Implementation Of National Health Insurance Research Articles

Characteristics of primary osteomyelitis among children in a medical center in Taipei, 1984-2002.

The presentation and sequelae of osteomyelitis are variable. This study evaluated the clinical manifestations and outcome of osteomyelitis in children in different age groups, and in different periods before and after the implementation of National Health Insurance (NHI). The records of pediatric patients with osteomyelitis treated at a medical center in Taipei from 1984 to 2002 were reviewed. Clinical features, pathogens, laboratory and imaging findings, treatment, and outcome were analyzed. The patients were stratified into 3 groups based on age: infants (< or = 3 months of age), young children (between 4 months and 5 years), and older children and adolescents (> 5 years). Based on the date of implementation of the NHI program, the study period was divided into 2 stages: prior to implementation, from January 1984 to February 1995; and after implementation, from March 1995 to December 2002. The records of 209 patients were reviewed, including 45 infants, 77 young children, and 87 older children. The most common presenting findings were local tenderness (79%), local swelling (72%), and fever (57%). The lower limbs were the most commonly involved sites (65%). Staphylococcus aureus (34%), Mycobacterium tuberculosis (10%), Salmonella species (7%), and Pseudomonas aeruginosa (6%) were the most frequently isolated pathogens. At the time of diagnosis, abnormalities were found on radiographs in 83% of patients and on radionuclide bone scans in 86%. Surgical intervention with local debridement and curettage was performed in 102 patients (49%). Sixty five patients (31%) developed complications, including specific bony sequelae in 26 (12%). Sepsis and septic arthritis were more common in infants (p < 0.01). A history of trauma, protracted course of osteomyelitis, and surgical intervention were more common in older children and adolescents (p < 0.01). After the implementation of NHI, a larger proportion of patients had negative cultures (p < 0.01), and the mean duration of antibiotic therapy was shorter (p = 0.01). The clinical characteristics of osteomyelitis associated with sepsis or septic arthritis, chronic changes, and the need for surgery may differ depending on the age of the child. S. aureus, M. tuberculosis, and salmonellae were the most common pathogens in this Taiwanese series. Implementation of NHI in the more recent decade of the study period was associated with a shorter duration of intravenous antibiotic administration.

Impact of National Health Insurance on the Survival Rate of Patients with Osteosarcoma In Taiwan: Review of 74 Patients

The 2-year survival rate for high-grade osteosarcoma was 46.9% before the introduction of National Health Insurance (NHI) in Taiwan on March 1, 1995, but increased to 73.8% after the implementation of NHI. The 5-year survival rate also increased, from 37.5% to 63.6%. Between May 1990 and May 2001, 74 patients with high-grade osteosarcoma were treated at our hospital. Median age was 17 years (range, 7-63 years). Inadequate surgical margins, poor histologic response to chemotherapy, advanced stage of disease, and incomplete treatment were strongly associated with poor prognosis. Before NHI, 10 patients had incomplete treatment, mainly because of unaffordable medical fees. After NHI, only three patients had incomplete treatment, due to personal reasons. Patient survival improved dramatically with advances in multiagent chemotherapy, but it was the NHI that enabled patients to complete expensive treatment courses, including preoperative neoadjuvant chemotherapy, limb-salvage surgery, and postoperative adjuvant chemotherapy. The NHI also improved the accessibility of medical care, with more patients presenting in the early stages of disease and, as a result, it not only improved survival rate but also increased the number of patients undergoing limb-salvage surgery. We concluded that the NHI significantly improved the survival rate for patients with osteosarcoma in Taiwan.

The role of Taiwan's National Health Insurance program in influencing adequate prenatal care.

This paper reviews achievements in the utilization of prenatal care by pregnant women in Taiwan by analysing the 1989 and 1996 National Maternal and Infant Health Survey data. More precisely, it identifies and examines the programmatic and non-programmatic factors that influence prenatal care utilization, thus determining the areas that require further attention from the programe. Logistic regression results show that the adequacy of prenatal care use was significantly associated with the implementation of the National Health Insurance (NHI). A higher likelihood of adequate care utilization was found among women who were married or employed, had a higher level of education, had more experience with regard to pregnancy and were at higher risk in terms of obstetrics. The effect of facility choice showed variations after the implementation of the NHI programme. Prior to NHI, no differences were noted between the use of clinics and hospitals. After the implementation of NHI, on the other hand, women who received most of their care from clinics had a higher likelihood of receiving more adequate prenatal care than those who received care from hospitals. Regional differences in seeking adequate prenatal care were also evident. Mothers who were living in southern areas were less likely to receive adequate prenatal care despite the implementation of NHI. The Bureau of NHI, therefore, still needs to work on mechanisms to ensure that more attention is given to the distribution of its medical resources and that additional health care accessibility is provided to pregnant women in these areas.

National Health Insurance and Technology Adoption: Evidence from Taiwan

Generous health‐insurance coverage may encourage hospitals to acquire and employ more advanced medical technologies. The authors examine the effects of Taiwan's 1995 implementation of National Health Insurance on technology adoption, ownership, and use by comparing changes in adoption, ownership, and use rates by private hospitals with changes by public nonteaching and public teaching hospitals. Using random‐effect panel probit and tobit models, the article finds strong empirical evidence that third‐party payment increases the probability of technology adoption, ownership, and use. (JEL H4, I)

National Health Insurance and the antenatal care use: a case in Taiwan

Many studies have found evidence for the importance of antenatal care on pregnancy outcomes. This paper focuses on the determinants of antenatal care use in Taiwan and provides a comparison of access to care before and after National Health Insurance (NHI) was implemented in 1995. A negative binomial model is applied to data from the 1989 and 1996 Taiwan Maternal and Infant Health Surveys to analyze antenatal care use. The results show that women in some situations had more antenatal care visits than average regardless of NHI implementation. These situations include: having a highly educated husband; gaining more weight than average during pregnancy; experiencing a first pregnancy; carrying twins or triplets; having care provided by a doctor rather than other caregivers; and switching to another health care facility during pregnancy. Regarding societal change, the trend toward delaying pregnancy is causing a change in care use. Additionally, three changes in care patterns after NHI are noteworthy. First, antenatal care visits at maternity clinics increased more than visits at hospitals. Second, before NHI's implementation, women who did blue-collar work or farm work sought care more frequently than housewives, but after NHI began government employees and businesswomen sought care more frequently. Third, antenatal care visits of mothers living in Taiwan's central area increased more than visits of those in the northern area. The expansion of medical care in aboriginal areas and outlying islands may prove to be one of NHI's best achievements.

Implementing managed competition in Israel

As of January 1, 1995, Israel's National Health Insurance (NHI) Law laid the foundations for regulating competition among the country's four private, not-for-profit sick funds. Prior to NHI the sick funds (SFs) had competed without governmental control. Extensive research on NHI implementation and the behavior of the sick funds (SFs) after passage of NHI reveals a paradoxical development: The NHI bill drew on the rhetoric of managed competition and did indeed establish a legal and structural framework for regulating competition among the SFs. Nevertheless, in practice, SF autonomy was constrained and competition over provision of statutory care was limited. Rather than fostering competition, the main thrust of the NHI reforms was to enhance central government's control over SF expenses in order to constrain government expenditures. The NHI reforms did encourage the SFs to cut costs and make visible service improvements. However, the reforms did not lead the SFs to reorganize, expand the scope of their services, or improve clinical quality, as the reformers had hoped. Nor did the reforms help eliminate the SF's operating deficits or insure financial stability for the whole health system. Furthermore, the reforms had unanticipated and undesired outcomes, including aggressive and illegal marketing by SFs and collaboration among SFs to restrict the extent of care provided under compulsory insurance. The Israeli case suggests that the theory of managed competition contains unrealistic assumptions about the types of competitive behavior that result from exposure to managed competition and the capacity of government and health providers to monitor quality. In addition to stemming from universal limitations to the managed competition model, the implementation pattern in Israel reflects local, historical forces and the interplay of Israel's powerful health system actors.

Nosocomial infection in a neonatal intensive care unit--from a viewpoint of national health insurance.

In order to survey both the epidemiology of nosocomial infection in our neonatal intensive care unit (NICU) and the changing face of nosocomial infection after the introduction of National Health Insurance (NHI) in Taiwan, we retrospectively reviewed the nosocomial infections which occurred in our NICU from March 1, 1991, to February 28, 1999. We also compared the nosocomial infections from the viewpoint of NHI. The mean rate of nosocomial infections in our NICU during these 8 years was 13.6%, and it had significantly increased after the NHI plan was implemented (from 7.9% to 19.0%). The most common type of nosocomial infection was blood stream infection (53.8%, 120 of 223 infections). Coagulase-negative Staphylococci and fungi were the two most common pathogens of nosocomial blood stream infection in our NICU, accounting for 28.1% and 24.2% of the infections, respectively. The survival rate of very low birth weight (VLBW) infants increased from 76.3% to 78.4% after the implementation of NHI. However, the nosocomial infection rate of the VLBW infants had markedly increased from 22.6% to 41.9%. The total number of hospitalization days of the patients with nosocomial infection was significantly greater than that of those without nosocomial infections (p < 0.05), and the patients with the lower birth weights had longer hospital stays. The risk factors for nosocomial infection including invasive procedures, multiple and empirical antibiotics, and extremely low birth weight premature infants, remained the same, but the prevalence of nosocomial infection in the neonatal intensive care unit has changed markedly since the NHI plan began. Further investigation to determine strategies for preventing nosocomial infection in very low birth weight infants is warranted.

Network analysis of Korean health insurance policy-making process.

This study examines how the decision-making process evolved in Korea during the initial phases of introduction and implementation of National Health Insurance. This study analyses the official documents and interviews views made with government officials and related personnel. We used the method of network analysis and multidimensional scaling in order to demonstrate how the major participants in the decision-making process developed and changed under the contemporary political situations. In the pre-implementation stage around 1976, major concerns were concentrated around the issues of financial support for social insurance, the fee schedule and who ought to be covered first. The total number of participants of the health or health-related organization was 61, which included the President, the Minister of Health and Social Affairs, representatives of special interest groups, etc. In the actual implementation period of 1982, different issues were brought up by the major participants. The number of participants in this period declined to 44 with the deletion of 19 and with the addition of two newly formed health insurance organizations. By 1988, as the implementation reached its final decision period, disagreements were centered on progressive premium rating and the administration of National Health Insurance. The number of participants increased to 60 after the addition of 16 participants. The analysis of this paper may provide some insight for other countries which wish to establish National Health Insurance; as reference to the policy-making process, it may provide some suggestions for when to initiate and how to formulate National Health Insurance policies.

Legal constraints and alternatives in the Veterans Administration.

The Veterans Administration is a federal system that has functioned, so far, independently of state and local laws and rules. The system has proven flexible, however, as it has adjusted to meet needs perceived within its organization where legal justification has been found. The impact of the overall health care system in the United States is beginning to be felt within the Veterans Administration as the possibility of national health insurance implementation may greatly affect the number and kinds of patients seen in the hospitals. Th response of the Veterans Administration system will have to be within its legal framework and an understanding of the relationship between the actual operation of the system and the law will be necessary. More and better understanding of the practical impact of external programs such as comprehensive health planning, manpower training and licensing laws will be necessary for the Veterans Administration to successfully adjust within the United States' health care framework.

Unintended consequences of requiring a license to help.

Current proposals for licensure, accreditation, and third-party reimbursement may have several unintended consequences. Until now discussion has focused on the effects of the proposed regulations on the development of psychology as a profession. Recent proposals, however, may have unexpected adverse consequences on three other areas as well: the education of professionals within psychology, the delivery of psychological and other helping services, and the self-definition of the consumer of psychological services. Any changes in licensure, accreditation, and reimbursement require compromises of our concerns for the profession, for the consumer, and for our own livelihood. Unless we consider the unintended consequences of current proposals, we may undermine the unity of our profession and the public's trust in psychology. All interventions have consequences, and one of the things we should learn to keep in the forefront of our consciousness is that the most important consequences of any intervention almost always turn out to be those consequences that were not intended. (Marcus, 1978, p. 66) For the past several years, psychologists have been debating the effects of licensing, credentialing, and implementation of national health insurance on the development of psychology as a profession (Albee, 1977a; Cummings, 1977; Gross, 1978; Koocher, 19791 Matarazzo, 1977). The discussion has emphasized defining what a psychologist is and determining what training is necessary to produce an individual competent to practice psychology. Two dominant themes have emerged from the discussion: ensuring psychology's place within the third-party reimbursement system and excluding other professions (e.g., social work and marriage and family counseling) from such a system. This article examines important unintended consequences of current efforts to regulate the , practice and training of psychologists. Specifically, we review how present proposals for regulation may influence the development of psychology as a profession. Then we examine how these may Vol. 36, No. 1, 13-21 Copyright 1981 by the American Psychological Association, Inc. 0003-066X/81/3601-0013$00.75 create adverse consequences for the education of professionals, the delivery of professional psychological and other helping services, and the consumers of these services. Within this framework, we show how third-party reimbursement influences psychologists in their efforts to define prac-