An Analysis of Financing of Health Maintenance Organizations - Case Study in Rochester Area

Translated Titles





劉宜君(I-Chun Liu)

Key Words

健康維護組織 ; 全民健康保險 ; 論次計酬制度 ; 群體醫療 ; Health Maintenance Organizations(HMOs) ; National Health Insurance ; Fee-for-service System ; Group Practice



Volume or Term/Year and Month of Publication

3期(2003 / 06 / 01)

Page #

121 - 151

Content Language


Chinese Abstract

去(2002)年相當賣座且感人至深的電影「迫在眉梢」中,男主角丹佐華盛頓(Denzel Washington)遭遇困窘的經濟狀況,偏偏獨子罹患嚴重的心臟病,不盡快換心就無法活下去,然而他的醫療保險公司(HMO)不能爲他支付金額龐大的手術費用,最後在走投無路的情況下,丹佐華盛頓只好封鎖醫院急診室綁架病人,希望能藉此迫使醫院接受他的愛子進行心臟手術。本片雖然親情至深,但是更披露出美國社會福利制度的不完善醫療保險的缺失,其中健康維護組織(Health Maintenance Organizations,簡稱HMOs)的給付範圍爲引發爭議的關鍵因素之一。 在美國實施頗爲有成效的HMOs,過去曾爲國內健康保險研究學者與專家所引進。HMOs的最大的優點爲論人頭計酬,比傳統的論次計酬(Fee-for-service)制度更能有效控醫療成本,並促進醫療供給者之間的競爭,醫療院所會主動提供被保險人保健服務,防患疾病於未然,節省約略25%的醫療費用。根據學者實證分析發現HMOs減少財務負擔的主要關鍵,在於減少住院率與住院日數。 台灣學者對於健康維護組織的討論焦點較著重於文獻探討與方案研究,本研究以實證分析健康維護組織的財務影響,並以美國紐約州羅徹斯特地區(Rochester)之HMOs,作爲健康維護組織財務影響的研究個案,探討HMOs的成長如何有效減緩該地區住院成本的增加,Rochester在美國保險醫療專家眼中係一顆耀眼的明珠,該地區推動HMO的成效也曾爲前美國總統柯林頓推動健康保險改革的模範。本研究發現HMOs確能降低該地區被保險人之門診率與住院日數,以減少醫療費用。最後,提出台灣在全民健保政策改革可參攷HMO制度原則的政策建議與配合因素。

English Abstract

The story of movie “John Q.” is to describe when John Q. Archibald (Academy Award-winner Denzel Washington) cannot afford and his health insurance will not cover when his son needs an emergency heart transplant operation. Finally, he takes the emergency room hostage in order to keep his alive. His health insurance company is an HMO. As the medical care cost is rising, health maintenance organizations (here after HMOs) are generating interest among health policy makers as an alternative to control expenditures. There is evidence available from a number of empirical studies; the results consistently show HMO enrollees as having the lowest total medical costs. Due to their incentive to contain health care costs, HMOs are prudent buyers of services that are needed for their subscribers including hospital services. In searching for the ways to reform the national health system, Taiwan’s researchers have expressed their interests in promoting HMO approach to become parts of national health insurance system. Many scholars and specialists discussed HMO’s concept and its policy implications. Specifically, this study focuses on empirical analysis of HMO’s financing. The focus of this paper is how the growth of HMOs, which is one of the competitive initiatives, has affected hospital cost inflation. According to American medical experts’ opinions, Rochester is seen as a jewel in a sea of health-care despair. Thus, I use US’s Rochester HMO model as my case study. The study finds that the growth of Rochester HMOs led to less hospital utilization and lower expenditures when compared to New York State. The policy analysis recommends: the government may consider a proposal to provide the option of adopting HMO’s principles to control medical expenditures.

Topic Category 人文學 > 人文學綜合
社會科學 > 社會科學綜合
社會科學 > 教育學