Global Budget System Research Articles

Multiple realization pathways of county-level medical alliances to improve service capacity:A fuzzy set qualitative comparative analysis

BackgroundThe long-standing dilemma of difficulties in the improvement of primary care in China has led to county-level medical alliances reforms in various regions throughout the country. ObjectiveTo analyze the combination of pathways that contribute to improving the service capabilities of county-level medical alliances, providing a reference for the improvement and promotion of county-level medical alliances. MethodsCNKI and Wanfang Data Knowledge Service Platform were searched by using "county-level medical alliance" "county health care unit" as keywords from 2020–01–01 to 2022- 11–26 to obtain 662 related papers, a total of 9 papers and 11 cases were selected in the analysis. Based on literature review and policy analysis, variables including scale of planning and implementation, close organizational structure, collaborative management system, information platform integration, regional resources sharing, medical insurance payment reform, and incentive mechanism design were identified as outcome variables. The fuzzy set qualitative comparative analysis was used to identify multiple realization pathways for the service capability improvement of county-level medical alliances. ResultsFour combinations of pathways were found to improve the service capability of county-level medical alliances. Pathway S1:planning and implementation scale * close organizational structure * collaborative management system * regional resources sharing * medical insurance payment reform * incentive mechanism design. Pathway S2:close organizational structure * collaborative management system * information platform integration * regional resources sharing * medical insurance payment reform * incentive mechanism design. Pathway S3:smaller scale of planning and implementation * close organizational structure * collaborative management system * non-integrated information platform * non-sharing of regional resources * medical insurance payment reform * incentive mechanism design. Pathway S4:smaller scale of planning and implementation * close organizational structure * collaborative management system * non-integrated information platform * regional resource sharing * medical insurance payment reform * no incentive mechanism design. ConclusionThe improvement of service capability of county-level medical alliances needs to focus on close organizational structure, establish management system focusing on the collaboration of departments and member institutions, and promote medical insurance payment reform such as global budget management system of medical insurance funds and diagnosis related groups(DRGs).

Data Visualization of Budgeting Assumptions: An Illustrative Case of Trans-disciplinary Applied Knowledge

Trans-disciplinary research combines different fields into new conceptual and methodological frameworks. In this study, the SECI model of knowledge creation, which consists of Socialization, Externalization, Combination, and Internalization conversion modes, is used to analyze the implementation of a structured budgeting visualization system by a trans-disciplinary team. Through applied research in implementing a global budgeting system, budgeting assumptions are made explicit through visualization, transforming the approach to the budgeting process and its accuracy. This visualization, in turn, is enabled by assumptions underlying revenue planning, business services and employee compensation, and a visual process. The system displays a stepped approach, indicated by icons, representing the tasks involved in the budget process. For example, the system requires uploading the previous year’s information, setting the assumptions, calculating the suggested figures based on assumptions, and amending the proposed outcome. As adapted by Rice and Rice (2005), SECI is applied as the socialization of tacit-to-tacit budgeting assumption knowledge is solidified during the design phase of this transformation exercise. The externalization phase, in which budgeting assumptions are transformed from tacit to explicit, is evidenced during the configuration phase of the new system. The systemic collaboration results in the explicit assumptions being collectively leveraged across the regions during and after the “go-live” phase of system development. Finally, the internalization phase involves the explicit assumptions being transformed into new tacit knowledge as the experts evolve new assumptions derived from the transformation process. Semiotics provides variance information through hue, with, for example, darker colours indicating higher variances. This trans-disciplinary communication provides the means for increased efficiency and effectiveness. The resulting budget framework is visually validated through a heatmap by comparing the budgeting accuracy and assumption 1 Contact author 2 Peer-Editor: Prof D Sewry. Dean of Commerce, Rhodes University. complexity between the different regions where it was implemented. In summary, value is added in developing a new data visualization process, focusing on the role of budgeting assumptions and using planning process visualizations. This approach improves communication efficiency, effectiveness, and understanding of budgeting while enhancing accuracy.

Counterfactual Decomposition of Health Care Expenditures: From Cost-Based Payment to a Global Budget System

Abstract This study divides health care expenditures into observable effects and structural shifts to explore the impacts of population ageing and high technology on the growth in outpatient service, inpatient service, and prescription drug expenditures in a health care system that has experienced a shift in payment schemes from a cost-based to a global budget system. By using the quantile decomposition method to examine data from Taiwan, the study shows that, in the short run, all expenditures exhibit an increasing trend in the higher percentiles. In the long run, an observable effect dominates the growth of health care expenditures. Specifically, population ageing leads to the growth of prescription drug expenditures in the higher percentiles. The adoption of high technology drives the growth of the top outpatient and inpatient service expenditures. These results suggest that while the government health care agency aims to control health care expenditures, improving the management of high-cost patients is likely to be one important avenue to improving the effectiveness of the cost control policy.

Kesiapan Rumah Sakit Dalam Implementasi Sistem Pembayaran Global Budget Di Kabupaten Purworejo

The Global Budget payment method was adopted because of the annual increase in healthcare costs, which requires for cost control to guarantee that expenditures are reasonable and resources are distributed fairly without reducing the standard of service. A global budget system provides hospitals the flexibility to utilize the budget to enhance healthcare while also providing financing stability for a predetermined period of time. In 2018, BPJS Kesehatan initiated a pilot project to integrate the INA CBGs and Global Budget mixed-method hospital payment system (global budget). Purworejo Regency is one of the areas designated as a pilot for the Global Budget payment system's deployment. The outcomes of the Hospital performance indicators in the first semester review were less than ideal. As a consequence, it is required to conduct study into the Hospital's readiness to implement the Global budget Payment System. A descriptive design and a qualitative methodology were used in the research. The management of four hospitals in Purworejo Regency is the topic of the study. Observations and interviews were used to explore the readiness of hospitals in implementing the Global Budget payment system in terms of health facilities perception, Quality Control and Cost Control strategies, Global Budget calculations, and patient satisfaction through the results of the Walk Through Audit. Through the four key variables mentioned above, the scoring technique is used to evaluate the readiness of hospitals to implement the Global Budget payment system. The modified CCCEAR (California Community Clinic EHR Evaluation and Readiness) tool is used for the readiness assessment, which has three readiness levels: 1) not ready (score 0-33), 2) moderately ready (34-66), and 3) definitely ready (67-100). Result : According to a qualitative examination of data from observations and interviews, the hospital received scores of 26 from assessor II and 24 from assessor I, positioning it in the second range. This demonstrates that the hospital fits into the category of being not ready and that it has not considered about developing a more comprehensive and in-depth plan for implementing the Global Budget payment system as well as how to create capacity to enable successful adoption and implementation. Conclusion : The hospital is not yet at its highest level of readiness to proceed with adopting the Global Budget payment system in Purworejo Regency, according to the findings of scoring on four variables of hospital readiness.

Manageable hospital service volume under global budgeting: evidence from a policy reform in Taiwan

ABSTRACT This paper investigates whether health care providers change their behaviour in response to different payment structures. Using a policy reform in Taiwan that allowed hospitals to switch from a global budgeting system, a reweighted fee-for-service system, to an individual budgeting system, a capitation system, the results show that the individual budgeting system led to lower services volumes. This effect is significant for more discretionary care but not for less elective services like cancer care.

Evaluation of Length of Stay, Care Volume, In-Hospital Mortality, and Emergency Readmission Rate Associated With Use of Diagnosis-Related Groups for Internal Resource Allocation in Public Hospitals in Hong Kong

Hong Kong's internal resource allocation system for public inpatient care changed from a global budget system to one based on diagnosis-related groups (DRGs) in 2009 and returned to a global budget system in 2012. Changes in patient and hospital outcomes associated with moving from a DRG-based system to a global budget system for inpatient care have rarely been evaluated. To examine associations between the introduction and discontinuation of DRGs and changes in length of stay, volume of care, in-hospital mortality rates, and emergency readmission rates in the inpatient population in acute care hospitals overall, stratified by age group, and across 5 medical conditions. This cross-sectional study included data from patients aged 45 years or older who were hospitalized in public acute care settings in Hong Kong before the introduction (April 2006 to March 2009), during implementation (April 2009 to March 2012), and after discontinuation (April 2012 to November 2014) of the DRG scheme. Data analysis was conducted from January to June 2021. Public hospitals transitioned from a global budget payment system to a DRG-based system in April 2009 and returned to a global budget system in April 2014. The main outcome was the association of use of DRGs with patient-level length of stay, in-hospital mortality rate, 1-month emergency readmission rate, and population-level number of admissions per month. An interrupted time series design was used to estimate changes in the level and slope of outcome variables after introduction and discontinuation of DRGs, accounting for pretrends. This study included 7 604 390 patient episodes. Overall, the mean (SD) age of patients was 68.97 (13.20) years, and 52.17% were male. The introduction of DRGs was associated with a 1.77% (95% CI, 1.23%-2.32%) decrease in the mean length of stay, a 2.90% (95% CI, 2.52%-3.28%) increase in the number of patients admitted, a 4.12% (95% CI, 1.89%-6.35%) reduction in in-hospital mortality, and a 2.37% (95% CI, 1.28%-3.46%) decrease in emergency readmissions. Discontinuation of the DRG scheme was associated with a 0.93% (95% CI, 0.42%-1.44%) increase in the mean length of stay and a 1.82% (95% CI, 1.47%-2.17%) reduction in the number of patients treated after adjusting for covariates; no statistically significant change was observed in in-hospital mortality (-0.14%; 95% CI, -2.29% to 2.01%) or emergency readmission rate (-0.29%; 95% CI, -1.30% to 0.71%). In this cross-sectional study, the introduction of DRGs was associated with shorter lengths of stay and increased hospital volume, and discontinuation was associated with longer lengths of stay and decreased hospital volume. In-hospital mortality and emergency readmission rates did not significantly change after discontinuation of DRGs.

Health Care Leaders’ Perspectives on the Maryland All-Payer Model

Since 2014, all hospitals in Maryland have operated under an all-payer global budget system. Hospital global budgets have gained renewed attention as a strategy for constraining cost growth, improving patient outcomes, and preserving health care access in rural and underserved communities. Lessons from the implementation of the Maryland All-Payer Model (MDAPM) may have implications for policy makers, payers, and hospitals in other settings seeking to adopt global budgets or other value-based payment models. To examine perspectives on the implementation of the MDAPM among health care leaders who participated in its design and execution. This qualitative study with semistructured telephone interviews was conducted from November 1, 2019, to February 11, 2020. The purposive sample of Maryland health care leaders represents diverse stakeholder groups, including hospitals, state government and regulatory agencies, the federal government, and payers. Key high-level themes were extracted from interviews using qualitative content analysis, with barriers and facilitators to implementation specified within each theme. A total of 20 interviews were conducted with hospital leaders (n = 6), state regulators (n = 4), federal regulators (n = 4), payer representatives (n = 3), and state leaders (n = 3). Key themes were labeled as (1) expectations (setting bold yet achievable goals), (2) autonomy (allowing hospitals to follow individual strategies within MDAPM parameters), (3) communication (encouraging early and ongoing communication between stakeholders), (4) actionable data (sharing useful hospital and patient-level data between stakeholders), (5) global budget calibration (anticipating technical challenges when negotiating budgets for individual hospitals), and (6) shared commitment to change (harnessing collective motivation for system change). Together, these themes suggest that implementing the payment model followed an evolving and collaborative process that requires stakeholder communication, data to guide decisions, and commitment to operating within the new payment system. The implementation of hospital global budgets in the state of Maryland offers generalizable lessons that can inform the evolution and expansion of this approach to value-based payment in other states and settings.

Balancing Efficiency and Access: Discouraging Emergency Department Boarding in a Global Budget System.

Reducing cost without sacrificing quality of patient care is an important yet challenging goal for healthcare professionals and policymakers alike. This challenge is at the forefront in the United States, where per capita healthcare costs are much higher than in similar countries around the world. The state of Maryland is unique in the hospital financing landscape due to its “capitation” payment system (also known as “global budget”), in which revenue for hospital-based services is set at the beginning of the year. Although Maryland’s system has yielded many benefits, including reduced Medicare spending, it also has had unintentional adverse consequences. These consequences, such as increased emergency department boarding and ambulance diversion, constrain Maryland hospitals’ ability to fulfill their role as emergency care providers and act as a safety net for vulnerable patient populations. In this article, we suggest policy remedies to mitigate the unintended consequences of Maryland’s model that should also prove instructive for a variety of emerging alternative payment mechanisms.

Supported Employment, Participation at Work, and Peer Support: A Qualitative, Participatory Case Study Report of the Geesthacht Model.

Background: For people who have experienced mental health crises or psychosocial disabilities, it is considerably more difficult to receive support to participate in work on an equal basis with others. In the town of Geesthacht, in Northern Germany, an integrative care network was implemented that allows for acute psychiatric treatment as well as participation in work and activities. This paper aims to explore the principles, advantages, and challenges of this innovative project.Methodology: Within the context of a participatory and collaborative process evaluation of a prospective controlled cohort study (PsychCare), researchers with and without experiential expertise conducted expert interviews and focus groups to evaluate the experiences of 37 employees, with and without lived experience, from various institutions associated with this care network. The data was analyzed using qualitative content analysis.Results: It was the change from financial compensation paid on a daily basis to a global treatment budget that allowed for a significant reduction of hospital beds in Geesthacht and freed up resources to implement a complex care network. Since then, various possibilities for participation, work, and activities for former service users, some of which are compensated financially, have been made available. These developments now allow for a less bureaucratic and often smooth transition from being a service user to involvement in participatory activities in the role of a peer, which is frequently perceived to be empowering and beneficial by participants with lived experience. At the same time, this care model has led to multiple role conflicts and different challenges for all parties involved.Conclusion: This innovative project in Geesthacht demonstrates the multifaceted potential of a global treatment budget system in the field of mental health care. To address certain downsides of the Geesthacht model, further development is necessary.

Provider responses to a global budgeting system: The case of drug expenditures in Taiwan hospitals.

In July 2002, a global budgeting system was imposed on hospitals in Taiwan. This system set a fixed budget for all hospitals within a region but included special provisions that sheltered reimbursements for drug expenditures. We study the size and nature of changes in hospital physicians' use of drugs for outpatient care following this budgetary change and find that drug expenditures for outpatient care increased by 11.7%. Our results suggest that physicians began prescribing more expensive drugs, more drugs, and drugs for longer periods but that these different responses did not all occur at the same time. The overall response was strongest in for-profit hospitals, but drug-related decisions changed in all hospital types.

The effectiveness of financial intervention strategies for reducing caesarean section rates: a systematic review

BackgroundThe increasing trend of Caesarean section (CS) in childbirth has become a global public health challenge. Previous studies have proposed financial intervention strategies for reducing CS rates by limiting caesarean delivery on maternal request (CDMR). This study synthesizes such strategies while evaluating their effectiveness.MethodsThe sources of data for this study are Cochrane Library, PubMed, EMBASE, and CINAHL. The publication period included in this study is from January 1991 to November 2018. The financial intervention strategies are divide into two categories: healthcare provider interventions and patient interventions. Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) was employed to assess the risk of bias of included studies. The outcome of each study was evaluated with Grades of Recommendation, Assessment, Development and Evaluation (GRADE) through the GRADEpro Guideline Development Tool software.ResultsNine studies were included in this systematic review: five with high certainty evidence (HCE), three with moderate certainty evidence (MCE), and one with low certainty evidence (LCE). Of the nine studies, seven are centered on the effect of provider-side interventions. Three of the HCE studies found that the diagnosis-related group payment system, risk-adjusted capitation, and equalizing fee for both facilities and physicians were effective intervention strategies. One HCE and one MCE study showed that only equalizing facility fees between vaginal and CS deliveries in healthcare service settings had no significant effect on reducing the CS rate. The MCE study showed that case payment had a negative effect on reducing the CS rates. One LCE study revealed that the effect of a global budget system was uncertain, and one HCE and one MCE study focused on combining both provider and patient-side interventions. However, equalizing fees for vaginal and CS deliveries and a co-payment policy for CDMRs failed to reduce the CS rate.ConclusionsThe effectiveness of risk-adjusted payment methods appears promising and should be the subject of further research. Financial interventions should consider stakeholders’ characteristics, especially the personal interests of doctors. Finally, high-quality randomized control trials and comparative studies on different financial intervention methods are needed to confirm or refute previous studies’ outcomes.

Determinants of the performance of traditional Chinese medicine clinics in Taiwan

The study attempts to investigate the features and determinants of the performance of Taiwanese Traditional Chinese Medicine (TCM) Clinics with data for 4905 TCM clinics over the 1998 to 2012 period. The empirical results from the fixed effects model and the Hausman-Taylor Model with cluster-robust standard errors reveal several interesting findings. First, consumer characteristics such as the frequency of disabling injuries has positive impacts on the volume of medical services provided by TCM clinics. These results imply that people are likely to select TCM as the option for medical treatment when they face the occurrence of physical injury in Taiwan. In addition, the scale measurements for TCM clinics including the numbers of physicians, medical personnel and divisions have significantly positive effects on the performance of TCM clinics, while their survival length also has the same effect. Finally, the global budget system under the NHI plays a key role in suppressing the revenue of TCM clinics through the peer review mechanism.

What happened to health service utilization, health care expenditures, and quality of care in patients with acute pancreatitis after implementation of global budgeting in Taiwan?

Aim:Acute pancreatitis is associated with significant morbidity and mortality. In the United States, more than 3,00,000 patients are admitted and about 20,000 die from acute pancreatitis per year. In Taiwan, the incidence rate of acute pancreatitis is 0.03% and the mortality rate among severe acute pancreatitis is 16.3%. The aim of the study was to evaluate the impact of the global budgeting system on health service utilization, health care expenditures, and quality of care among patients with acute pancreatitis in Taiwan.Materials and methods:The National Health Insurance Research Database (NHIRD) was used for analysis. Data on patients with acute pancreatitis diagnosed during the period 2000 and 2001 were used as baseline data, and data from 2004 and 2005 were used as post-intervention data. The length of stay (LOS), diagnostic costs, drug cost, therapy costs, total costs, risk of readmission within 14 days, and risk of revisiting the emergency department (ED) within 3 days of discharge before and after implementation of the global budgeting system were compared and analyzed.Results:Data on 2810 patients with acute pancreatitis were analyzed in this study. There was a significant difference in mean LOS before and after introduction of the global budget system (7.34 ± 0.22 days and 7.82 ± 0.22 days, respectively; P < .001)). The mean total costs before and after implementation of the global budget system were Taiwan dollars (NT$) 28,290.66 ± 1576.32 and NT$ 42,341.83 ± 2285.23, respectively. The mean rate of revisiting the ED within 3 days decreased from 9.9 ± 0.9% before adoption of global budgeting to 7.2 ± 0.6% after implementation of the system. The mean 14-day re-admission rates before and after introduction of global budgeting were 11.6 ± 1.0% and 7.9 ± 0.7%, respectively.Conclusion:The global budget system was associated with significantly longer length of stay, higher health care expenditures, and better quality of care in patients treated for acute pancreatitis.

Spatio-Temporal Variations of Soil Active Layer Thickness in Chinese Boreal Forests from 2000 to 2015

The soil active layer in boreal forests is sensitive to climate warming. Climate-induced changes in the active layer may greatly affect the global carbon budget and planetary climatic system by releasing large quantities of greenhouse gases that currently are stored in permafrost. Ground surface temperature is an immediate driver of active layer thickness (ALT) dynamics. In this study, we mapped ALT distribution in Chinese boreal larch forests from 2000 to 2015 by integrating remote sensing data with the Stefan equation. We then examined the changes of the ALT in response to changes in ground surface temperature and identified drivers of the spatio-temporal patterns of ALT. Active layer thickness varied from 1.18 to 1.3 m in the study area. Areas of nonforested land and low elevation or with increased air temperature had a relatively high ALT, whereas ALT was lower at relatively high elevation and with decreased air temperatures. Interannual variations of ALT had no obvious trend, however, and the ALT changed at a rate of only −0.01 and 0.01 m year−1. In a mega-fire patch of 79,000 ha burned in 2003, ΔALT (ALTi − ALT2002, where 2003 ≤ i ≤ 2015) was significantly higher than in the unburned area, with the influence of the wildfire persisting 10 years. Under the high emission scenario (RCP8.5), an increase of 2.6–4.8 °C in mean air temperature would increase ALT into 1.46–1.55 m by 2100, which in turn would produce a significant positive feedback to climate warming.

Managing health expenditure inflation under a single-payer system: Taiwan's National Health Insurance

As nations strive to achieve and sustain universal health coverage (UHC), they seek answers as to what health system structures are more effective in managing health expenditure inflation. A fundamental macro-level choice a nation has to make is whether to adopt a single- or a multiple-payer health system. Using Taiwan's National Health Insurance (NHI) as a case, this paper examines how a single-payer system manages its health expenditure growth and draws lessons for other countries whose socioeconomic development is similar to Taiwan's. Our analyses show that as a single payer, Taiwan's NHI is able to exercise its monopsony power to manage its health expenditure growth. This is achieved primarily through the adoption of a system-wide global budget. The global budget sets a hard aggregate budget cap to limit NHI's total spending to its expected revenue, with the annual budget growth rate established by a process of negotiation among key stakeholders. The global budget system is complemented by comprehensive and continuous monitoring and review of encounter records of all providers and patients, enabled by the NHI's advanced information technology. However, by paying its providers using a point-based fee schedule, Taiwan's NHI suffers from inefficient service provision. In particular, providers have incentives to increase use of services and drugs with positive profit margins. Furthermore, Taiwan demonstrates that its control of NHI expenditure growth might be leading it to inadequately meet the changing needs of the population, resulting in the rapid growth of private insurance to cover services excluded or not fully covered by the NHI. If this trend persists and results in a two-tier system, Taiwan's NHI may risk compromising the equity it has achieved in the past two decades.

Counterfactual Decomposition Of Health Care Expenditures: From Cost-Based Payment To Global Budget System

This study employs patient-level data to investigate the growth of health care expenditures by decomposing outpatient, inpatient and prescription drug expenditures into observable effect and structural change in a health care system that experiences the shift of payment schemes from cost-based to global budget system in 2002. The Natioanl Health Insurance claim data which include around three-million patients was used to create a patient-level data set for the year 2000, 2005, and 2010 in Taiwan. This study employs the (recentered) influence function (RIF) unconditional quantile regression to decompose health care expenditures into observable effect and structural change. The payment shift results in negative structural changes on the growth of outpatient and prescription drug expenditures at the lower percentiles in the short run. In the long run, the observable effect still dominates the growth of health care expenditures at the higher percentiles. Specifically, population ageing accounts for the growth of inpatient expenditures and top prescription drug expenditures. The adoption of high technology mainly contributes to the growth of outpatient expenditures at the higher percentiles. Although cost control policy, like the global budget system, can lower the growth of health care expenditures in the short run, population ageing and adoption of high technology still likely drives the expenditures of high-cost patients in the long run.

The impact of the global budget system on dynamics of dental manpower and utilization of dental services.

Background:This study aimed to investigate dentists’ supply and practice patterns following the implementation of the global budget system in Taiwan.Materials and Methods:Data of reimbursement claims, municipal socioeconomic status and dental manpower were collected from the National Health Insurance administration, the Ministry of Internal Affair, and the Ministry of Health and Welfare, respectively. A multivariate linear regression method was used for data analysis.Results:A municipality that reported a higher percentage of tertiary educated population (t = 3.718, P < 0.001), a higher per capita income (t = 6.172, P < 0.001), a higher population density (t = 6.172, P < 0.001), or a lower percentage of elderly population (t = −2.506, P = 0.014) was more likely to have a higher number of dentists per 100,000 population. A municipality that reported a higher Herfindahl-Hirschman Index (HHI) value (t = 2.880, P = 0.005) was more likely to show a higher move-out rate among dentists. The rate was lower after the implementation of the global budget system (t = −2.436, P = 0.018). A municipality that had a higher percentage of elderly population (t = 3.628, P < 0.001), a lower percentage of young population (t = −2.138, P = 0.035), or a higher rate of population growth (t = 4.412, P < 0.001) was more likely to display a higher move-in rate among dentists. The percentage of amalgam restorations in total claims reduced from 19.82% to 17.94%, while the percentage of tooth-colored material restorations increased from 25.46% to 28.79%.Conclusion:This study has demonstrated a stabilizing effect of the global budget system on dynamics of dental manpower in Taiwan. A relationship between HHI and dentists’ move-out rate has been found. The relationship between municipal socioeconomic status and the density of dentists has also been confirmed. In addition, reduced utilization of amalgam restorations was accompanied by increased utilization of tooth-colored material restorations. Further investigations are indicated.

The impact of global budgeting on health service utilization, health care expenditures, and quality of care among patients with pneumonia in Taiwan.

This study evaluated the effect of global budgeting on health service utilization, health care expenditures, and the quality of care among patients with pneumonia in Taiwan. The National Health Insurance Research Database (NHIRD) was used for analysis. Data on patients diagnosed with pneumonia during 2000-2001 (the prebudget group) were used as the baseline data, and data on patients diagnosed with pneumonia during 2004-2005 (the postbudget group) were used as the postintervention data. The length of stay (LOS), diagnostic costs, drug costs, therapy costs, total costs, risk of readmission within 14 days, and risk of revisiting the Emergency Department (ED) within 3 days of discharge before and after implementing the global budget system were analyzed and compared. Data on 32,535 patients with pneumonia were analyzed. The mean LOS increased from 6.36 ± 0.07 to 10.78 ± 0.09 days after implementing the global budget system. The mean total costs in the prebudget and postbudget groups were 22,697.82 ± 542.40 and 62,016.7 ± 793.19 New Taiwan dollars (NT$), respectively. The mean rate of revisiting the ED within 3 days decreased from 5.5 ± 0.2 % to 4.6 ± 0.1 % in the prebudget and postbudget groups, respectively. The mean rates of readmission within 14 days before were 6.1 ± 0.2 % and 8.2 ± 0.2 % in the prebudget and postbudget groups, respectively. Global budgeting is associated with a significantly longer LOS, higher health care costs, and poorer quality of care among patients with pneumonia.

Stochastic Frontier Analysis를 이용한 제약회사의 효율성과 그 결정요인분석

Background & Methods: The purpose of this research is to estimate the efficiency of the pharmaceutical firms and the determi-nants of their efficiency. Stochastic frontier analysis(SFA) and panel study are applied to the data of 60 domestic pharmaceutical firms from 2006 to 2012.Results & Conclusion: First, the result of the stochastic frontier analysis shows that overall efficiency of the pharmaceutical firms is increasing as time goes by. However, if firms are classified by the scale, the larger firms show more efficiency and if classified by the degree of innovativeness, the innovative firms show more efficiency compared to the non-innovative firms. This evidences show that the scale and R&D investment have significant relationships with the efficiency of the pharmaceutical firms. Therefore, it is nec-essary to increase the national level of investment for the fundamental researches to vitalize R&D of the new drugs.Second, the result of estimation of the determinants of efficiency shows that the firms with larger sales promotion expenses and entertainment expenses have less efficiency compared to the other firms. This can be explained by the structural characteristics of the small generic pharmaceutical firms. Therefore, the government had better make the pharmaceutical firms to reduce sales pro-motion and entertainment expenses and increase R&D expenses by introducing systems such as global budgeting system on medi -cine or reference pricing system.Keyword : Stochastic frontier analysis, pharmaceutical firm, efficiency, panel data, panel study

The influence of medical cost controls implemented by Taiwan's national health insurance program on doctor-patient relationships.

To prevent medical costs from rising, the National Health Insurance administration implemented the global budget system for financial reform, effective 1 July 2004. Since the implementation of this system, patients have been required to pay for some medicines to limit costs to the system. More recently, as they have faced constant increases in health insurance fees and also faced an increase in the number of medical expenses they must pay during an economic recession and a rise in unemployment, would the economic burden on the people of Taiwan not be increased? Even though National Health Insurance is a form of social insurance, does it guarantee social equality? The value of the healthcare industry is irreplaceable, so the most critical concern is whether worsening doctor-patient relationships will worsen healthcare quality. In short, while the global budget system saves on National Health Insurance costs, whether its implementation has affected healthcare quality is also worth exploring. This commentary also hopes to serve as a reference for the implementation of national health insurance in the United States.