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Health Care IndustryThe most complicated Service Industry
Prof. HongJen Chang, MD, MPH, MSFor Global Health, NTU
2012. 5.11
Unless noted, the course materials are licensed under Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Taiwan (CC BY-NC-SA 3.0)
Outline
Introducing myself Do you know how to ask questions and
read numbers Basic concept of health care –
examples International Criteria of a good health
care system The performance of Taiwan’s NHI
About Myself
Graduate of Yang Ming Medical School, NTU School of Public Health and HSPH
Joined the Government for 16 years before change career as Biotech Venture Capitalist
Head of DOH’s IT Department, Founding DG of CDC, Head of BNHI……
Teaches at YMU, “Case Studies in Health Policy”, on top of my job as an investor.
"The average citizen pays 20 U.S. dollars per person, per month."
"They can go to any doctor, any hospital they want. They pay, on the average, two U.S. dollars and a maximum of about 10 U.S. dollars each visit. And we don't have a waiting list."
Hong-jen Chang, ABC News October 25, 2003
Biodiscover
1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 20030
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
5.5
6
6.5
3.994.1
4.37 4.29 4.294.37
4.24 4.2
4.67 4.77
4.88 4.93
5.27 5.29 5.27 5.335.46
5.435.9
6.03
6.26
0.8127715301307510.82226675907022
0.8127333862764650.7704684695835140.6853902164465160.5938969276253240.5138857204605770.4720938817975370.466097589855650.4563658377572880.5154313845118130.453389135073035
0.442356665280075
1.648408755482571.843076289123231.883986955713632.00507457144626
2.762934781059862.92780766074942.940434881794283.055185761111553.144274965284883.11280825390912
3.38080912208363.477351058591833.58856771810923
2.205500239050452.103429545411982.181369650068432.1582399900984
1.821057581327751.767364321902551.814208700037221.803353880231351.845014478089111.866857077809862.004922895672482.101797144263912.23207491655083
National Health Expenditures as % of GDP1983-2003
YEAR
% of GDP
Total Health Expenditures
Private Sector
Health Insurance
Government Soctor
NHI
石曜堂
Hongjen Chang, MD, MPH, MSAdjunct ProfessorNational YangMing University
Money or Life?
Bridging cultural differences for a sustainable Health care system
Meiji Ishin heralded the introduction of modern health care system to Asia
Otto Von Bismarck 1815-1898
楢山節考 Narayama Bushiko
(1983 今村昌平 )
Money or Life?
Narayama Bushiko
“the custom, harshly implacable to Occidental eyes, of transporting the aged and infirm rustic villagers to the barren heights of Mount Narayama, where a rough nature soon solves the problem of feeding and maintaining them. In the Japan of long ago………, the approach to the geriatric enigma was drastic but simple. “
The New York Times, June 20, 1961
The Health Care Cost of Smoking
11
Conclusions: If people stopped smoking, there would be a savings
in health care costs, but only in the short term. Eventually,
smoking cessation would lead to increased health care costs.
(N Engl J Med 1997;337:1052-7.)
願付法(Willingness to Pay)
How to valuate
Life ?
The Black and
White Pill 12
Wikimedia PHenry
13
SUPPOSE A PERSON FACES A HAZARD THAT WILL KILL HIM OR HER WITH PROBABILITY “P”, IF HE SURVIES, HE WILL LIVE HIS NORMAL LIFE WITH WHATEVER WEALTH HE POSSESSES. HOWEVER, SOMEONE ARRIVES WITH A WHITE PILL THAT IF TAKEN WILL SURELY ELIMINATE THE DEATH RISK FROM THIS HAZARD. HOW MUCH “X” WOULD THE INDIVIDUAL BE WILLING TO PAY FOR THE WHITE PILL?
(B) THE WHITE PILL EXPERIMENT
FUTURE LIFE
LOTTERY
O
O
O
O
BUY WHITE PILL
REFUSE WHITE PILL
(WEALTH W - X)
(WEALTH W)
FUTURE LIFE
LOTTERY
LIVE
(WEALTH W)NODE
(WEALTH W)
DIE
HongJen Chang
14
10-9 10-8 10-7 10-6 10-5 10-4 10-3 10-2 10-1 100
1
10
102
103
104
105
106
107
108
PMAX
= 0.10
PROBABILITY OF DEATH (HOWARD)
AN ILLUSTATIVE RESULT (BLACK PILL)
$X
HongJen Chang
THE WTP APPROACH
15
(A) THE BLACK PILL EXPERIMENT
A PERSON IS OFFERED THE CHANCE TO TAKE A PILL THAT WILL KILL HIM INSTANTLY AND PAINLESSLY WITH PROBABILITY “P”, IF HE TAKES THE PILL, HE WILL RECEIVE $X. SHOULD HE ACCEPT?
FOR EXAMPLE, SHOULD THE PERSON ACCEPT A P = 1/10,000 INCREMENTAL CHANCE OF DEATH FOR A PAYMENT OF $1,000?
O
O
O
O
REJECT BLACK PILL
ACCEPT BLACK PILL
(WEALTH W)
(WEALTH W + $X)
FUTURE LIFE
LOTTERY
LIVE
(WEALTH W + $X)P
(WEALTH W + $X)
FUTURE LIFE
LOTTERY
I - P
DIE
HongJen Chang
16PROBABILITY OF DEATH (HOWARD)
$X
10-9 10-8 10-7 10-6 10-5 10-4 10-3 10-2 10-1 100
1
10
102
103
104
105
106
107
AN ILLUSTATIVE RESULT (WHITE PILL)
Ve =“ECONOMICVALUE OFLIFE”
HongJen Chang
Japan’s Co-payment reform, 2002
Under 3: 20% 3-69: 30% 70 and above: 10% (high income 20%)
› Younger senior (70-74)› Elder senior (75 and above)
Japan’s Health care reform, 2006
2006: Senior citizen (> 70) with annual income above 6.3 million Yen, › copayment rate 20% 30%
2008: 70-74 10 % 20% 2008 – 20% copayment extend to
preschool from the previous under 3
Professor Naoki Ikegami at the World Bank , 2004
…Japan has dealt with financing constraints in light of its stagnating economy. In addition to gradual restructuring, co-pays and premiums have increased significantly. Workers who had no co-payment twenty years ago now are responsible for 30% of their medical fees.
And we proudly announce the 50 million uninsured!
ehbs.kff.org
Tony Blair’s expensive Breakfast
BBC
A poor report card
The NHS fails its own bewilderingly complicated health check
The Economist, Oct. 2006
www.economist.com
SolidarityThe rich pay for the poor
The healthy pay for the sickThe young pay for the
elderly
Peter Smith Professor, University of
YorkOct. 12, 2004 Gastein,
Austria23
Mission statement of the Singaporean Minstry of Health
Good health is to a great extent the responsibility of the individual. The Ministry also plays a key role in reducing illness in Singapore through the control and prevention of diseases and ensuring that the resources are allocated appropriately to do this
Ensuring Singaporeans have access to good and affordable healthcare that is appropriate to needs while emphasize the principle of co-payment.
China
A three tier system with MSA, Deductibles, and limited benefit catastrophic insurance covering urban workers
125 cities > 1 million by 2010
Wikimedia Shizhao
Copyright ©2008 by Project HOPE, all rights reserved.
Winnie Yip and Ajay Mahal, The Health Care Systems Of China And India: Performance And Future Challenges, Health Affairs, Vol 27, Issue 4, 921-932
26
Health Affairs
Copyright ©2008 by Project HOPE, all rights reserved.
Winnie Yip and William C. Hsiao, The Chinese Health System At A Crossroads, Health Affairs, Vol 27, Issue 2, 460-468
27
Health Affairs
Health Spending and Health Status Indicators in Selected OECD Countries and Taiwan, 2004
Countries
Total healthspending as
% of GDP
Total healthspending per person (US$ PPP)
Life expectancy at birth (years)
Infant mortalityrate (per 1,000 live births)
Taiwan 6.26 1,440 76.4 2.9
Japan 8.0** 2,249* 82.1 2.8
Czech Republic
7.3 1,361 75.8 3.7
Poland 6.5 805 75.0 4.2
Germany 10.9* 3,005** 78.6 6.8
U. K.8.3 2,546 77.8* 5.1
United States15.3 6,102 76.8* 6.9**
*2000 figures**2003 figures
HongJen Chang
29
資料來源 : 1. OECD Health Data,2000~2002 2. 行政院衛生署編印之中華民國 89 年衛生統計動向 3. International Health Policy 之 Chart VIII-5 from Multinational Comparisons of Health System Data,2000
Percentage of GDP Spent on Health Care
13.0%
10.6%
9.5% 9.1%8.3% 8.1% 8.0% 7.8%
7.3%6.6%
5.9% 5.4%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
United
States
[2000]
Germany
[2000]
France
[2000]
Canada
[2000]
Australia
[2000]
OECD
Median
[2000]
New
Zealand
[2000]
J apan
[2000]
United
Kingdom
[2000]
Finland
[2000]
Korea
[2000]
Taiwan
[2000]
HongJen Chang
30
資料來源 : 1. OECD Health Data,2000~2002 2. 行政院衛生署編印之中華民國 89 年衛生統計動向 , 主計處 91 年 8 月 13 日國情統計通報專題分析 3. International Health Policy 之 Chart VIII-1 from Multinational Comparisons of Health System Data,2000
US Dollars
HongJen Chang
31
Per Capita Expenditures on Pharmaceuticals,Adjusted for Cost-of-Living Differences
484 478
405
301 300
239 237 234 229
193
125106
0
50
100
150
200
250
300
350
400
450
500
France
[1999]
United
States
[1999]
Canada
[2000]
J apan
[1998]
Germany
[1998]
OECD
Median
[1998]
Australia
[1998]
Finland
[1999]
United
Kingdom
[1997]
New
Zealand
[1997]
Korea
[1999]
Taiwan
[2000]
US Dollar
資料來源 : 1. OECD Health Data,2000~2001 2. 行政院衛生署編印之中華民國 89 年衛生統計動向 , 主計處 91 年 8 月 13 日國情統計通報專題分析 3. International Health Policy 之 Chart VIII-9 from Multinational Comparisons of Health System Data,2000
HongJen Chang
32
資料來源 : 1. OECD Health Data,2000~2001 2. 行政院衛生署編印之中華民國 89 年衛生統計動向 , 主計處 91 年 8 月 13 日國情統計通報專題分析 3. International Health Policy 之 Chart VIII-9 from Multinational Comparisons of Health System Data,2000
Annual Physician Visits per Capita
16.0
6.5 6.5 6.4 6.3 6.0 5.44.3
11.8
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
J apan
[1996]
Germany
[1996]
France
[1996]
Canada
[1998]
Australia
[1999]
United
States
[1996]
United
Kingdom
[1998]
Finland
[1999]
Taiwan
[2000]
No. of visit
HongJen Chang
33
資料來源 : 1. OECD Health Data, 2000~2001 2. 行政院衛生署編印之中華民國 89 年衛生統計動向 , 主計處 91 年 8 月 13 日國情統計通報專題分析 3. International Health Policy 之 Chart VIII-9 from Multinational Comparisons of Health System Data,2000
Per Capita Expenditures on Hospital Care,Adjusted for Cost-of-Living Differences
$1,764
$1,080
$930$867 $827 $804
$675 $645 $629$529
$251 $250
$0
$200
$400
$600
$800
$1,000
$1,200
$1,400
$1,600
$1,800
UnitedKingdom[1995]
Canada[2000]
France[1999]
UnitedStates[1999]
Australia[1997]
Germany[1998]
Japan[1998]
NewZealand[1993]
Finland[1999]
OECDMedian[1998]
Korea[1999]
Taiw an[2000]
US Dollar
HongJen Chang
World health Report 2000
Evaluation of Health System› Overall level of Health› Distribution of Health in the
population› Overall level of responsiveness› Distribution of responsiveness› Distribution of financial
contribution
High-performing Health systems
The OECD Health ProjectQuality: Better Health through better
careAccess to careResponsiveness: SatisfactionHealth care spending: affordability and
sustainable financingEfficiency: value for money
35
The Performance of NHI Universality Accessibility Affordability Sustainable Financing Responsiveness Equity Efficiency Public Satisfaction
36
Integration of Social Health Insurance
37
Labor Insurance
Medical benefits
Gov’t Employee Insurance
Medical benefits
Farmer Insurance
Medical benefits
Other insurance programs
Medical benefits
Uninsured (40%)
National Health Insurance
(99% of population)1995
HongJen Chang
Universal Coverage (2003)
38
Insured
BEFORE NHI AFTER NHI
Uninsured (8.6 million)
Insured
Uninsured1.33%
98.67%
41%
59%
HongJen Chang
保險憑證 - 健保 IC 卡
註 記 內 容 :重要檢查及藥品處方登錄、各項就醫紀錄登 錄、重大傷病登錄、器官捐贈或安寧緩和醫 療意願登錄等。 使用率監控:透過檔案分析,對於高利用率案件進行管理。 傳染性疾病追蹤: H1N1 、 SARS
39
1234 5678 9012
89/12/31
B123456789楊志良
HongJen Chang
National Health Expenditures as % of GDP 1991~2009
4.45 4.68
4.81 4.87
5.25 5.36 5.35 5.43 5.60 5.53
5.88 5.96 6.15 6.20 6.24 6.25 6.16
6.45
6.87
2.09 2.13 2.22 2.21
1.95 1.91 2.03 2.08 2.16 2.21 2.27 2.36 2.45 2.55 2.69 2.67 2.60
2.76 2.90
1.60 1.78 1.82
1.94
2.66 2.89 2.84 2.91 3.00 2.90
3.12 3.18 3.21 3.19 3.18 3.17 3.16 3.32
3.52
0.76 0.77 0.77 0.72 0.64
0.56 0.48 0.44 0.44 0.42 0.48 0.42 0.49 0.47 0.37 0.40 0.40 0.36 0.44
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Total Health Expenditures Private Sector
Health Insurance Government Sector
%of GDP
Year
HongJen Chang
Satisfaction Rate
39.0%
50.2%
61.0%
65.4% 66.5% 68.3%
63.3% 63.8%
67.2%
65.6%
71.1%
78.50%
66.40%
59.70%
70.90%
76.30%
47.0%
36.5%
27.0%
22.5%
23.4%
22.0%
25.9% 24.5%
24.2%20.1%
17.2%
13.60%
21.60%
29.60%
20.60%15.90%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
Satisfied Dissatisfied
41
(1995~ 2004)
Satisfied (DOH)Satisfied (BNHI)
Dissatisfied (DOH)Dissatisfied (BNHI)
1995/5 1995/9 1996/6 1998/1 1998/4 1998/11 1999/5 2000/3 2000/10 2001/6 2001/12 2002/5 2002/8 2002/11 2003/7 2004/4
HongJen Chang
42
Satisfaction level (%) very good good moderate bad
very bad
not sure N/A refusal
Overall satisfaction 6.3 42.0 31.6 11.9 2.8 5.4 --- 0.0
Dignity 31.3 50.4 11.8 3.6 0.7 2.3 --- 0.0
Autonomy 21.8 43.1 13.6 4.1 0.9 9.2 4.7 2.7
Confidentiality 12.4 21.0 6.5 3.5 0.9 34.0 13.6 8.2
Prompt attention 8.9 39.0 28.0 17.7 2.6 3.9 --- 0.0
Communication 27.3 51.9 16.3 3.3 0.3 0.8 --- 0.1
Quality of basic amenities 20.6 53.7 21.7 2.6 0.1 1.2 --- 0.1
Choice of care provider 23.7 48.1 13.6 3.7 0.8 6.0 2.6 1.5
Public satisfaction with the health system according to WHO criteria
HongJen Chang
Rank country index1 Colombia 0.992* Taiwan 0.992
(1994 : 0.881)
2 Luxembourg 0.9813-5 Belgium 0.9793-5 Djibouti 0.9793-5 Denmark 0.9796-7 Germany 0.9788-11 Japan 0.9778-11 United Kingdom 0.97712-15 Sweden 0.97617-19 Canada 0.97420-22 Netherlands 0.97338-40 Switzerland 0.96453 South Korea 0.95554-55 US 0.954101-102 Singapore 0.929188 China 0.638
* :Taiwan index for 1998
43
Fairness of financing contribution to health
systems in selected countries, WHO index, 1997
HongJen Chang
The Performance of NHI
Universality: 99% Accessibility: Free Choice Affordability: Inexpensive. Equity: Fairer but … Sustainable Financing: WTP? Responsiveness: Fair Efficiency: High (Hospitals, BNHI) Public Satisfaction: High (too
high ?)
44
Possible Factors Contributing tothe Success of Taiwan’s NHI
Single-payer system Competitive market on the health
care delivery side Information technology offers
additional cutting edge management tool for NHI› 100% electronic claim processing› smart card
Strong generic pharmaceutical industry
Family support Diligent health care workers
45
Challenges of the Future
Cost pressure from aging of the population and introduction of new medicine and technology
Doctor shopping and over prescription resulting in duplication and waste is an increasing public concern
Demand for health care outstrips our willingness to pay
Political pressure To privatize the BNHI and/or to
introduce multi-payer system Hospitals and doctors are increasing
dis-satisfied in the system
46
Thank you
47
Wikimedia Martin Belam
PAGE WORK LICENSE AUTHOR/SOURCE
5 This work is from: http://www2.biodiscover.com/news/healthcare/article/82231.html , and used subject to http://www.biodiscover.com/agreement.htmlThis work is used subject to the fair use doctrine of Article 52, 65 Taiwan Copyright Act by GET.2012/8/10 visited
6 This work is from 石曜堂 < 我們要往哪裡走?-健康照護再造的前瞻思維- >, 《醫療爭議審議報導系列 45 》 , p6, Bureau of National Health Insurance, 2010.3.and used subject to the fair use doctrine of the Taiwan Copyright Act Article 50 by GET
8 Wikipedia Evert A. Duykinck http://zh.wikipedia.org/wiki/File:Otto_von_Bismarck.JPG
8 Wikimedia commons Geographicus Rare Antique Mapshttp://commons.wikimedia.org/wiki/File:1781_Japanese_Temmei_1_Manuscript_Map_of_Taiwan_and_the_Ryukyu_Dominion_-_Geographicus_-_TaiwanRyukyu-unknown-1781.jpg
9 This楢山節考movie poster is from:http://www.cinemaffiche.com/recherche.php?langue=en&jours=0&ligne1=2&ligne2=2&page=1&lettre=B&motif= This work is used subject to the fair use doctrine of Article 52, 65 Taiwan Copyright Act by GET.2012/8/10 visited
12 Wikimedia commons PHenryhttp://commons.wikimedia.org/wiki/File:PharmacistsMortar.svg
13 National YangMing UniversityHongjen Chang
PAGE WORK LICENSE AUTHOR/SOURCE
14 National YangMing UniversityHongjen Chang
15 National YangMing UniversityHongjen Chang
16 National YangMing UniversityHongjen Chang
20 Kaiser/Hret 2003 Survey and CNN/money calculationshttp://money.cnn.com/2003/09/09/pf/insurance/employerhealthplans/ This work is used subject to the fair use doctrine of Article 52, 65 Taiwan Copyright Act by GET.2012/8/10 visited
21 BBC Election2010http://news.bbc.co.uk/2/hi/uk_news/politics/election_2010/parties_and_issues/8645845.stm This work is used subject tohttp://www.bbc.co.uk/terms/personal.shtml#113.2/3.2.3 (i) 2012/8/10 visited
22 The Economist, Oct. 2006This work is used subject to the fair use doctrine of Article 52, 65 Taiwan Copyright Act by GET.2012/8/10 visited
25 Wikimedia commons Shizhaohttp://commons.wikimedia.org/wiki/File:Wumen.jpg
PAGE WORK LICENSE AUTHOR/SOURCE
26 Winnie Yip and Ajay Mahal, The Health Care Systems Of China And India: Performance And Future Challenges, Health Affairs, Vol 27, Issue 4, 921-932
27 Winnie Yip and William C. Hsiao, The Chinese Health System At A Crossroads, Health Affairs, Vol 27, Issue 2, 460-468Copyright ©2008 by Project HOPE, all rights reserved.
28 National YangMing UniversityHongjen Chang可能需要來源!
29 National YangMing UniversityHongjen Chang
30 National YangMing UniversityHongjen Chang
31 National YangMing UniversityHongjen Chang
32 National YangMing UniversityHongjen Chang
33 National YangMing UniversityHongjen Chang
37 National YangMing UniversityHongjen Chang
Percentage of GDP Spent on Health Care
13.0%
10.6%
9.5% 9.1%8.3% 8.1% 8.0% 7.8%
7.3%6.6%
5.9% 5.4%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
United
States
[2000]
Germany
[2000]
France
[2000]
Canada
[2000]
Australia
[2000]
OECD
Median
[2000]
New
Zealand
[2000]
J apan
[2000]
United
Kingdom
[2000]
Finland
[2000]
Korea
[2000]
Taiwan
[2000]
Per Capita Expenditures on Pharmaceuticals,Adjusted for Cost-of-Living Differences
484 478
405
301 300
239 237 234 229
193
125106
0
50
100
150
200
250
300
350
400
450
500
France
[1999]
United
States
[1999]
Canada
[2000]
J apan
[1998]
Germany
[1998]
OECD
Median
[1998]
Australia
[1998]
Finland
[1999]
United
Kingdom
[1997]
New
Zealand
[1997]
Korea
[1999]
Taiwan
[2000]
Annual Physician Visits per Capita
16.0
6.5 6.5 6.4 6.3 6.0 5.44.3
11.8
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
J apan
[1996]
Germany
[1996]
France
[1996]
Canada
[1998]
Australia
[1999]
United
States
[1996]
United
Kingdom
[1998]
Finland
[1999]
Taiwan
[2000]
Per Capita Expenditures on Hospital Care,Adjusted for Cost-of-Living Differences
$1,764
$1,080
$930$867 $827 $804
$675 $645 $629$529
$251 $250
$0
$200
$400
$600
$800
$1,000
$1,200
$1,400
$1,600
$1,800
UnitedKingdom[1995]
Canada[2000]
France[1999]
UnitedStates[1999]
Australia[1997]
Germany[1998]
Japan[1998]
NewZealand[1993]
Finland[1999]
OECDMedian[1998]
Korea[1999]
Taiw an[2000]
PAGE WORK LICENSE AUTHOR/SOURCE
38 National YangMing UniversityHongjen Chang
39 National YangMing UniversityHongjen Chang
40 National YangMing UniversityHongjen Chang資料來源? (“應該”是老師自己畫的,從全民健保資料庫弄來的@@)
41 National YangMing UniversityHongjen Chang資料來源?
42 National YangMing UniversityHongjen Chang資料來源?
43 National YangMing UniversityHongjen Chang資料來源?
47 Wikimedia Commonshttp://commons.wikimedia.org/wiki/File:Lighthouse_at_night,_Chania.jpg