Provider Behavior Under Global Budgeting and Policy Responses

Abstract

Third-party payer systems are consistently associated with health care cost escalation. Taiwan’s single-payer, universal coverage National Health Insurance (NHI) adopted global budgeting (GB) to achieve cost control. This study captures ophthalmologists’ response to GB, specifically service volume changes and service substitution between low-revenue and high-revenue services following GB implementation, the subsequent Bureau of NHI policy response, and the policy impact. De-identified eye clinic claims data for the years 2000, 2005, and 2007 were analyzed to study the changes in Simple Claim Form (SCF) claims versus Special Case Claims (SCCs). The 3 study years represent the pre-GB period, post-GB but prior to region-wise service cap implementation period, and the post-service cap period, respectively. Repeated measures multilevel regression analysis was used to study the changes adjusting for clinic characteristics and competition within each health care market. SCF service volume (low-revenue, fixed-price patient visits) remained constant throughout the study period, but SCCs (covering services involving variable provider effort and resource use with flexibility for discretionary billing) increased in 2005 with no further change in 2007. The latter is attributable to a 30% cap negotiated by the NHI Bureau with the ophthalmology association and enforced by the association. This study demonstrates that GB deployed with ongoing monitoring and timely policy responses that are designed in collaboration with professional stakeholders can contain costs in a health insurance–financed health care system.

Letter to the editor: “Utilization of CT and MRI scanning in Taiwan, 2000–2017”

“…Previous studies have shown the underreporting of CT and MRI in US inpatient claims data [ 12 ], which may also occur in Taiwan. The NHI Bureau limits the reimbursement of multiple CT scans for a patient at the same day and imposes penalties for outliers in service volumes, leading to changes in provider behavior such as discretionary billing [ 13 ]. To observe this phenomenon, we compared the number of CT scans in claim records with total CT scans, including uncoded and self-pay scans, in our hospital during 2010–2017.…”