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Cost sharing and Copayment: Lessons from 10 Countries

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The rising health care cost has reached the point where cost sharing from patients might be essential to sustain the health system. This report is aimed to synthesize lessons on cost charing policies in 10 countries; namely, Australia, Canada, Finland, Germany, Japan, Singapore, South Korea, Taiwan, R.O.C., United Kingdom, and United States of America. The study comprises two components. The first is literature review general information of each country on its current health insurance systems, basic principles for cost sharing, approaches and rates used for cost sharing, mechanisms to protect the disadvantaged population, as well key concerns about implementing cost sharing policy. Second, a systematic review is used to explore the effects of cost sharing and copayment policies on health services access/utilization, out-of-pocket expenditures, health care expenditures, quality of care, administrative cost.

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Jens Holst

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Commentary: Patient Cost Sharing and Medical Expenditures for the Elderly
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Effects of Cost Sharing on Care Seeking and Health Status: Results From the Medical Outcomes Study
Ronald Andersen

American Journal of Public Health, 2001

Objectives. This study sought to determine the effect of cost sharing on medical care use for acute symptoms and on health status among chronically ill adults.

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Effects of cost sharing on seeking outpatient care: a propensity-matched study in Germany and Switzerland
Thomas Rosemann

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Background Several studies have assessed the effect of cost sharing on health service utilization (HSU), mostly in the USA. Results are heterogeneous, showing different effects. Whereas previous studies compared insurants within one health care system but different modes of insurance, we aimed at comparing two different health care systems in Europe: Germany and Switzerland. Furthermore, we assessed the impact of cost sharing depending on socio-demographic factors as well as health status. Methods Two representative samples of 5197 Swiss insurants with and 5197 German insurants without cost sharing were used to assess the independent association between cost sharing and the use of outpatient care. To minimize confounding, we performed crosssectional analyses between propensity score matched Swiss and German insurants. We investigated subgroups according to health and socio-economic status to assess a potential social gradient in HSU.

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The effect of cost-sharing in private health insurance on the utilization of health care services between private insurance purchasers and non-purchasers: a study of the Korean health panel survey (2008-2012)
Kyoung Hee Cho

BMC health services research, 2015

Private health insurance in South Korea mainly functions as supplementary and complementary health insurance that compensates for insufficient coverage by National Health Insurance. However, full private coverage of public sector cost-sharing led to the problem of encouraging moral hazard-induced utilization, resulting in a policy change that occurred in October 2009. At that time, the Korean government introduced a minimum cost-sharing policy for indemnity health insurance. The purpose of this study was to analyze the effect of cost-sharing in private health insurance on health care utilization. We analyzed data collected from the Korean Health Panel Survey from October 2008 to December 2011. We restricted the two groups to 803 purchasers with indemnity health insurance and 7023 non-purchasers who did not obtain any private health insurance. A difference-in-difference analysis was used to evaluate the effect of the 2009 policy. After the policy change, the utilization of outpatient...

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Effect of cost sharing on utilization of general physician care: A cross-sectional survey from Shiraz, Iran
masoud arefnezhad

International Journal of Preventive Medicine, 2018

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American Economic Review, 2010

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Health Policy, 2005

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This report is aimed to synthesize lessons on cost charing policies in 10 countries; namely, Australia, Canada, Finland, Germany, Japan, Singapore, South Korea, Taiwan, R.O.C., United Kingdom, and United States of America. The study comprises two components. The first is literature review general information of each country on its current health insurance systems, basic principles for cost sharing, approaches and rates used for cost sharing, mechanisms to protect the disadvantaged population, as well key concerns about implementing cost sharing policy. Second, a systematic review is used to explore the effects of cost sharing and copayment policies on health services access/utilization, out-of-pocket expenditures, health care expenditures, quality of care, administrative cost. 3 ²®ÊÂÙ³ÊîÒËÂѲµÚ²› ÂÔËÒ ̈ÒÂÀÕÊÇ‹ ‹ÇÀÆ‹ÒÁ̋‹Ò²ÂÔ̈ÒÂÊÙ˚¾Ò¼ ̈ÒÂÀÕÊ‹Ç Â‹ÇÀÆ‹ÒÁ̋‹Ò²ÂÔ̈ÒÂÊÙ˚¾Ò¼ (Cost Sharing) ˚Í̶á©‹ÄгÂÐà®È ÀÕËÄÑ̈̈ÒÂáÄÐÇÔ ṎÒ®Õé á©̈©‹Ò̶̈Ñ ä³©ÒÀ³ÂÑŁºÒ˚Í̶Âв²ÊÙ˚¾Ò¼³ÂÐà®È Ñê ç á©‹â­Á®ÑéÇä³áÄ›Ç ÊÒÀÒ¬ÆîÒá ̈ÍÍ̈䭛ೠ3 ³ÂÐྮã˺‹ç ̋Í 1. Copayment (̈Ò‹ÇÀÆ‹ÒÁ ß ÆÙ­²ÂÔ̈ÒÂãË›̈ѲµÚ›ãË›²ÂÔ̈ÒÂâ­Á©Â̶), 2. Deductible (̈Ò‹ÇÀÆ‹ÒÁ ß ÆÙ­²ÂÔ̈Ò ®ÕéÂÒ̋Ò˚Ñê ©› ÂÐ­Ñ²Ë Öé̶), 3. 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ÆÒ̈ µÚ›³ÂÐ̈Ñ © á©‹˚›ÍÀÚÄÆÒ̈̈Ò®²®Ç ÁÑ̶äÀ‹ÊÒÀÒ¬ÊÂÙ³³ÂÐà­è ­Ñ̶̈Ä‹ÒÇä­› á©‹ËÒ̈ÊÒÀÒ¬­îÒà Ô ̈ÒÂä­› ÆÂÔ̶̋ÇÂÍÍ̈á²²ãË›Âв²àÂÕÁ²̶‹ÒÁ à éÍ̶ÆÒ̈µÚ›³ÂÐ̈Ñ © ÍÒÆÊÑ²Ê ̈ѲËÄÑ̈à̈ßø‒áÄÐÇÔ ṎÒ â­Á઼ÒÐ µÚ›³ÂÐ̈Ñ © ÂÒÁãËÀ‹ Í̈ÆÒ̈ Õê ËÒ̈©›Í̶̈Ò®îÒ̈ÒÂÈÖ̈ÉÒà̈ÕéÁÇ̈ѲµÄ˚Í̶ Copayment ã Í Ò̋© ̈‹Í àÂÔéÀ ­î Ò à Ô ̈Ò ̋ÇÂà©ÂÕ Á Àà̈è ² ˚› Í ÀÚ Ä ¼ê łÒ ®Õé ÀÕ ³ ÂÐâÁŁ ‒ à¼é Í ãŁ› Êî Ò ËÂÑ ² à³ÂÕ Á ²à®Õ Á ²̈Ñ ² ˚› Í ÀÚ Ä ËÄÑ ̶ ̈Ò ­îÒà Ô ̈Ò 8 ̈Ô©©Ô̈ÂÂÀ³ÂÐ̈ÒÈ µÚ›à˚ÕÁ ã̋‹˚Í˚Ͳ¼ÂÐ̋ÙßÊ¬Ò²Ñ ÇÔÆÑÁà¼éÍ̈Ò¼ќ ÒËÄÑ̈³ÂÐ̈Ñ ÊÙ˚¾Ò¼ä®Á ®ÕéãË›̈ÒÂÊ Ñ²Ê Ù ̈ÒÂÈÖ̈ÉÒ Õê â­Á઼ÒÐ ¼.­Â.ÊÑÀî Ôí ÈÂÕ îÒÂ̶ÊÇÑÊ­Ôí áÄÐ̋Ùß¼ÑŁ Õ ÂÂÀÇÑ Ò ˚Ͳ¼ÂÐ̋Ùß ÂÈ. ¼.ÆÔÂÙ©À‒ ÈÂÕÂÑ© ²ÑÄÄ‒ áÄÐ ¼.Æà­èÆ ÂÂÀ ÑŁÍÒÂÕÁ‒ ®Õéä­›Ł‹ÇÁãË›̋îÒá Ð îÒ®Õéà³ ³ÂÐâÁŁ ‒ áÄÐ ¼.Í ÙÇÑœ ‒ ÈÙ¾ŁÙ©Ô̈ÙÄ ®Õéà³ µÚ›Ê›Ò̶áÂ̶²Ñ ­ÒÄãÆ ãË›µÚ›à˚ÕÁ ®îÒ̶Ò ­›Ò Õê ˚Ͳ¼ÂÐ̋Ùß̋ÂÚ ÍÒÆÒÂÁ‒®̈Ù ®‹Ò ®Ñ̶ê ®ÕéÁÑ̶ÀÕŁÕÇÔ©ÍÁÚ‹áÄÐÄ‹Ç̶ÄѲä³áÄ›Ç ®Õäé ­›ãË›̋ÇÒÀÂÚ›áÄЮÑ̈ÉÐá̈‹µÚ›à˚ÕÁ ÊîÒËÂѲ³ÂÐâÁŁ ‒®Õéà̈Ô­˚Öê ÆÒ̈ÂÒÁ̶Ò ̈ÒÂÈÖ̈ÉÒ Õê µÚ›à˚ÕÁ ˚ÍÍÙ®ÔÈãË› ¼.Ê̶Ç Ä‹Ç̶ÄѲä³áÄ›Ç Ô©ÁÒÂÑÀ¼̶È‒ µÚ› 9 ÊÒ²Ѻ ²®̋Ñ­Á‹Í .................................................................................................................................................2 Abstract ..................................................................................................................................................3 ²®ÊÂÙ³ÊîÒËÂѲµÚ›²ÂÔËÒÂ............................................................................................................................4 ̈Ô©©Ô̈ÂÂÀ³ÂÐ̈ÒÈ ...................................................................................................................................9 ÊÒ²Ѻ ..................................................................................................................................................10 ÊÒ²Ѻ©ÒÂÒ̶ ........................................................................................................................................11 ÊÒ²Ѻ¾Ò¼...........................................................................................................................................13 ²®®Õé 1...................................................................................................................................................14 ²®®Õé 2...................................................................................................................................................18 ÍÍÊà©ÂàÄÕÁ (Australia)......................................................................................................................23 á̋ Ò­Ò (Canada)............................................................................................................................27 ½~ áÄ ­‒ (Finland) ...........................................................................................................................32 àÁÍÂÀÑ Õ (Germany)........................................................................................................................35 ºÕé³Ùƒ (Japan)....................................................................................................................................41 ÊÔ̶̋â³Â‒ (Singapore).........................................................................................................................47 à̈ÒËÄÕã©› (South Korea) ...................................................................................................................53 ä©›ËÇÑ (Taiwan)...............................................................................................................................64 ÍÑ̶̈ÃÉ (UK) .....................................................................................................................................75 ÊËÂÑłÍàÀÂÔ̈Ò (USA)..........................................................................................................................81 àÍ̈ÊÒÂÍ›Ò̶ÍÔ̶ ........................................................................................................................................90 10 ÊÒ²Ѻ©ÒÂÒ̶ ©ÒÂÒ̶®Õé 1 ³ÂÑŁºÒ˚Í̶Âв²ÊÙ˚¾Ò¼ 4 ³ÂÐྮ......................................................................................15 ©ÒÂÒ̶®Õé 2 à³ÂÕÁ²à®ÕÁ²̋ÇÒÀá©̈©‹Ò̶ÂÐËÇ‹Ò̶³ÂÑŁºÒ˚Í̶Âв²ÊÙ˚¾Ò¼ 4 ³ÂÐྮ .................................15 ©ÒÂÒ̶®Õé 3 áËÄ‹̶˚›ÍÀÚijÂÐྮÊéÍÍÔàÄ̋®ÂÍ Ô̋Ê‒˚Í̶³ÂÐà®È®Õé®Òî ̈ÒÂÈÖ̈ÉÒ............................................19 ©ÒÂÒ̶®Õé 4 ÊÂÙ³ÆîÒ Ç ²®̋ÇÒÀÆÒ̈łÒ ˚›ÍÀÚÄ Medline ..........................................................................20 ©ÒÂÒ̶®Õé 5 ÊÂÙ³ÆîÒ Ç ²®̋ÇÒÀÆÒ̈łÒ ˚›ÍÀÚÄ Proquest Dissertation and Thesis.................................21 ©ÒÂÒ̶®Õé 6 ˚›ÍÀÚÄà³ÂÕÁ²à®ÕÁ²˚Í̶³ÂÐà®È®Õé®Òî ̈ÒÂÈÖ̈ÉÒ ........................................................................22 ©ÒÂÒ̶®Õé 7 Regionalization in Provinces and Territories, Canada.......................................................29 ©ÒÂÒ̶®Õé 8 Health Expenditures by Service Category, Canada...........................................................29 ©ÒÂÒ̶®Õé 9 Estimated Number of Physicians’ Services per Family with and with Copayment...........31 ©ÒÂÒ̶®Õé 10 Copayment Level, Germany .............................................................................................38 ©ÒÂÒ̶®Õé 11 Health Insurance System, Japan......................................................................................43 ©ÒÂÒ̶®Õé 12 Hospital Bill Size for Appendectomy, Singapore..............................................................48 ©ÒÂÒ̶®Õé 13 Medisave Contributions, Singapore..................................................................................49 ©ÒÂÒ̶®Õé 14 Outpatient Treatments, Singapore....................................................................................50 ©ÒÂÒ̶®Õé 15 Procedures Medisave Limites, Singapore........................................................................51 ©ÒÂÒ̶®Õé 16 Number of Health Care Institutions, South Korea............................................................53 ©ÒÂÒ̶®Õé 17 Number of Covered Population (2005), South Korea......................................................55 ©ÒÂÒ̶®Õé 18 Premium Contribution Rates, South Korea ......................................................................56 ©ÒÂÒ̶®Õé 19 Premium Revenues and Growth Rates by Year, South Korea .......................................57 ©ÒÂÒ̶®Õé 20 Health Insurance Benefits, South Korea ..........................................................................57 ©ÒÂÒ̶®Õé 21 Types of Copayment, South Korea ..................................................................................58 ©ÒÂÒ̶®Õé 22 Expenditure of Insurance Benefit, South Korea...............................................................60 ©ÒÂÒ̶®Õé 23 Expenditure of Cash Benefit, South Korea ......................................................................61 ©ÒÂÒ̶®Õé 24 Expenditure of Service Benefits by Type, South Korea ..................................................62 ©ÒÂÒ̶®Õé 25 NHI Applicants, Dependents and Insuring Agencies, Taiwan, R.O.C.............................66 ©ÒÂÒ̶®Õé 26 Premium Contribution Rates, Taiwan, R.O.C...................................................................67 ©ÒÂÒ̶®Õé 27 Premium Calculation Formulas, Taiwan, R.O.C. .............................................................67 ©ÒÂÒ̶®Õé 28 Premium Revenues and Growth Rates by Year, Taiwan, R.O.C....................................68 ©ÒÂÒ̶®Õé 29 Global Budget (2003-2007), Taiwan, R.O.C. ...................................................................68 11 ©ÒÂÒ̶®Õé 30 Basic Outpatient Care Copayment, Taiwan, R.O.C.........................................................70 ©ÒÂÒ̶®Õé 31 Copayment Rates for Inpatient Care, Taiwan, R.O.C......................................................70 ©ÒÂÒ̶®Õé 32 NHI Catastrophic Illnesses, Taiwan, R.O.C. ....................................................................72 ©ÒÂÒ̶®Õé 33 Comparison between pre- and post-copayment increase, Taiwan, R.O.C.....................74 ©ÒÂÒ̶®Õé 34 Growth in NHS Expenditures, UK ....................................................................................79 ©ÒÂÒ̶®Õé 35 Market Shares of Private Insurance Companies, UK ......................................................79 ©ÒÂÒ̶®Õé 36 NHS Source of Finance, UK.............................................................................................80 ©ÒÂÒ̶®Õé 37 ÊÂÙ³µÄ̈ÒÂÆÒ̈̈ÒÂÈÖ̈ÉÒã ³ÂÐà®ÈÊËÂÑłÍàÀÂÔ̈Ò................................................................84 12 ÊÒ²Ѻ¾Ò¼ ¾Ò¼®Õé 1 Organizational Chart of the Health System, Australia..........................................................24 ¾Ò¼®Õé 2 Financing Flowchart, Australia ..............................................................................................26 ¾Ò¼®Õé 3 Financial Flow, Canada.........................................................................................................28 ¾Ò¼®Õé 4 Federal Transfers as a Share of Provincial Health Expenditures, Canada.........................30 ¾Ò¼®Õé 5 Health System of Germany...................................................................................................36 ¾Ò¼®Õé 6 Health Insurance System, Japan ..........................................................................................42 ¾Ò¼®Õé 7 Relations between parties of National Health Insurance, South Korea...............................54 ¾Ò¼®Õé 8 Trends of NHI Benefits Cost, South Korea...........................................................................60 ¾Ò¼®Õé 9 Taiwan NHI Organization Chart, Taiwan, R.O.C..................................................................65 ¾Ò¼®Õé 10 Trend of NHI Financial Status, Taiwan, R.O.C...................................................................69 ¾Ò¼®Õé 11 Public Satisfaction Rate with NHI, Taiwan, R.O.C.............................................................70 ¾Ò¼®Õé 12 Structure of Department of Health, UK...............................................................................75 ¾Ò¼®Õé 13 Structure of NHS, UK ..........................................................................................................77 13 ²®®Õé 1 ̈ÒÂÀÕÊÇ‹ ‹ÇÀÆ‹ÒÁ̋‹Ò²ÂÔ̈ÒÂÊÙ˚¾Ò¼ ³ÂÑŁºÒ˚Í̶Âв²ÊÙ˚¾Ò¼á²²©‹Ò̶ç à éÍ̶ÆÒ̈Âв²ÊÙ˚¾Ò¼˚Í̶á©‹ÄгÂÐà®È ÀÕ³ÂÑŁºÒ®Õéá©̈©‹ Ò̶̈Ñ ̈ÒÂÀÕÊ‹Ç Â‹ÇÀÆ‹ ÒÁ̋‹Ò²ÂÔ̈Ò ÊÙ˚¾Ò¼ (Cost Sharing) ÆÖ̶ÀÕ̋ÇÒÀËÀÒÁâ­Á ÑÁ®Õéá©̈©‹Ò̶̈Ñ ØÖé̶³ÂÑŁºÒ˚Í̶Âв²ÊÙ˚¾Ò¼ ÊÒÀÒ¬ÆîÒá ̈ ÍÍ̈䭛ೠ4 ³ÂÐྮã˺‹ ̋Í 1. National Health Service (NHS / Beveridge Model) à³ ÂڳᲲ®Õéà › ̈Ò³ÂÐ̈Ñ ÊÙ˚¾Ò¼¬›Ç Ë ›Ò (Universal Coverage) ®Õé¬ÍÇ‹ÒÊÙ˚¾Ò¼à³ ÊÔ® Ôâ­ÁŁÍ² áÄÐÂÑł²ÒÄÀÕË ›Ò®ÕéÂѲµÔ­ŁÍ²ÊÙ˚¾Ò¼˚Í̶ ³ÂÐŁÒŁ ®Ñê̶³ÂÐà®È â­Áà³ ®Ñê̶µÚ›ØêÍáÄеڛãË›²ÂÔ̈ÒÂÊÙ˚¾Ò¼ ãŁ›à̶Ô ¾ÒÉÕÍÒ̈Âà³ áËÄ‹̶®Ù ËÄÑ̈ ³ÂÐà®È®Õé ãŁ›Âв² Õê àŁ‹ ÍÑ̶̈ÃÉáÄÐÊÔ̶̋â³Â‒ (©ÒÂÒ̶®Õé 1) 2. Social Health Insurance (SHI / Bismarck Model) à³ ÂڳᲲ®Õé¬ÍÇ‹Ò³ÂÐŁÒŁ µÚ›ãŁ›áÂ̶̶Ò à³ ̈Ää̈ËÄÑ̈®Õé®îÒãË›ÊÑ̶̋ÀÍÁÚ‹áÄÐà­Ô Ë ›Ò©‹Íä­› ÀṎÒÂÆÑ­©Ñê̶̈Í̶®Ù ³ÂÐ̈Ñ ÊÙ˚¾Ò¼¾Ò̋²Ñ̶̋Ѳ â­ÁãŁ›à̶Ô ÊÀ®²ÆÒ̈µÚ›Æ›Ò̶̶Ò (Employer) µÚ›¬Ú̈Æ›Ò̶̶Ò (Employee) áÄÐÂÑł²ÒÄ̈ÄÒ̶ ØÖé̶µÚ›³ÂÐ̈Ñ © ÆÐä­›ÂѲÊÔ® Ô ³ÂÐâÁŁ ‒®Ñê̶ã ÂÚ³²ÂÔ̈ÒÂÊÙ˚¾Ò¼ (Health Benefit) áÄÐã ÂÚ³à̶Ô Ł­àŁÁ (Cash Benefit) ³ÂÐà®È®ÕéãŁ›Âв² Õê àŁ‹ àÁÍÂÀÑ Õ 3. Private Health Insurance (PHI / Consumer Sovereignty Model) à³ ÂڳᲲ®Õé¬ÍÇ‹Ò ³ÂÐŁÒŁ á©‹ÄÐ̋ à³ µÚ›²ÂÔâ¾̋®ÕéÀÕË ›Ò®ÕéÂѲµÔ­ŁÍ²­ÚáÄÊÙ˚¾Ò¼© àÍ̶ àÀéÍÀṎÒÂàÆè²³ƒÇÁ̈èÂѲµÔ­ŁÍ² ̋‹Ò²ÂÔ̈ÒÂÊÙ˚¾Ò¼˚Í̶© àÍ̶ á©‹à¼éÍà³ ̈ÒÂ̈ÂÐÆÒÁ̋ÇÒÀàÊÕéÁ̶ ÆÖ̶ä­›ÆÑ­à³ ̈Í̶®Ù ³ÂÐ̈Ñ ÊÙ˚¾Ò¼àÍ̈Ł â­ÁÍÒÈÑÁà̶Ô ®Ù ËÄÑ̈ÆÒ̈̈ÒÂà̈è²à²ÕêÁ³ÂÐ̈Ñ (Premium) ÆÒ̈µÚ›³ÂÐ̈Ñ © ÂÒÁ̋ ËÂÍÂÒÁ̈ÄÙ‹À ÂÑł²ÒÄÀÕ Ë ›Ò®Õ飋ÇÁàËÄ͵ڛ®Õé­›ÍÁâÍ̈ÒÊã ÊÑ̶̋Àà¼éÍã˛䭛ÂѲ²ÂÔ̈ÒÂÊÙ˚¾Ò¼®ÕéÆîÒà³ ¼ê łÒ ³ÂÐà®È®ÕéãŁ›Âв² Õê àŁ‹ ÊËÂÑłÍàÀÂÔ̈Ò 4. National Health Insurance (NHI) à³ ÂڳᲲċÒÊÙ­®Õé¼Ñœ ÒÆÒ̈ 2 ÂڳᲲáÂ̈1 ÀÕÄÑ̈ÉßÐà­‹ ̋Í ÀÕµÚ›ØêͲÂÔ̈ÒÂá²²ÂÇÀÈÚ Á‒áË‹̶à­ÕÁÇ ã ˚ßЮÕéµÚ›ãË›²ÂÔ̈ÒÂËÄÑ̈ÀÒÆÒ̈¾Ò̋àÍ̈Ł ³ÂÐà®È®ÕéãŁ›Âв² Õê àŁ‹ ä©›ËÇÑ áÄÐà̈ÒËÄÕã©› 14 ©ÒÂÒ̶®Õé 1 ³ÂÑŁºÒ˚Í̶Âв²ÊÙ˚¾Ò¼ 4 ³ÂÐྮ Source: Lee SY, Chun CB, Lee YG, Seo NK. The National Health Insurance system as one type of new typology: The case of South Korea and Taiwan. Health Policy. 2008 Jan;85(1):105-13. ©ÒÂÒ̶®Õé 2 à³ÂÕÁ²à®ÕÁ²̋ÇÒÀá©̈©‹Ò̶ÂÐËÇ‹Ò̶³ÂÑŁºÒ˚Í̶Âв²ÊÙ˚¾Ò¼ 4 ³ÂÐྮ Source: Lee SY, Chun CB, Lee YG, Seo NK. The National Health Insurance system as one type of new typology: The case of South Korea and Taiwan. Health Policy. 2008 Jan;85(1):105-13. ³ÂÑŁºÒ˚Í̶Âв²ÊÙ˚¾Ò¼®Ñ̶ê 4 ³ÂÐྮ ÀÕ̋ÇÒÀá©̈©‹Ò̶̈Ñ ã 4 ³ÂÐà­è ã˺‹ ̋Í 1.̋Ùß̋‹Ò®Ò̶ ÊÑ̶̋À˚Í̶Âв²ÊÙ˚¾Ò¼ â­ÁÂв² NHS áÄÐ NHI ¬ÍÇ‹ÒÊ‹Ç ̈ÄÒ̶ÀÕË ›Ò®ÕéÂѲµÔ­ŁÍ²­ÚáÄÊÙ˚¾Ò¼˚Í̶ ³ÂÐŁÒŁ ®Ñê̶³ÂÐà®È (Universalism) ã ˚ßЮÕéÂв² PHI à › ®ÕÍé ÊÔ ÂоҼ˚Í̶³ÂÐŁÒŁ á©‹ÄÐ̋ (Liberalism) áÄÐÂв² SHI ¬ÍÇ‹ÒÊ¬Ò ³ÂÐ̈Ͳ̈ÒÂáÄÐÊ‹Ç ̈ÄÒ̶©›Í̶‹ÇÀÀÍ̈Ñ ­ÚáÄÊÙ˚¾Ò¼˚Í̶¼ Ñ̶̈Ò 15 (Corporatism) 2.̈ÒÂ̋Dz̋ÙÀ̈îÒ̈ѲµÚ›ãË›²ÂÔ̈Ò¾Ò̋àÍ̈Ł ˚Í̶Âв² NHS áÄÐ NHI ÆÐÀÕ̋ÇÒÀà˚›À̶Ç­ ÀÒ̈̈Ç‹ÒÂв² SHI áÄÐ PHI 3.̈ÒÂÊ Ñ²Ê Ù ̶²³ÂÐÀÒßÆÒ̈¾Ò̋ÂÑł ØÖé̶Âв² NHS áÄÐ SHI ÆÐÀÕÀÒ̈®ÕéÊÙ­ áÄÐ 4.²®²Ò®Ë ›Ò®ÕéËÄÑ̈˚Í̶¾Ò̋ÂÑł ã Âв² NHS ÆÐà³ µÚ›ãË›²ÂÔ̈ÒÂÊÙ˚¾Ò¼àÍ̶ (provider) Ê‹Ç ã Âв² NHI ¾Ò̋ÂÑłÆÐà³ µÚ›̈Òî ̈Ѳ (conductor) áÄÐã Âв² SHI ¾Ò̋ÂÑłÆÐà³ µÚ›̋Dz̋ÙÀ­ÚáĵڛãË›²ÂÔ̈Ò Cost Sharing ÊÒÀÒ¬᲋̶䭛ೠ3 ³ÂÐྮã˺‹ç ̋Í 1. Copayment à³ ̈Ò‹ÇÀÆ‹ÒÁ ß ÆÙ­²ÂÔ̈ÒÂãË›̈ѲµÚ›ãË›²ÂÔ̈ÒÂâ­Á©Â̶ ØÖé̶ÍÒÆà³ ̈ÒÂ̈îÒË ­ ÂÒ̋Ò©ÒÁ©ÑÇ (Copayment) ËÂÍà³ ÊÑ­Ê‹Ç Â›ÍÁÄÐ˚Í̶̋‹ÒãŁ›Æ‹ÒÁ®ÕéµÚ›ãË›²ÂÔ̈ÒÂàÂÕÁ̈à̈è² (Coinsurance) ØÖé̶ ã ÂÒÁ̶Ò ÕêÆÐãŁ›̋îÒÂÇÀÇ‹Ò Copayment â­Á®ÑéÇä³à³ ̈ÒÂÍÒÈÑÁËÄÑ̈̈ÒÂ¼ê łÒ ®Ò̶àÈÂÉłÈÒÊ©Â‒ÆÙľÒ̋ (Microeconomics) Ç‹ÒµÚ›ØêÍÆÐÄ­³ÂÔÀÒß̈ÒÂãŁ›²ÂÔ̈ÒÂÄ̶ (Quantity) ËÒ̈© àÍ̶©›Í̶Æ‹ÒÁ̋‹Ò²ÂÔ̈ÒÂà¼ÔéÀ˚Öê (Price) ØÖé̶ä­›ÂѲ̈Ò¼ÔÊÚÆ ‒ã ̈ÒÂÈÖ̈ÉÒÇÔÆÑÁ2 à̈ÕéÁÇ̈Ѳ Copayment ã Í­Õ© àŁ‹ RAND Health Insurance Experiment3, 4 ØÖé̶¼²Ç‹Ò ‚ Copayment ÀյĮîÒãË›̈ÒÂãŁ›²ÂÔ̈ÒÂÄ­Ä̶ (Utilization) â­ÁÇÑ­ÆÒ̈ÆîÒ Ç ̋ÂÑê̶®ÕÀé ÒÂѲ ²ÂÔ̈Òµڛ³Çƒ Á Í̈ ËÂÍ ÆîÒ Ç ÇÑ Í âÂ̶¼ÁÒ²ÒÄ ‚ Copayment äÀ‹Àյĩ‹Í̈ÂÐ²Ç ̈ÒÂÂÑ̈ÉÒ (Intensity) â­ÁÇÑ­ÆÒ̈ÆîÒ Ç áÄгÂÐྮ˚Í̶ ²ÂÔ̈ÒÂÊÙ˚¾Ò¼®Õéä­›Â²Ñ ©‹Í³¡ ‚ Copayment ÊÒÀÒ¬Ł‹ÇÁÄ­̈ÒÂãŁ›²ÂÔ̈Ò®ÕéäÀ‹ÆîÒà³ Ä̶ ‚ Copayment ÍÒÆÀյĮîÒãË›̈ÒÂãŁ›²ÂÔ̈Ò®ÕéÆîÒà³ Ä­Ä̶ä­›­Ç› Á ‚ Copayment ÀÕµÄÄ­̈ÒÂÂѲ²ÂÔ̈Ò³Í̶̈Ñ âÂ̋²Ò̶Ł Ô­Ä̶ àŁ‹ Pap smear, Mammogram ‚ Copayment ÍÒÆÀյĮîÒãË›ÊÙ˚¾Ò¼áÁ‹Ä̶ â­Á઼Òеڛ³ƒÇÁ®ÕéÀÕłÒ Ð®Ò̶àÈÂÉł̈ÔÆáÄÐÊÑ̶̋À äÀ‹­Õ ‚ Copayment ÍÒÆЮîÒãË›µ³Ú› ǃ Á©ÂÐàÇßËÒ²ÂÔ̈ÒÂÊÙ˚¾Ò¼®ÕéÀÕ Copayment ¬Ú̈̈Ç‹Ò (Shopping Around) ‚ Âв² Copayment ®ÕéØÑ²Ø›Í ÆÐÀÕ̋Ò‹ ãŁ›Æ‹ÒÁã ̈Ò²ÂÔËÒÂÆÑ­̈ÒÂÊÚ̶ 2. Deductible à³ ̈Ò‹ÇÀÆ‹ÒÁ ß ÆÙ­²ÂÔ̈Ò ®ÕéÂÒ̋Ò˚Ñê ©› ÂÐ­Ñ²Ë Öé̶ à³ÂÕÁ²àÊÀÍ à³ à̈ßø‒®Õé µÚ›³ÂÐ̈Ñ © ãŁ›à³ÂÕÁ²à®ÕÁ²Ç‹Ò̈ÒÂàÆè²³ƒÇÁ Ñê ç ÀÕ̋ÇÒÀÂÙ áÂ̶¬Ö̶ÂЭѲ®Õé©›Í̶à˚›ÒÂѲ²ÂÔ̈ÒÂÊÙ˚¾Ò¼­›ÇÁÊÔ® ®Ô Õé ÀÕÍÁÚ‹ËÂÍäÀ‹ ØÖé̶ÊÒÀÒ¬ĭ̈Ò²ÂÔ̈Ò®ÕéäÀ‹ÆîÒà³ Ä̶ä­› á©‹ÍÒÆÀÕ˚›ÍàÊÕÁã ̈ÂßÕ®ÕéµÚ›³ƒÇÁäÀ‹ÊÒÀÒ¬³ÂÐàÀÔ ̋ÇÒÀÂÙ áÂ̶˚Í̶¾ÒÇÐ̋ÇÒÀàÆè²³ƒÇÁ®ÕéÀÕÍÁÚ‹ä­›­ÕÀÒ̈¼Í Æ ®îÒã˛䭛ÂѲ̈ÒÂÂÑ̈ÉÒ®ÕéäÀ‹®Ñ àÇÄÒ ©ÑÇÍÁ‹Ò̶àŁ‹ ²ÂÔÉÑ®³ÂÐ̈Ñ ÍÒÆ̈îÒË ­ãË›µÚ›³ƒÇÁ©›Í̶Æ‹ÒÁ̋‹Ò²ÂÔ̈ÒÂ˚Ñê ©éîÒ 1,000 ²Ò® à¼éÍà˚›ÒÂѲ̈Ò©ÂÇÆÂÑ̈ÉÒ µÚ›³ƒÇÁ®ÕéÀÕ 16 ÍÒ̈ÒÂäÀ‹ÂÙ áÂ̶áÄÐ̋Ô­Ç‹ÒÊÒÀÒ¬ÂÑ̈ÉÒàÍ̶ä­› ËÂÍ µÚ›³ƒÇÁ®ÕéÍÒ̈ÒÂÂÙ áÂ̶á©‹ÀÕà̶Ô äÀ‹à¼ÕÁ̶¼Í ÍÒÆäÀ‹à˚›ÒÂѲ ²ÂÔ̈Ò 3. 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ÂÚ³á²²Ê‹Ç Â‹ÇÀÆ‹ÒÁáÄÐÍÑ©ÂÒ®Õé̈Òî Ë ­ÊîÒËÂѲ²ÂÔ̈Ò³ÂÐྮ©‹Ò̶çã ³ÂÐà®È®ÕéÈ̈Ö ÉÒ 3. ̈Ää̈ã ̈Ò³̈³Í̶³ÂÐŁÒŁ ®ÕéäÀ‹ÊÒÀÒ¬ƋÒÁÊ‹Ç Â‹ÇÀ®Õé̈Òî Ë ­ ãË›ÊÒÀÒ¬à˚›Ò¬Ö̶áÄÐä­›Â²Ñ ²ÂÔ̈Ò®ÕÆé îÒà³ 4. 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Social Affairs and Health European Observatory on Health Systems and Policies Federal Ministry for Health and Social Security European Observatory on Health Systems and Policies Ministry of Health, Labour and Welfare ‚ World Bank ÊÔ̶̋â³Â‒ ‚ Ministry of Health à̈ÒËÄÕã©› ‚ National Health Insurance Corporation, Ministry of Health & Welfare ä©›ËÇÑ ‚ Bureau of National Health Insurance, Department of Health ÍÑ̶̈ÃÉ ‚ National Health Service ‚ European Observatory on Health Systems and Policies ÊËÂÑłÍàÀÂÔ̈Ò ‚ Center for Medicare & Medicaid Services Website ‚ http://www.health.gov.au/ ‚ http://www.euro.who.int/observatory/ ‚ http://www.hc-sc.gc.ca/index_e.html ‚ http://www.euro.who.int/observatory/ ‚ http://www.stm.fi/ ‚ http://www.euro.who.int/observatory/ ‚ http://www.bmg.bund.de/cln_041/EN ‚ http://www.euro.who.int/observatory/ ‚ http://www.mhlw.go.jp/english/wp/wphw/index.html ‚ http://www.worldbank.org/ ‚ http://www.moh.gov.sg/ ‚ http://english.mohw.go.kr/ ‚ 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Private expenditure on health (% GDP) Health expenditure per capita (PPP US$) Physicians (per 100,000 population) Key Level Infant mortality rate (per 1,000 live births) Under-five mortality rate (per 1,000 live births) Unemployment rate (% of labor force) Life expectancy at birth, female Life expectancy at birth, male Data Year 2005 2005 2005 Australia Canada Finland Germany Japan Korea Singapore Taiwan* UK USA Thailand 20.3 80.9 32.3 80.3 5.2 78.9 82.7 79.1 127.9 82.3 47.9 77.9 4.3 79.4 22.7 - 60.2 79 299.8 77.9 63 69.6 31,794 33,375 32,153 29,461 31,267 22,029 29,663 15,291 33,238 41,890 8,677 19752005 2005 2005 1.3 1.1 0.4 0.2 0.5 1 2.2 2.9 0.2 1 1.3 19.5 13.1 17.6 13.1 17.4 15.9 14.4 18.8 13.9 19.7 18.6 9.4 19.5 8.5 9.7 18 16.1 20.8 12.3 21.7 7.8 2004 6.5 6.8 5.7 8.2 6.3 2.9 1.3 6.16 7 6.9 2.3 2004 3.1 3 1.7 2.4 1.5 2.7 2.4 - 1.1 8.5 1.2 2,004 3,123 3,173 2,203 3,171 2,293 1,135 1,118 - 2,560 6,096 293 200004 247 214 316 337 198 157 140 - 230 256 37 Country Province Municipality Lander Country Country Country Country Country State Country 2005 5 5 3 4 3 5 3 5 5 6 18 2005 6 6 4 5 4 5 3 - 6 7 21 19962006 6.6 7.7 10.1 8.5 4.5 4 - - 5.6 5 - 2005 83.3 82.6 82 81.8 85.7 81.5 81.4 79.8 81.2 80.4 74.5 2005 78.5 77.9 75.6 76.2 78.7 74.3 77.5 73.7 76.7 75.2 65 Source: 1. Human Development Report 2007/2008 2. Ministry of Interior, Directorate-General of Budget Accounting and Statistics, Department of Health, Taiwan R.O.C. 22 ÍÍÊà©ÂàÄÕÁ (Australia) ³ÂÐà®ÈÍÍÊà©ÂàÄÕÁ ÀÕ³ÂÐŁÒ̈ 20 Ä›Ò ̋ Ê‹Ç ã˺‹ 66% ÍÁÚ‹ã à˚©àÀÍ̶ ³̈̋ÂÍ̶ã Âв²ÂÑł²ÒÄ ̈ÄÒ̶ (Federal Government) ®ÕéÀÕ 8 ÂÑł (States) ³ÂÐŁÒ̈ÂÀÕ̋ÇÒÀËÄÒ̈ËÄÒÁ®Ò̶ÇÑœ ÂÂÀÊÚ̶ â­ÁÊ‹Ç ã˺‹à³ µÚ›Í¼Á¼à˚›Ò áÄÐÀÕ̋ ¼ê àÀÍ̶³ÂÐÀÒß 2.4% ˚Í̶³ÂÐŁÒ̈ ØÖé̶ÀÑ̈ÀÕÂÒÁä­›áÄÐÊÙ˚¾Ò¼©éîÒ̈Ç‹Ò ÀÒ©ÂłÒ ˚Í̶³ÂÐà®È ̋‹ÒãŁ›Æ‹ÒÁÊÙ˚¾Ò¼̋Ô­à³ 9.6% ˚Í̶ GDP (6.5% â­Á¾Ò̋ÂÑł 3.1% â­Á¾Ò̋àÍ̈Ł ) ØÖé̶ 46% ˚Í̶̋‹ÒãŁ›Æ‹ÒÁÊÙ˚¾Ò¼Æ‹ÒÁâ­ÁÂÑł²ÒÄ̈ÄÒ̶ áÄÐ 22% Æ‹ÒÁâ­Á States áÄÐÀṎÒÂÆ‹ÒÁ Out-ofpocket ³ÂÐÀÒß 20% ØÖé̶Ê‹Ç ã˺‹à³ ̋‹ÒÁÒ ²ÂÔ̈Ò娄 ©̈ÂÂÀ áÄÐ̋‹Ò²ÂÔ̈Ò®Ò̶̈ÒÂá¼®Á‒Íé ç ØÖé̶äÀ‹ä­› ÍÁÚ‹ã ŁÙ­ÊÔ® Ô³ÂÐâÁŁ 5‒ ÂÑł²ÒÄ̈ÄÒ̶à³ µÚ›­ÚáÄ âÁ²ÒÁÊÙ˚¾Ò¼ËÄÑ̈áÄÐ̶²³ÂÐÀÒß®Õéà̈ÕéÁÇ˚›Í̶ ã ˚ßЮÕé States ÆÐÀÕÍÔÊÂÐ ã ̈ÒÂãË›²ÂÔ̈ÒÂÊÙ˚¾Ò¼ à éÍ̶ÆÒ̈¬Íà³ àÆ›Ò˚Í̶âÂ̶¼ÁÒ²ÒÄÂÑł áÄÐÀÕÂÑł²ÒÄ®›Í̶¬Ôé (Local Government) ³ÂÐÀÒß 850 áË‹̶ ®Õé­ÚáÄàÂéÍ̶à̈ÕéÁÇ̈Ѳ̈ÒÂÊÒ ÒÂßÊÙ˚áÄÐÊÔé̶áÇ­Ä›ÍÀ Í̈ÆÒ̈ ÕêÁÑ̶ÀÕµÚ›ãË›²ÂÔ̈ÒÂàÍ̈Ł ÆîÒ Ç Ë éÖ̶ ÍÁ‹Ò̶äÂ̈è©ÒÀ²®²Ò®̋ÇÒÀÂѲµÔ­ŁÍ²à̈ÕéÁÇ̈ѲÊÙ˚¾Ò¼ÂÐËÇ‹Ò̶ÂÑł²ÒÄÂЭѲ©‹Ò̶ç ËÂÍÂÐËÇ‹Ò̶ ÂÑł̈ѲàÍ̈Ł ÁÑ̶äÀ‹ŁÑ­àÆ à éÍ̶ÆÒ̈ÀÕ Privatization ÀÒ̈˚Öê àÂéÍÁç ̈Ò³ÂѲà³ÄÕéÁ ˚ Ò­ã˺‹ã­ç©‹ÍÂв²ÊÙ˚¾Ò¼˚Í̶³ÂÐà®È ÆЩ›Í̶ä­›ÂѲ̋ÇÒÀàËè ŁÍ²ÆÒ̈®Ñê̶ ÂÑł²ÒÄ̈ÄÒ̶áÄÐ States ©ÑÇÍÁ‹Ò̶̈ÒÂà³ÄÕéÁ á³Ä̶®ÕéÊîÒ̋Ѻ àŁ‹ ̈ÒÂ䭛ĭËÁ‹Í ¾ÒÉÕÊîÒËÂѲà̶Ô ®ÕéÆ‹ÒÁà²ÕêÁ ³ÂÐ̈Ñ ÊÙ˚¾Ò¼ (Public Support for Private Health Insurance) ØÖé̶®îÒãË›ÂÑł²ÒÄ̈ÄÒ̶©›Í̶ãŁ›̶²³ÂÐÀÒßä³ ®Ñ̶ê ÊÔê AU$2 ¼Ñ Ä›Ò ã ³¡¼.È. 2544 Æ ®îÒãË›Âв²³ÂÐ̈Ñ ÊÙ˚¾Ò¼¾Ò̋àÍ̈Ł ÀÕ̋ÇÒÀÊîÒ̋ѺáÄв®²Ò®äÀ‹ ­›ÍÁä³̈Ç‹Ò¾Ò̋ÂÑł ËÂÍ̈ÒÂà¼ÔéÀÍÑ©ÂÒ̈ÒÂÆ‹ÒÁã˛ἮÁ‒ GP ÆÒ̈ 85% à³ 100% ˚Í̶ÂÒ̋Ò̈ÄÒ̶ à¼éÍ ̈ÂЩٛ ã˛ἮÁ‒à²Ô̈Æ‹ÒÁâ­Á©Â̶ÀÒ̈˚Öê á® ®ÕéÆÐãË›µÚ›³ƒÇÁÆ‹ÒÁä³̈‹Í 23 ¾Ò¼®Õé 1 Organizational Chart of the Health System, Australia Source: Healy J, Sharman E, Lokuge B, European Observatory on Health Systems and Policies. Health systems in transition : Australia. 2006. ²Ù̋ÄÒ̈ÂÊÒ ÒÂßÊÙ˚ÀÕÍÁÚ‹³ÂÐÀÒß 570,000 ̋ á¼®Á‒Ê‹Ç ã˺‹ÍÁÚ‹ã ¾Ò̋àÍ̈Ł â­Á 60% à³ á¼®Á‒àÇŁ³ıԲѩԮÑéÇä³ (General Practitioner, GP) ØÖé̶ÆЮîÒË ›Ò®Õéà³ Gate-keeper ̈‹Í ®ÕéÆÐÊ‹̶©‹Íä³ÁÑ̶ á¼®Á‒઼ÒЮÒ̶àÀéÍÆîÒà³ Í̈ÆÒ̈ ÕêÁÑ̶ÀÕâÂ̶¼ÁÒIJÒÄàÍ̈Ł 301 áË‹̶ ̋Ô­à³ 30% ˚Í̶ÆîÒ Ç à©ÕÁ̶ ˚Í̶³ÂÐà®È Âв²³ÂÐ̈Ñ ÊÙ˚¾Ò¼áÄÐ̈ÒÂÀÕÊÇ‹ ‹ÇÀÆ‹ÒÁ̋‹Ò²ÂÔ̈ÒÂÊÙ˚¾Ò¼ ã ³¡¼.È. 2518 ÀṎÒÂàÂÔéÀÂв²³ÂÐ̈Ñ ÊÙ˚¾Ò¼ Medibank áÄÐä­›̈‹Í©Ñê̶ Health Insurance Commission (HIC) ˚Öê à¼éͲÂÔËÒÂÆÑ­̈Ò ØÖé̶̈îÒË ­Ç‹ÒµÚ›³ƒÇÁÍÒÆàÄÍ̈Æ‹ÒÁ̋‹Ò²ÂÔ̈Ò®Ò̶̈ÒÂá¼®Á‒àÍ̶ä³ ̈‹Í áÄ›Çà²Ô̈̋ ä­› 85% ˚Í̶ÂÒ̋Ò̈ÄÒ̶ÆÒ̈ Medibank ËÂÍ á¼®Á‒ÍÒÆà³ µÚ›à²Ô̈à̶Ô 85% Ñê àÍ̶ â­Á µÚ›³ƒÇÁäÀ‹©›Í̶àÊÕÁ̋‹ÒãŁ›Æ‹ÒÁã­ç ØÖé̶ÆÐàËè 䭛NjÒá¼®Á‒ÆÐÀÕÂÒÁä­›ÆÒ̈ÇÔ ÕáÂ̈ÀÒ̈̈Ç‹Ò ã Ł‹Ç̶ 7-8 ³¡©‹ÍÀÒ Medibank ä­›ÂѲ̈Ò³ÂѲà³ÄÕéÁ à³ ÂÐÁÐç àŁ‹ ³ÂÐŁÒŁ ÊÒÀÒ¬àÄÍ̈䭛NjÒÆÐÍÍ̈ÆÒ̈â̋Â̶̈ÒÂà¼éÍä³ ØêͳÂÐ̈Ñ ÊÙ˚¾Ò¼àÍ̈Ł ËÂÍ Æ‹ÒÁ¾ÒÉÕ 2.5% à¼éÍà³ ̋‹Òà²ÕêÁ³ÂÐ̈Ñ ãË› Medibank ØÖé̶©‹Í®îÒãË›à̈Ô­³»ºËÒ 24 ³ÂÐŁÒŁ ˚Ò­ËÄÑ̈³ÂÐ̈Ñ ÊÙ ˚¾Ò¼ÀÒ̈˚Öê àÂéÍÁç ÆÖ̶ä­›ÀṎÒÂÂêÍ ½£́ Âв²³ÂÐ̈Ñ ÊÙ˚¾Ò¼ãËÀ‹ à³ á²² ³»ÆÆÙ²Ñ ãŁ›ŁéÍÇ‹Ò Medicare ØÖé̶ãŁ›à̶Ô ¾ÒÉÕà³ áËÄ‹̶̶²³ÂÐÀÒßËÄÑ̈ â­ÁãŁ›ÍÑ©ÂÒ 1.5% ˚Í̶ÂÒÁä­› â­ÁµÚ›ÀÕ ÂÒÁä­› ›ÍÁÆÐä­›ÂѲ̈ÒÂÁ̈àÇ› Ê‹Ç µÚ›®ÕéÀÕÂÒÁä­›ÊÚ̶̈Ç‹Òà̈ßø‒®Õé̈îÒË ­á©‹äÀ‹ä­›®îÒ³ÂÐ̈Ñ ÊÙ˚¾Ò¼àÍ̈Ł ©›Í̶Æ‹ÒÁà¼ÔéÀÍṎ 1% ˚Í̶ÂÒÁä­› Medicare ̋ÂͲ̋ÄÙÀ³ÂÐŁÒŁ ®Ù̈̋ ³ÂÐŁÒŁ ŁÒÇ ÔÇØÕáÄ ­‒®ÕéÍÁÚ‹ã ³ÂÐà®È ©ÄÍ­Æ Ñ̈®‹Í̶à®ÕéÁÇÆÒ̈³ÂÐà®È®ÕéÀÕ˚›Í©̈Ä̶‹ÇÀ̈Ñ â­ÁËÄÑ̈̈Ò µÚ›³ÂÐ̈Ñ © ÊÒÀÒ¬ÂѲ²ÂÔ̈Ò®Ñê̶á²²µÚ›³ƒÇÁ Í̈áÄеڛ³ƒÇÁã ÆÒ̈âÂ̶¼ÁÒ²ÒÄ˚Í̶ÂÑł ä­›â­ÁäÀ‹©›Í̶àÊÕÁ̋‹ÒãŁ›Æ‹ÒÁã­ç Ê‹Ç ̈ÒÂÂѲ²ÂÔ̈ÒÂÆÒ̈®ÕéÍé ç ÆÐãŁ› Medical Benefits Schedule áÄÐ Pharmaceutical Benefits Schedule à¼éÍŁ‹ÇÁÊ̶à̋ÂÒÐË‒̋‹Ò²ÂÔ̈ÒÂáÄÐ̋‹ÒÁÒ²Ò̶ÍÁ‹Ò̶ Á̈àÇ› ²ÂÔ̈Ò ²Ò̶ÍÁ‹Ò̶ àŁ‹ ̈Ò®îÒ IVF (in vitro fertilization) ÈÑÄÁ̈ÂÂÀ©̈á©‹̶ ²ÂÔ̈Ò娄 ©̈ÂÂÀáÄÐ̈ÒÂá¼®Á‒ ®Ò̶àÄÍ̈ÆÒ̈¾Ò̋àÍ̈Ł á¼®Á‒ GP Ê‹Ç ã˺‹ÆЮîÒàÂéÍ̶à²Ô̈Æ‹ÒÁÆÒ̈ Medicare ©ÒÀÂÒ̋Ò̈ÄÒ̶ ã ˚ßЮÕéá¼®Á‒²Ò̶®‹Ò ÍÒÆãŁ›ÇÔ ṎÒÂà̈è²à̶Ô ÆÒ̈µÚ›³ƒÇÁâ­Á©Â̶̈‹Í áÄ›ÇÍÍ̈ã²àÊÂèÆà¼éÍãË›µÚ›³ƒÇÁä³à²Ô̈à̶Ô ̋ ÆÒ̈ Medicare àÍ̶ Ê‹Ç ̋‹ÒãŁ›Æ‹ÒÁÊîÒËÂѲ²ÂÔ̈ÒÂ̈ÒÂá¼®Á‒઼ÒЮÒ̶ Medicare ÆÐà²Ô̈̋ ãË› 85% á©‹ËÒ̈µÚ›³ƒÇÁäÀ‹©›Í̶̈ÒÂÂÍ ̋ÔÇ ÊÒÀÒ¬àÄÍ̈˚Íã˛ʋ̶©‹Íä³ËÒá¼®Á‒઼ÒЮÒ̶àÍ̈Ł ä­› â­Á®Ò̶ Medicare ÆÐà²Ô̈̋ ãË› 75% ˚Í̶ ̋‹Ò ÂÂÀà ÕÁÀá¼®Á‒áÄÐ̋‹Ò©ÂÇÆÇÔ ÔƪÑÁà¼ÔéÀà©ÔÀ©‹Ò̶ç á©‹µÚ›³ƒÇÁ©›Í̶Æ‹ÒÁ̋‹ÒãŁ›Æ‹ÒÁÍé çàÍ̶ ­›ÇÁà̶Ô Ê‹Ç ©ÑÇ ËÂÍà̶Ô ÆÒ̈³ÂÐ̈Ñ ÊÙ˚¾Ò¼àÍ̈Ł (¬›ÒÀÕ) ÍÁ‹Ò̶äÂ̈è©ÒÀ ËÒ̈µÚ›³ÂÐ̈Ñ © 䭛ƋÒÁ̋‹Ò²ÂÔ̈Ò©‹Ò̶çÆ ¬Ö̶ÂЭѲ ®Õé̈Òî Ë ­ Medicare ÆÐŁ‹ÇÁÂѲµÔ­ŁÍ²̋‹ÒãŁ›Æ‹ÒÁ 80% ©ÄÍ­ 1 ³¡ ÆÒ̈˚›ÍÀÚÄã ³¡¼.È. 2547 ÀṎÍ̶®Ù ³ÂÐ̈Ñ ÊÙ˚¾Ò¼¾Ò̋àÍ̈Ł 41 áË‹̶ â­ÁÀÕÍÁÚ‹ 6 ̈Í̶®Ù ®Õé ̋ÂͲ̋ÂÍ̶Ê‹Ç á²‹̶̈Ò©ÄÒ­¬Ö̶ 76% (̋Ô­©ÒÀÂÒÁä­›ÆÒ̈à²ÕêÁ³ÂÐ̈Ñ ) ØÖé̶ÀÕ Medibank Private áÄÐ Medical Benefits Fund of Australia à³ ÊÍ̶̈Í̶®Ù ®Õéã˺‹®ÕéÊÙ­ â­Á Medibank Private à³ ̈Ò Privatization ÀÒÆÒ̈ HIC ã ³¡¼.È. 2540 ̈Í̶®Ù ³ÂÐ̈Ñ ÊÙ˚¾Ò¼àÍ̈Ł àËÄ‹Ò Õê ÆÐÍÁÚ‹ã ̋ÇÒÀ­ÚáÄ˚Í̶ Private Health Insurance Administration Council ØÖé̶ÀÕÍîÒ ÒÆ̈îÒË ­˚›Í²Ñ̶̋Ѳ©‹Ò̶çä­› àŁ‹ ̈ÒÂË›ÒÀ ³ıÔàÊ ã²ÊÀÑ̋Â˚Í̶µÚ›³ÂÐ̈Ñ © áÄÐ̈ÒÂË›ÒÀ̈îÒË ­ÍÑ©ÂÒà²ÕêÁ³ÂÐ̈Ñ áÄÐÊÔ® Ô³ÂÐâÁŁ ‒®äÕé À‹à³ ÂÂÀ µÄ˚Í̶̈ÒÂÀÕÊÇ‹ ‹ÇÀÆ‹ÒÁ ÆÒ̈̈ÒÂʲ̋› łÒ ˚›ÍÀÚÄ Medline ¼²Ç‹ÒÀṎÒÂÈÖ̈ÉÒ˚Í̶³ÂÐà®ÈÍÍÊà©ÂàÄÕÁ 10 àÂéÍ̶ á©‹ä­›©­Ñ àÂéÍ̶®Õéà̈ÕéÁÇ̈ѲÁÒÍÍ̈ 5 àÂéÍ̶6-10 áÄЩѭàÂéÍ̶®ÕÇé ©Ñ ¬Ù³ÂÐÊ̶̋‒˚Í̶̈ÒÂÈÖ̈ÉÒäÀ‹©Â̶̈Ѳ̋ÇÒÀ©›Í̶̈ÒÂÍÍ̈ 5 àÂéÍ̶11-15 Ê‹Ç łÒ ˚›ÍÀÚÄÇÔ®ÁÒ Ô¼ ‒ äÀ‹ÀṎÒÂÈÖ̈ÉÒ˚Í̶³ÂÐà®ÈÍÍÊà©ÂàÄÕÁ 25 ¾Ò¼®Õé 2 Financing Flowchart, Australia Source: Healy J, Sharman E, Lokuge B, European Observatory on Health Systems and Policies. Health systems in transition : Australia. 2006. 26 á̋ Ò­Ò (Canada) ³ÂÐà®Èá̋ Ò­ÒÀÕ³ÂÐŁÒ̈³ÂÐÀÒß 32 Ä›Ò ̋ ÍÒÈÑÁÍÁÚ‹ã 10 ÆÑ̶ËÇÑ­ (Province) áÄÐ 3 Territories ØÖé̶ÀÕÂв²²ÂÔ̈ÒÂÊÙ˚¾Ò¼˚Í̶© àÍ̶ áÄÐÂÑł²ÒÄ̈ÄÒ̶ÀÕ²®²Ò®äÀ‹ÀÒ̈ Ñ̈ ̋‹ÒãŁ›Æ‹ÒÁÊÙ˚¾Ò¼̋Ô­ à³ 9.8% ˚Í̶ GDP (6.8% â­Á¾Ò̋ÂÑł 3% â­Á¾Ò̋àÍ̈Ł ) ³ÂÐÀÒß 70% ˚Í̶̋‹ÒãŁ›Æ‹ÒÁ­›Ò ÊÙ˚¾Ò¼ Æ‹ÒÁâ­Á¾Ò̋ÂÑł ã ˚ßЮÕé³ÂÐÀÒß 15% à³ Out-of-pocket áÄÐ 12% à³ ³ÂÐ̈Ñ ÊÙ˚¾Ò¼àÍ̈Ł 16 ¾ÒÁã©›̈ıËÀÒÁ Canada Health Act ³ÂÐŁÒŁ ®Ù̈̋ ÂÇÀ®Ñê̶µÚ›®Õéà˚›ÒÀÒÍÒÈÑÁã ³ÂÐà®ÈŁ‹Ç̶ ÂÐÁÐàÇÄÒ®Õé̈îÒË ­ ÆÐä­›ÂѲ²ÂÔ̈ÒÂÊÙ˚¾Ò¼®ÕéÆîÒà³ â­ÁäÀ‹©›Í̶àÊÕÁ̋‹ÒãŁ›Æ‹ÒÁ â­Áã á©‹ÄÐÆÑ̶ËÇÑ­ÆÐÀÕ Regional Health Authorities (RHA) ØÖé̶à³ ̈Ò¬‹ÒÁÍîÒ ÒÆ̈Ò²ÂÔËÒÂ̶²³ÂÐÀÒßÀÒÆÒ̈̈ÂЮÂÇ̶ÊÙ˚¾Ò¼ ®îÒË ›Ò®Õé­ÚáÄÂв²̈ÒÂãË›²ÂÔ̈ÒÂÊÙ˚¾Ò¼á̈‹³ÂÐŁÒŁ ®Õéä­›ÂѲ̈ÒÂÆÑ­Ê ­›ÇÁÇÔ ṎÒ®Õéá©̈©‹Ò̶̈Ñ ä³ àŁ‹ RHA Ê‹Ç ã˺‹ÆÐà³ µÚ›Æ‹ÒÁà̶Ô à­Í ãË›̈²Ñ àÆ›ÒË ›Ò®Õé˚Í̶âÂ̶¼ÁÒ²ÒÄ ã ˚ßЮÕé RHA ²Ò̶áË‹̶ÍÒÆãŁ›ÇÔ ṎÒ ØêͲÂÔ̈ÒÂÆÒ̈µÚ›ãË›²ÂÔ̈ÒÂàÍ̈Ł ã ¾Ò¼ÂÇÀÆÖ̶¬ÍÇ‹Ò RHA à³ ®Ñê̶µÚ›ØêͲÂÔ̈Ò (Purchaser) áÄеڛãË›²ÂÔ̈Ò (Provider) ̋‹ÒãŁ›Æ‹ÒÁ­›Ò ÊÙ˚¾Ò¼˚Í̶³ÂÐà®Èá̋ Ò­ÒÀÕÀÚÄ̋‹Òà¼ÔéÀ˚Öê àÂéÍÁç ÆÒ̈ 7% GDP ã ³¡¼.È. 2519 à³ 9.9% ã ³¡¼.È. 2547 ØÖé̶ÀÕÀÚÄ̋‹Ò C$130 ¼Ñ Ä›Ò â­Áà̈Ͳ̋ÂÖé̶Ë Öé̶ (43%) à̈Ô­˚Öê ®ÕéâÂ̶¼ÁÒ²ÒÄáÄÐ á¼®Á‒µÚ›­ÚáÄÂÑ̈ÉÒ ÍṎ 23% ãŁ›ÊîÒËÂѲâ̋Â̶̈Ò©‹Ò̶ç®Õéà̈Ô­˚Öê ®ÕÆé Ñ̶ËÇÑ­ Í̈ÆÒ̈ ÕêÍṎ 30% ãŁ›ÊÒî ËÂѲ ²ÂÔ̈ÒÂÊÙ˚¾Ò¼¾Ò̋àÍ̈Ł 16 â­Á³»ÆÆÑÁËÄÑ̈®Õé®Òî ãË›̋Ò‹ ãŁ›Æ‹ÒÁ­›Ò ÊÙ˚¾Ò¼à¼ÔéÀ˚Öê ̋Í ̈Ò®Õé³ÂÐŁÒ̈ÂÊÚ̶ÍÒÁÙ ÀÕÊÑ­Ê‹Ç à¼ÔéÀÀÒ̈˚Öê 17 ²ÂÔ̈ÒÂÊÙ˚¾Ò¼ã ³ÂÐà®Èá̋ Ò­Ò ¬ÍÇ‹ÒÀÕ̋Ùß¾Ò¼ã ÂÐ­Ñ²Ë Öé̶ â­ÁÆÒ̈̈ÒÂÊîÒÂÇÆã ³¡¼.È. 2549 ¼²Ç‹Ò³ÂÐŁÒŁ 55% àŁéÍÀÑé ã ̋Ùß¾Ò¼²ÂÔ̈Ò®Õé© àÍ̶ä­›ÂѲ ã ˚ßЮÕéÍṎ 37% äÀ‹àŁéÍàŁ‹ Ñê 18 27 ¾Ò¼®Õé 3 Financial Flow, Canada Source: Marchildon GP, Mossialos E, Allin S, European Observatory on Health Systems and Policies. Health systems in transition : Canada. Toronto: University of Toronto Press; 2006. 28 ©ÒÂÒ̶®Õé 7 Regionalization in Provinces and Territories, Canada Source: Marchildon GP, Mossialos E, Allin S, European Observatory on Health Systems and Policies. Health systems in transition : Canada. Toronto: University of Toronto Press; 2006. ©ÒÂÒ̶®Õé 8 Health Expenditures by Service Category, Canada Source: Marchildon GP, Mossialos E, Allin S, European Observatory on Health Systems and Policies. Health systems in transition : Canada. Toronto: University of Toronto Press; 2006. Âв²³ÂÐ̈Ñ ÊÙ˚¾Ò¼áÄÐ̈ÒÂÀÕÊÇ‹ ‹ÇÀÆ‹ÒÁ̋‹Ò²ÂÔ̈ÒÂÊÙ˚¾Ò¼ Âв²ÊÙ˚¾Ò¼˚Í̶³ÂÐà®Èá̋ Ò­Ò ãŁ›à̶Ô ¾ÒÉÕÍÒ̈Âã ÆÑ̶ËÇÑ­à³ áËÄ‹̶̶²³ÂÐÀÒßËÄÑ̈‹ÇÀ̈Ѳà̶Ô ÊÀ®²ÆÒ̈ÂÑł²ÒÄ̈ÄÒ̶ áÄÐã 2 ÆÑ̶ËÇÑ­ÀṎÒÂà̈è²à²ÕêÁ³ÂÐ̈Ñ (Premium) à¼ÔéÀà©ÔÀÍṎ (â­ÁµÚ›®ÕéÀÕłÒ Ð ÁÒ̈Æ ÆÐä­›ÂѲ̈ÒÂÁ̈àÇ› ) ̋Í Alberta ÀṎÒÂà̈è²ÍÑ©ÂÒ̶̋®Õé C$528 ©‹Í̋ áÄÐ C$1,056 ©‹Í̋ÂͲ̋ÂÑÇ ã ˚ßЮÕé British Columbia à̈è²ÍÑ©ÂÒ̶̋®Õé C$648 ©‹Í̋ , C$1,152 ©‹Í̋ÂͲ̋ÂÑÇ®ÕéÀÕÊÀÒŁÔ̈ 2 ̋ áÄÐ C$1,296 ©‹Í̋ÂͲ̋ÂÑÇ®ÕéÀÕÊÀÒŁÔ̈ 3 ̋ ˚Öê ä³ ÍṎÂÚ³á²²Ë Öé̶ä­›á̈‹®Õé Ontario ØÖé̶ã ³¡¼.È. 2547 ä­›àÂÔÀé à̈è² ¾ÒÉÕà¼ÔéÀà©ÔÀ (Surtax) à¼éÍà³ à²ÕêÁ³ÂÐ̈Ñ ­›ÇÁÍÑ©ÂÒ®ÕéÍÔ̶̈Ѳà̶Ô à­Í á©‹à̶Ô ÆÒ̈à²ÕêÁ³ÂÐ̈Ñ Õêà³ à¼ÕÁ̶ 29 13% ˚Í̶ÂÒÁä­›ËÄÑ̈ àÀéÍà®ÕÁ²̈Ѳà̶Ô ¾ÒÉÕÍÒ̈ (70%) áÄÐà̶Ô ÊÀ®²ÆÒ̈ÂÑł²ÒÄ̈ÄÒ̶ (17%) Ê‹Ç ̈Ò ³ÂÐ̈Ñ ÊÙ ˚ ¾Ò¼àÍ̈Ł à³ à¼Õ Á ̶Âв²àÊÂÔ À µ‹ Ò ̈Ää̈̈ÒÂÆ› Ò ̶̶Ò (Employment-based) ®Õé Ê ÒÀÒ¬ ̋ÂͲ̋ÄÙÀ䭛઼ÒвÂÔ̈ÒÂÊÙ˚¾Ò¼®ÕéÍÁÚ‹ Í̈àË Í Canadian Health Act à®‹Ò Ñê ã ²Ò̶ÆÑ̶ËÇÑ­ ¾Ò¼®Õé 4 Federal Transfers as a Share of Provincial Health Expenditures, Canada Source: Marchildon GP, Mossialos E, Allin S, European Observatory on Health Systems and Policies. Health systems in transition : Canada. Toronto: University of Toronto Press; 2006. 30 µÄ˚Í̶̈ÒÂÀÕÊÇ‹ ‹ÇÀÆ‹ÒÁ ÆÒ̈̈ÒÂʲ̋› łÒ ˚›ÍÀÚÄ Medline ¼²Ç‹ÒÀṎÒÂÈÖ̈ÉÒ˚Í̶³ÂÐà®Èá̋ Ò­Ò 25 àÂéÍ̶ á©‹ä­›©Ñ­àÂéÍ̶®Õé à̈ÕéÁÇ̈ѲÁÒÍÍ̈ 15 àÂéÍ̶19-33 àÂéÍ̶®ÕéäÀ‹ÀÕàÍ̈ÊÒª²Ñ²à©èÀ 8 àÂéÍ̶34-41 áÄЩѭàÂéÍ̶®ÕéÇÑ©¬Ù³ÂÐÊ̶̋‒˚Í̶ ̈ÒÂÈÖ̈ÉÒäÀ‹©Â̶̈Ѳ̋ÇÒÀ©›Í̶̈ÒÂÍÍ̈ 1 àÂéÍ̶42 Ê‹Ç łÒ ˚›ÍÀÚÄÇÔ®ÁÒ Ô¼ ‒ ÀṎÒÂÈÖ̈ÉÒ˚Í̶³ÂÐà®È á̋ Ò­Ò 6 àÂéÍ̶ á©‹à³ àÂéÍ̶®ÕéÇÑ©¬Ù³ÂÐÊ̶̋‒äÀ‹©Â̶̈Ѳ̋ÇÒÀ©›Í̶̈ÒÂ43-48 Study 1. Utilization of Publicly Insured Health Services in Saskatchewan Before, During and After Copayment49 ̈ÒÂÈÖ̈ÉÒ Õêà̈Ô­˚Öê ã ³¡¼.È. 2523 à éÍ̶ÆÒ̈ÆÑ̶ËÇÑ­ Saskatchewan ³ÂÐʲ³»ºËÒ̋‹ÒãŁ›Æ‹ÒÁ²ÂÔ̈Ò ÊÙ˚¾Ò¼ ÆÖ̶ä­›àÂÔéÀà̈è² Copayment ÆÒ̈µÚ›³ƒÇÁâ­Á©Â̶ ©Ñê̶á©‹à­Í àÀÉÒÁ ¼.È.2511 â­ÁÍ ÙºÒ©Ôã˛ἮÁ‒ ÊÒÀÒ¬àÂÕÁ̈à̈è²̋‹Ò²ÂÔ̈ÒÂä­› C$1.50 ©‹Í̋ÂÑê̶®ÕéµÚ›³ƒÇÁÀÒÂѲ̈ÒÂÂÑ̈ÉÒ®Õé̋ÄÔ Ô̈ áÄÐ C$2 ©‹Í̋ÂÑê̶ ËÒ̈à³ ̈ÂßÕÍé ç àŁ‹ ̈Ò©ÂÇÆÂÑ̈ÉÒ®Õé²›Ò ˚Í̶µÚ›³ƒÇÁËÂÍ®ÕéâÂ̶¼ÁÒ²ÒÄ Ê‹Ç ²ÂÔ̈Òµڛ³ƒÇÁã µÚ›³ƒÇÁ©›Í̶Æ‹ÒÁ C$2.50 ©‹ÍÇÑ ÊîÒËÂѲ 30 ÇÑ áÂ̈ ËÄÑ̶ÆÒ̈ Ñê ©›Í̶Æ‹ÒÁ C$1.50 ©‹ÍÇÑ á©‹ÂÇÀáÄ›ÇäÀ‹à̈Ô 90 ÇÑ ©Ô­©‹Í̈Ñ â­Á̋ÂͲ̋ÂÑÇ®ÕéÀÕłÒ ÐÁÒ̈Æ ÆÐä­›ÂѲ̈ÒÂÁ̈àÇ› ©‹ÍÀÒ âÁ²ÒÁ̈ÒÂà̈è² Copayment ä­›¬Ú̈Á̈àÄÔ̈ã à­Í ÊÔ̶ËÒ̋À¼.È. 2514 Beck áÄÐ Horne ÆÖ̶ä­›ÈÖ̈ÉÒµÄ˚Í̶ Copayment â­ÁÇÔà̋ÂÒÐË‒ÆÒ̈łÒ ˚›ÍÀÚÄ®Õéä­›ÆÒ̈̈ÄÙ‹À ©ÑÇÍÁ‹Ò̶ 40,000 ̋ÂͲ̋ÂÑÇã ÆÑ̶ËÇÑ­ Saskatchewan ¼²Ç‹ÒÍÑ©ÂÒ̈ÒÂãŁ›²ÂÔ̈Ò©ÂÇÆÂÑ̈ÉÒÆÒ̈á¼®Á‒Ä­Ä̶ 5.66% ­Ñ̶áÊ­̶ã ©ÒÂÒ̶ á©‹ÍÑ©ÂÒ̈ÒÂ Í âÂ̶¼ÁÒ²ÒÄ ̋ÇÒÀ¬Õéã ̈ÒÂ Í âÂ̶¼ÁÒ²ÒÄ áÄÐÆîÒ Ç ÇÑ Í äÀ‹à³ÄÕéÁ á³Ä̶ ˚›ÍÊÂÙ³ Copayment Ł‹ÇÁÄ­ÍÑ©ÂÒ̈ÒÂãŁ›²ÂÔ̈Ò©ÂÇÆÂÑ̈ÉÒÆÒ̈á¼®Á‒³ÂÐÀÒß 5.66% á©‹äÀ‹ä­› Ł‹ÇÁÄ­³ÂÔÀÒß ̋ÇÒÀ¬Õé áÄÐÆîÒ Ç ÇÑ Í ˚Í̶̈ÒÂãŁ›²ÂÔ̈Òµڛ³ƒÇÁã ®ÕéâÂ̶¼ÁÒ²ÒÄ ©ÒÂÒ̶®Õé 9 Estimated Number of Physicians’ Services per Family with and with Copayment Source: Beck RG, Horne JM. Utilization of publicly insured health services in Saskatchewan before, during and after copayment. Med Care. 1980 Aug;18(8):787-806. 31 ½~ áÄ ­‒ (Finland) ½~ áÄ ­‒à³ ³ÂÐà®È®ÕéÀÕ˚ Ò­àÄè̈ ÀÕ³ÂÐŁÒ̈Âà¼ÕÁ̶ 5.2 Ä›Ò ̋ ØÖé̶ÀÒ̈̈Ç‹Ò³ÂÐà®ÈÊÔ̶̋â³Â‒ àÄè̈ ›ÍÁ á©‹à éÍ̶ÆÒ̈ÀÕ¼ê ®Õé̈Ç›Ò̶˚ÇÒ̶à³ ÍÑ ­Ñ² 7 ˚Í̶̈ÄÙ‹À³ÂÐà®Èã ÁÙâ³ ®îÒãË›³ÂÐŁÒŁ ÍÒÈÑÁÍÁÚ‹ ̈ÂÐÆÑ­̈ÂÐÆÒÁ â­Á 2 ã 3 ÍÒÈÑÁÍÁÚ‹ã ©ÑÇàÀÍ̶ áÄÐ 1 ã 3 ÍÒÈÑÁÍÁÚ‹ã Ł ²®50 ³ÂÐà®È½~ áÄ ­‒ ᲋̶ ̈Ò³̈̋ÂÍ̶ÍÍ̈à³ 5 ÆÑ̶ËÇÑ­ áÄÐ 1 à̈ÒÐ ̋‹ÒãŁ›Æ‹ÒÁÊÙ˚¾Ò¼̋Ô­à³ 7.4% ˚Í̶ GDP (5.7% â­Á¾Ò̋ÂÑł 1.7% â­Á¾Ò̋àÍ̈Ł ) à éÍ̶ÆÒ̈à̋Áà³ ÍÁÚ‹¾ÒÁã©›³ÂÐà®ÈÊÇÕà­ ̈Ç‹Ò 600 ³¡áÄгÂÐà®ÈÂÑÊàØÕÁ̈Ç‹Ò 100 ³¡ Âв²ÊÙ˚¾Ò¼ ˚Í̶³ÂÐà®È½~ áÄ ­‒ÆÖ̶ä­›ÂѲÍÔ® Ô¼ÄÆÒ̈á Ç̋Ô­˚Í̶³ÂÐà®È®Ñê̶ÊÍ̶ ÂÇÀ®Ñê̶̈Ò³̈̋ÂÍ̶á²²ÂÑł (State) áÄÐà®È²ÒÄ (Municipality) áÀ›ÆÐÀÕ¾ÒÉÒ˚Í̶©ÑÇàÍ̶ á©‹³ÂÐŁÒŁ 6% ãŁ›¾ÒÉÒÊÇÕà­ Í̈ÆÒ̈ ÕêÁÑ̶ÀṎÒ ³ÂÐÊÒ ̋ÇÒÀ‹ÇÀÀÍã ­›Ò ©‹Ò̶ç®Õéá ‹ á½ ̈Ѳ³ÂÐà®Èà­ ÀÒÂ‒̋ äÍØ‒áÄ ­‒ áÄÐ ÍÂ‒àÇÁ‒ à®È²ÒÄ (Municipality) ÀÕ®Ñê̶ËÀ­ 448 áË‹̶ ÀÕʾÒà®È²ÒÄ (Municipal Council) ®ÕéÀÕÇÒÂÐ 4 ³¡ ÀÕ ÍîÒ ÒÆ©Ñ­ÊÔ ãÆä­›à̈Ͳ®Ù̈àÂéÍ̶ àŁ‹ ̈ÒÂÈÖ̈ÉÒ¼ê łÒ áÄвÂÔ̈Ò®Ò̶ÊÑ̶̋À®ÑéÇä³ ÂÇÀ®Ñê̶²ÂÔ̈ÒÂÊÙ˚¾Ò¼ ØÖ̶é ÀÕÀÚÄ̋‹Òà³ 2 ã 3 ˚Í̶̋‹ÒãŁ›Æ‹ÒÁ²ÂÔ̈ÒÂÊÙ˚¾Ò¼˚Í̶³ÂÐà®È à®È²ÒÄÊ‹Ç ã˺‹ (75%) ÀÕ³ÂÐŁÒ̈Âà¼ÕÁ̶ 10,000 ̋ áÄÐÀÕà®È²ÒÄÍÁÚ‹ 20% ®ÕéÀÕ³ÂÐŁÒ̈ ›ÍÁ̈Ç‹Ò 2,000 ̋ Âв²³ÂÐ̈Ñ ÊÙ˚¾Ò¼ Âв²ÊÙ˚¾Ò¼˚Í̶³ÂÐà®È½~ áÄ ­‒ ÀṎÒ¼ќ ÒÀÒá²²̋‹ÍÁà³ ̋‹ÍÁä³ÍÁ‹Ò̶©‹Íà éÍ̶ äÀ‹³ÂÒ̈ıá ‹ ŁÑ­Ç‹ÒÀṎÒ³ıÔÂÚ³Âв²ÊÙ˚¾Ò¼àŁ‹ à­ÕÁÇ̈Ѳ³ÂÐà®ÈÍé ç á©‹¼²ÀṎÒÂÆÑ­©Ñê̶ National Health Insurance (NHI) ã Ł‹Ç̶³¡¼.È. 2503 à¼éÍ­ÚáÄàÂéÍ̶ÁÒáÄÐ̈Ò²ÂÔ̈ÒÂâ­Á¾Ò̋àÍ̈Ł ©‹ÍÀÒä­›ÍÍ̈̈ıËÀÒÁ Primary Health Care Act ã ³¡¼.È. 2515 ØÖé̶à³ ̈ÒÂ̈îÒË ­²®²Ò®ãË›à®È²ÒÄÂѲµÔ­ŁÍ²à̈ÕéÁÇ̈Ѳ̈Ò­ÚáÄÊÙ˚¾Ò¼ ³łÀ¾ÚÀÔáÄвÂÔ̈ÒÂÊÙ˚¾Ò¼¼ê łÒ Íé ç ©‹ÍÀÒã ³¡¼.È. 2517 ä­›à¼ÔéÀ²ÂÔ̈ÒÂÊÙ˚¾Ò¼ÂЭѲâÂ̶¼ÁÒ²ÒÄ áÄÐ ã ³¡¼.È. 2527 ä­›à¼ÔéÀ²ÂÔ̈Ò®Ò̶ÊÑ̶̋ÀÍé ç ÂÑł²ÒÄ̈ÄÒ̶̈è̋Í‹ ÁçÄ­²®²Ò®Ä̶ÍÁ‹Ò̶©‹Íà éÍ̶ NHI à³ Âв²³ÂÐ̈Ñ ÊÑ̶̋Àá²²Ë Öé̶ ØÖé̶à³ ̈Í̶®Ù ÆÒ̈à̶Ô à²ÕêÁ³ÂÐ̈Ñ (Premium) ®ÕéÆ‹ÒÁÆÒ̈µÚ› Æ›Ò̶áÄеڛ¬Ú̈Æ›Ò̶ ØÖé̶ÂÑłÆÐÆ‹ÒÁà̶Ô ÊÀ®² à¼éÍà³ ̈ÒÂÂѲ³ÂÐ̈Ñ Ç‹Òà̶Ô ˚Í̶̈Í̶®Ù ÆÐäÀ‹©éîÒ̈Ç‹Ò̋‹ÒãŁ›Æ‹ÒÁ®Õé à̈Ô­˚Öê ØÖé̶ÀÕ²®²Ò®Ë ›Ò®Õé®Ñ²Ø›Í ̈ѲÂв²˚Í̶à®È²ÒÄÍÁÚ‹²›Ò̶ ©ÑÇÍÁ‹Ò̶àŁ‹ ²ÂÔ̈Òµڛ³ƒÇÁ Í̈²Ò̶ÍÁ‹Ò̶ ÊÒÀÒ¬à²Ô̈ä­›ÆÒ̈®Ñê̶ÊÍ̶Âв² 32 ËÄÑ̈̈ÒÂÊîÒ̋Ѻ̋;Ò̋ÂÑłÀÕË ›Ò®ÕéÂѲµÔ­ŁÍ²ÊÙ˚¾Ò¼˚Í̶³ÂÐŁÒŁ ®Ù̈̋ â­ÁÍÒÈÑÁà®È²ÒÄà³ 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(Innungskrankenkassen, IKK) 42 ̈Í̶®Ù ‚ Farmers’ Funds (Landwirtschaftliche Krankenkassen, LKK) 20 ̈Í̶®Ù ‚ Miners’ Fund (Bundesknappschaft) 1 ̈Í̶®Ù ‚ Sailors’ Fund (See-Krankenkasse) 1 ̈Í̶®Ù 35 ¾Ò¼®Õé 5 Health System of Germany Source: European Observatory on Health Systems and Policies. Health systems in transition : Germany. 2000. 36 ØÖé̶ÆÐàËè 䭛NjÒ̈ÒÂà˚›Òâ̋Â̶̈Ò Sickness Fund ÆÐ˚Öê ÍÁÚ‹̈Ѳ¼ê ®ÕéÍÁÚ‹ÍÒÈÑÁáÄÐÄÑ̈ÉßÐ̶Ò ®Õé®îÒ Sickness Fund ÀÕÍîÒ ÒƳÂѲà³ÄÕéÁ ÍÑ©ÂÒ̈ÒÂÆ‹ÒÁà²ÕêÁ³ÂÐ̈Ñ áÄÐ̈Ò‹ÇÀÆ‹ÒÁä­›©ÒÀ̈æËÀÒÁ à¼éÍãË› ÊÒÀÒ¬̋ÂͲ̋ÄÙÀ̋‹ÒãŁ›Æ‹ÒÁ®Õéà̈Ô­˚Öê ÆÒ̈˚›ÍÀÚij¡¼.È. 2543 µÚ›¬Ú̈Æ›Ò̶̶Ò ®ÕéÀÕÂÒÁä­›äÀ‹à̈Ô DM77,400 ÆЩ›Í̶à³ ÊÀÒŁÔ̈ Sickness Fund á©‹ËÒ̈ÀÕÂÒÁä­›à̈Ô ̈Ç‹Ò Ñê ÆÐ˚Öê ÍÁÚ‹̈Ѳ̋ÇÒÀÊÀÑ̋ÂãÆ ³»ÆÆÙ²Ñ Sickness Fund ̋ÂͲ̋ÄÙÀ³ÂÐŁÒ̈³ÂÐÀÒß 88% ØÖé̶Ê‹Ç ã˺‹ 74% à˚›Òâ̋Â̶̈Ò©ÒÀ¾Ò̋²Ñ̶̋Ѳ áÄÐ 14% à˚›Òâ̋Â̶̈Ò©ÒÀ̋ÇÒÀÊÀÑ̋ÂãÆ Ê‹Ç ³ÂÐ̈Ñ ÊÙ˚¾Ò¼àÍ̈Ł ̋ÂͲ̋ÄÙÀ³ÂÐŁÒ̈ 9% ã ˚ßЮÕé 2% ˚Í̶³ÂÐŁÒ̈ÂØÖé̶à³ ©îÒÂÇÆ ®ËÒ 䭛ÂѲ²ÂÔ̈ÒÂÊÙ˚¾Ò¼â­ÁÆÒ̈ÂÑł²ÒÄâ­ÁäÀ‹àÊÕÁ̋‹ÒãŁ›Æ‹ÒÁ áÄÐàËÄ͵ڛ®ÕéäÀ‹ ÀÕËÄÑ̈³ÂÐ̈Ñ ã­ç 0.1% ²ÂÔ̈ÒÂÊÙ˚¾Ò¼ (Health Benefits) ®Õé̋ÂͲ̋ÄÙÀ³ÂÐ̈Ͳ­›ÇÁ ̈ÒÂ̋Ñ­̈ÂÍ̶ ³Í̶̈Ñ áÄÐÂÑ̈ÉÒâÂ̋ ÂÇÀ®Ñê̶̋‹ÒãŁ›Æ‹ÒÁã ̈ÒÂà­Ô ®Ò̶ Í̈ÆÒ̈ ÕêÁÑ̶ÀյijÂÐâÁŁ ‒®Õéà³ à̶Ô (Cash Benefits) ÊîÒËÂѲ̈ÒÂ˚Ò­̶Ò à éÍ̶ÆÒ̈³ƒÇÁà³ àÇÄÒäÀ‹à̈Ô 6 Êѳ­ÒË‒áÂ̈ ØÖé̶ÆÐä­›à̶Ô à­Í à©èÀÆîÒ Ç ÆÒ̈µÚ›Æ›Ò̶ ÂÇÀ®Ñê̶ÆÐä­›à̶Ô ÆÒ̈ Sickness Fund ÍṎ 80% ˚Í̶à̶Ô à­Í ÀÒ̈¬Ö̶ 78 Êѳ­ÒË‒©‹Í̈ÒÂàÆè²³ƒÇÁ 1 ̋ÂÑê̶ ̈ÒÂÀÕÊÇ‹ ‹ÇÀÆ‹ÒÁ̋‹Ò²ÂÔ̈ÒÂÊÙ˚¾Ò¼ ̈ÒÂÆ‹ÒÁà²ÕêÁ³ÂÐ̈Ñ ̋Ô­©ÒÀÂÒÁä­› ³»ÆÆÙ²Ñ ÍÁÚ‹®ÕéÍÑ©ÂÒ 13.5% ØÖé̶µÚ›Æ›Ò̶áÄеڛ¬Ú̈Æ›Ò̶‹ÇÀ̈Ñ Æ‹ÒÁ¹ƒÒÁ ÄÐ 6.75% Ê‹Ç µÚ›®ÕéÀÕÂÒÁä­›©éîÒ̈Ç‹Ò DM630 µÚ›Æ›Ò̶ÆÐà³ µÚ›Æ‹ÒÁà²ÕêÁ³ÂÐ̈Ñ ®ÕéÍ©Ñ ÂÒ 10% ̈ÒÂ̋îÒ ÇßÍÑ©ÂÒ̈Ò ƋÒÁ Õê ÆÐ̋Ô­ÆÒ̈µÄÂÇÀ˚Í̶̋‹ÒãŁ›Æ‹ÒÁÊÙ˚¾Ò¼àªÄÕéÁ˚Í̶ÊÀÒŁÔ̈ã Sickness Fund ®Ù̈̈Í̶®Ù ËÒ­›ÇÁà̶Ô ÂÒÁä­›ÆÒ̈à²ÕêÁ³ÂÐ̈Ñ ®Ù̈̈Í̶®Ù ̈ÒÂ̋îÒ Çß­›ÇÁÇÔ Õ Õê ®îÒãË›à̈Ô­³ÂÒ̈æ̈ÒÂß‒µ›Ú³ÂÐ̈Ñ © Á›ÒÁÍÍ̈ÆÒ̈̈Í̶®Ù ®ÕéÀÕà²ÕêÁ³ÂÐ̈Ñ ÀÒ̈ à̈Ô ̋‹ÒàªÄÕéÁ ä³à³ ÊÀÒŁÔ̈̈Ѳ̈Í̶®Ù ®ÕéÀÕà²ÕêÁ³ÂÐ̈Ñ ¬Ú̈̈Ç‹Ò ÆÒ̈̈ÒÂÊîÒÂÇÆ̋ÇÒÀàËè ̈ÄÙ‹ÀµÚ³› ÂÐ̈Ñ © ®ÕÁé Ò› Á ̈Í̶®Ù ¼²Ç‹ÒàË©ÙµÄËÄÑ̈ 58% ̋Íà¼éÍãË›ä­›Í©Ñ ÂÒà²ÕêÁ³ÂÐ̈Ñ ®Õé¬Ú̈Ä̶ ã ˚ßЮÕéµÚ›®ÕéäÀ‹ä­›Á›ÒÁ ãË›̋ÇÒÀÊîÒ̋Ѻ ̈ѲµÄ³ÂÐâÁŁ ‒®ÕéÆÐä­›ÂѲ ÀÒ̈̈Ç‹ÒÍÑ©ÂÒà²ÕêÁ³ÂÐ̈Ñ ÆÒ̈©ÒÂÒ̶ÆÐàËè ̈ÒÂà³ÄÕéÁ á³Ä̶ÍÑ©ÂÒ̈ÒÂÀÕÊ‹Ç Â‹ÇÀÆ‹ÒÁÊîÒËÂѲ²ÂÔ̈Ò©‹Ò̶ç ®Ñ̶ê Õê Á̈àÇ› µÚ›ÀÕ ÂÒÁä­› ›ÍÁ µÚÇ› ‹Ò̶̶Ò áÄÐà­è̈ÍÒÁÙ©éîÒ̈Ç‹Ò 18 ³¡ ̈ÒÂÀÕÊ‹Ç Â‹ÇÀÆ‹ÒÁÆÐÀÕà¼­Ò ÍÁÚ®‹ Õé 2% ˚Í̶ÂÒÁä­›̈Í‹ ËÑ̈ ¾ÒÉÕ Í̈ÆÒ̈ Õê µÚ›³Çƒ ÁâÂ̋àÂêÍÂÑ̶®Õéä­›à̋ÁÆ‹ÒÁä³áÄ›ÇÍÁ‹Ò̶ ›ÍÁ 1% ˚Í̶ÂÒÁä­›áÄÐÀռéÔ̈ÂÂÀ̈Ò­ÚáÄ ÊÙ˚¾Ò¼© àÍ̶®Õé­Õ ÆÐä­›ÂѲ̈ÒÂÁ̈àÇ› àŁ‹ ̈Ñ 37 ©ÒÂÒ̶®Õé 10 Copayment Level, Germany Source: European Observatory on Health Systems and Policies. Health systems in transition : Germany. 2000. ÊîÒËÂѲ̈Ò³ÂÐ̈Ñ ÊÙ˚¾Ò¼àÍ̈Ł ØÖé̶ÀÕÍÁÚ‹ 52 ²ÂÔÉÑ® ÆÐÀÕÇÔ ṎÒÂ̋Ô­à²ÕêÁ³ÂÐ̈Ñ ©ÒÀÍÒÁÙ à¼È áÄÐ ³ÂÐÇÑ©ÔâÂ̋ ØÖé̶³ÂÐŁÒ̈ 7.1 Ä›Ò ̋ ®ÕéÍÁÚ‹ã Âв² Õê ³ÂÐ̈Ͳ­›ÇÁµÚ›®ÕéÍÍ̈ÆÒ̈ Sickness Fund à éÍ̶ÆÒ̈ÀÕ ÂÒÁä­›à̈Ô ÂЭѲ®Õé̈îÒË ­, µÚ›®ÕéÀṎÔÆ̈ÒÂà³ ˚Í̶© àÍ̶, áÄÐàÆ›ÒË ›Ò®Õé˚Í̶ÂÑł®ÕéÁÑ̶äÀ‹ÀÕÊÔ® ÔÂѲ²ÂÔ̈ÒÂÊÙ˚¾Ò¼ ½ÂÕ µÚ›³ÂÐ̈Ñ © ã Âв² Õê ÆЩ›Í̶Æ‹ÒÁ̋‹Ò²ÂÔ̈ÒÂÊÙ˚¾Ò¼àÀéÍà˚›ÒÂѲ²ÂÔ̈Ò áÄ›Ç îÒã²àÊÂèÆÀÒà²Ô̈à̶Ô ̋ 38 ¾ÒÁËÄÑ̶ áÀ›Ç‹ÒÂÑł²ÒÄÆÐ̈îÒË ­ÍÑ©ÂÒ̋‹Ò²ÂÔ̈ÒÂäÇ›áÄ›Ç ã ®Ò̶³ıԲѩԵڛãË›²ÂÔ̈ÒÂÆÐ̋Ô­̋‹Ò²ÂÔ̈ÒÂà̈Ô ̈Ç‹Ò Ñê ÍÁ‹Ò̶ ›ÍÁ ³ÂÐÀÒß 1.7-2.3 à®‹Ò ØÖé̶à³ ÂЭѲ®ÕéÊÚ̶ÊÙ­®ÕéÆÐÊÒÀÒ¬à²Ô̈̋ ä­› µÄ˚Í̶̈ÒÂÀÕÊÇ‹ ‹ÇÀÆ‹ÒÁ ÆÒ̈̈ÒÂʲ̋› łÒ ˚›ÍÀÚÄ Medline ¼²Ç‹ÒÀṎÒÂÈÖ̈ÉÒ˚Í̶³ÂÐà®ÈàÁÍÂÀÑ Õ 23 àÂéÍ̶ á©‹ä­›©Ñ­àÂéÍ̶ ®Õéà̈ÕéÁÇ̈ѲÁÒÍÍ̈ 4 àÂéÍ̶ 28, 54-56 áÄÐàÂéÍ̶®ÕéÇÑ©¬Ù³ÂÐÊ̶̋‒˚Í̶̈ÒÂÈÖ̈ÉÒäÀ‹©Â̶̈Ѳ̋ÇÒÀ©›Í̶̈ÒÂÍÍ̈ 15 àÂéÍ̶ 57-71 ÆÖ̶ä­› îÒàÊ Íã ®Õé Õêà¼ÕÁ̶ 4 àÂéÍ̶ â­ÁàÂéÍ̶®Õé 2 ÊÂÙ³ÆÒ̈²®̋Ñ­Á‹Í à éÍ̶ÆÒ̈ª²Ñ²à©èÀà³ ¾ÒÉÒàÁÍÂÀÑ áÄÐàÂéÍ̶®Õé 3 áÄÐ 4 à³ ̈ÒÂÈÖ̈ÉÒà­ÕÁÇ̈Ñ á©‹©Õ¼ÔÀ¼‒ 2 áË‹̶ Ê‹Ç łÒ ˚›ÍÀÚÄÇÔ®ÁÒ Ô¼ ‒ äÀ‹ ÀṎÒÂÈÖ̈ÉÒ˚Í̶³ÂÐà®ÈàÁÍÂÀÑ Õ Study 1. Knowledge of “Hardship Exemptions” in statutory sickness insurance72 Eller áÄÐ Baumann ä­›®îÒ̈ÒÂÊîÒÂÇƵڛ³ÂÐ̈Ñ © ã â̋Â̶̈Ò Sickness Fund 18,238 ̋ ã àÀÍ̶ Augsburg (ØÖé̶ÀÕÊ®Ô Ôä­›ÂѲÁ̈àÇ› á©‹ÁÑ̶äÀ‹ä­›à˚›Òâ̋Â̶̈ÒÂ) ¼²Ç‹Ò 61.58% äÀ‹®ÂÒ²Ç‹Ò Copayment ÊÒÀÒ¬ à²Ô̈̋ ä­› áÄÐ 27.78% äÀ‹®ÂÒ²̈æà̈ßø‒̈ÒÂä­›ÂѲÁ̈àÇ› ̈ÒÂÆ‹ÒÁ Copayment Í̈ÆÒ̈ ÕêÁÑ̶¼²ÍṎÇ‹Ò µÚ›³ÂÐ̈Ñ © Ê‹Ç ã˺‹ä­›ÂѲ®ÂÒ²˚›ÍÀÚÄÆÒ̈ºÒ©ÔáÄÐà¼éÍ Ê Ô® ÀÒ̈̈Ç‹ÒÆÒ̈µÚ›ãË›²ÂÔ̈ÒÂÊÙ˚¾Ò¼ àË©ÙµÄËÄÑ̈ ®ÕéÁÑ̶äÀ‹à˚›Òâ̋Â̶̈ÒÂ̋Í̋Ô­Ç‹Ò© àÍ̶ÀÕÂÒÁä­›ÀÒ̈à̈Ô ä³ Study 2. Impact of co-payments on patient behavior: evidence from a natural experiment73 Grabka áÄÐ̋ßÐ ä­›®îÒ̈ÒÂÈÖ̈ÉÒµÄ˚Í̶̈ÒÂ̈îÒË ­ãË›ÀÕÊ‹Ç Â‹ÇÀÆ‹ÒÁ 10 Euros/3 à­Í ØÖé̶ÀÕµÄ ²Ñ̶̋Ñ²ãŁ›©Ñê̶á©‹à­Í À̈ÂÒ̋À¼.È. 2547 ©‹Í̈ÒÂÊ‹̶àÊÂÔÀãË›µÚ›³ÂÐ̈Ñ © ÀÕ̋ÇÒÀÂѲµÔ­ŁÍ²­ÚáÄÊÙ˚¾Ò¼© àÍ̶ ÀÒ̈˚Öê ¼²Ç‹ÒÍÑ©ÂÒ̈Ò¼²á¼®Á‒Ä­Ä̶ËÄÑ̶ÆÒ̈ÀÕ Copayment àÀéÍà®ÕÁ²̈Ѳ̈‹Í ÀÕ Copayment â­ÁÆÒ̈ ̈ÒÂÇÔà̋ÂÒÐË‒à¼ÔéÀà©ÔÀ ÁÑ̶¼²ÍṎÇ‹Ò̈Ò²ÂÔ̈Ò®ÕéÆîÒà³ äÀ‹ä­›Ä­Ä̶ ˚›ÍÊÂÙ³ Copayment ÊÒÀÒÂ¬ãŁ›à³ à̋ÂéÍ̶ÀÍŁ‹ÇÁÄ­̈ÒÂãŁ›²ÂÔ̈Òµڳ› ƒÇÁ Í̈®ÕéäÀ‹ÆîÒà³ Ä̶ä­› Study 3. Patient cost sharing and social inequalities in access to health care in three western European countries74 Study 4. Patient cost sharing and physician visits by socioeconomic position: findings in three Western European countries75 Lostao áÄÐ Regidor ä­›ÈÖ̈ÉÒà³ÂÕÁ²à®ÕÁ²˚›ÍÀÚÄ National Health Survey ˚Í̶³ÂÐà®ÈàÁÍÂÀÑ Õ (³¡¼.È. 2535, 2541) ¹ÂÑé̶àÈÊ (³¡¼.È. 2533, 2543) áÄÐÊà³ (³¡¼.È. 2530, 2544) ©Õ¼ÔÀ¼‒ã ÇÒÂÊÒ 2 ª²Ñ² àÊ ÍÇ‹ÒÂв² Copayment ®ÕéàÁÍÂÀÑ ãŁ›ÍÁÚ‹ã Ł‹Ç̶ Ñê (Copayment ઼ÒвÂÔ̈Òµڛ³ƒÇÁã ) ‹ÒÆЮîÒ 39 ãË›à̈Ô­̋ÇÒÀàÊÀ;Ò̋ÂÐËÇ‹Ò̶Ł ŁÑê ®Ò̶ÊÑ̶̋ÀÀÒ̈̈Ç‹ÒÂв²˚Í̶¹ÂÑé̶àÈÉ (Copayment ²ÂÔ̈Òµڛ³ƒÇÁ Í̈ áÄÐã ) áÄÐÊà³ (äÀ‹ÀÕ Copayment) à éÍ̶ÆÒ̈ Copayment ÍÒÆÄ­̋ÇÒÀ¬Õé˚Í̶̈ÒÂä³¼²á¼®Á‒ ØÖé̶µÚ›®ÕéÍÁÚ‹ ã Ł ŁÑê ©éîÒ̈Ç‹ÒÆÐä­›ÂѲµÄ̈ÂЮ²ÀÒ̈̈Ç‹Ò ã ˚ßЮÕéµÄ˚Í̶ Copayment ©‹Í̋ÇÒÀ¬Õéã ̈ÒÂà˚›ÒÂѲ̈ÒÂÂÑ̈ÉÒ ã âÂ̶¼ÁÒ²ÒÄäÀ‹ŁÑ­àÆ ˚›ÍÊÂÙ³ äÀ‹ÊÒÀÒ¬ÊÂٳ䭛 à éÍ̶ÆÒ̈à³ ˚›ÍÀÚÄà̈‹Ò 40 ºÕ³é Ùƒ (Japan) ³ÂÐà®ÈºÕé³Ùƒ ÀÕ³ÂÐŁÒ̈ 128 Ä›Ò ̋ ØÖé̶ÀÕÍÒÁÙ˚ÑÁàªÄÕéÁÁÒÇ Ò ®ÕéÊÙ­ã âÄ̈ á©‹̋‹ÒãŁ›Æ‹ÒÁÊÙ˚¾Ò¼ äÀ‹ä­›ÊÚ̶ÀÒ̈ àÀéÍà®ÕÁ²̈Ѳ³ÂÐà®È®Õé¼Ñœ ÒáÄ›ÇÍé ç ̋‹ÒãŁ›Æ‹ÒÁÊÙ˚¾Ò¼̋Ô­à³ 7.8% ˚Í̶ GDP (6.3% â­Á ¾Ò̋ÂÑł 1.5% â­Á¾Ò̋àÍ̈Ł )76, 77 µÚ›ãË›²ÂÔ̈ÒÂÊ‹Ç ã˺‹̈Ç‹Ò 83% à³ ¾Ò̋àÍ̈Ł µÚ›³ƒÇÁÊÒÀÒ¬àÄÍ̈ á¼®Á‒áÄÐÊ¬Ò ¼ÁÒ²ÒÄä­›©ÒÀ©›Í̶̈Ò Âв²³ÂÐ̈Ñ ÊÙ˚¾Ò¼áÄÐ̈ÒÂÀÕÊÇ‹ ‹ÇÀÆ‹ÒÁ̋‹Ò²ÂÔ̈ÒÂÊÙ˚¾Ò¼ Âв²³ÂÐ̈Ñ ÊÙ˚¾Ò¼˚Í̶³ÂÐà®ÈÀÕ¼ê łÒ ̋Ä›ÒÁ̈Ѳ Sickness Fund ˚Í̶³ÂÐà®ÈàÁÍÂÀÑ Õ ­Ñ̶ÆÐ àËè ä­›ÆÒ̈̈æËÀÒÁ Health Insurance Law (Kenpo-ho) ³¡¼.È. 2465 ®Õãé Ë›̋ÇÒÀÊîÒ̋Ѻ̈ѲµÚ›ÀÕÊÙ˚¾Ò¼­Õ à éÍ̶ÆÒ̈à³ ̈îÒÄÑ̶ÊîÒ̋Ѻ©‹Í̈ÒÂà¼ÔéÀµÄµÄÔ©áÄÐ̈Ò®ËÒÂ˚Í̶³ÂÐà®È ØÖé̶©‹ÍÀÒä­›ÀṎÒÂà³ÄÕéÁ á³Ä̶ÍṎ ËÄÒÁ̋ÂÑê̶ Æ ÀÒ¬Ö̶̈æËÀÒÁ National Health Insurance Law ØÖé̶ÍÍ̈ã ³¡¼.È. 2501 áÄвÑ̶̋Ñ²ãŁ›ÆÂÔ̶ÆÑ̶ ã ³¡¼.È. 2504 ®îÒãË›³ÂÐà®ÈºÕé³Ùƒ ÀÕËÄÑ̈³ÂÐ̈Ñ ÊÙ˚¾Ò¼¬›Ç Ë ›ÒÀÒÆ ¬Ö̶³»ÆÆÙ²Ñ ÆÒ̈˚›ÍÀÚÄã ³¡¼.È. 2539 ̶²³ÂÐÀÒßËÄÑ̈ (84%) ®ÕéãŁ›Ê Ñ²Ê Ù Âв²³ÂÐ̈Ñ ÊÙ˚¾Ò¼˚Í̶³ÂÐà®È ÀÒÆÒ̈à²ÕêÁ³ÂÐ̈Ñ ®ÕéÆ‹ÒÁÆÒ̈µÚ›Æ›Ò̶̶Ò µÚ›¬Ú̈Æ›Ò̶̶Ò áÄÐÂÑł²ÒÄ áÄÐÀṎÒÂÆ‹ÒÁ Out-of-pocket ³ÂÐÀÒß 12% ³ÂÐŁÒŁ ®Ù̈̋ ÍÁÚ‹ã Âв²³ÂÐ̈Ñ ÊÙ˚¾Ò¼¾Ò̋²Ñ̶̋Ѳ (Kai Hoken) â­ÁÆÐ᲋̶ÍÍ̈à³ 3 ̈ÄÙ‹À ̋Í 1.Âв²³ÂÐ̈Ñ ÊÙ˚¾Ò¼ÊîÒËÂѲµÚ›¬Ú̈Æ›Ò̶̶Ò áÄеڛ¼Öé̶¼Ô̶ (Employee’s Health Insurance), 2.Âв²³ÂÐ̈Ñ ÊÙ˚¾Ò¼ÊîÒËÂѲàÆ›Ò˚Í̶̈ÔÆ̈ÒÂ, µÚ›à̈ÉÕÁÂÍÒÁÙáÄеڛ¼Öé̶¼Ô̶ (National Health Insurance, Kokuho), áÄÐ 3. Âв²³ÂÐ̈Ñ ÊÙ˚¾Ò¼ÊîÒËÂѲµÚ›ÊÚ̶ÍÒÁÙ (Health Insurance for the Elderly, Roken) Í̈ÆÒ̈ ÕêÁÑ̶ÀÕ Sickness Fund ÍṎËÄÒÁ›ÍÁ̈Í̶®Ù ®Õãé Ë›ÊÔ® Ô³ÂÐâÁŁ ‒ã ÂÚ³à̶Ô Ê­à¼ÔéÀà©ÔÀ­›ÇÁ 41 ¾Ò¼®Õé 6 Health Insurance System, Japan Source: Fukawa T. Public Health Insurance in Japan. Washington, D.C.: World Bank Institute; 2002. 42 ©ÒÂÒ̶®Õé 11 Health Insurance System, Japan Source: Fukawa T. Public Health Insurance in Japan. Washington, D.C.: World Bank Institute; 2002. Employee’s Health Insurance ³ÂÐ̈Ͳ­›ÇÁ 3 ³ÂÐྮÁ‹ÍÁ 1. Society-managed Health Insurance (Kumiai) ̋ÂͲ̋ÄÙÀµÚ›¬Ú̈Æ›Ò̶̶Ò ã Ê¬Ò ³ÂÐ̈Ͳ̈Ò ˚ Ò­ã˺‹ ̋Ô­à³ 25.4% ˚Í̶³ÂÐŁÒ̈ 㠳¡¼.È. 2540 ÍÑ©ÂÒà²ÕêÁ³ÂÐ̈Ñ ÍÁÚ‹®Õé 8.5% ˚Í̶ÂÒÁä­› ³»ÆÆÙ²Ñ ÀÕ ÍÁÚ‹̈Ç‹Ò 1,814 ̈Í̶®Ù 2. Government-managed Health Insurance (Seikan) ̋ÂͲ̋ÄÙÀµÚ›¬Ú̈Æ›Ò̶̶Ò ã Ê¬Ò ³ÂÐ̈Ͳ̈ÒÂ˚ Ò­̈ÄÒ̶áÄÐàÄè̈ ̋ÂͲ̋ÄÙÀ³ÂÐŁÒ̈®ÕéàËÄÍ 30.7% ²ÂÔËÒÂ̶Ò â­ÁÊîÒ Ñ̶̈Ò ®ÕéÀÕÍÁÚ‹ 298 áË‹̶ ÀÕÍÑ©ÂÒà²ÕêÁ³ÂÐ̈Ñ 8.5% ˚Í̶à̶Ô à­Í 43 3. Mutual Aid Associations (Kyosai Kumiai) ̋ÂͲ̋ÄÙÀ¼ Ñ̶̈Ò ˚Í̶ÂÑł ̋ÂÚàÍ̈Ł áÄеڛ¼Öé̶¼Ô̶ ̋Ô­à³ 9.2% ˚Í̶³ÂÐŁÒ̈ ÍÑ©ÂÒà²ÕêÁ³ÂÐ̈Ñ 8.5% ³»ÆÆÙ²Ñ ÀÕÍÁÚ‹ 82 ̈Í̶®Ù µÚ›³ƒÇÁã Âв² Õê ËÒ̈à³ µÚ›³ÂÐ̈Ñ © ©›Í̶‹ÇÀÆ‹ÒÁ̋‹Ò²ÂÔ̈ÒÂÊÙ˚¾Ò¼ 10% ã ˚ßЮÕéµÚ›¼Öé̶¼Ô̶˚Í̶µÚ›³ÂÐ̈Ñ © ©›Í̶Æ‹ÒÁ̋‹Ò²ÂÔ̈Òµڛ³ƒÇÁ ã 20% áÄÐ̋‹Ò²ÂÔ̈Òµڛ³ƒÇÁ Í̈ 30% National Health Insurance à³ Âв²³ÂÐ̈Ñ ÊÙ˚¾Ò¼ŁÙÀŁ (Community-based Health Insurance) ØÖé ̶̋ÂͲ̋ÄÙÀµÚ› ®Õéä À‹ä ­› ³ ÂÐ̈ͲÍÒŁÕ ¼ ã Ê¬Ò ³ÂÐ̈Ͳ̈ÒÂ àŁ‹ àÆ› Ò˚Í̶̈Ô Æ̈Ò ŁÒÇ Ò µÚ› à̈ÉÕÁÂÍÒÁÙ ÂÇÀ®Ñê̶µÚ›¼Öé̶¼Ô̶ ̋Ô­à³ 34.7% ˚Í̶³ÂÐŁÒ̈ áÀ›Ç‹ÒÆÐÀÕÊÔ® Ô³ÂÐâÁŁ ‒®Ò̶ÊÙ˚¾Ò¼àËÀÍ ̈Ѳ Employee’s Health Insurance á©‹µÚ›³ÂÐ̈Ñ © ã ̈ÄÙ‹À ÕêÆÐÀÕ cost sharing ®ÕéÊÚ̶̈Ç‹Ò áÄÐä­›ÂѲÊÔ® Ô ³ÂÐâÁŁ ‒ã ÂÚ³à̶Ô Ê­®ÕéÆîÒ̈Ñ­̈Ç‹Ò ÍÑ©ÂÒ̈ÒÂÆ‹ÒÁà²ÕêÁ³ÂÐ̈Ñ ÆÐá©̈©‹Ò̶̈Ñ ä³©ÒÀ¼ê ®Õé áÄÐ˚Öê ÍÁÚ‹̈ѲÂÒÁä­› áÄЮÂѼÁ‒ÊÔ ®ÕéÀÕÍÁÚ‹ µÚ›³ƒÇÁã Âв² Õê ËÒ̈à³ µÚ›³ÂÐ̈Ñ © ©›Í̶‹ÇÀÆ‹ÒÁ̋‹Ò²ÂÔ̈ÒÂÊÙ˚¾Ò¼ 30% ËÒ̈à³ µÚ› à̈ÉÕÁÂÍÒÁÙ©›Í̶Æ‹ÒÁ 20% ã ˚ßЮÕéµÚ›¼Öé̶¼Ô̶˚Í̶µÚ›à̈ÉÕÁÂÍÒÁÙ ©›Í̶Æ‹ÒÁ̋‹Ò²ÂÔ̈Òµڛ³ƒÇÁã 20% áÄÐ̋‹Ò²ÂÔ̈Ò µÚ›³ƒÇÁ Í̈ 30% ÊîÒËÂѲ®Ñê̶ÊÍ̶Âв²˚›Ò̶©› ä­›ÀṎÒÂ̈îÒË ­à¼­Ò ̈ÒÂÀÕÊ‹Ç Â‹ÇÀÆ‹ÒÁ̋‹Ò²ÂÔ̈ÒÂÊÙ˚¾Ò¼äÇ›®Õé 64,000 àÁ ©‹Íà­Í ØÖé̶ÊÒÀÒ¬©éîÒÄ̶̈Ç‹Ò Õêä­› ËÒ̈ÀÕłÒ ÐÁÒ̈Æ ÀÒ̈ËÂÍä­›à̋ÁÆ‹ÒÁ¬Ö̶ÂЭѲÊÚ̶ÊÙ­ÀÒáÄ›Ç 3 à­Í ã 1 ³¡ Health Insurance for the Elderly à̈Ô­˚Öê ã ³¡¼.È. 2526 à¼éÍà³ ̈ÒÂ̈ÂÐÆÒÁ̋ÇÒÀàÊÕéÁ̶®Ò̶ ÊÙ˚¾Ò¼ÂÐËÇ‹Ò̶̈Í̶®Ù ©‹Ò̶ç áÄÐà¼éÍà³ ̈ÒÂÀÕÊ‹Ç Â‹ÇÀÆ‹ÒÁÀÒ̈˚Öê â­ÁµÚ›³ÂÐ̈Ñ © ã ÊÍ̶Âв²áÂ̈®ÕéÀÕ ÍÒÁÙ 70 ³¡˚Öê ä³ áÄеڛ¼Ô̈Ò®ÕéÀÕÍÒÁÙ 65-69 ³¡ ÆЩ›Í̶à˚›ÒÂв² Õê ÆÒ̈˚›ÍÀÚÄã ³¡¼.È. 2541 µÚ›³ƒÇÁ©›Í̶Æ‹ÒÁ 500 àÁ ©‹ÍÇÑ (ÊÚ̶ÊÙ­äÀ‹à̈Ô 2,000 àÁ ©‹Íà­Í ) ÊîÒËÂѲ²ÂÔ̈Òµڛ³ƒÇÁ Í̈ áÄÐ 1,100 àÁ ©‹ÍÇÑ ÊîÒËÂѲ ²ÂÔ̈Òµڛ³ƒÇÁã ØÖé̶à̶Ô ®Õéä­›ÆÐà³ à̶Ô ̈Í̶®Ù ÊîÒËÂѲµÚ›ÊÚ̶ÍÒÁÙâ­Á઼ÒÐ (Pooled Fund for the Elderly) µÄ˚Í̶̈ÒÂÀÕÊÇ‹ ‹ÇÀÆ‹ÒÁ ÆÒ̈̈ÒÂʲ̋› łÒ ˚›ÍÀÚÄ Medline ¼²Ç‹ÒÀṎÒÂÈÖ̈ÉÒ˚Í̶³ÂÐà®ÈºÕé³Ùƒ 12 àÂéÍ̶ á©‹ä­›©Ñ­àÂéÍ̶®Õé à̈ÕéÁÇ̈ѲÁÒÍÍ̈ 1 àÂéÍ̶78 áÄÐä­›©Ñ­àÂéÍ̶®ÕéÇÑ©¬Ù³ÂÐÊ̶̋‒˚Í̶̈ÒÂÈÖ̈ÉÒäÀ‹©Â̶̈Ѳ̋ÇÒÀ©›Í̶̈ÒÂÍÍ̈ 6 àÂéÍ̶7984 ÆÖ̶àËÄÍ îÒàÊ Íã ®Õé Õê®Ñê̶ËÀ­ 5 àÂéÍ̶ Ê‹Ç łÒ ˚›ÍÀÚÄÇÔ®ÁÒ Ô¼ ‒ äÀ‹ÀṎÒÂÈÖ̈ÉÒ˚Í̶³ÂÐà®ÈºÕé³Ùƒ ̈ÒÂÈÖ̈ÉÒ®Õé 1-4 àÆÒÐÆ̶ä³®Õé̈ÄÙ‹À Employee’s Health Insurance Ê‹Ç ̈ÒÂÈÖ̈ÉÒ®Õé 5 àÆÒÐÄ̶ä³®Õé̈ÄÙ‹À National Health Insurance 44 Study 1. The effect of a cost sharing provision in Japan85 Study 2. Effects of an increase in patient copayments on medical service demands of the insured in Japan86 Study 3. Effects of the increase in co-payments from 20 to 30 percent on the compliance rate of patients with hypertension or diabetes mellitus in the employed health insurance system87 Babazono áÄÐ̋ßÐ ä­›È̈Ö ÉÒµÄ˚Í̶ Copayment ©‹Í̈ÒÂãŁ›²ÂÔ̈ÒÂÊÙ˚¾Ò¼˚Í̶µÚ›³ÂÐ̈Ñ © ®Ñê̶ËÀ­ 4 ̋ÂÑê̶ â­Á̋ÂÑê̶áÂ̈à³ ̈ÒÂàÂÔéÀà̈è² Copayment 10% ã ³¡¼.È. 2527 ̋ÂÑê̶®ÕéÊÍ̶à³ ̈ÒÂà¼ÔéÀÍÑ©ÂÒ Copayment ÆÒ̈ 10% à³ 20% ã ³¡¼.È. 2540 áÄÐ̋ÂÑê̶®ÕéÊÒÀà³ ̈ÒÂà¼ÔéÀÍÑ©ÂÒ Copayment ÆÒ̈ 20% à³ 30% ã ³¡¼.È. 2546 ̈ÒÂÈÖ̈ÉÒã ÊÍ̶̋ÂÑê̶áÂ̈ ãŁ›ÇÔ ṎÒÂÈÖ̈ÉÒ̋Ä›ÒÁ̈Ñ ̋Í̈ÒÂÇÔà̋ÂÒÐË‒˚›ÍÀÚÄ̈ÒÂãŁ› ²ÂÔ̈ÒÂÊÙ˚¾Ò¼ã 1 ³¡̈‹Í áÄÐ 1 ³¡ËÄÑ̶ÆÒ̈̈Ò³ÂѲ Copayment µÄ̈ÒÂÈÖ̈ÉÒã ̋ÂÑê̶áÂ̈ ¼²Ç‹ÒÍÑ©ÂÒ̈ÒÂãŁ›²ÂÔ̈ÒÂÊÙ˚¾Ò¼Ä­Ä̶ â­Á઼ÒвÂÔ̈Òµڛ³ƒÇÁ Í̈ Ê‹Ç ̈ÒÂÈÖ̈ÉÒ̋ÂÑê̶®ÕéÊÍ̶ ¼²Ç‹ÒÍÑ©ÂÒ̈ÒÂãŁ›²ÂÔ̈Òµڛ³ƒÇÁã Ä­Ä̶ 6.96%, ÍÑ©ÂÒ̈ÒÂãŁ›²ÂÔ̈Òµڛ³ƒÇÁ Í̈Ä­Ä̶ 4.79% áÄÐÍÑ©ÂÒ̈ÒÂãŁ›²ÂÔ̈Ò娄 ©̈ÂÂÀÄ­Ä̶ 5.77% Í̈ÆÒ̈ ÕêÁÑ̶¼²Ç‹Ò̋‹ÒãŁ›Æ‹ÒÁ©‹ÍÇÑ ÊîÒËÂѲ²ÂÔ̈Ò µÚ›³ƒÇÁã Ä­Ä̶ 3.15%, ̋‹ÒãŁ›Æ‹ÒÁ©‹ÍÇÑ ÊîÒËÂѲ²ÂÔ̈Òµڛ³ƒÇÁ Í̈ Ä­Ä̶ 13% áÄÐ̋‹ÒãŁ›Æ‹ÒÁ©‹ÍÇÑ ÊîÒËÂѲ ²ÂÔ̈Ò娄 ©̈ÂÂÀ Ä­Ä̶ 11.48% ØÖé̶©ÑÇàÄ˚­Ñ̶̈Ä‹ÒÇ ã̈Ä›à̋ÕÁ̶̈Ѳ̈ÒÂÈÖ̈ÉÒã ̋ÂÑê̶áÂ̈ Í̈ÆÒ̈ ÕêÁÑ̶¼²Ç‹ÒµÚ› ÀÕÂÒÁä­› ›ÍÁÆÐä­›ÂѲµÄ̈ÂЮ²ÀÒ̈ ÍÁ‹Ò̶äÂ̈è©ÒÀ äÀ‹ÊÒÀÒ¬ÊÂÙ³à̈ÕéÁÇ̈Ѳ̋Ùß¾Ò¼̈Ò­ÚáÄÂÑ̈ÉÒä­› ˚›ÍÊÂÙ³ ̈ÒÂà¼ÔéÀ Copayment ÆÒ̈ 0% à³ 10% à³ 20% ÊÒÀÒ¬Ł‹ÇÁÄ­ÍÑ©ÂÒ̈ÒÂãŁ›²ÂÔ̈Ò µÚ›³ƒÇÁ Í̈ µÚ›³ƒÇÁã áÄÐ®Ñ ©̈ÂÂÀ ÂÇÀ®Ñê̶®îÒãË›̋‹ÒãŁ›Æ‹ÒÁÊÙ˚¾Ò¼Ä­Ä̶ á©‹µÚ›ÀÕÂÒÁä­› ›ÍÁÆÐä­›ÂѲ µÄ̈ÂЮ²ÀÒ̈ áÄÐäÀ‹ÊÒÀÒ¬ÊÂÙ³à̈ÕéÁÇ̈Ѳ̋Ùß¾Ò¼̈Ò­ÚáÄÂÑ̈ÉÒä­› Ê‹Ç ã ̋ÂÑê̶®ÕéÊÒÀ ä­›ÆîÒ̈Ñ­˚Ͳà˚©˚Í̶̈ÒÂÈÖ̈ÉÒà¼ÕÁ̶µÚ›³ƒÇÁ̋ÇÒÀ­Ñ âÄËÔ©ÊÚ̶áÄеڛ³ƒÇÁà²ÒËÇÒ à¼éÍãË›ÊÒÀÒ¬ÈÖ̈ÉÒà̈ÕéÁÇ̈Ѳ̋Ùß¾Ò¼̈Ò­ÚáÄÂÑ̈ÉÒä­› â­Á̈Ò­ڮÕé Compliance Rate µÄ̈ÒÂÈÖ̈ÉÒ¼²Ç‹Ò Compliance Rate ˚Í̶µÚ›³ƒÇÁ̋ÇÒÀ­Ñ âÄËÔ©ÊÚ̶®Ñê̶®ÕéÀÕáÄÐäÀ‹ÀÕ¾ÒÇÐá®Â̈Ø›Í áÄеڛ³ƒÇÁà²ÒËÇÒ ®ÕéÀÕ ¾ÒÇÐá®Â̈Ø›Í äÀ‹à³ÄÕéÁ á³Ä̶ á©‹µÚ›³ƒÇÁà²ÒËÇÒ ®ÕéäÀ‹ÀÕ¾ÒÇÐá®Â̈Ø›Í ÀÕ Compliance Rate Ä­Ä̶ÆÒ̈ 83.7% à³ 66.7% ˚›ÍÊÂÙ³ ̈ÒÂà¼ÔéÀ Copayment ÆÒ̈ 20% à³ 30% ÍÒÆÄ­̋Ùß¾Ò¼̈Ò­ÚáÄÂÑ̈ÉÒã µÚ›³ƒÇÁ à²ÒËÇÒ ®ÕéäÀ‹ÀÕ¾ÒÇÐá®Â̈Ø›Í 45 Study 4. The impact of partial cost sharing on the attitude of insured persons with hypertension88 ̈ÒÂÈÖ̈ÉÒ Õê à³ µÄ̶Ò ÆÒ̈ Ñ̈ÇÔÆÑÁ®ÕÀà­ÔÀ ØÖé̶ä­›®îÒ©Ñê̶á©‹̈ÒÂàÂÔéÀÀÕ Copayment 10% ã ³¡¼.È. 2527 â­ÁÇÔà̋ÂÒÐË‒˚›ÍÀÚÄã²àÊÂèÆÂѲà̶Ô ÆÒ̈µÚ›³ƒÇÁ̋ÇÒÀ­Ñ âÄËÔ©ÊÚ̶ 199 ̋ µÄ̈ÒÂÈÖ̈ÉÒ¼²Ç‹Ò µÚ›³ƒÇÁà˚›Ò ÂѲ²ÂÔ̈ÒÂÀÒ̈ã Ł‹Ç̶ 6 à­Í áÂ̈̈‹Í ̈ÒÂà̈è² Copayment áÄÐÄ­Ä̶ã Ł‹Ç̶ 6 à­Í ËÄÑ̶̈ÒÂà̈è² Copayment á©‹ËÄÑ̶ÆÒ̈ Ñê ÍÑ©ÂÒ̈ÒÂÂѲ²ÂÔ̈ÒÂ̈ÄѲÀÒÍÁÚ‹ã ÂЭѲ³̈©Ô Í̈ÆÒ̈ ÕêÁÑ̶¼²Ç‹Ò Copayment ÆÐÀÕ µ Ä©‹ Í µÚ› ³ƒ Ç ÁãËÀ‹ ÀÒ̈̈Ç‹ Ò µÚ› ³ƒ Ç Áà̈‹ Ò áÄÐÀÕ µ Ä©‹ Í µÚ› ³ƒ Ç Á®Õé ÀÕ ¾ ÒÇÐá®Â̈Ø› Í ÀÒ̈̈Ç‹ Ò µÚ› ³ƒ Ç Á®Õé ä À‹ ÀÕ ¾ÒÇÐá®Â̈Ø›Í ˚›ÍÊÂÙ³ Copayment ÀյĮîÒãË›ÍÑ©ÂÒ̈ÒÂÂѲ²ÂÔ̈ÒÂÄ­Ä̶ â­Á઼Òеڛ³ƒÇÁãËÀ‹ áÄеڛ³ƒÇÁ®ÕéÀÕ ¾ÒÇÐá®Â̈Ø›Í á©‹µÄ­Ñ̶̈Ä‹ÒÇà³ á²²ŁÑéÇ̋ÂÒÇ Study 5. The effect of copayments and income on the utilization of medical care by subscribers to Japan’s National Health Insurance System89 Kupor áÄÐ Liu ÇÔà̋ÂÒÐË‒ÆÒ̈˚›ÍÀÚij¡¼.È. 2527 áÄг¡¼.È. 2532 ¼²Ç‹Ò Copayment ÀÕµÄÄ­ÍÑ©ÂÒ ̈ÒÂãŁ›²ÂÔ̈ÒÂÄ̶ á©‹äÀ‹ÀÒ̈ Ñ̈ â­Á઼ÒвÂÔ̈Òµڛ³ƒÇÁ Í̈ áÄеڛÀÕÂÒÁä­› ›ÍÁä­›ÂѲµÄ̈ÂЮ²ÀÒ̈®ÕéÊÙ­ 46 ÊÔ̶̋â³Â‒ (Singapore) ÊÔ̶̋â³Â‒à³ ³ÂÐà®È˚ Ò­àÄè̈ ÀÕ³ÂÐŁÒ̈Âà¼ÕÁ̶ 4 Ä›Ò ̋ á©‹ÀÕàÈÂÉł̈ÔÆ®ÕéàÆÂÔº ³ÂÐŁÒŁ ÀÕÂÒÁä­› áÄÐ̈ÒÂÈÖ ̈ ÉÒÊÚ ̶ ä­› ÂÑ ² ̈ÒÂÆÑ ­ ãË› à ³ ³ÂÐà®È®Õé ÀÕ Â Ð²²ÊÙ ˚ ¾Ò¼®Õé ÀÕ ³ ÂÐÊÔ ® Ô ¾ Ò¼ÀÒ̈®Õé ÊÙ ­ áË‹ ̶ Ë Öé ̶ 90 à éÍ̶ÆÒ̈ãŁ›ËÄÑ̈̈Ò®ÕéÇ‹Ò ³ÂÐŁÒŁ á©‹ÄÐ̋ ÀÕË ›Ò®ÕéÂѲµÔ­ŁÍ²­ÚáÄÊÙ˚¾Ò¼áÄÐ̋‹ÒãŁ›Æ‹ÒÁ­›Ò ÊÙ˚¾Ò¼˚Í̶ © àÍ̶ Âв²³ÂÐ̈Ñ ÊÙ˚¾Ò¼³ÂÐྮ©‹Ò̶ç (Medisave, MediShield, Medifund, áÄÐ ElderShield) à³ à¼ÕÁ̶̈Ò “Ł‹ÇÁ” Ä­¾ÒÂÐ̋‹ÒãŁ›Æ‹ÒÁÊÙ˚¾Ò¼˚Í̶³ÂÐŁÒŁ à®‹Ò Ñê 91 ̋‹ÒãŁ›Æ‹ÒÁÊÙ˚¾Ò¼̋Ô­à³ 3.7% ˚Í̶ GDP (1.3% â­Á¾Ò̋ÂÑł 2.4% â­Á¾Ò̋àÍ̈Ł ) à®‹Ò Ñê µÚ›ãË›²ÂÔ̈ÒÂÂЭѲ³łÀ¾ÚÀÔÊ‹Ç ã˺‹ 80% à³ ˚Í̶àÍ̈Ł ã ˚ßЮÕéâÂ̶¼ÁÒ²ÒÄÊ‹Ç ã˺‹ 80% à³ ˚Í̶ÂÑł ØÖé̶ÊÒÀÒ¬᲋̶ÍÍ̈à³ 2 ̈ÄÙ‹À (cluster) Í̶̋‒̈ÂäÀ‹áÊÇ̶ËÒ̈îÒä®ÕéÂÑł²ÒÄà³ àÆ›Ò˚Í̶ ̋Í National Healthcare Group (NHG) áÄÐ Singapore Health Services (SingHealth) â­Á ̈ÄÙ‹À NHG ³ÂÐ̈Ͳ­›ÇÁ âÂ̶¼ÁÒ²ÒÄ 4 áË‹̶, ÈÚ Á‒̈ÒÂá¼®Á‒઼ÒЮÒ̶ 1 áË‹̶, Polyclinic 9 áË‹̶, Ê¬Ò²Ñ ̈ÒÂá¼®Á‒઼ÒЮÒ̶ 3 áË‹̶ ã ˚ßЮÕé SingHealth ³ÂÐ̈Ͳ­›ÇÁâÂ̶¼ÁÒ²ÒÄ 3 áË‹̶, ÈÚ Á‒̈ÒÂá¼®Á‒઼ÒЮÒ̶ 5 áË‹̶, Polyclinic 9 áË‹̶ ÇÑ©¬Ù³ÂÐÊ̶̋‒ËÄÑ̈̋Íà¼éÍãË›à̈Ô­̈ÒÂá˚‹̶˚Ñ ÂÐËÇ‹Ò̶ 2 ̈ÄÙ‹À áÄÐà¼éÍãË›à̈Ô­³ÂÐÊÔ® Ô¾Ò¼ã ̈Ò²ÂÔËÒÂÆÑ­̈Ò ²ÂÔ̈Òµڛ³ƒÇÁã âÂ̶¼ÁÒ²ÒÄ á²‹̶ÍÍ̈à³ ÂЭѲ©‹Ò̶ç ̋Í A, B1, B2, C ØÖé̶à³ÂÕÁ²àÊÀÍ Ë͵ڛ³ƒÇÁ ¼ÔàÈÉ ³Ò ̈ÄÒ̶ áÄÐÊÒÀѺ©ÒÀÄîҭѲ ËÄÑ̈̈Ò®ÑéÇä³̋͵ڛ³ƒÇÁÆЩ›Í̶Æ‹ÒÁà̶Ô à¼ÔéÀËÒ̈©›Í̶̈ÒÂÂѲ²ÂÔ̈ÒÂã ÂЭѲ®ÕéÊÚ̶ ˚Öê ØÖé̶ÆÐÀÕ ̈ÒÂ̈îÒË ­ÂÒ̋Ò˚Í̶²ÂÔ ̈ÒÂÂÐ­Ñ ²©‹ Ò̶çÊîÒËÂѲ âÂ̋á©‹ Ä ÐâÂ̋ÍÁ‹Ò̶ŁÑ ­àÆ ©ÒÂÒ̶ ˚›Ò̶Ä‹Ò̶áÊ­̶©ÑÇÍÁ‹Ò̶̈ÒÂ̈îÒË ­ÂÒ̋Ò̋‹Ò²ÂÔ̈ÒÂÂЭѲ©‹Ò̶çÊîÒËÂѲ̈Òµ‹Ò©Ñ­äÊ›©Ôé̶³̈©Ô ØÖé̶̈ÒÂ̈îÒË ­ÂÒ̋Ò ­›ÇÁÇÔ Õ Õê ®îÒãË›µÚ›³ƒÇÁÊÒÀÒ¬àÄÍ̈ÂѲ²ÂÔ̈ÒÂä­›©ÒÀÍÁ‹Ò̶ÍÔÊÂÐ ©ÒÀ̈îÒÄÑ̶̋ÇÒÀÊÒÀÒ¬ã ̈ÒÂÆ‹ÒÁ˚Í̶ © àÍ̶ ®Ñê ̶ Õê Í Ù À Ò Ç‹ Ò ̋Ù ß ¾Ò¼̈ÒÂ­Ú á ÄÂÑ ̈ ÉÒâÂ̋à­Õ Á Ç̈Ñ ˚Í̶á©‹ Ä ÐáË‹ ̶ äÀ‹ á ©̈©‹ Ò ̶̈Ñ ÀÒ̈ Ñ ̈ 47 ©ÒÂÒ̶®Õé 12 Hospital Bill Size for Appendectomy, Singapore Source: Ministry of Health, Singapore Note: AH = Alexandra Hospital, CGH = Changi General Hospital, KKH = KK Woman’s and Children’s Hospital, NUH = National University Hospital, SGH = Singapore General Hospital, TTSH = Tan Tock Seng Hospital 48 Âв²³ÂÐ̈Ñ ÊÙ˚¾Ò¼áÄÐ̈ÒÂÀÕÊÇ‹ ‹ÇÀÆ‹ÒÁ̋‹Ò²ÂÔ̈ÒÂÊÙ˚¾Ò¼ 1. Medisave à̈Ô­˚Öê ©Ñê̶á©‹³¡¼.È. 2527 à³ Âв²̈Ò²Ñ̶̋ѲãË›³ÂÐŁÒŁ ̈Ñ à̶Ô à­Í Ê‹Ç Ë Öé̶äǛ㠲ѺŁÕ Ò̋Ò ˚Í̶© àÍ̶ (Ordinary Account) à¼éÍäÇ›ÊîÒËÂÑ²ãŁ›à³ ̋‹ÒÂÑ̈ÉÒ¼ÁÒ²ÒÄ®ÕéÍÒÆà̈Ô­˚Öê ã Í Ò̋© ©ÒÀÍÑ©ÂÒ®Õé áÊ­̶ã ©ÒÂÒ̶ ÆîÒ Ç à̶Ô ®Õéà̈Ô $33,500 ÊîÒËÂѲµÚ›®ÕéÍÒÁÙäÀ‹à̈Ô 55 ³¡ ÆЬÚ̈ îÒä³äÇ›ã Special Account Ê‹Ç µÚ›®ÍÕé ÒÁÙ 55 ³¡˚Öê ä³ ÆЬÚ̈ îÒä³äÇ›ã Retirement Account Æ àÀéÍÀÕÁÍ­à̶Ô ¬Ö̶ÂÐ­Ñ²Ë Öé̶ Ê‹Ç ®Õéà̈Ô ̈è ÆÐ îÒ̈ÄѲÀÒäÇ›®Õé Ordinary Account Í̈ÆÒ̈ Õê µÚ›®ÕéÀÕÍÒÁÙ̋² 55 ³¡ ÀÕË ›Ò®ÕéÂÑ̈ÉÒÁÍ­à̶Ô ˚Ñê ©éîÒ㠲ѺŁÕäÇ› ®Õé $28,500 áÄÐÊÒÀÒ¬¬Í à̶Ô Ê‹Ç à̈Ô ÀÒãŁ›ä­› à éÍ̶ÆÒ̈à̶Ô ­Ñ̶̈Ä‹ÒÇäÀ‹ä­› îÒÀÒÊ›Ò̶à³ ̈Í̶®Ù ³ÂÐ̈Ñ ÊÙ˚¾Ò¼®ÕéÊ‹Ç ̈ÄÒ̶ ÆÖ̶äÀ‹ÍÒƬÍ䭛NjÒà³ Âв²³ÂÐ̈Ñ ÊÙ˚¾Ò¼®Õéá®›ÆÂÔ̶ ©ÒÂÒ̶®Õé 13 Medisave Contributions, Singapore Source: Ministry of Health, Singapore ³ÂÐŁÒŁ ÊÒÀÒ¬à˚› Ò ÂÑ ² ²ÂÔ ̈ Ò®Õé Ê ¬Ò ¼ÁÒ²ÒÄä­› ®Ù ̈ áË‹ ̶ ®Õé ä ­› ÂÑ ² ̈ÒÂÂÑ ² ÂÍ̶ÆÒ̈â̋Â̶̈Ò Medisave ØÖé̶ËÒ̈ÀṎÒÂÂѲà˚›ÒäÇ›ã âÂ̶¼ÁÒ²ÒÄ ÆÐàÂÔéÀÆÒ̈̈Ò³ÂÐÀÒß̋‹ÒãŁ›Æ‹ÒÁ (financial counseling session) áÄ›Çà®ÕÁ²̈ѲÁÍ­à̶Ô ®ÕéÀÕÍÁڋ㠲ѺŁÕ Medisave ˚Í̶µÚ›³ƒÇÁ à¼éÍÊÂٳNjҵڛ³ƒÇÁ©›Í̶Æ‹ÒÁà̶Ô à¼ÔÀé ஋Òã­ â­Á®Ò̶µÚ›³ƒÇÁÆЩ›Í̶àØ ©‒ÀͲªÑ ®ÐãË›®Ò̶â̋Â̶̈Ò Medisave ©Ñ­à̶Ô ã ²ÑºŁÕÀÒÆ‹ÒÁ̋‹Ò²ÂÔ̈Ò®Ò̶̈Ò ἮÁ‒®ÕéâÂ̶¼ÁÒ²ÒÄàÂÕÁ̈à̈è² Í̈ÆÒ̈ Õê à¼éÍà³ ̈Ò³Í̶̈Ñ äÀ‹ãË›à̶Ô ËÀ­̈‹Í àÇÄÒÍÑ ̋Ç ÁÑ̶ÀṎÒ ̈îÒË ­ Withdrawal Limit ØÖé̶ÀÒ̈¼Í®ÕéÆÐ̋ÂͲ̋ÄÙÀ̋‹ÒãŁ›Æ‹ÒÁÊîÒËÂѲ̈ÒÂÂÑ̈ÉÒÂЭѲ B2 áÄÐ C ä­› ã ˚ßÐ ®ÕÂé ЭѲ A áÄÐ B1 µÚ›³ƒÇÁ©›Í̶àÊÕÁà̶Ô à¼ÔéÀàÍ̶ 49 ©ÒÂÒ̶®Õé 14 Outpatient Treatments, Singapore Source: Ministry of Health, Singapore ‚ ‚ ‚ ‚ ‚ ‚ ‚ ‚ ‚ ‚ ̋‹Ò²ÂÔ̈Ò®Õé Medisave ̋ÂͲ̋ÄÙÀ ³ÂÐ̈Ͳ­›ÇÁ ̈Ò²ÂÔ̈Òµڛ³Çƒ Á Í̈ ̈Ò©Ñê̶̋¾‒áÄÐ̋ÄÍ­²Ù©Â ̈Ò²ÂÔ̈Òµڛ³Çƒ Áã (Inpatient Cases) (äÀ‹à̈Ô $450 ©‹ÍÇÑ ) ÂÇÀ̋‹Ò©ÂÇÆâ­Áá¼®Á‒ (äÀ‹à̈Ô $50 ©‹ÍÇÑ ) ̈Ò²ÂÔ̈Òµڛ³Çƒ Áã ŁÑéÇ̋ÂÒÇà¼é͵‹Ò©Ñ­ (Day Surgery) (äÀ‹à̈Ô $300 ©‹ÍÇÑ ) ÂÇÀ̋‹Ò©ÂÇÆâ­Á á¼®Á‒ (äÀ‹à̈Ô $30 ©‹ÍÇÑ ) ̈Òµ‹Ò©Ñ­ (Inpatient/Day Surgery) ˚Öê ÍÁÚ‹̈Ѳ̋ÇÒÀØÑ²Ø›Í áÄÐÂЭѲ̈ÒÂãË›²ÂÔ̈Ò®ÕéàÄÍ̈ ­Ñ̶ áÊ­̶ã ©ÒÂÒ̶ ̈ÒÂÂÑ̈ÉÒ®Ò̶ÆÔ©àÇŁ (äÀ‹à̈Ô $150 ©‹ÍÇÑ ) ÂÇÀ̋‹Ò­ÚáÄÂÑ̈ÉÒâ­Áá¼®Á‒(äÀ‹à̈Ô $50 ©‹ÍÇÑ ) áÄÐ ÂÇÀáÄ›ÇäÀ‹à̈Ô $5,000 ©‹Í³¡ ̈Ò²ÂÔ̈Òµڛ³Çƒ Áã âÂ̶¼ÁÒ²ÒÄŁÙÀŁ (äÀ‹à̈Ô $150 ©‹ÍÇÑ ) ÂÇÀ̋‹Ò­ÚáÄÂÑ̈ÉÒâ­Áá¼®Á‒(äÀ‹à̈Ô $30 ©‹ÍÇÑ ) áÄÐÂÇÀáÄ›ÇäÀ‹à̈Ô $3,500 ©‹Í³¡ ̈Ò²ÂÔ̈Òµڛ³Çƒ Áã âÂ̶¼ÁÒ²ÒÄà¼éÍ̈Ò¼Ñ̈½£́ (äÀ‹à̈Ô $50 ©‹ÍÇÑ ) ÂÇÀ̋‹Ò­ÚáÄÂÑ̈ÉÒâ­Áá¼®Á‒ (äÀ‹à̈Ô $30 ©‹ÍÇÑ ) áÄÐÂÇÀáÄ›ÇäÀ‹à̈Ô $3,000 ©‹Í³¡ ̈Ò²ÂÔ̈ÒÂã Ê¬Ò ¼Ñ̈½£́ (hospice) (äÀ‹à̈Ô $160 ©‹ÍÇÑ ) ÂÇÀ̋‹Ò­ÚáÄÂÑ̈ÉÒâ­Áá¼®Á‒(äÀ‹à̈Ô $30 ©‹ÍÇÑ ) ̈Ò­ÚáĵڛÊÚ̶ÍÒÁÙ (day care) (äÀ‹à̈Ô $20 ©‹ÍÇÑ ) áÄÐÂÇÀáÄ›ÇäÀ‹à̈Ô $1,500 ©‹Í³¡ 50 ©ÒÂÒ̶®Õé 15 Procedures Medisave Limites, Singapore Source: Ministry of Health, Singapore Í̈ÆÒ̈ ÕêÁÑ̶ÀÕâ̋Â̶̈ÒÂ઼ÒÐÊîÒËÂѲµÚ›³ƒÇÁâÂ̋àÂêÍÂÑ̶ ©ÒÀá Ç®Ò̶àÇŁ³ıԲѩÔÀÒ©ÂłÒ ®îÒãË› µÚ›³ƒÇÁÆ‹ÒÁà¼ÕÁ̶ $30 áÂ̈˚Í̶̋‹Ò²ÂÔ̈Ò (deductible) áÄÐ 15% ˚Í̶ÆîÒ Ç à̶Ô ®Õéà̈Ô ̈Ç‹Ò Ñê ®Ñê̶ Õê Medisave äÀ‹̋ÂͲ̋ÄÙÀ²ÂÔ̈Ò©‹Íä³ Õê ‚ ‚ ‚ ‚ ̈Ò©ÂÇÆÇÔ ÆÔ ªÑÁ®Õéà̈Ô­˚Öê ã ̈ÒÂÂѲ̈ÒÂÂÑ̈ÉÒá²²µÚ›³Çƒ Áã ®Õé¬Ú̈Á̈àÄÔ̈ ̈Ò®îÒÈÑÄÁ̈ÂÂÀ©̈á©‹̶ ÍÙ³̈Âß‒¼ÁÙ̶‹Ò̶̈ÒÁ ̋‹Ò¬¼ÁÒ²ÒÄ, ̋‹Òâ®ÂÈѼ®‒,̋‹ÒØÑ̈ÂÕ­ ÏÄÏ 2. MediShield à̈Ô­˚Öê ã ³¡ 2533 à³ Âв²³ÂÐ̈Ñ ÊÙ˚¾Ò¼ (Health Insurance) ÊîÒËÂѲâÂ̋®ÕéÀÕ̋‹ÒãŁ›Æ‹ÒÁÊÚ̶ ̋ÂͲ̋ÄÙÀ̈ÒÂÂÑ̈ÉÒ®ÕéÂЭѲ B2 áÄÐ C â­Á³ÂÐŁÒŁ ÊÒÀÒ¬ îÒà̶Ô Medisave ˚Í̶© àÍ̶ÀÒÆ‹ÒÁ̋‹Òà²ÕêÁ ³ÂÐ̈Ñ ä­› ³ÂÐŁÒŁ ÊÒÀÒ¬àÄÍ̈®ÕéÆÐÍÍ̈ÆÒ̈â̋Â̶̈ÒÂä­›©ÒÀ̋ÇÒÀÊÀÑ̋ÂãÆ (opt-out) àÀéÍÀṎÒÂÂÑ̈ÉÒà̈Ô­˚Öê µÚ›³ƒÇÁÆЩ›Í̶Æ‹ÒÁà²êÍ̶©› $1,500 ÊîÒËÂѲÂЭѲ B2 áÄÐ $1,000 ÊîÒËÂѲ ÂЭѲ C â­Á̋‹ÒãŁ›Æ‹ÒÁ®ÕéàËÄÍ 80-90% ÆÐÆ‹ÒÁâ­Á MediShield â­ÁÀṎÒÂ̈îÒË ­à¼­Ò äÇ›­̶Ñ Õê ‚ ̈Ò²ÂÔ̈Òµڛ³Çƒ Áã $250 ©‹ÍÇÑ ÊîÒËÂѲ̈ÒÂ Í âÂ̶¼ÁÒ²Òij̈©Ô áÄÐ $500 ©‹ÍÇÑ ÊîÒËÂѲ̈ÒÂ Í ã Ë›Í̶ ICU ‚ ̈Òµ‹Ò©Ñ­á²²©‹Ò̶ç $150-$1,100 ‚ ̈Ò¹»̶à̋ÂéÍ̶ÀÍ©‹Ò̶çâ­Á̈Òµ‹Ò©Ñ­ (surgical implant) $2,500 ‚ ®Ñ̶ê ÕêÂÇÀáÄ›ÇäÀ‹à̈Ô $50,000 ©‹Í³¡ áÄÐ $200,000 ©ÄÍ­ŁÕÇÔ© 51 ÍÁ‹Ò̶äÂ̈è©ÒÀ MediShield äÀ‹̋ÂͲ̋ÄÙÀâÂ̋ÂÙ áÂ̶®Õéà̈Ô­˚Öê áÄÐä­›ÂѲ̈ÒÂÂÑ̈ÉÒã Ł‹Ç̶ 12 à­Í ̈‹Í à˚›Ò‹ÇÀâ̋Â̶̈Ò ÈÑÄÁ̈ÂÂÀ©̈á©‹̶ ̋ÇÒÀ¼Ô̈ÒÂá©‹̈Òî à Ô­ áÄÐâÂ̋®Ò̶ÆÔ©àÇŁ 3. Medifund à̈Ô ­ ˚Öê ã ³¡ 2536 áÄÐÀÕ ÀÚ Ä ̋‹ Ò $1.5 ¼Ñ Ä› Ò ã ³¡ 2550 ̈Í̶®Ù Õê à ³ ̈Í̶®Ù à̶Ô ²ÂÔ Æ Ò̋à¼é Í Ł‹ÇÁàËÄ͵ڛ³ƒÇÁ®ÕéäÀ‹ÊÒÀÒ¬ƋÒÁ̋‹Ò²ÂÔ̈ÒÂáÀ›̈ÂЮÑé̶ÂЭѲ B2 ËÂÍ C ä­› µÚ›³ƒÇÁ®ÕéÀÕ̋ÇÒÀÆîÒà³ ©›Í̶ãŁ› ÆÐ ­îÒà Ô ̈Òµ‹Ò ̋ßÐ̈ÂÂÀ̈ÒÂ˚Í̶âÂ̶¼ÁÒ²ÒÄ®Õé®îÒ̈Ò­ÚáÄÂÑ̈ÉÒ â­ÁÆмÔÆÒÂßÒà³ ÂÒÁçä³ â­ÁµÚ›³ƒÇÁ®Õé à̋ÁÆ‹ÒÁ̋‹Òà²ÕêÁ³ÂÐ̈Ñ MediSave ËÂÍ MediShield ÆÐä­›ÂѲÊÔ® Ô¼ÔàÈÉÀÒ̈̈Ç‹Ò 4. Eldershield à̈Ô­˚Öê ã ³¡ 2545 à³ Âв²³ÂÐ̈Ñ ÊÙ˚¾Ò¼ÊîÒËÂѲ̈Ò­Úáĵڛ¼Ô̈Ò (severe disability) â­Á̈Ò ƋÒÁà̶Ô Ł‹ÇÁàËÄÍÂÒÁà­Í ̋ÂͲ̋ÄÙÀ³ÂÐŁÒŁ ®ÕéÍÁÚ‹ã â̋Â̶̈Ò MediSave ®ÕÍé ÒÁÙ 40 ³¡˚Öê ä³â­ÁÍÑ©â ÀÑ©Ô â­ÁÆÐÀṎÒÂÆ‹ÒÁ 2 ³ÂÐྮ ̋Í ElderShield300 ($300 ©‹Íà­Í à³ àÇÄÒ 60 à­Í ) áÄÐ ElderShield400 ($400 ©‹Íà­Í à³ àÇÄÒ 72 à­Í ) µÄ˚Í̶̈ÒÂÀÕÊÇ‹ ‹ÇÀÆ‹ÒÁ ÆÒ̈̈ÒÂʲ̋› łÒ ˚›ÍÀÚÄ Medline ¼²Ç‹ÒÀṎÒÂÈÖ̈ÉÒ˚Í̶³ÂÐà®ÈÊÔ̶̋â³Â‒ 2 àÂéÍ̶ á©‹à³ àÂéÍ̶®ÕéÀÕ ÇÑ©¬Ù³ÂÐÊ̶̋‒˚Í̶̈ÒÂÈÖ̈ÉÒäÀ‹©Â̶̈Ѳ̋ÇÒÀ©›Í̶̈ÒÂ11, 92 Ê‹Ç łÒ ˚›ÍÀÚÄÇÔ®ÁÒ Ô¼ ‒ äÀ‹¼²ÀṎÒÂÈÖ̈ÉÒ˚Í̶ ³ÂÐà®ÈÊÔ̶̋â³Â‒ 52 à̈ÒËÄÕã©› (South Korea) ³ÂÐà®Èà̈ÒËÄÕã©› ÀÕ³ÂÐŁÒ̈ 48 Ä›Ò ̋ ̋‹ÒãŁ›Æ‹ÒÁÊÙ˚¾Ò¼̋Ô­à³ 5.6% ˚Í̶ GDP (2.9% â­Á ¾Ò̋ÂÑł 2.7% â­Á¾Ò̋àÍ̈Ł ) µÚ›ãË›²ÂÔ̈ÒÂÊ‹Ç ã˺‹à³ ¾Ò̋àÍ̈Ł ©ÒÂÒ̶®Õé 16 Number of Health Care Institutions, South Korea Source: National Health Insurance Corporation, South Korea Âв²³ÂÐ̈Ñ ÊÙ˚¾Ò¼áÄÐ̈ÒÂÀÕÊÇ‹ ‹ÇÀÆ‹ÒÁ̋‹Ò²ÂÔ̈ÒÂÊÙ˚¾Ò¼ ³ÂÐà®Èà̈ÒËÄÕã©› ä­›ÍÍ̈ Medical Insurance Act ©Ñê̶á©‹³¡¼.È. 2506 ©‹ÍÀÒã ³¡¼.È. 2520 ̈èä­› àÂÔéÀâ̋Â̶̈Ò³ÂÐ̈Ñ ÊÙ˚¾Ò¼ÊîÒËÂÑ²Ê¬Ò ³ÂÐ̈Ͳ̈Ò®ÕéÀÕÄÚ̈Æ›Ò̶ÀÒ̈̈Ç‹Ò 500 ̋ áÄÐã ÍṎ 2 ³¡¬Ñ­ÀÒä­› ˚ÁÒÁ̋ÇÒÀ̋ÂͲ̋ÄÙÀä³ÁÑ̶Ê¬Ò ³ÂÐ̈Ͳ̈Ò®ÕéÀÕÄÚ̈Æ›Ò̶ÀÒ̈̈Ç‹Ò 300 ̋ Æ ÊÒÀҬʛÒ̶ËÄÑ̈³ÂÐ̈Ñ ÊÙ˚¾Ò¼¬›Ç Ë ›Ò䭛㠳¡¼.È. 2532 ©‹ÍÀÒã ³¡¼.È. 2543 ä­›̈‹Í©Ñê̶ National Health Insurance Corporation (NHIC) â­Á̈ÒÂ̋DzÂÇÀÂв²³ÂÐ̈Ñ ÊÙ˚¾Ò¼Á‹ÍÁç®Ñê̶ËÀ­äÇ›®Õéà­ÕÁÇ (Single Insurer) áÄÐÀÕ Health Insurance Review Agency (HIRA) ®îÒË ›Ò®Õ鮲®Ç ̈ÒÂà²Ô̈̋‹ÒãŁ›Æ‹ÒÁÆÒ̈µÚ›ãË›²ÂÔ̈ÒÂÇ‹ÒÀÕ̋ÇÒÀ àËÀÒÐÊÀÀÒ̈ ›ÍÁà¼ÕÁ̶ã­ 53 ¾Ò¼®Õé 7 Relations between parties of National Health Insurance, South Korea Source: National Health Insurance Corporation, South Korea ̈Í̶®Ù ®ÕéãŁ›²ÂÔËÒÂÆÑ­̈ÒÂ̋Íà̶Ô à²ÕêÁ³ÂÐ̈Ñ (Premium) ÆÒ̈ÊÒÀÊ‹Ç ̋Í µÚ›Æ›Ò̶ µÚ›¬Ú̈Æ›Ò̶ áÄÐà̶Ô ÊÀ®²ÆÒ̈ÂÑł²ÒÄ ³»ÆÆÙ²Ñ ÍÁÚ‹®Õé 4.77% ˚Í̶à̶Ô à­Í µÚ›³ÂÐ̈Ñ © ᲋̶à³ 2 ³ÂÐྮ ̋Í 1.µÚ›¬Ú̈Æ›Ò̶ã ¾Ò̋ÂÑłáÄÐàÍ̈Ł (Employee in Private Sector & Government/Private School Employee) áÄÐ 2.àÆ›Ò˚Í̶̈ÔÆ̈ÒÂã àÀÍ̶áÄÐŁ ²® (Self-employed Insured in Urban and Rural Areas) ã ³¡ 2548 ³ÂÐŁÒŁ 47 Ä›Ò ̋ (96.4%) ä­›ÂѲËÄÑ̈³ÂÐ̈Ñ ÊÙ˚¾Ò¼ ÆÒ̈â̋Â̶̈Ò NHI ã ˚ßЮÕéµÚ›ÀÕÂÒÁä­› ›ÍÁÍṎ̈Ç‹Ò 1.7 Ä›Ò ̋ (3.6%) ä­›ÂѲ̋ÇÒÀ̋Ù›À̋ÂÍ̶ã â̋Â̶̈Ò Medical Aid Program ­Ñ̶©ÒÂÒ̶ Í̈ÆÒ̈ ÕêÁÑ̶ãË›̋ÇÒÀ̋Ù›À̋ÂÍ̶á̈‹ŁÒÇ©‹Ò̶ŁÒ©Ô®Õéà˚›ÒÀÒ®îÒ̶Ò ã ³ÂÐà®È à̈ÒËÄÕã©›ÍṎ­›ÇÁ 54 ©ÒÂÒ̶®Õé 17 Number of Covered Population (2005), South Korea Source: National Health Insurance Corporation, South Korea µÚ›³ÂÐ̈Ñ © ³ÂÐྮ®Õé 1 ÆÐãŁ›à̶Ô à­Í à³ łÒ ã ̈ÒÂ̋îÒ Ç Ê‹Ç µÚ›³ÂÐ̈Ñ © ³ÂÐྮ®Õé 2 ÆÐÀÕ ÊÚ©Âã ̈ÒÂ̋îÒ Ç Contribution Points ©ÒÀÂÒÁä­›áÄÐÀÚÄ̋‹Ò®ÂѼÁ‒ÊÔ ®ÕéÀÕÍÁÚ‹ áÄ›Ç̋Úß̈Ѳ Value per point (³»ÆÆÙ²Ñ ÍÁÚ‹®Õé 139.9 won; US$1 = 946.6 won) áÄ›ÇÂÑł²ÒÄÆÐÂѲµÔ­ŁÍ²̋ÂÖé̶Ë Öé̶˚Í̶ÆîÒ Ç à̶Ô ®Õé̋îÒ Ç ä­› Ê‹Ç ®ÕéàËÄÍÆÐÊ‹̶àÂÕÁ à̈è²ÆÒ̈µÚ›³ÂÐ̈Ñ © â­Áà̶Ô ÊÀ®²®ÕéÂÑł²ÒÄ îÒÀÒãŁ› Ê‹Ç Ë Öé̶ÀÒÆÒ̈¾ÒÉÕÍÒ̈ ®ÑéÇä³ (General Taxation) áÄÐÍṎÊ‹Ç Ë Öé̶ÀÒÆÒ̈¾ÒÉÕ²ÙËÂÕé (Tobacco Tax) ØÖé̶ä­›Ł‹ÇÁ®îÒãË›Ê¬Ò ̈ÒÂß‒ ®Ò̶̈ÒÂà̶Ô ­Õ˚Öê ÀÒ̈ àÀéÍà®ÕÁ²̈Ѳ̈‹Í ³¡¼.È. 2545 55 ©ÒÂÒ̶®Õé 18 Premium Contribution Rates, South Korea Source: National Health Insurance Corporation, South Korea 56 ©ÒÂÒ̶®Õé 19 Premium Revenues and Growth Rates by Year, South Korea Source: National Health Insurance Corporation, South Korea Benefit Package ³ÂÐ̈Ͳ­›ÇÁ Service Benefits áÄÐ Cash Benefits â­Á Service Benefits ̋ÂͲ̋ÄÙÀ̋‹ÒãŁ›Æ‹ÒÁ®Ù̈³ÂÐྮ©ÄÍ­̈ÂÐ²Ç ̈ÒÂÂÑ̈ÉÒ ©Ñê̶á©‹ ̋‹Ò©ÂÇÆÇÔ ÔƪÑÁ ̋‹Ò©ÂÇÆ®Ò̶Ë›Í̶³ıԲѩÔ̈Ò ÇÑÊ­Ù®Ò̶̈ÒÂá¼®Á‒ ̋‹ÒÂÑ̈ÉÒ ̋‹Òµ‹Ò©Ñ­ ̋‹ÒãŁ›Æ‹ÒÁã ̈ÒÂÊ‹̶àÊÂÔÀáÄгÍ̶̈Ñ âÂ̋ ̋‹Ò̈ÒÁ¾Ò¼²îҲѭ ÂÇÀ®Ñê̶̋‹Ò à­Ô ®Ò̶ ®Ñ̶ê ÕêÁ̈àÇ› ²ÂÔ̈Ò®ÕéäÀ‹ÆîÒà³ àŁ‹ ̈ÒÂàÊÂÔÀ̋ÇÒÀ̶ÒÀ ©ÒÂÒ̶®Õé 20 Health Insurance Benefits, South Korea Source: National Health Insurance Corporation, South Korea Ê‹Ç Cash Benefits à³ µÄ³ÂÐâÁŁ ‒®ÕéµÚ›³ÂÐ̈Ñ © ÆÐä­›ÂѲã ÂÚ³à̶Ô Ê­ ä­›á̈‹ 1.̈ÒÂà²Ô̈̋‹ÒÂÑ̈ÉÒ ̋ ®Õéä­›ÊîÒÂÍ̶Æ‹ÒÁä³̈‹Í àÀéÍà̈Ô­̈ÂßÕªÙ̈àªÔ 2.̋‹ÒŒÒ³ ̈ÔÆȼ (250,000 won) 3.̈ÒÂà²Ô̈̋ à̶Ô 57 Copayment ËÒ̈䭛ƋÒÁä³à̈Ô 1,200,000 won ã 30 ÇÑ 4.̈ÒÂ̈îÒË ­à¼­Ò Copayment â­ÁËÒ̈ µÚ›³ÂÐ̈Ñ © 䭛ƋÒÁ Copayment ä³à̈Ô 3,000,000 won ã 6 à­Í ÆÐä­›̈ÒÂÁ̈àÇ› äÀ‹©›Í̶Æ‹ÒÁ Copayment ÍṎ©‹Íä³ 5.̈ÒÂà²Ô̈̋ ̋‹ÒÍÙ³̈Âß‒ÊîÒËÂѲµÚ›¼Ô̈ÒÂä­› 80% Copayment ˚Í̶²ÂÔ ̈Òµڛ ³ƒÇ Á Í̈ÀÕ ÍÑ© ÂÒá©̈©‹ Ò̶̈Ñ ä³˚Öê ÍÁÚ‹̈Ñ ² ³ÂÐྮáÄЮÕé ©Ñê ̶˚Í̶ Ê¬Ò ¼ÁÒ²ÒÄ à¼éÍÆÚ̶ãÆãË›ãŁ›²ÂÔ ̈Ò®ÕéÊ¬Ò ²ÂÔ̈ÒÂ˚ Ò­àÄè̈̈‹Í ©ÑÇÍÁ‹Ò̶àŁ‹ ̈ÒÂãŁ›²ÂÔ̈Ò®Õé̋ÄÔ Ô ̈ µÚ› ³ ÂÐ̈Ñ © ®Õé Í ÒÁÙ › Í Á̈Ç‹ Ò 65 ³¡ ©› Í ̶Æ‹ Ò Á̋‹ Ò ²ÂÔ ̈ Ò 3,000 ÇÍ µÚ› ÊÚ ̶ ÍÒÁÙ Æ‹ Ò Á 1,500 ÇÍ ã ̈ÂßÕ ®Õé ̋‹ÒãŁ›Æ‹ÒÁäÀ‹à̈Ô 15,000 ÇÍ á©‹ËÒ̈à̈Ô ̈Ç‹Ò Ñê µÚ›³ÂÐ̈Ñ © ©›Í̶Æ‹ÒÁ 30% á©‹ËÒ̈à³ ®ÕéâÂ̶¼ÁÒ²ÒÄ ÍÑ©ÂÒ Copayment ÆÐà¼ÔéÀ˚Öê ©ÒÀÄîҭѲ­Ñ̶©ÒÂÒ̶ Ê‹Ç ²ÂÔ̈Òµڛ³ƒÇÁã µÚ›³ÂÐ̈Ñ © ©›Í̶Æ‹ÒÁÍÑ©ÂÒ̶̋®Õé 20% ©ÒÂÒ̶®Õé 21 Types of Copayment, South Korea Source: National Health Insurance Corporation, South Korea 58 ÊîÒËÂѲ²ÂÔ̈Ò©ÂÇÆÊÙ˚¾Ò¼áÄÐ̋Ñ­̈ÂÍ̶âÂ̋àÂêÍÂÑ̶ µÚ›³ÂÐ̈Ñ äÀ‹©›Í̶àÊÕÁ̋‹ÒãŁ›Æ‹ÒÁã­ç Ê‹Ç ²ÂÔ̈Ò ©ÂÇÆ̋Ñ­̈ÂÍ̶âÂ̋ÀÐàÂè̶ 5 Ł Ô­ ÆÐÀÕÂв² Copayment ઼ÒÐ â­Á NHIC ÆÐÆ‹ÒÁ 80% áÄеڛ³ÂÐ̈Ñ © Æ‹ÒÁ 20% ÊîÒËÂѲ̈Ò©ÂÇÆ̋Ñ­̈ÂÍ̶ÀÐàÂè̶̈ÂÐà¼ÒÐÍÒËÒ ÄîÒäÊ›ã˺‹ à©›Ò À áÄЩѲ á©‹ËÒ̈à³ ÀÐàÂè̶³Ò̈ À­ÄÚ̈ µÚ›³ÂÐ̈Ñ © ÊÒÀÒ¬ÂѲ²ÂÔ̈ÒÂä­›½ÂÕ ²ÂÔ̈Ò®ÕéäÀ‹ªÙ̈àªÔ áÄÐäÀ‹ÆîÒà³ ÆÐäÀ‹ä­›ÂѲ̋ÇÒÀ̋ÂͲ̋ÄÙÀ©ÒÀ ÊÔ® Ô³ÂÐâÁŁ ‒ ÂÒÁÆ‹ÒÁã ³¡¼.È. 2548 ©ÒÀÊÔ® ÔâÁŁ ‒ ÀÕÀÚÄ̋‹Ò̈Ç‹Ò 18 ¼Ñ Ä›Ò ÇÍ ØÖé̶à¼ÔéÀ˚Öê ÆÒ̈³¡¼.È. 2541 ̈Ç‹Ò 3 à®‹Ò (­Ñ̶¾Ò¼) â­ÁÊ‹Ç ã˺‹à³ ̋‹ÒãŁ›Æ‹ÒÁà̈ÕéÁÇ̈Ѳ̈ÒÂãË›²ÂÔ̈ÒÂÊÙ˚¾Ò¼ ­Ñ̶áÊ­̶ã ©ÒÂÒ̶ ËÒ̈ ÆîÒá ̈©ÒÀ³ÂÐྮ²ÂÔ̈Ò Æм²Ç‹Ò²ÂÔ̈Òµڛ³ƒÇÁ Í̈ÀÕÂÒÁÆ‹ÒÁÀÒ̈®ÕéÊÙ­ ÂÍ̶Ä̶ÀÒä­›á̈‹²ÂÔ̈Òµڛ³ƒÇÁã áÄÐ̋‹ÒÁÒ 59 ¾Ò¼®Õé 8 Trends of NHI Benefits Cost, South Korea Source: National Health Insurance Corporation, South Korea ©ÒÂÒ̶®Õé 22 Expenditure of Insurance Benefit, South Korea Source: National Health Insurance Corporation, South Korea 60 ©ÒÂÒ̶®Õé 23 Expenditure of Cash Benefit, South Korea Source: National Health Insurance Corporation, South Korea 61 ©ÒÂÒ̶®Õé 24 Expenditure of Service Benefits by Type, South Korea Source: National Health Insurance Corporation, South Korea 62 µÄ˚Í̶̈ÒÂÀÕÊÇ‹ ‹ÇÀÆ‹ÒÁ ÆÒ̈̈ÒÂʲ̋› łÒ ˚›ÍÀÚÄ Medline ¼²Ç‹ÒÀṎÒÂÈÖ̈ÉÒ˚Í̶³ÂÐà®Èà̈ÒËÄÕã©› 4 àÂéÍ̶ á©‹ä­›©Ñ­àÂéÍ̶®Õé ÇÑ©¬Ù³ÂÐÊ̶̋‒˚Í̶̈ÒÂÈÖ̈ÉÒäÀ‹©Â̶̈Ѳ̋ÇÒÀ©›Í̶̈ÒÂÍÍ̈ 3 àÂéÍ̶11, 93, 94 Ê‹Ç łÒ ˚›ÍÀÚÄÇÔ®ÁÒ Ô¼ ‒ ÀÕ ̈ÒÂÈÖ̈ÉÒ˚Í̶³ÂÐà®Èà̈ÒËÄÕã©› 4 àÂéÍ̶ á©‹à³ àÂéÍ̶®ÕéÇÑ©¬Ù³ÂÐÊ̶̋‒äÀ‹©Â̶̈Ѳ̋ÇÒÀ©›Í̶̈ÒÂ95-98 Study 1. The effects of patient cost sharing on ambulatory utilization in South Korea 99 Kim áÄÐ̋ßÐä­›ÈÖ̈ÉÒµÄ˚Í̶̈ÒÂÆ‹ÒÁ̋‹Ò²ÂÔ̈Ò©‹Í̋ÇÒÀ©›Í̶̈ÒÂà˚›ÒÂѲ̈ÒÂÂÑ̈ÉÒÆÒ̈á¼®Á‒ (demand for physician service) â­ÁÇÔà̋ÂÒÐË‒˚›ÍÀÚÄ̈ÒÂÊîÒÂÇÆ National Health and Nutrition Survey ã ³¡¼.È. 2541 ¼²Ç‹Ò Copayment ÍÒÆäÀ‹ÊÒÀÒ¬Ł‹ÇÁÄ­̈ÒÂãŁ›²ÂÔ̈ÒÂä­›ÀÒ̈ Ñ̈ à éÍ̶ÆÒ̈ Price Elasticity äÀ‹ä­›ÀÕ̋‹Ò©Ô­Ä²ÍÁ‹Ò̶ÀÕ ÑÁÊîÒ̋Ѻ®Ò̶Ê¬Ô©Ô ã ˚ßЮÕéʾÒÇÐÊÙ˚¾Ò¼˚Í̶µÚ›³ƒÇÁà³ ©ÑÇá³Â®ÕéÀյĩ‹Í̈ÒÂãŁ› ²ÂÔ̈ÒÂÀÒ̈̈Ç‹Ò áÄеڛ³ƒÇÁÂÒÁä­› ›ÍÁ ÆÐä­›ÂѲµÄ̈ÂЮ²ÆÒ̈ Copayment ÀÒ̈̈Ç‹Ò à éÍ̶ÆÒ̈ Price Elasticity ©Ô­Ä²ÀÒ̈̈Ç‹Ò Í̈ÆÒ̈ ÕêÁÑ̶¼²ÍṎÇ‹Ò ̈ÒÂãŁ› Copayment à¼éÍ̈ÂЩٛ ãË›µÚ›³ÂÐ̈Ñ © ä³ÂѲ²ÂÔ̈Ò ®ÕÊé ¬Ò ¼ÁÒ²ÒÄ˚ Ò­àÄè̈̈‹Í ÍÒÆäÀ‹ä­›µÄÍÁ‹Ò̶®Õé©›Í̶̈Ò ˚›ÍÊÂÙ³ Copayment äÀ‹ÊÒÀÒ¬Ł‹ÇÁÄ­̈ÒÂãŁ›²ÂÔ̈ÒÂä­›ÀÒ̈ Ñ̈ ÍṎ®Ñê̶ÁÑ̶äÀ‹ÊÒÀÒ¬ÆÚ̶ãÆãË› µÚ›³ÂÐ̈Ñ © ãŁ›Âв²Ê‹̶©‹Íä­› 63 ä©›ËÇÑ (Taiwan) ³ÂÐà®Èä©›ËÇÑ ÀÕ³ÂÐŁÒ̈³ÂÐÀÒß 23 Ä›Ò ̋ ³»ÆÆÙ²Ñ ¬Íà³ Ê‹Ç Ë Öé̶˚Í̶³ÂÐà®ÈÆÕ á©‹ÀÕÂв² ÊÙ˚¾Ò¼á²² NHI ̋Ä›ÒÁ̈Ѳ³ÂÐà®Èà̈ÒËÄÕã©› ̋‹ÒãŁ›Æ‹ÒÁÊÙ˚¾Ò¼̋Ô­à³ 6.16% ˚Í̶ GDP ÂÒÁÆ‹ÒÁ®Ò̶ ̈ÒÂá¼®Á‒˚Í̶³ÂÐà®Èä©›ËÇÑ ã ³¡ 2549 ÀÕÀÚÄ̋‹Ò NT$423 ¼Ñ Ä›Ò ØÖé̶à³ ©› ®Ù ̋‹Ò²ÂÔ̈Òµڛ³ƒÇÁ Í̈ 65% áÄеڛ³ƒÇÁã 35%100 Âв²³ÂÐ̈Ñ ÊÙ˚¾Ò¼ ³ÂÐà®Èä©›ËÇÑ ³ıÔÂÚ³Âв²ÊÙ˚¾Ò¼ã à­Í ÀÕ Ò̋À 2538 ãŁ›ŁéÍâ̋Â̶̈ÒÂÇ‹Ò National Health Insurance Program (NHI) ²ÂÔËÒÂÆÑ­̈ÒÂâ­Á Bureau of National Health Insurance (BNHI) ØÖé̶ÊÑ̶̈Ñ­ Department of Health à³ µÚ›ØêͲÂÔ̈ÒÂà¼ÕÁ̶µÚ›à­ÕÁÇã Âв²ÊÙ˚¾Ò¼ (Single Payer) ̋ÂͲ̋ÄÙÀ³ÂÐŁÒŁ 99% (22.3 Ä›Ò ̋ ) ÂÇÀ®Ñê̶ŁÒÇ©‹Ò̶³ÂÐà®È®ÕéÀÕ Resident Permits ­›ÇÁ ÀṎÒÂÆîÒá ̈µÚ›³ÂÐ̈Ñ © ÍÍ̈à³ 6 ̈ÄÙ‹ÀÁ‹ÍÁ ­Ñ̶©ÒÂÒ̶100 64 ¾Ò¼®Õé 9 Taiwan NHI Organization Chart, Taiwan, R.O.C. Source: Bureau of National Health Insurance, Department of Health 65 ©ÒÂÒ̶®Õé 25 NHI Applicants, Dependents and Insuring Agencies, Taiwan, R.O.C. Source: Bureau of National Health Insurance, Department of Health â̋Â̶̈Ò NHI ̋ÂͲ̋ÄÙÀÊ¬Ò ²ÂÔ̈ÒÂ̈Ç‹Ò 90% (18,289 áË‹̶) µÚ›ãË›²ÂÔ̈ÒÂÊ‹Ç ã˺‹à³ ¾Ò̋àÍ̈Ł µÚ›³ƒÇÁÊÒÀÒ¬àÄÍ̈µÚ›ãË›²ÂÔ̈ÒÂä­›ÍÁ‹Ò̶ÍÔÊÂÐ â­ÁäÀ‹ÆîÒà³ ©›Í̶ÀṎÒÂÊ‹̶©ÑÇ áÄÐäÀ‹ÀÕ Gate-keeper µÚ›³ƒÇÁ ÊÒÀÒ¬ÂѲ²ÂÔ̈Ò®Ò̶̈ÒÂá¼®Á‒ä­›®Ù̈³ÂÐྮ ÂÇÀ®Ñê̶̈ÂßÕªÙ̈àªÔ ®Õéà̈Ô­ã ©‹Ò̶³ÂÐà®È ÂÇÀ®Ñê̶̈ÒÂÂѲ ²ÂÔ̈ÒÂã ³ÂÐà®ÈÆÕ ̈èÊÒÀÒ¬à²Ô̈̋ ̋‹ÒãŁ›Æ‹ÒÁä­› ̈Í̶®Ù ®ÕéãŁ›²ÂÔËÒÂÆÑ­̈ÒÂ̋Íà̶Ô à²ÕêÁ³ÂÐ̈Ñ (Premium) ÆÒ̈ÊÒÀÊ‹Ç ̋Í µÚ›Æ›Ò̶ µÚ›¬Ú̈Æ›Ò̶ áÄÐà̶Ô ÊÀ®²ÆÒ̈ÂÑł²ÒÄ ³»ÆÆÙ²Ñ ÍÁÚ‹®Õé 4.55% ˚Í̶à̶Ô à­Í ®Ñê̶ Õêä­›̈îÒË ­ÍÑ©ÂÒ̈ÒÂÆ‹ÒÁà²ÕêÁ³ÂÐ̈Ñ ®Õéá©̈©‹Ò̶̈Ñ ©ÒÀµÚ›³ÂÐ̈Ñ © ̈ÄÙ‹À©‹Ò̶ç â­ÁµÚ›³ÂÐ̈Ñ © 3 ̈ÄÙ‹ÀáÂ̈ÆÐãŁ›à̶Ô à­Í à³ łÒ ã ̈ÒÂ̋îÒ Çß Ê‹Ç ̈ÄÙ‹À®Õé àËÄÍ ÆÐãŁ›̋‹ÒàªÄÕéÁ˚Í̶ Premium ®Õéä­›ÆÒ̈ 3 ̈ÄÙ‹ÀáÂ̈ à³ łÒ ã ̈ÒÂ̋îÒ Çß Ê‹Ç µÚ›®ÕéäÀ‹à˚›Ò˚‹ÒÁ̈Ò Á̈àÇ› Premium ®Ò̶ÂÑł²ÒÄ̈èÀṎÒÂÆÑ­Âв²à̶Ô ̈Ú› áÄÐ Âв²µ‹Í ŁîÒÂÐ â­ÁÊک®ÕéãŁ›̋îÒ Ç Premium áÄÐ ÂÒÁä­›ÆÒ̈ Premium áÊ­̶ã ©ÒÂÒ̶ 66 ©ÒÂÒ̶®Õé 26 Premium Contribution Rates, Taiwan, R.O.C. Source: Bureau of National Health Insurance, Department of Health ©ÒÂÒ̶®Õé 27 Premium Calculation Formulas, Taiwan, R.O.C. Source: Bureau of National Health Insurance, Department of Health 67 ©ÒÂÒ̶®Õé 28 Premium Revenues and Growth Rates by Year, Taiwan, R.O.C. Source: Bureau of National Health Insurance, Department of Health BNHI ÆÐÆ‹ÒÁà̶Ô á̈‹µÚ›ãË›²ÂÔ̈Ò­›ÇÁ 2 Âв²ã˺‹ ̋Í Fee-for-service ©ÒÀÂÒ̋ÒÀÒ©ÂłÒ ̈ÄÒ̶ áÄÐ Case Payment ÊîÒËÂѲËÑ©¬̈Ò 53 Ł Ô­ (®Ñ̶ê á²²µÚ›³ƒÇÁã áÄÐ Í̈) ØÖé̶ÆÐÀṎÒÂ̈îÒË ­ÍÑ©ÂÒ̈ÒÂà¼ÔéÀ Global Budget â­ÁÍÔ̶̈ѲµÄ̈Ò³ÂÐàÀÔ ̋Ùß¾Ò¼˚Í̶Ê¬Ò ²ÂÔ̈ÒÂ̋Ú‹ÊѺºÒ ©ÒÂÒ̶®Õé 29 Global Budget (2003-2007), Taiwan, R.O.C. Source: Bureau of National Health Insurance, Department of Health áÀ›ã ÂÐÁÐáÂ̈˚Í̶â̋Â̶̈ÒÂÆÐÂÒ²Âé á©‹­›ÇÁÍÑ©ÂÒ̈ÒÂà¼ÔéÀ˚Öê ˚Í̶̋‹ÒãŁ›Æ‹ÒÁ®Ò̶̈ÒÂá¼®Á‒ 5.54% ©‹Í³¡ áÄÐÍÑ©ÂÒ̈ÒÂ̈ÒÂà¼ÔéÀ˚Öê ˚Í̶ÂÒÁä­›ÆÒ̈ Premium 4.7% ©‹Í³¡ ®îÒã˛㠳»ÆÆÙ²Ñ ³ÂÐà®Èä©›ËÇÑ ÀÕ ³»ºËÒà̶Ô ÊîÒÂÍ̶Ä­Ä̶à éÍ̶ÆÒ̈ÂÒÁÂѲáÄÐÂÒÁÆ‹ÒÁ஋Ò̈Ñ 68 ¾Ò¼®Õé 10 Trend of NHI Financial Status, Taiwan, R.O.C. Source: Bureau of National Health Insurance, Department of Health ̈ÒÂÀÕÊÇ‹ ‹ÇÀÆ‹ÒÁ̋‹Ò²ÂÔ̈ÒÂÊÙ˚¾Ò¼ Copayment ˚Í̶³ÂÐà®Èä©›ËÇÑ ÀÕÇÑ©¬Ù³ÂÐÊ̶̋‒ËÄÑ̈à¼éÍ̈ÂЩٛ ãË›µÚ›³ÂÐ̈Ñ © ä³ÂѲ²ÂÔ̈ÒÂ¼ê łÒ ®Õé Ê ¬Ò ²ÂÔ ̈ ÒÂ˚ Ò­àÄè ̈ áÄÐÊ‹ ̶ àÊÂÔ À ̈ÒÂá¼®Á‒ á µ ÆÕ ã ÂÐÁÐáÂ̈˚Í̶â̋Â̶̈ÒÂÀÕ ̈ ÒÂà̈è ² Basic Copayment ØÖé̶©›Í̶àÊÕÁ̋‹ÒãŁ›Æ‹ÒÁÀÒ̈˚Öê ©ÒÀ˚ Ò­˚Í̶Ê¬Ò ¼ÁÒ²ÒÄ®Õéä³ÂѲ²ÂÔ̈Ò â­ÁÆÐäÀ‹ÀṎÒÂà̈è²̋‹Ò ÁÒ ̋‹Ò©ÂÇÆÇÔ ÔƪÑÁ áÄÐ̋‹ÒÂÑ̈ÉÒà¼ÔéÀà©ÔÀÍṎ ËÄÑ̶ÆÒ̈ Ñê ä­›ÀṎÒ³ÂѲ˚Öê ÍÑ©ÂÒ Copayment ËÄÒÁ̋ÂÑê̶ ̋ÂÑê̶ áÂ̈ã ³¡¼ .È. 2540 ä­›àÂÔé Àà̈è²̋‹ Ò²ÂÔ̈Òµڛ ³ƒÇÁ Í̈²Ò̶ÍÁ‹Ò̶ ̋‹ Ò̈ÒÁ¾Ò¼²î Ҳѭ ̋‹ ÒÁÒ áÄÐ̋‹Ò²ÂÔ̈Ò à¼Ôé À à©Ô ÀÊî Ò ËÂÑ ² µÚ› ®Õé À ÒãŁ› ² ÂÔ ̈ Òµڛ ³ƒ Ç Á Í̈à̈Ô ̈Ç‹ Ò 25 ̋ÂÑê ̶ ©‹ Í ³¡ ©‹ Í ÀÒã ³¡ ¼ .È. 2541 ä­› à ¼Ôé ÀÍÑ © ÂÒ Copayment ã âÂ̶¼ÁÒ²ÒÄâÂ̶àÂÕÁ á¼®Á‒ áÄÐã ³¡ 2545 ä­›ÀṎÒ³ÂѲà¼ÔéÀ̈ÒÂà̈è²̋‹Ò²ÂÔ̈Ò©ÂÇÆ®Ò̶ Ë›Í̶³ıԲѩÔ̈Ò®ÕéâÂ̶¼ÁÒ²ÒÄ˚ Ò­ã˺‹áÄÐâÂ̶àÂÕÁ á¼®Á‒ ØÖé̶ÀյĮîÒãË›̋ÇÒÀ¼Ö̶¼ÍãÆ˚Í̶³ÂÐŁÒŁ Ä­Ä̶ á©‹̈̈è ÄѲ­Õ˚Öê ã àÇÄÒ©‹ÍÀÒ 69 ¾Ò¼®Õé 11 Public Satisfaction Rate with NHI, Taiwan, R.O.C. Source: Bureau of National Health Insurance, Department of Health ©‹ÍÀÒã ³¡ 2548 ä­›³ÂѲ Copayment ̋ÂÑê̶Ä‹ÒÊÙ­ ­Ñ̶áÊ­̶ã ©ÒÂÒ̶ Í̈ÆÒ̈ Õê ËÒ̈ÀṎÒÂÊÑé̶ÁÒÀÚÄ̋‹Ò ÀÒ̈̈Ç‹ Ò NT$100 µÚ› ³ ÂÐ̈Ñ © ©› Í ̶Æ‹ Ò Áà¼Ôé À ÍÕ ̈ NT$20 ©‹ Í ®Ù ̈ ç NT$100 ®Õé à ¼Ôé À ˚Öê Ê‹ Ç Copayment ÊîÒËÂѲ²ÂÔ̈Òµڛ³ƒÇÁã ÆÐ˚Öê ÍÁÚ‹̈ѲÆîÒ Ç ÇÑ Í ØÖé̶ÆÐäÀ‹à̈Ô NT$24,000 ©‹Í̋ÂÑê̶ ËÂÍ NT$41,000 ©‹Í³¡ (ÊîÒËÂѲâÂ̋à­ÔÀ) µÚ›³ƒÇÁ®ÕéãŁ›²ÂÔ̈Ò®Ò̶̈ÒÂá¼®Á‒ÀÒ̈̈Ç‹Ò 50 ̋ÂÑê̶ã ÂͲ 3 à­Í (ËÂÍ 20 ̋ÂÑê̶©‹Íà­Í ) ÆÐÀÕâ̋Â̶̈ÒÂãË›̋Òî ³ÂÖ̈ÉÒ (High Utilization Counseling) ©ÒÂÒ̶®Õé 30 Basic Outpatient Care Copayment, Taiwan, R.O.C. Source: Bureau of National Health Insurance, Department of Health Note: NT$ (US$1 = NT$35) ©ÒÂÒ̶®Õé 31 Copayment Rates for Inpatient Care, Taiwan, R.O.C. Source: Bureau of National Health Insurance, Department of Health 70 ‚ ‚ ‚ ‚ ‚ ‚ Copayment ä­›ÂѲ̈ÒÂÁ̈àÇ› ã ̈ÂßÕ©Í‹ ä³ Õê Catastrophic & Rare diseases ̋ÄÍ­²Ù©Â ²ÂÔ̈Ò®Ò̶̈ÒÂá¼®Á‒ã ¬Ôé ®ÙÂ̈Ñ ­Ò ̋ÂͲ̋ÂÑÇÂÒÁä­› ›ÍÁ ®ËÒµ‹Ò ÈÖ̈ à­è̈ÍÒÁÙ©éîÒ̈Ç‹Ò 3 ³¡ 71 ©ÒÂÒ̶®Õé 32 NHI Catastrophic Illnesses, Taiwan, R.O.C. Source: Bureau of National Health Insurance, Department of Health 72 µÄ˚Í̶̈ÒÂÀÕÊÇ‹ ‹ÇÀÆ‹ÒÁ ÆÒ̈̈ÒÂʲ̋› łÒ ˚›ÍÀÚÄ Medline ¼²Ç‹ÒÀṎÒÂÈÖ̈ÉÒ˚Í̶³ÂÐà®Èä©›ËÇÑ 5 àÂéÍ̶ á©‹ä­›©Ñ­àÂéÍ̶®Õé à̈ÕéÁÇ̈ѲÁÒÍÍ̈ 3 àÂéÍ̶101-103 áÄÐàÂéÍ̶®ÕéÇÑ©¬Ù³ÂÐÊ̶̋‒˚Í̶̈ÒÂÈÖ̈ÉÒäÀ‹©Â̶̈Ѳ̋ÇÒÀ©›Í̶̈ÒÂÍÍ̈ 1 àÂéÍ̶104 Ê‹Ç łÒ ˚›ÍÀÚÄÇÔ®ÁÒ Ô¼ ‒ ÀṎÒÂÈÖ̈ÉÒ˚Í̶³ÂÐà®Èä©›ËÇÑ 5 àÂéÍ̶ á©‹à³ àÂéÍ̶®ÕéÇÑ©¬Ù³ÂÐÊ̶̋‒äÀ‹©Â̶̈Ѳ ̋ÇÒÀ©›Í̶̈Ò 4 àÂéÍ̶105-108 Study 1. The effects of outpatient co-payment policy on healthcare usage by the elderly in Taiwan109 Huang áÄÐ̋ßÐ ä­›ÈÖ̈ÉÒ˚›ÍÀÚÄ̈ÒÂãŁ›²ÂÔ̈ÒÂ˚Í̶µÚ›³ƒÇÁâÂ̋àÂêÍÂÑ̶®ÕéÍÒÁÙÀÒ̈̈Ç‹Ò 65 ³¡ ÆÒ̈ łÒ ˚›ÍÀÚÄ̈ÒÂà²Ô̈Æ‹ÒÁ˚Í̶ BNHI ÊÒ˚Òä©›ËÇÑ â­Áà³ÂÕÁ²à®ÕÁ²ÂÐËÇ‹Ò̶̈‹Í (̈Ñ ÁÒÁ 2544 - ÀÕ Ò̋À 2545) áÄÐËÄÑ̶̈Ò³ÂѲ˚Öê ̋‹Ò²ÂÔ̈Ò (̈Ñ ÁÒÁ 2545 - ÀÕ Ò̋À 2546) ¼²Ç‹Ò ‚ Hospital type choice: ÍÑ©ÂÒ̈ÒÂàÄÍ̈ãŁ›²ÂÔ̈Ò®ÕéâÂ̶¼ÁÒ²ÒÄ˚ Ò­ã˺‹ ›ÍÁÄ̶àÄè̈ ›ÍÁ ã ˚ßЮÕé ÍÑ©ÂÒ̈ÒÂàÄÍ̈ãŁ›²ÂÔ̈Ò®ÕéâÂ̶¼ÁÒ²ÒÄ˚ Ò­àÄè̈ÀÒ̈˚Öê àÄè̈ Í› Á ‚ Hospital visit frequency: ̋ÇÒÀ¬Õ˚é Í̶̈ÒÂä³ãŁ›²ÂÔ̈Ò®ÕéâÂ̶¼ÁÒ²ÒÄÄ­Ä̶ÆÒ̈ 12.15 ̋ÂÑê̶ à³ 11.99 ̋ÂÑê̶ ÍÁ‹Ò̶ÀÕ ÑÁÊîÒ̋Ѻ®Ò̶Ê¬Ô©Ô (p<0.01) ‚ Pharmaceutical cost & Drug use days: ̋‹ÒãŁ›Æ‹ÒÁà̈ÕéÁÇ̈ѲÁÒ ($21.16 -> $22.36) áÄÐÆîÒ Ç ÇÑ ã ̈ÒÂãŁ›ÁÒ (17.06 -> 17.14) à¼ÔéÀ˚Öê ÍÁ‹Ò̶ÀÕ ÑÁÊîÒ̋Ѻ®Ò̶Ê¬Ô©Ô (p<0.01) ‚ Diagnosis-treatment cost: ̋‹ÒãŁ›Æ‹ÒÁà̈ÕÁé Ç̈Ѳ̈Ò©ÂÇÆÇÔ ÆÔ ªÑÁáÄÐ̈ÒÂÂÑ̈ÉÒ ($6.81 -> $7.80) à¼ÔéÀ˚Öê ÍÁ‹Ò̶ÀÕ ÑÁÊîÒ̋Ѻ®Ò̶Ê¬Ô©Ô (p<0.01) ‚ Copayment: ̋‹Ò²ÂÔ̈ÒÂàªÄÕÁé à¼ÔéÀ˚Öê ÍÁ‹Ò̶ÀÕ ÑÁÊîÒ̋Ѻ®Ò̶Ê¬Ô©Ô ($5.12 -> $6.00) ‚ Total cost: ©› ®Ù ÂÇÀà¼ÔéÀ˚Öê ÆÒ̈ $35.57 à³ $39.55 ˚›ÍÊÂÙ³ µÚ›³ƒÇÁÀÕá Çâ ›ÀàÄÍ̈®ÕéÆÐÄ­ÆîÒ Ç ̋ÂÑê̶˚Í̶̈ÒÂä³âÂ̶¼ÁÒ²ÒÄ (Hospital visit frequency) á® ®ÕéÆÐà³ÄÕéÁ ä³ãŁ›²ÂÔ̈Ò®ÕéÊ¬Ò ²ÂÔ̈ÒÂ˚ Ò­àÄè̈̈Ç‹Ò (Hospital type choice) ®Ñê̶ç®ÕéÆÐàÊÕÁ̋‹Ò²ÂÔ̈Ò¬Ú̈ Ä̶ 73 ©ÒÂÒ̶®Õé 33 Comparison between pre- and post-copayment increase, Taiwan, R.O.C. Source: Huang JH, Tung CM. The effects of outpatient co-payment policy on healthcare usage by the elderly in Taiwan. Arch Gerontol Geriatr. 2006 Jul-Aug;43(1):101-16. Study 2. National Health Insurance in Taiwan: Welfare Analysis and Hospital Competition110 Chen ä­›ÈÖ̈ÉÒµÄ˚Í̶ Copayment ©‹Í¼Ã©Ô̈ÂÂÀ̈ÒÂãŁ›²ÂÔ̈ÒÂÂв²Ê‹̶©‹Í˚Í̶µÚ›³ÂÐ̈Ñ © â­Á ̈ÒÂÇÔà̋ÂÒÐË‒˚›ÍÀÚÄ BNHI’s Out-of-pocket Payment Project ³¡¼.È. 2547 ¼²Ç‹ÒÍÑ©ÂÒ Copayment ®Õé ̈îÒË ­ à³ ÊÔé̶ÆÚ̶ãÆ®ÕéÁÑ̶äÀ‹áÂ̶¼Í®ÕéÆЮîÒãË›µÚ›³ÂÐ̈Ñ © à˚›ÒÂѲ̈ÒÂÂÑ̈ÉÒµ‹Ò Âв²̈ÒÂÊ‹̶©‹Íä­› à éÍ̶ÆÒ̈ µÚ›³ÂÐ̈Ñ © ©›Í̶Æ‹ÒÁá¼̶̈Ç‹Ò̈ÒÂä³âÂ̶¼ÁÒ²ÒÄ®Õé© àÍ̶©›Í̶̈ÒÂâ­Á©Â̶ Í̈ÆÒ̈ ÕêÁÑ̶¼²Ç‹Ò̋‹Ò Price Elasticity ›ÍÁ̈Ç‹Ò Education Elasticity áÄÐ Quality Elasticity ØÖé̶áÊ­̶ãË›àËè Ç‹Ò Copayment ‹ÒÆÐÀÕ ²®²Ò®©‹ Í ̈Ò³ÂÑ ² à³ÄÕé Á ¼Ã©Ô ̈ ÂÂÀ˚Í̶µÚ› ³ ÂÐ̈Ñ © › Í Á̈Ç‹ Ò ̈ÒÂãË› ˚› Í ÀÚ Ä áÄÐ̋Ù ß ¾Ò¼²ÂÔ ̈ ÒÂ˚Í̶ âÂ̶¼ÁÒ²ÒÄ á©‹à éÍ̶ÆÒ̈̈ÒÂÈÖ̈ÉÒ ÕêãŁ›˚›ÍÀÚÄ̈‹Í ̈ÒÂ˚Öê Copayment ̋ÂÑê̶Ä‹ÒÊÙ­ ÆÖ̶äÀ‹ÍÒÆ îÒÀÒãŁ›ÊÂÙ³ à̈ÕéÁÇ̈ѲµÄ®Õéá®›ÆÂÔ̶ä­› ˚›ÍÊÂÙ³ ÍÑ©ÂÒ Copayment ®Õãé Ł›ÍÁÚ‹ äÀ‹ÊÒÀÒ¬ÆÚ̶ãÆãË›µÚ›³ÂÐ̈Ñ © ãŁ›Âв²Ê‹̶©‹Íä­› 74 ÍÑ̶̈ÃÉ (UK) ³ÂÐà®ÈÍÑ̶̈ÃÉà³ à̈ÒЮÕéÀÕ³ÂÐŁÒ̈ÂÍÒÈÑÁÍÁÚ‹ 60 Ä›Ò ̋ ÀṎÒÂÊ›Ò̶ËÄÑ̈³ÂÐ̈Ñ ÊÙ˚¾Ò¼¬›Ç Ë ›Ò ÀÒ©Ñê̶á©‹³¡¼.È. 2491 â­ÁÂÑł²ÒÄà³ ®Ñê̶µÚ›ØêÍáÄеڛãË›²ÂÔ̈Ò â­ÁÀÕ National Health Service (NHS) à³ Í̶̋‒̈ÂËÄÑ̈ã ̈Ò²ÂÔËÒÂÆÑ­̈Ò ©ÒÀ̈æËÀÒÁ National Health Service Act ¼.È. 2520 ³ÂÐŁÒŁ ®Ù̈̋ ÊÒÀÒ¬ÂѲ²ÂÔ̈ÒÂÊÙ˚¾Ò¼â­ÁäÀ‹àÊÕÁ̋‹ÒãŁ›Æ‹ÒÁ111 ̋‹ÒãŁ›Æ‹ÒÁÊÙ˚¾Ò¼̋Ô­à³ 8.1% ˚Í̶ GDP (7% â­Á ¾Ò̋ÂÑł 1.1% â­Á¾Ò̋àÍ̈Ł ) Âв²ÊÙ˚¾Ò¼˚Í̶³ÂÐà®ÈÍÑ̶̈ÃÉ ÀÕ Department of Health ®îÒË ›Ò®Õé̈Òî Ë ­ âÁ²ÒÁÊÙ˚¾Ò¼©‹Ò̶ç ÂÇÀ®Ñê̶­ÚáÄ NHS ­Ñ̶¾Ò¼ Í̈ÆÒ̈ ÕêÁÑ̶ÀṎÂЮÂÇ̶Íé ç®Õéà̈ÕéÁÇ˚›Í̶̈ѲÂв²ÊÙ˚¾Ò¼ÍṎ ̋Í Department of Social Security, Department of the Environment, Transport and the Regions, Ministry of Agriculture, Food and Fisheries, áÄÐ Department for Education and Employment ¾Ò¼®Õé 12 Structure of Department of Health, UK Source: European Observatory on Health Systems and Policies. Health systems in transition : United Kingdom. 1999. NHS ä­›ÂѲ̈Ò³ıÔÂÚ³à¼éÍãË›ÀÕ³ÂÐÊÔ® Ô¾Ò¼áÄÐà̈Ô­̋ÇÒÀ‹ÇÀÀÍÂÐËÇ‹Ò̶Ë ‹ÇÁ̶Ò ©‹Ò̶ç®Õéà̈ÕéÁÇ˚›Í̶ ̈ѲÊÙ˚¾Ò¼ÀÒ̈˚Öê â­Áâ̋Â̶Ê›Ò̶³»ÆÆÙ²Ñ ÆÐÀÕ Primary Care Groups (PCGs) ØÖé̶ËÀÒÁ¬Ö̶̈ÄÙ‹À˚Í̶á¼®Á‒ àÇŁ³ıÔ²Ñ©Ô ®ÕéÂѲµÔ­ŁÍ²ÊÙ˚¾Ò¼˚Í̶³ÂÐŁÒŁ ©Ñê̶á©‹ 50,000 ¬Ö̶ 250,000 ̋ Ê‹Ç ®ÕéÊÍ̶̋Í NHS Trusts à³ ̋Ú‹ÊѺºÒ®ÕéÀÕË ›Ò®Õé­áÚ Ä̈ÒÂãË›²ÂÔ̈ÒÂÊÙ˚¾Ò¼ ³ÂÐà®ÈÍÑ̶̈ÃÉÀÕâÂ̶¼ÁÒ²ÒÄàÍ̈Ł ³ÂÐÀÒß 230 áË‹̶ ØÖ̶é ÀÕ 5 ̈ÄÙ‹À ̋Í General Healthcare Group Ltd., Nuffield Trust Ltd., BUPA Hospitals Ltd., Community 75 Hospitals Group, áÄÐ PPP Columbia Healthcare Ltd. ®Õéà³ µÚ› îÒ©ÄÒ­ â­Áà³ àÆ›Ò˚Í̶̈Ç‹Ò 60% ˚Í̶ âÂ̶¼ÁÒ²ÒÄàÍ̈Ł ®ÕéÀÕã ³ÂÐà®È (65% ˚Í̶ÆîÒ Ç à©ÕÁ̶âÂ̶¼ÁÒ²ÒÄàÍ̈Ł ) 76 ¾Ò¼®Õé 13 Structure of NHS, UK Source: European Observatory on Health Systems and Policies. Health systems in transition : United Kingdom. 1999. ³ÂÐŁÒŁ à̈Ͳ®Ù̈̋ ä­›ÂѲ̈ÒÂ˚Öê ®Ðà²ÕÁ ̈ѲἮÁ‒àÇŁ³ıԲѩԮÑéÇä³ (General Practitioner, GP) ØÖé̶ÊÒÀÒ¬ÂѲ²ÂÔ̈ÒÂä­›®̈Ù ÍÁ‹Ò̶©ÄÍ­ 24 ŁÑéÇâÀ̶ â­ÁÊÒÀÒ¬àÄÍ̈á¼®Á‒®©Õé àÍ̶©›Í̶̈ÒÂ䭛઼ÒÐã ¼ê ®Õé á¼®Á‒ GP ÆÐà³ µÚ›­áÚ Äà²êÍ̶©› áÄÐÊ‹̶©‹Íá¼®Á‒઼ÒЮÒ̶àÀéÍÆîÒà³ ÆÒ̈˚›ÍÀÚij¡¼.È. 2541 ÀÕá¼®Á‒ GP 27,392 ̋ ØÖé̶ÆÐãË›²ÂÔ̈ÒÂà³ 8,994 ̈ÄÙ‹Àá¼®Á‒ (Practice) ̋Ô­à³ ̋‹ÒàªÄÕéÁ 3 ̋ ©‹Í̈ÄÙ‹À â­ÁÀÕá Çâ ›À ®Ṏé ÄÙ‹ÀÆÐã˺‹˚Öê àÂéÍÁç ³»ÆÆÙ²Ñ 63% ˚Í̶̈ÄÙ‹Àá¼®Á‒ ÀÕá¼®Á‒ GP ÍÁÚ‹©Ñê̶á©‹ 4 ̋ ˚Öê ä³ ̈ÄÙ‹Àá¼®Á‒àËÄ‹Ò Õê ãË›²ÂÔ̈ÒÂã ÄÑ̈ÉßÐ̈ÒÂà³ ̋Ú‹ÊѺºÒ̈Ѳ NHS Í̈ÆÒ̈ ÕêÁÑ̶ÀÕâÂ̶¼ÁÒ²ÒÄ®ÑéÇä³ã ¼ê ®Õé (District General Hospital) à³ Âв²ËÄÑ̈ã ̈Ò­ÚáÄÊÙ˚¾Ò¼˚Ñê ©‹ÍÀÒ á©‹ÄÐáË‹̶̋ÂͲ̋ÄÙÀ³ÂÐŁÒ̈³ÂÐÀÒß 150,000200,000 ̋ ̈ÂÐÆÒÁÍÁÚ‹®ÑédzÂÐà®ÈÍÁ‹Ò̶®ÑéǬÖ̶ áÄÐÁÑ̶ÀÕâÂ̶¼ÁÒ²ÒÄŁÙÀŁ ˚ Ò­©Ñê̶á©‹ 50-200 à©ÕÁ̶©ÒÀ ¼ê ®Õé©‹Ò̶ç ­›Ç ÁÍÑ©ÂÒ̈ÒÂà¼ÔéÀ̶²³ÂÐÀÒßµ‹ Ò ̈Ää̈¾ÒÉÕ®Õé ›Í Á̈Ç‹ ÒÍÑ ©ÂÒ̈ÒÂà¼Ôé À̋‹ÒãŁ›Æ‹ÒÁÊÙ ˚¾Ò¼ ®î ÒãË› ³ÂÐà®ÈÍÑ̶̈ÃÉ̈îÒÄÑ̶³ÂÐʲ³»ºËÒ112 áÀ›Ç‹Ò²ÂÔ̈ÒÂÊÙ˚¾Ò¼˚Í̶³ÂÐà®ÈÍÑ̶̈ÃÉÆÐãË›̋ÇÒÀ̋ÂͲ̋ÄÙÀ¬›Ç Ë ›Ò á©‹˚›ÍÀÚÄã ³¡¼.È. 2539 ¼²Ç‹Ò 14.6% ˚Í̶̋‹ÒãŁ›Æ‹ÒÁÊÙ˚¾Ò¼ÁÑ̶ÍÁÚ‹ã ¾Ò̋àÍ̈Ł ÀÕ³ÂÐŁÒŁ ³ÂÐÀÒß 77 11% ®ÕéÀÕ³ÂÐ̈Ñ ÊÙ˚¾Ò¼¾Ò̋àÍ̈Ł ˚›ÍÀÚÄã ³¡à­ÕÁÇ̈Ñ Ñê ÀÕ²ÂÔÉÑ®³ÂÐ̈Ñ ÊÙ˚¾Ò¼àÍ̈Ł ÍÁÚ‹ 25 áË‹̶ (7 áË‹̶ à³ á²²äÀ‹áÊÇ̶ËÒ̈îÒäÂ) ØÖé̶ÀÕÊ‹Ç ©ÄÒ­­Ñ̶áÊ­̶ã ©ÒÂÒ̶ 78 ©ÒÂÒ̶®Õé 34 Growth in NHS Expenditures, UK Source: Dixon J, Harrison A. Funding the NHS. A little local difficulty? BMJ. 1997 Jan 18;314(7075):216-9. ©ÒÂÒ̶®Õé 35 Market Shares of Private Insurance Companies, UK Source: European Observatory on Health Systems and Policies. Health systems in transition : United Kingdom. 1999. Âв²³ÂÐ̈Ñ ÊÙ˚¾Ò¼áÄÐ̈ÒÂÀÕÊÇ‹ ‹ÇÀÆ‹ÒÁ̋‹Ò²ÂÔ̈ÒÂÊÙ˚¾Ò¼ Âв²ÊÙ˚¾Ò¼˚Í̶³ÂÐà®ÈÍÑ̶̈ÃÉãŁ›à̶Ô ¾ÒÉÕ à³ áËÄ‹̶̶²³ÂÐÀÒßËÄÑ̈ (81.5%) áÄÐÀÕà̶Ô ÆÒ̈ Âв²³ÂÐ̈Ñ ÊÙ˚¾Ò¼ (National Insurance) à¼ÔéÀà©ÔÀÍṎàÄè̈ ›ÍÁ ã ˚ßЮÕé̈ÒÂÀÕÊ‹Ç Â‹ÇÀÆ‹ÒÁ ̋Ô­à³ 2.1% ØÖé̶ä­›ÆÒ̈̋‹ÒÁÒ ̋‹Ò©ÂÇÆ®Ò̶ÆÑ̈ÉÙ̈ÂÂÀ áÄÐ̋‹Ò²ÂÔ̈Ò娄 ©̈ÂÂÀ Ê‹Ç ̈ÒÂÀÕÊ‹Ç Â‹ÇÀÆ‹ÒÁ̋‹Ò²ÂÔ̈ÒÂÊÙ˚¾Ò¼ ÁÑ̶ à³ ³ÂÐà­è ®Õé¬̈à¬ÕÁ̶̈Ñ ÍÁÚ‹ ®îÒãË›äÀ‹ÊÒÀÒ¬ÊÂÙ³˚›ÍÀÚÄã Ê‹Ç Õê˚Í̶³ÂÐà®ÈÍÑ̶̈ÃÉä­› 79 ©ÒÂÒ̶®Õé 36 NHS Source of Finance, UK Source: European Observatory on Health Systems and Policies. Health systems in transition : United Kingdom. 1999. µÄ˚Í̶̈ÒÂÀÕÊÇ‹ ‹ÇÀÆ‹ÒÁ ÆÒ̈̈ÒÂʲ̋› łÒ ˚›ÍÀÚÄ Medline ¼²Ç‹ÒÀṎÒÂÈÖ̈ÉÒ˚Í̶³ÂÐà®ÈÍÑ̶̈ÃÉ 7 àÂéÍ̶ á©‹ä­›©Ñ­àÂéÍ̶®Õé à̈ÕéÁÇ̈ѲÁÒÍÍ̈ 4 àÂéÍ̶28, 113-115 áÄЩѭàÂéÍ̶®ÕéÇÑ©¬Ù³ÂÐÊ̶̋‒˚Í̶̈ÒÂÈÖ̈ÉÒäÀ‹©Â̶̈Ѳ̋ÇÒÀ©›Í̶̈ÒÂÍÍ̈ 2 àÂéÍ̶116, 117 Ê‹Ç łÒ ˚›ÍÀÚÄÇÔ®ÁÒ Ô¼ ‒ äÀ‹ÀṎÒÂÈÖ̈ÉÒ˚Í̶³ÂÐà®ÈÍÑ̶̈ÃÉ Study 1. Patients’ attitudes to co-payments for general practitioner services: do they reflect the prevailing system?118 O’Reilly áÄÐ̋ßÐ ä­›ÈÖ̈ÉÒ˚›ÍÀÚÄÆÒ̈̈ÒÂÊîÒÂÇƳÂÐŁÒŁ ̈ÄÙ‹À©ÑÇÍÁ‹Ò̶ 11,870 ̋ ã äÍÂ‒áÄ ­‒ ¼²Ç‹Ò³ÂÐŁÒŁ ®ÕéäÀ‹à̋Á©›Í̶ÀÕÊ‹Ç Â‹ÇÀÆ‹ÒÁ Ê‹Ç ã˺‹äÀ‹àËè ­›ÇÁ̈Ѳ Copayment ã ˚ßЮÕé³ÂÐŁÒŁ ®Õé©›Í̶ ÀÕÊ‹Ç Â‹ÇÀÆ‹ÒÁÍÁÚ‹áÄ›ÇàËè ­›ÇÁ Í̈ÆÒ̈ ÕêÁÑ̶¼²Ç‹Ò̋ÇÂà̈è²̋‹Ò²ÂÔ̈ÒÂà¼ÔéÀËÒ̈ÀṎÒµԭ Ñ­ ˚›ÍÊÂÙ³ ³ÂÐŁÒŁ ®ÕéÁÑ̶äÀ‹à̋Á©›Í̶ÀÕÊ‹Ç Â‹ÇÀÆ‹ÒÁ ÀÕá Çâ ›À®ÕéÆÐäÀ‹àËè ­›ÇÁ̈Ѳ Copayment 80 ÊËÂÑłÍàÀÂÔ̈Ò (USA) ³ÂÐà®ÈÊËÂÑłÍàÀÂÔ̈Ò ÀÕ³ÂÐŁÒ̈ 300 Ä›Ò ̋ ÀÕ̋ÇÒÀàÆÂÔº̈›ÒÇË ›Òã ®Ù̈ç­›Ò ÀÕÂв²ÊÙ˚¾Ò¼®Õé à › ¾Ò̋àÍ̈Ł à³ ËÄÑ̈ ̋‹ÒãŁ›Æ‹ÒÁÊÙ˚¾Ò¼̋Ô­à³ 15.4% ˚Í̶ GDP (6.9% â­Á¾Ò̋ÂÑł 8.5% â­Á ¾Ò̋àÍ̈Ł ) ØÖé̶ÊÚ̶®ÕéÊÙ­ã âÄ̈ á©‹̈ÄѲÀÕµÚ›®ÕéäÀ‹ÀÕËÄÑ̈³ÂÐ̈Ñ ÊÙ˚¾Ò¼̈Ç‹Ò 45 Ä›Ò ̋ Âв²ÊÙ˚¾Ò¼ÀÕ˚›Íà­‹ ̋Í Managed Care ØÖé̶à³ ̈ÒµÊÀµÊÒ ÂÐËÇ‹Ò̶µÚ›ØêͲÂÔ̈ÒÂáÄеڛãË›²ÂÔ̈Ò ®ÕéÀÕÂڳᲲÁ‹ÍÁç®Õé ËÄÒ̈ËÄÒÁÀÒ̈ ã ®Õé ÕêÆÖ̶ÆÐà › ઼ÒÐÂв²³ÂÐ̈Ñ ÊÙ˚¾Ò¼®Õéà³ ˚Í̶ÂÑł²ÒÄ 2 Âв²ã˺‹ ̋Í Medicare áÄÐ Medicaid Âв²³ÂÐ̈Ñ ÊÙ˚¾Ò¼áÄÐ̈ÒÂÀÕÊÇ‹ ‹ÇÀÆ‹ÒÁ̋‹Ò²ÂÔ̈ÒÂÊÙ˚¾Ò¼ Medicare à³ Âв²³ÂÐ̈Ñ 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ÆÖ̶ÀÕÂв²³ÂÐ̈Ñ ÊÙ˚¾Ò¼àÊÂÔÀ àÂÕÁ̈Ç‹Ò Supplementary Insurance119 ØÖé̶᲋̶ÍÍ̈䭛ೠ2 ³ÂÐྮ ̋Í Private Supplementation ˚Í̶µÚ›³ÂÐ̈Ñ © àÍ̶ áÄÐ Public Supplementation ÆÒ̈ Medicaid àŁ‹ 81 â̋Â̶̈Ò Qualified Medicare Beneficiary (QMB) ØÖé̶̋ÂͲ̋ÄÙÀµÚ›³ÂÐ̈Ñ © ®ÕéÀÕłÒ ÐÁÒ̈Æ 1 â­Á Medicaid ÆÐà³ µÚ›Æ‹ÒÁ Premium, Copayment, áÄÐ Deductible à˚›Ò Medicare ãË›µÚ›³ÂÐ̈Ñ © Medicaid ̋ÂͲ̋ÄÙÀ³ÂÐŁÒŁ 2 ̈ÄÙ‹Àã˺‹ ̋Í ̈ÄÙ‹À Categorically Needy ËÀÒÁ¬Ö̶ ̋ÂͲ̋ÂÑÇ®Õé à˚›Òä­› ©ÒÀà̈ßø‒ Aid to Families with Dependent Children (AFDC), ˺Ô̶©Ñê̶̋¾‒áÄÐà­è̈ÍÒÁÙ©éîÒ̈Ç‹Ò 6 ³¡®Õé̋ÂͲ̋ÂÑÇÀÕÂÒÁä­›©éîÒ̈Ç‹Ò 133% ˚Í̶ Federal Poverty Level (FPL), à­è̈ÍÒÁÙ 6-9 ³¡ ®Õé̋ÂͲ̋ÂÑÇÀÕ ÂÒÁä­›©éîÒ̈Ç‹Ò 100% ˚Í̶ FPL, µÚ›­ÚáÄà­è̈ÍÒÁÙ©éîÒ̈Ç‹Ò 18 ³¡ Ê‹Ç Medicaid ̈ÄÙ‹À®ÕéÊÍ̶̋Í Medically Needy ØÖé̶ÆÐÀÕã ²Ò̶ÂÑł2 ËÀÒÁ¬Ö̶̋ÂͲ̋ÂÑÇ®ÕéÀÕÂÒÁä­›ÀÒ̈̈Ç‹Òà̈ßø‒®Õé̈Òî Ë ­ á©‹ÀÕ̋ÇÒÀÆîÒà³ ®Ò̶ÊÙ˚¾Ò¼ ̈ÄÙÀ‹ Õê ÆÐ̋ÂͲ̋ÄÙ À ËºÔ ̶ ©Ñê ̶ ̋¾‒ Æ ¬Ö ̶ 60 ÇÑ ËÄÑ ̶ ̋ÄÍ­, à­è ̈ ÍÒÁÙ ©éî Ò ̈Ç‹ Ò 18 ³¡ , à­è ̈ áÂ̈à̈Ô ­ , ̋ ©Ò²Í­ Í̈ÆÒ̈ Õê²Ò̶ÂÑłÁÑ̶ÍÒÆà¼ÔéÀ̋ÇÒÀ̋ÂͲ̋ÄÙÀä­›ÍṎ©ÒÀ©›Í̶̈Ò â­Á©›Í̶ä­›ÂѲ̋ÇÒÀàËè 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à̈Ô­ÆÒ̈̈ÒÂãŁ›²ÂÔ̈ÒÂÀÒ̈à̈Ô ä³ áÄÐ̈ÒÂãŁ›²ÂÔ̈Ò®ÕéÀÒ̈ à̈Ô ä³ Ñê ÊÒÀÒ¬ĭÄ̶ä­›â­ÁÇÔÆÒÂߺÒß˚Í̶µÚ›³ƒÇÁã àÂéÍ̶̈ÒÂÆ‹ÒÁà̶Ô â­Áã Ł‹Ç̶ Ñê ÀÕµÚ›³ÂÐ̈Ñ © ³ÂÐÀÒß 30% ®Õé©›Í̶Æ‹ÒÁ Copayment â­Á®Ò̶ Medi-Cal (California’s Medicaid) ÆÐËÑ̈ $1 ÊîÒËÂѲ ²ÂÔ̈Òµڛ³ƒÇÁ Í̈ áÄÐ $0.50 ÊîÒËÂѲ̋‹ÒÁÒ ÍÍ̈ÆÒ̈à̶Ô ®ÕéÆÐÆ‹ÒÁãË›µÚ›ãË›²ÂÔ̈Ò â­ÁäÀ‹Ê ãÆÇ‹Ò®Ò̶µÚ›ãË› ²ÂÔ̈ÒÂÆÐà̈è² Copayment ÆÒ̈µÚ›³ƒÇÁä­›ËÂÍäÀ‹ 1 à̶Ô à­Í ©éîÒ̈Ç‹Ò Federal Poverty Level (FPL) áÄЮÂѼÁ‒ÊÔ äÀ‹à̈Ô 2 ஋Ò˚Í̶à̈ßø‒ÊîÒËÂѲ Supplemental Security Income (SSI) Arkansas, California, Connecticut, District of Columbia, Florida, Georgia, Hawaii, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Montana, Nebraska, New Hamshire, New Jersey, New York, North Carolina, North Dakota, Pennsylvania, Puerto Rico, Rhode Island, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin 2 82 ©‹ÍÀÒä­›ÀṎÒÂÈÖ̈ÉÒ Health Insurance Experiment â­Á RAND Corporation (RAND HIE)3 ØÖ̶é ãŁ› ÇÔ Õ Randomized Controlled Trial (RCT) â­Á̈ÒÂãË›̋ÂͲ̋ÂÑÇÆÒ̈ 6 ¼ê ®Õé3 à˚›ÒÂв²³ÂÐ̈Ñ ÊÙ˚¾Ò¼ â­Á ÊÙ‹À 1 Âв²ÆÒ̈®Ñê̶ËÀ­ 14 Âв² ØÖé̶á©̈©‹Ò̶̈Ñ ã àÂéÍ̶ Copayment áÄÐ Deductible â­ÁÀÕ©Ñê̶á©‹̈Ò 䭛ÂѲ²ÂÔ̈ÒÂÊÙ˚¾Ò¼â­ÁäÀ‹àÊÕÁ̋‹ÒãŁ›Æ‹ÒÁ ä³Æ ¬Ö̶Âв²®ÕéµÚ›³ƒÇÁ©›Í̶Æ‹ÒÁàÍ̶®Ñê̶ËÀ­ ÀÕÍṎ̈ÒÂÈÖ̈ÉÒË Öé̶®Õé ‹ÒÊ ãÆ ¼²Ç‹Ò µÚ›³ÂÐ̈Ñ © Medicare ®Õéà̋Áà³ ÊÀÒŁÔ̈̈Ѳ HMO ®Õé³~­©ÑÇä³ à©èÀãÆ®ÕéÀÕÊ‹Ç Â‹ÇÀÆ‹ÒÁà¼éÍÂÑ̈ÉÒÊÔ® Ô³ÂÐâÁŁ ‒®ÕéÀÕÍÁÚ‹121 µÄ˚Í̶̈ÒÂÀÕÊÇ‹ ‹ÇÀÆ‹ÒÁ ÆÒ̈̈ÒÂʲ̋› łÒ ˚›ÍÀÚÄ Medline ¼²Ç‹ÒÀṎÒÂÈÖ̈ÉÒ˚Í̶³ÂÐà®ÈÊËÂÑłÍàÀÂÔ̈Ò 335 àÂéÍ̶ á©‹ä­›©Ñ­ àÂéÍ̶®Õéà̈ÕéÁÇ̈ѲÁÒÍÍ̈ 85 àÂéÍ̶19, 21, 24, 27, 28, 32, 33, 51, 54, 122-197 àÂéÍ̶®Õé˚›ÍÀÚÄäÀ‹¼Í 29 àÂéÍ̶198-226 áÄЩѭ àÂéÍ̶®ÕéÇÑ©¬Ù³ÂÐÊ̶̋‒˚Í̶̈ÒÂÈÖ̈ÉÒäÀ‹©Â̶̈Ѳ̋ÇÒÀ©›Í̶̈ÒÂËÂÍà³ à¼ÕÁ̶²®̋ÇÒÀáÊ­̶̋ÇÒÀ̋Ô­àËè ÍÍ̈ 175 àÂéÍ̶2, 11, 92, 116, 119, 121, 227-395 Ê‹Ç łÒ ˚›ÍÀÚÄÇÔ®ÁÒ Ô¼ ‒ ÀṎÒÂÈÖ̈ÉÒ˚Í̶³ÂÐà®ÈÊËÂÑłÍàÀÂÔ̈Ò 13 àÂéÍ̶ á©‹à³ àÂéÍ̶®Õéà̈ÕéÁÇ̈ѲÁÒ 1 àÂéÍ̶396 áÄÐÀÕÇÑ©¬Ù³ÂÐÊ̶̋‒äÀ‹©Â̶̈Ѳ̋ÇÒÀ©›Í̶̈Ò 12 àÂéÍ̶95, 258, 397-406 3 1) Dayton, OH; 2) Seattle, WA; 3) Fitchburg, MA; 4) Franklin County, MA; 5) Charleston, SC; 6) Georgetown County, SC 83 ©ÒÂÒ̶®Õé 37 ÊÂÙ³µÄ̈ÒÂÆÒ̈̈ÒÂÈÖ̈ÉÒã ³ÂÐà®ÈÊËÂÑłÍàÀÂÔ̈Ò No. Study 1 Brian, 1974215 Title California's Medi-Cal copayment experiment (A) Design Setting Copayment CT OPD Free vs $1/first 2 visits/month & $0.50/first 2 prescriptions/month California's Medi-Cal copayment experiment (B) Survey OPD Free vs $1/first 2 visits/month & $0.50/first 2 prescriptions/month Free vs $1/first 2 visits/month & $0.50/first 2 prescriptions/month $1/first 2 visits/month & $0.50/first 2 prescriptions/month 2 Roemer, 1975407 Copayments for ambulatory care: penny-wise and pound-foolish BA OPD IPD 3 Hopkins, 1975408 Survey OPD 4 Hopkins, 1975409 Survey OPD $1/first 2 visits/month & $0.50/first 2 prescriptions/month 5 Hankin, 1980410 Cost-sharing and prior authorization effects on Medicaid services in California: Part I. The Beneficiaries’ Reactions Cost-sharing and prior authorization effects on Medicaid services in California: Part II. The Providers’ Reactions The impact on utilization of a copayment increase for ambulatory BA Mental Copay increase (n/d) Results Copay ãŁ›²ÂÔ̈ÒÂÂÑ̈ÉÒâÂ̋ ›ÍÁ̈Ç‹Ò Free - 17% ÊîÒËÂѲ AFDC - 1% ÊîÒËÂѲµÚ›Ê̶Ú ÍÒÁÙ - 4% ÊîÒËÂѲµÚ›¼Ô̈Ò Copay ãŁ›²ÂÔ̈Ò©ÂÇÆ̋Ñ­̈ÂÍ̶ ›ÍÁ̈Ç‹Ò Free - 45% ÊîÒËÂѲ Pap smear - 58% ÊîÒËÂѲ “Total Obstetrical Care” Copay & Free ãŁ›²ÂÔ̈Ò©ÂÇÆÇÔ ÔƪÑÁÊ‹Ç ã˺‹äÀ‹©‹Ò̶̈Ñ àÇ› ̈Ò©ÂÇÆ©ÒáÄÐËÚ Copayment äÀ‹ä­›à³ à˩ٵĮÕé®Òî ãË›µÚ›³ƒÇÁäÀ‹ÀÒãŁ›²ÂÔ̈Ò Copay ãŁ›²ÂÔ̈Òµڛ³ƒÇÁ Í̈Ä­Ä̶̈Ç‹Ò Free ³ÂÐÀÒß 2 à­Í á©‹ËÄÑ̶ÆÒ̈ Ñê Copay ̈ÄÑ²ãŁ›²ÂÔ̈Òµڛ³ƒÇÁã ÀÒ̈̈Ç‹Ò Free µÚ›³ÂÐ̈Ñ © 17% ̋Ô­Ç‹ÒÆÐä­›Â²Ñ ²ÂÔ̈ÒÂÄ­Ä̶ (à³ ̈ÄÙ‹À High Medical Need) µÚ›³ÂÐ̈Ñ © äÀ‹̋Í‹ Á®ÂÒ²˚›ÍÀÚÄ áÄÐÀÑ̈ÊÑ²Ê ̈Ѳ Prior Authorization Copayment äÀ‹ä­›ÀµÕ Ä©‹ÍµÚ›ãË›²ÂÔ̈ÒÂÀÒ̈ Ñ̈ µÚ›ãË›²ÂÔ̈ÒÂ̈Ñ̶ÇÄàÂéÍ̶ Prior Authorization ÀÒ̈̈Ç‹Ò Copayment µÚ›ãË›²ÂÔ̈ÒÂ̋Ô­Ç‹ÒµÚ›³ƒÇÁäÀ‹ ‹ÒÆÐà­Í­Â›Í ̈ÒÂãŁ›²ÂÔ̈ÒÂÆÔ©àÇŁÄ­Ä̶àÄè̈ ›ÍÁ áÄÐÀÕµÄäÀ‹ Ò 84 6 7 8 9 10 psychiatric care Newhouse, Some interim results from a controlled trial of cost sharing in 19813 health insurance Effects of cost-sharing on users of a Wolfson, 411 state's health service program 1982 Assessing the impact of copayment Aved, 412 on family planning services: a 1983 preliminary analysis in California Scheffler, The United Mine Workers' health plan. An analysis of the cost-sharing 1984413 program Utilization of child health clinics Fischer, 414 following introduction of a copayment 1984 Effect of cost-sharing on the use of medical services by children: interim results from a randomized controlled trial The impact of cost sharing on emergency department use OPD BA OPD Free å Copay (n/d) 2nd FP Copay $10-$20 2nd O/IPD ̈ÒÂãŁ›²ÂÔ̈Òµڳ› ƒÇÁ Í̈áÄÐã Ä­Ä̶ 30% 2nd WB Copay 40% (O/IPD) Deduct $250 (IPD) (UMWA) Copay $15 (average; range $0$44) RCT 2nd OPD (RAND) µÄ˚Í̶ Copayment ©‹Í̈ÒÂãŁ›²ÂÔ̈Ò³ÂÐྮ©‹Ò̶ç äÀ‹©‹Ò̶̈Ñ RCT 2nd ER (RAND) OPD OPD 14 plans (Free, Copay at varying degree) (RAND) Copay 0% ÀÕ̋‹ÒãŁ›Æ‹ÒÁÊÚ̶̈Ç‹Ò Copay 95% ÍÁÚ‹ 42% Copay 0% ®ÕéàÆè²³ƒÇÁäÀ‹ÂÙ áÂ̶ãŁ›²ÂÔ̈ÒÂË›Í̶ªÙ̈àªÔ à³ 3 ஋Ò˚Í̶µÚ› àÆè²³ƒÇÁÂÙ áÂ̶ ̈ÒÂãŁ›²ÂÔ̈ÒÂÄ­Ä̶ä­›ÀÒ̈¬Ö̶ 30% 2nd O/IPD (UMWA) CC+BA IPD 11 Leibowitz, 1985415 12 O’Grady, 1985416 13 Valdez, 1985417 Shapiro, 1986418 Consequences of cost-sharing for children's RCT health Effects of cost sharing on seeking care for RCT serious and minor symptoms. Results of a 2nd randomized controlled trial 15 Roddy, 1986419 16 Greene, 1986420 Cost sharing and use of health services. The United Mine Workers of America Health Plan Cost sharing and its effects on hospital utilization. The Blue Cross and Blue Shield of North Carolina experience 14 Copay 0%, 25%, 50%, 95% (RAND) Copayment ÁÔé̶ÀÒ̈̈ÒÂãŁ›²ÂÔ̈ÒÂÁÔé̶ ›ÍÁ â­ÁÀյĩ‹Í²ÂÔ̈Òµڛ³ƒÇÁ Í̈ ÀÒ̈̈Ç‹Ò²ÂÔ̈Òµڳ› ƒÇÁã RCT Case: A å B Control: A å A A1: Free ̈ÒÂãŁ›²ÂÔ̈ÒÂäÀ‹Ä­Ä̶ µÚ›ÁÒ̈Æ äÀ‹ä­›ÂѲµÄ̈ÂЮ² µÚ›ãË›²ÂÔ̈Ò 22% ÀÕµÚ›ÀÒãŁ›²ÂÔ̈ÒÂÄ­Ä̶ µÚ›³ƒÇÁ²ÂÔÆÒ̋à̶Ô Ä­Ä̶ ̈ÒÂãŁ›²ÂÔ̈ÒÂà­è̈ÍÒÁÙ©éîÒ̈Ç‹Ò 6 à­Í Ä­Ä̶àÄè̈ ›ÍÁ Copay ãŁ›²ÂÔ̈Ò ͛ Á̈Ç‹Ò Free ÊîÒËÂѲ̈ÒÂàÆè²³ƒÇÁàÄè̈ ›ÍÁ (6.3% vs 9%) ̈ÒÂãŁ›²ÂÔ̈ÒÂàÀéÍÀṎÒÂàÆè²³ƒÇÁÂÙ áÂ̶äÀ‹©‹Ò̶̈Ñ (22.3% vs 17.9%) ã ̈ÄÙ‹ÀµÚ›ÁÒ̈Æ ¼²Ç‹Ò Copay àÆè²³ƒÇÁÂÙ áÂ̶ÀÒ̈̈Ç‹Ò Free Á ÁÑ (8) á©‹¼²Ç‹ÒµÄäÀ‹ÁÒÇ Ò à éÍ̶ÆÒ̈̈ÒÂãŁ›²ÂÔ̈ÒÂ̈ÄѲà¼ÔéÀÊÚ̶ ̈Ç‹Òà­ÔÀ ̈ÄÙ‹À®­ÄÍ̶ ÀṎÒÂãŁ›²ÂÔ̈Òµڛ³ƒÇÁã Ä­Ä̶ 11.3% áÄÐ LOS Ä­Ä̶ 0.3 ÇÑ ÆÒ̈³¡̈Í‹ Ë ›Ò ̈ÄÙ‹À̋Dz̋ÙÀ ÀṎÒÂãŁ›²ÂÔ̈Òµڛ³ƒÇÁã Ä­Ä̶ 3.4% 85 17 18 19 Manning, 1986421 Wallen, 1986422 Wells, 1987423 How cost sharing affects the use of ambulatory mental health services Male-female differences in mental health visits under cost-sharing Cost-sharing and the use of general medical physicians for outpatient mental health care The effect of office visit copayments on utilization in a health maintenance organization Mental A2: Copay 20% A3: Deduct OPD $25/$50, Deduct IPD $100 B: Deduct $100/$150/$200 Copay 10%/15%/20% (RAND) Free ãŁ›²ÂÔ̈ÒÂà¼ÔÀé 133% àÀéÍà®ÕÁ²̈Ѳ Copay 95% Mental (UMWA) µÚ›³ÂÐ̈Ñ © à¼ÈŁÒÁä­›ÂѲµÄ̈ÂЮ²ÀÒ̈̈Ç‹Òà¼È˺Ô̶ RCT 2nd Mental (RAND) Cost Sharing äÀ‹Àյĩ‹Í̈ÒÂàÄÍ̈á¼®Á‒ BA OPD Free å Copay $5 RCT 2nd 2nd 20 Cherkin, 19894 21 Cherkin, 1990424 The effect of office visit copayments on preventive care services in an HMO BA OPD Free å Copay $5 22 Anderson, 1991425 RCT OPD Free vs Copay+Deduct 23 Rogers, 1991426 Cherkin, 1992427 A comparison of cost-sharing versus free care in children: effects on the demand for office-based medical care Effects of cost sharing in health insurance on disability days Is magnitude of co-payment effect related to income? Using census data for health services research Physician response to the United Mine Workers' cost-sharing program: the other side of the coin Effect of a copayment on use of the emergency department in a health maintenance organization Impact of visit copayments on outpatient 2nd OPD 2nd OPD 4 groups (Free, Copay at 3 varying degrees) (n/a) 2nd OPD Free å $7.50/visit CT ER Free vs $25-30/visit BA Mental A: Free å $20/visit 24 25 Fahs, 1992428 26 Selby, 1996429 27 Simon, ̈ÒÂãŁ›²ÂÔ̈Ò³łÀ¾ÚÀÔÄ­Ä̶ 10.9% â­Á઼Òеڛ³ÂÐ̈Ñ © à¼È˺Ô̶ áÄÐ µÚ›®Õéà̋ÁãŁ›²ÂÔ̈ÒÂà³ ³ÂÐÆîÒÍÁÚ‹̈Í‹ áÄ›Ç ̈ÒÂãŁ›²ÂÔ̈ÒÂá¼®Á‒઼ÒЮÒ̶Ä­Ä̶ 3.3% µÄ˚Í̶ Copay ÁÒÇ Ò ©ÄÍ­ 1 ³¡ ̈Ò©ÂÇÆ‹Ò̶̈ÒÁÄ­Ä̶ 14% ̈ÒÂãË›ÇÑ̋ØÕ à­è̈, ̈Ò©ÂÇÆ̋Ñ­̈ÂÍ̶ÀÐàÂè̶à¼È˺Ô̶, ̈ÒÂãŁ›ÁÒâÂ̋ËÑÇãÆ äÀ‹à³ÄÕéÁ á³Ä̶ Copay+Deduct Ł‹ÇÁÄ­̋‹ÒãŁ›ÆÒ‹ ÁÊÙ˚¾Ò¼ ØÖé̶à³ µÄÀÒÆÒ̈̈ÒÂÄ­̈ÒÂãŁ› ²ÂÔ̈Ò Restricted Activity Day ©‹Í³¡©‹Í̋ Ä­Ä̶ 1-2 ÇÑ ã ̈ÄÙ‹À Copay ÊÚ̶ µÄ˚Í̶ Copay äÀ‹á©̈©‹Ò̶̈Ñ ©ÒÀÂÒÁä­›˚Í̶µÚ›³ÂÐ̈Ñ © áÀ› Copayment ÆÐŁ‹ÇÁÄ­̋‹ÒãŁ›ÆÒ‹ ÁÊÙ˚¾Ò¼˚Í̶ Copay á©‹µÚ›ãË›²ÂÔ̈Ò ÍÒÆŁ­àŁÁ­›ÇÁ̈ÒÂà¼ÔéÀ̋‹ÒãŁ›ÆÒ‹ ÁÆÒ̈ Free Copay ãŁ›²ÂÔ̈Ò ͛ Á̈Ç‹Ò Free 15% â­Á઼Òеڮ› ÕéäÀ‹ä­›ÀÕ¾ÒÇÐà‹̶­‹Ç ÀÒ̈ Copay & Free ÍÑ©ÂÒ©ÒÁäÀ‹©‹Ò̶̈Ñ A: µÚ›³ƒÇÁÂÒÁãËÀ‹ÀÒÂѲ²ÂÔ̈ÒÂÄ­Ä̶ 16% 86 1996430 28 29 30 31 32 Shekelle, 1996431 Magid, 1997432 Solanki, 1999433 Solanki, 2000434 Stein, 2000435 33 Wong, 2001436 34 Remler, 2003437 35 Stein, 2003438 36 Rice, 2004439 37 Ciemins, 2004440 38 Hsu, 2004441 mental health utilization by members of a health maintenance organization The effect of cost sharing on the use of chiropractic services Absence of association between insurance copayments and delays in seeking emergency care among patients with myocardial infarction Cost-sharing and the utilization of clinical preventive services The direct and indirect effects of costsharing on the use of preventive services The effect of copayments on drug and alcohol treatment following inpatient detoxification under managed care Effects of cost sharing on care seeking and health status: results from the Medical Outcomes Study Health status and heterogeneity of costsharing responsiveness: how do sick people respond to cost-sharing? Drug and alcohol treatment among privately insured patients: rate of specialty substance abuse treatment and association with cost-sharing The impact of cost-sharing on appropriate utilization and health status: a review of the literature on seniors The effect of parity-induced copayment reductions on adolescent utilization of substance use services Cost-sharing: patient knowledge and effects on seeking emergency department care B: $20 å $30/visit B: µÚ›³ƒÇÁÂÒÁà̈‹ÒÀÒÂѲ²ÂÔ̈ÒÂÄ­Ä̶ 9% RCT 2nd BA Alt (RAND) ̈ÒÂãŁ›²ÂÔ̈ÒÂÄ­Ä̶ 50% ©‹Í®Ù̈ç Copay ®Õàé ¼ÔéÀ˚Öê 25% ER Copay $25-$100 Copay ä­›ÂѲ̈Ò­ÚáľÒÇÐ̈Ä›ÒÀà êÍËÑÇãÆ©ÒÁÍÁ‹Ò̶®Ñ ®‹Ç̶®Õ äÀ‹ á©̈©‹Ò̶ÆÒ̈ Free 2nd Prev Copay varies (n/d) 2nd Prev Copay varies (n/d) 2nd Mental Copay varies (n/d) ̈ÒÂ̶­ Copay ‹ÒÆÐà³ ÇÔ Õ®̶Õé ‹ÒÁ®ÕéÊ­Ù ã ̈ÒÂà¼ÔéÀ̈ÒÂÂѲ²ÂÔ̈Ò³Í̶̈Ñ âÂ̋ ̈ÒÂ̶­ Copay ‹ÒÆÐà³ ÇÔ ®Õ ̶Õé ‹ÒÁ®ÕéÊ­Ù ã ̈ÒÂà¼ÔÀé ̈ÒÂÂѲ²ÂÔ̈Ò³Í̶̈Ñ âÂ̋ ̈ÒÂ̶­ Copay ‹ÒÆÐà³ ÇÔ ®Õ ̶Õé ‹ÒÁ®ÕéÊ­Ù ã ̈ÒÂà¼ÔÀé ̈ÒÂÂѲ̈Ò²îҲѭÊÒ àʼ©Ô­ 2nd OPD Copay 0% vs 50% vs 100% Copay Ä­̈ÒÂãŁ›²ÂÔ̈Ò®Ù̈ÂЭѲ̋ÇÒÀÂÙ áÂ̶ á©‹äÀ‹¼²Ç‹Ò Health Status á©̈©‹Ò̶̈Ñ 2nd OPD - µÄ˚Í̶ Copay ©‹Í̈ÒÂãŁ›²ÂÔ̈Ò ÀÕ̋ÇÒÀá©̈©‹Ò̶̈Ñ ©ÒÀʾÒÇÐÊÙ˚¾Ò¼ ˚Í̶µÚ›³ƒÇÁ 2nd Mental Copay varis Copay ÊÚ̶ãŁ›²ÂÔ̈Ò ›ÍÁ̈Ç‹Ò Copay ©éîÒ LR - - Copay ãŁ›²ÂÔ̈Ò ͛ ÁÄ̶áÄÐÊÙ˚¾Ò¼áÁ‹Ä̶ 2nd Mental Copay decrease ̈ÒÂÄ­ Copay ®îÒãË›̈ÒÂãŁ›²ÂÔ̈ÒÂà¼ÔÀé ˚Öê Survey ER Copay: Perceived vs Actual µÚ›³ƒÇÁÀÑ̈äÀ‹®ÂÒ²˚›ÍÀÚÄà̈ÕéÁÇ̈ѲÍÑ©ÂÒ̋‹Ò²ÂÔ̈ÒªÙ̈àªÔ µÚ›³ƒÇÁ 57% ³ÂÐÀÒß̋‹ÒãŁ›ÆÒ‹ Á©éîÒ̈Ç‹Ò̋ÇÒÀà³ ÆÂÔ̶ $20 ˚Öê ä³ µÚ›³ƒÇÁ 11% ̋Ô­ÆÐËÄṎàÄÕÁé ̶̈ÒÂãŁ›²ÂÔ̈Ò ­›ÇÁàË©ÙµÄ Copayment 87 Does patient cost sharing matter? Its impact on recommended versus controversial cancer screening services Care-seeking behavior in response to emergency department copayments 2nd Prev (n/d) Copay Àյĩ‹Í̈Ò©ÂÇÆ̋Ñ­̈ÂÍ̶ÀÐàÂè̶©‹ÍÀÄÚ̈ËÀÒ̈ ÀÒ̈̈Ç‹Ò̈Ò©ÂÇÆ ̋Ñ­̈ÂÍ̶ÀÐàÂè̶à©›Ò À Survey ER Copay $5-$100 Trends in clinic visits and diagnosed Chlamydia trachomatis and Neisseria gonorrhoeae infections after the introduction of a copayment in a sexually transmitted infection clinic Cost-sharing requirements and access to mental health care among medicare enrollees with schizophrenia The impact of increased cost sharing on Medicaid enrollees 2nd OPD Copay $15-$65 41% ˚Í̶µÚ›³ƒÇÁ Âв٠Copay ä­›¬Ú̈©›Í̶ 19% ˚Í̶µÚ›³ƒÇÁÀṎÒÂà³ÄÕéÁ á³Ä̶¼Ã©Ô̈ÂÂÀ̈ÒÂãŁ›²ÂÔ̈Ò â­Á 12% ä³ ÂѲ²ÂÔ̈Ò®ÕéÍé , 9% ŁÄÍ̈ÒÂä³Ë›Í̶ªÙ̈àªÔ , 2% äÀ‹ä³âÂ̶¼ÁÒ²ÒÄÍṎ àÄÁ Copay ãŁ›²ÂÔ̈ÒÂÄ­Ä̶ 28.5% 2nd Mental Copay 50% Copay ÀÕá Çâ ›ÀãŁ›²ÂÔ̈Ò ›ÍÁÄ̶ 25-45% BA O/IPD, ER Effects of a cost-sharing exemption on use of preventive services at one large employer Changes in access to primary care for Medicaid beneficiaries and the uninsured: the emergency department perspective BA Prev BA O/IPD, ER 39 Liang, 2004442 40 Reed, 2005443 41 Rietmeijer, 2005444 42 Slade, 2005445 43 Wright, 2005446 44 Busch, 2006447 45 Lowe, 2006448 46 Hsu, 2006449 Cost-sharing for emergency care and unfavorable clinical events: findings from the safety and financial ramifications of ED copayments study ER Free å Copay $5 for OPD, $50 for ER, $250 for IPD Premium same for single, double for family Copay $10-$15/visit åFree Premium $6-$12/month Copay $5 (primary visit), $3 (lab & xray), $2-$25 (drugs), $3-$10 (procedure), $50 (ER), $250 (IPD) Private Insurance: Free vs Copay $20-$35 Free vs Copay $50-$100 ÆîÒ Ç µÚ›˚Öê ®Ðà²ÕÁ Ä­Ä̶ 44% ÍÍ̈ÆÒ̈â̋Â̶̈Ò µÚ›®ÕéÍÍ̈­›ÇÁàË©ÙµÄàÂéÍ̶ Cost Sharing à³ ̈ÄÙ‹À®ÕéäÀ‹ä­›ÂѲ²ÂÔ̈Ò®Õé ÆîÒà³ ÀÒ̈̈Ç‹ÒµÚ›®ÍÕé Í̈­›ÇÁàË©ÙµÄÍé ç µÚ›®ÕéÍÍ̈­›ÇÁàË©ÙµÄàÂéÍ̶ Cost Sharing à³ ̈ÄÙ‹À®ÕéÀÕË ÊÕê Ô $500 ˚Öê ä³ áÄÐà̋Áä­›ÂѲ̈Ò³ıÔàÊ ̈ÒÂÂÑ̈ÉÒ ÀÒ̈̈Ç‹ÒµÚ›®ÕéÍÍ̈­›ÇÁàË©ÙµÄÍé ç µÚ›ÁÒ̈Æ ä­›ÂѲµÄ̈ÂЮ²ÀÒ̈®ÕéÊÙ­ ̈ÒÂÁ̈àÇ› Cost Sharing äÀ‹ÀÕµÄÄ­̈ÒÂãŁ›²ÂÔ̈ÒÂ̋Ñ­̈ÂÍ̶âÂ̋ ̈ÒÂ˚Öê ®Ðà²ÕÁ Ä­Ä̶ ®îÒãË›µÚ›ä›ËÄÑ̈³ÂÐ̈Ñ ÀÒÂѲ²ÂÔ̈Ò®ÕéË›Í̶ªÙ̈àªÔ ÀÒ̈˚Öê ÆÒ̈ 18% à³ 22% Private Insurance: Copay $20-$35 ãŁ›²ÂÔ̈Ò ›ÍÁ̈Ç‹Ò Free 12% Copay $50-$100 ãŁ›²ÂÔ̈Ò ›ÍÁ̈Ç‹Ò Free 23% 88 Medicare: Free vs Copay $20-$50 Medicare: Copay $20-$50 ãŁ›²ÂÔ̈Ò ›ÍÁ̈Ç‹Ò Free 4% ̈ÒÂãŁ›²ÂÔ̈Òµڛ³ƒÇÁã äÀ‹à¼ÔéÀ©ÒÀÍÑ©ÂÒ Copay Note: ER = Emergency, OPD = Outpatient Department, IPD = Inpatient Department, O/IPD = Both, WB = Well Baby Clinic, FP = Family Planning, Prev = Preventive Services, Alt = Alternative Medicine, 2nd = Secondary Data Analysis, CC = Case Control, BA = Before-After, CT = Controlled Trial, RCT = Randomized Controlled Trial, LR = Literature Review, RAND = RAND Health Insurance Experiment, UMWA = United Mine Workers of America, n/d = No data 89 àÍ̈ÊÒÂÍ›Ò̶ÍÔ̶ 1. 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