疊床架屋、資源浪費,不論複雜度、困難度,一律統包的「包裹給付」,更讓醫師心生「不同工卻同酬」的不平。

婦產科醫師鄭吟豪指出,產婦無論自然生產、剖腹產、難產,健保都是統包到出院只給付三萬多元。

鄭吟豪說,上個月一位少女,肚子痛掛急診,抽血、驗尿後才發現已懷孕,進一步超音波檢查,證實已足月,且胎位不正,必須緊急手術。「這當中所有的檢查費,全部算在住院生產裡,這麼不公平,有誰還會願意去作緊急的醫療照護?」

這應是少有的特例,但健保給付常按「規定」行事,醫師若願花時間提申覆,健保局也會再斟酌。

合理門診量「不合理」

小兒科的給付也相對低廉。

小兒科醫師林秉鴻指出,兒科用藥簡單,完全沒有利用藥價差補貼的空間。醫材、處置相對於大人而言,也只是「小兒科」,像點滴,大人一天需要4瓶,小孩用量一瓶不到。

但兒科處置卻困難又耗時,以新生兒黃膽換血來說,備血、核對血型,抽血、輸血,歷時3小時,需要兩名醫師一起操作,健保只給付3,000點(2010年1點=0.92元);手忙腳亂的打針,則是一次給付37點。林秉鴻曾為一位唐氏兒打針,因孩子肉軟、血管扁,針打不進去,一共打了48針才成功,孩子受苦,醫生也很心疼,結果給付一毛也沒有多。

另外,「合理門診量」也被醫師質疑做半套。

洪浩雲指出,健保局訂定合理門診量,超過就砍給付,問題是病人要求加掛,醫生忍心拒絕嗎?以台大為例,有半數的病人來自外縣市,病人不遠千里而來,醫生能拒絕嗎?「醫院為什麼不設計只要達到合理門診量就不得加掛的制度?為什麼健保局把得罪病人的難題丟給醫生,又懲罰醫生?」他不滿地問。

合理支付制度

「事情沒有不能解決的!」對於健保制度的變革,健保局長戴桂英樂觀地表示,公共政策雖不可能戲劇性的轉變,但在有法律依據的前提與民氣可用的當頭,無論是調整支付或縮減給付範圍,都大有可為。以特殊材料差額負擔為例,一開始不可行,如今已立法通過。

對於當前支付標準的種種不合理,戴桂英表示,健保支付標準乃參考過去公勞保制訂,再逐年調高,健保局也已逐步調整偏低的給付,如兒科的新生兒照護、婦產科的腹腔鏡手術等。其他像衛生署3年300億元的醫療改革計畫,其中的230億元即由全民健保配合支付。

為了重振5大科執業意願,健保局也提高了支付標準。戴桂英指出,今年除了投入3.2億元實施急診品質提升計畫,針對重大傷病處置及轉診效率給予獎勵外,還加碼21億元,提高外、婦、兒科的診察費。

戴桂英表示,5大科的問題錯綜複雜,健保局絕對會努力調整支付來挽救,但需要一些證據來支持。為此,健保局委託相關單位進行「各科醫療資源耗用評估」,8月已完成評估,再經公正超然的委員會審視後,明年可望投入40億元調高目前偏低的手術與處置給付。

「加碼5大科並不會排擠別科的費用,」戴桂英指出,總額成長上限已由去年4.7%提高到近6%,明年二代健保上路後,可依年度醫療支出估算隔年健保費用,經費不足問題得以改善。

對於離島、原鄉及偏遠地區,健保局也提出了獎勵計畫,給予當地及鄰近醫院點值保障;對於資源不足地區的急救責任醫院,給予急診點值保障,診察費加乘30~50%的優惠。

論質、論人多元支付制度

為改善論量計酬導致衝量而犧牲品質的醫療現象,健保局也苦思辦法改善,其中以2001年漸進導入的「論質計酬計畫」,最見成效。

該計畫以醫療品質及效果做為支付依據,分階段將糖尿病、氣喘、乳癌、高血壓、精神分裂症、肝炎、初期慢性腎臟病等納入試辦。

戴桂英指出,其中以品質指標明確的糖尿病效果最顯著,參與方案者從2003年的7萬9,000人,成長到28萬4,000人,參與方案一年後,66%患者的糖化血色素獲得改善。健保局計畫從今年9月起,要將其由試辦改納正式支付標準。

此外,2011年7月,在前衛生署長楊志良的推動下,健保局也開始試辦為期3年的「論人計酬計畫」。

該計畫有區域、社區醫療群,及醫院忠誠病人3種模式,以每人每年平均醫療費用算出虛擬式總和,讓醫療提供者為轄下病患提供整合服務,若虛擬總額高於試辦對象實際使用的點數,差額便化為回饋金回饋給醫療院所。

此方案顛覆「看越多賺越多」的衝量思維,楊志良的說法是:「民眾越健康,醫院賺越多!」

透過一方面增加對5大科及偏遠醫療的給付,一方面開發多元支付方案;健保局長戴桂英表示,希望從中尋找到最佳模式,引導醫療服務提供者朝整體、全人醫療照護發展,並讓台灣醫療生態更健全。

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EN

Reforming the NHI Payments System

Chang Chiung-fang /photos courtesy of Chuang Kung-ju /tr. by Phil Newell

Pediatrician Lin Binghong describes the difference between Taiwan’s National Health Insurance (NHI) system and those of other countries thus: “In other countries they eat the eggs, only in Taiwan do we eat the chickens!”

When people in Taiwan pay their health insurance premiums, it’s as if they get a “no-limit credit card” in return, and they can consume in the healthcare market without any bottom line to worry about.

For the last 17 years, the Bureau of National Health Insurance (BNHI) has had to frugally use its limited resources and ensure their reasonable distribution in an effort to see that all citizens get their fair share of healthcare. Although the NHI “global budgeting” system has effectively controlled increases in the total amount the BNHI spends in a given year on healthcare, the payments system for hospitals and doctors has distorted the “medical ecosystem.” It has been said that, “rather than working in a hospital making people healthy, it’s more profitable to open a clinic and make them more beautiful!” It’s no wonder that so many doctors take the path of least resistance, or even decide regretfully to “pack it in.”

The BNHI has created this problem, and it is up to the BNHI to solve it. To restore the medical ecosystem, there will have to be reform to make the NHI payments system fairer and more reasonable.


An old Chinese proverb declares: “You can’t ask a horse to gallop but feed it only half its fill.”

When you only pay 50 cents on the dollar, naturally it’s going to affect the career paths that doctors will choose. Hung Hao-yun, who has for the time being abandoned general surgery to focus on cosmetic surgery, says: “Taiwan has unemployed workers, so why is there demand for foreign labor to be brought into the country? Similarly, there is no shortage of doctors, it’s just that no one will take jobs in the ‘Big Five’ [surgery, internal medicine, OBGYN, pediatrics, and emergency medicine]. In both cases the low compensation being offered is failing to attract the available people into the available jobs.”

Former legislator Shen Fu-hsiung, who is also a well-known physician, explains how the payment system distorts the medical ecosystem. Although Taiwan’s physicians are not state employees, they work under a system with only a single payer. The BNHI buys services on behalf of all citizens, while medical providers are restricted to the single payer. But the payer and the providers are not in a symmetrical relationship: what the BNHI says is, literally, the law.

The insurance payment system even has altered test reports in Taiwan, creating the false impression of a remarkably high incidence of many types of illnesses.

Hung Hao-yun takes endoscopy as a for-instance. In order to apply for payment, these days there are almost no negative test results (i.e. results in which the patient’s condition is normal). “If you know the tricks of the trade,” says Hung, “any endoscopy can show an inflammation, ulceration, or shadow.”

The NHI payment system even has created the possibility that some skills could completely disappear.

Shen Fu-hsiung notes that there are currently only two hospitals in all of Taiwan that do surgery for pancreatic cancer. The procedure is very complex, starting at eight in the morning and going until eight at night. Since it is impossible for one surgical team to finish the job, another has to take over. But the BNHI doesn’t pay enough, so over time more and more hospitals have dropped out until now National Taiwan University Hospital and Tai­pei Veterans’ General Hospital are the only ones left. Obviously medical students who study at other institutions won’t have any chance to observe this procedure, and in the future maybe no one will be capable of doing it.

Like talking to a wall

“The BNHI uses every trick in the book to cut payments,” says Shen Fu-­hsiung. But this kind of excessive “micro-manage­ment” has left doctors feeling like their profession has lost its dignity and autonomy.

One doctor wrote an essay online, entitled “It’s Like Talking to a Wall,” in which he criticized all the unreasonable things that the BNHI does in the interests of cost-cutting.

Because the payments are reviewed after the fact, the system will not pay for medical procedures that appear, in retrospect, to have been unnecessary or redundant. But the criteria they use for cutting such items out of the final bill often leave doctors mystified.

For example: A patient spends 30 days in intensive care, but the BNHI cuts out payments for 10 days of use of a respirator. Surgery for lung cancer includes both removal of the lung lobe and radical lymph node dissection, but no payment is forthcoming for the latter.

A lot of doctors feel that “package payments” that take no account of the level of complexity or difficulty of care are unfair, so that you get paid the same for each and every procedure of a certain category, regardless of how much effort or skill was actually applied.

Obstetrician Zheng Yin­hao points out that no matter whether a birth goes naturally and smoothly, is by C-section, or is a difficult birth, the BNHI pays a single flat fee (which comes to about NT$30,000) to cover everything right up through the mother’s discharge from the hospital.

According to Zheng, last month a teenage girl came into the ER with a stomachache, and after testing her blood and urine, it was found that she was in an advanced stage of pregnancy. An ultrasound scan showed that the fetus was in an abnormal position and the girl needed emergency surgery to save the baby. “The BNHI ended up paying us for a routine birth, which is supposed to cover all the costs incurred at any time during the mother’s hospital stay. That means that there was no extra payment for the emergency room visit or all the tests we had to run, so the hospital essentially ended up losing money by caring for a critically ill patient and saving her baby’s life. That’s simply unfair. Who is going to willingly provide emergency care under these circumstances?”

Overwhelmed

Payments for pediatrics are likewise “on the cheap.”

Recalling that many hospitals and doctors make up for low consultation payments by turning a profit on medications, pediatrician Lin Bing­hong points out that in pediatrics there isn’t much call for complex prescriptions, so there’s little money to be had there. The same applies to all other medical materials. For example, whereas an adult needs four bottles of intravenous drip per day, a child uses less than one.

But dealing with children is in fact more difficult and time-consuming. For example, to do a blood transfusion for a newborn—including preparing the blood, confirming that the blood type matches, drawing blood, and infusing the new blood—takes two doctors and three hours, but NHI credits the caregivers with only 3000 points. For shots for children—which are always a real hassle for doctors as they involve lots of coaxing, fidgeting, and even kicking and screaming—NHI offers only 37 points per shot. (In 2010, one point was equal to NT$0.92, or only about three US cents.)

Another thing that really draws the ire of physicians is the standard for the “reasonable number” of patients that doctors should see during their clinic hours.

Hung Hao-yun points out that the BNHI sets limits on the “reasonable number” of patients that doctors can see in a given time period, and pays a reduced fee for any in excess of that. The problem is that when too many patients show up for clinic hours, are doctors just supposed to turn them away? At National Taiwan University Hospital, for example, which is located in Tai­pei City, half the patients come from outside of Tai­pei—will a doctor really have the heart to refuse to see a patient who has made a long journey? “The hospitals just dump the problem onto the doctors. Why don’t they simply stop registering additional patients once the ‘reasonable number’ has been reached? And why does the BNHI leave to the hospitals and doctors the unpleasant task of making patients angry by turning them away, yet the doctors who do so end up earning less overall?”

A reasonable payments system

“There is no problem that doesn’t have a solution!” optimistically declares BNHI director-general Day Guey-ing about reform of the NHI system. Although public policy cannot be dramatically transformed overnight, as long as there is a basis in law and sufficient public attention to and discussion of the issue, there is a great deal that can be done, whatever the issue. For example, in the past if a patient preferred to get a higher-quality implant than the one paid for by the NHI, the patient would have to pay 100% of the cost of their preferred option. A lot of people complained that the BNHI should at least cover an amount equivalent to the NHI-funded implant, with the patient only having to make up the difference. But the way the law was then written there was nothing the BNHI could do. Now, however, the necessary legislation has been passed.

As for the unreasonable aspects of payment standards, Day says that the standards used for the current NHI system were originally based on those set for the much earlier health insurance schemes covering only civil servants and laborers, with gradual increases year by year. The BNHI has already adjusted some excessively low payments, such as for neonatal nursing care or gynecological laparoscopic surgery. Also, the BNHI will cover NT$23 billion in payments out of the Department of Health’s three-year, NT$30-billion healthcare reform plan.

The BNHI will also raise payment levels to attract more doctors to enter the “Big Five” specializations. Day points out that in addition to the NT$320 million being invested this year alone as part of a plan to upgrade the quality of emergency medicine, a further NT$2.1 billion will go toward consultation fees for the fields of surgery, OBGYN, and pediatrics.

Day states that the Big Five problem is intricate and complex, and although the BNHI will do its best to raise payments to help solve it, they want some kind of evidence that they are not wasting their money. To this end, the BNHI commissioned an “Evaluation of Healthcare Resources Used in Various Medical Specializations.” The report was completed in August, and after a review by an impartial panel, it is likely that the government will invest NT$4 billion to increase payment levels for currently undervalued surgeries and treatments.

“Increasing payments for the Big Five will definitely not squeeze out payments for the other specializations,” adds Day. The limit for total growth of the global NHI budget has been raised from 4.7% last year to nearly 6% this year. When the second generation of NHI comes online next year, the insurance premiums for any given year will be set based on the healthcare expenses of the preceding year, so there is hope for improvement in terms of the shortfall in total funding of the program.

As for the problem of healthcare on offshore islands and in remote areas, the BNHI has proposed an incentive program under which local and neighborhood clinics will get minimum guaranteed “points” in the system. For hospitals with responsibility for emergency medicine in areas with inadequate healthcare resources, the BNHI will provide minimum guaranteed emergency medicine points, and an added incentive of 30–50% per consultation.

Quality-weighted, patient-centered

The BNHI has also been taking measures to change the reality that payments are calculated on the basis of quantity of treatments without regard to quality or difficulty. The most effective measure has been a program for calculating payment based on quality, which first came into effect in 2001 and has been gradually extended over time.

The program bases payments on the quality and effectiveness of medical treatment. It has been implemented on a trial basis in phases, covering such illnesses as diabetes, asthma, breast cancer, high blood pressure, schizophrenia, liver cancer, and early-stage chronic kidney disease.

Day Guey-ing says that the system has been most effective with diabetes, for which there are clear quality indicators. The number of people in the program has grown from 79,000 in 2003 to 284,000 today, and 66% of all patients have shown improvement in their glycated hemoglobin (HbA1c) within one year of joining the program. The BNHI plans to formally incorporate quality-weighted payment for diabetes treatments into the payments system starting in September of 2012.

In August of 2011, under the direction of then minister of health Yaung Chih-liang, the BNHI also began three-year trial implementation of a “patient-centered payment program.” Rather than paying hospitals to treat individual illnesses, the program rewards them for keeping the individual healthy.

Here’s how it works: First a group of people is identified. (The trial program includes three different types of groups: residents of a specific region, residents of a specific community, or regular “loyal” patients at a specific hospital.) The BNHI calculates an average sum per person per year (e.g., NT$22,000) as a total budget for the group. The healthcare providers for each group provide comprehensive services to the patients in their jurisdiction. If a patient ends up needing less than NT$22,000 in healthcare for the given year, the surplus is given to the institutional providers as a bonus.

This program undermines the old logic of “the more patients that come in, the more money you make.” Instead, as Yaung puts it, “The healthier people are, the more money hospitals make!”

So there you have it: On one hand, the BNHI will increase payments for the Big Five and for healthcare in remote locations, and on the other will use more diversified payment systems to change incentives that distort the behavior of healthcare providers. BNHI director-general Day Guey-ing says that out of all of this they hope to evolve the most effective system possible, nudge providers toward comprehensive care of the whole individual, and restore Taiwan’s “medical ecosystem” to health.

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