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美國共和黨參議員檔下一項政府醫療保險(Medicare)相關的法案,遭到醫師與民眾群起圍攻。
其實,美國有關Medicare醫療保險制度的改革,每年都是國會議員不得不面對的難題。這點有點像台灣的全民健保,始終都在為財務平衡傷腦筋。在美國,今年美國這個問題越顯急迫,因為有一項很具爭議性的法案卡在國會,這項法案主張減少政府對私人Medicare保險公司的補助,以增加給醫師的幾付。七月初,美國眾議院通過了這項法案(355比59),不過在參議院,共和黨參議員齊力檔下了這項法案。
在美國,醫療給付與保險費用基本上是循市場機制,所以醫療費用或醫療保險費用非常昂貴。美國沒有全民保險。企業主必須依規定為員工加保,一般人民可以決定是否加入私人保險公司的醫療保險,並選擇加入何種保險。就業中的美國人,因為有雇主負擔部份醫療保險費用,多半可以擁有足夠的醫療保險。退休老人若無相當積蓄,可能無力負擔醫療保險費用,就醫將陷入困難。為了照顧老人或其他弱勢團體,美國政府因此設立Medicare保險制度。簡單的說,Medicare是美國聯邦政府經營的醫療保險,主要是為了照顧退休老人與特定弱勢族群,有點像美國版的(局部的)全民健保。由於是由美國政府負擔保險費用,為避免保費過份膨脹,Medicare的醫療給付並不完全循市場機制,美國政府會有所介入。每年各方勢力莫不為Medicare的幾付問題遊說、角力。
除了Medicare,美國還有私人保險公司提供Medicare Advantage Plan可供選擇。這等於是政府Medicare的私人版。參加這個計畫的人可以獲得和Medicare一樣或更多的醫療保障,提供Medicare Advantage Plan的保險公司則可獲得美國政府的補助。這次引起爭議的法案,就是要減少對這些私人保險公司的補助,研究發現這些私人Medicare Advantage的運作成本,比政府的Medicare高出13%,缺乏效率。該法案試圖把省下的錢用在預防醫學、加強對低收入戶的保障、以及略微提高醫師的幾付。
布希政府與共和黨反對這項法案,他們認為縮減對保險公司的補助,將影響Medicare Advantage Plan的運作,最終仍將傷害被保險人的權益,布希總統甚至揚言將否決此法案。此時,醫師團體發動大規模的遊說,包括購買電視與廣播的時段播出廣告(如上),指控共和黨為保護保險公司的利益而犧牲民眾的利益,頗得選民的共鳴,民主黨(多數黨)的領袖,內華達州的Harry Reid更是決定推動重新表決,共和黨議員也不敢輕忽。
民主黨雖然贊成通過這項法案,但是他們的票數不足已通過這項法案。所以,現在只能寄望共和黨籍參議員。共和黨的參議員身為執政黨,與布希政府的步伐一致,反對這項法案。會不會有共和黨籍議員的看法被醫師團體的遊說改變,將決定這項重新投票的結果。
新聞來源:
The Senate Stalls on Medicare
Doctors Press Senate to Undo Medicare Cuts
This post is very informative. Medicare has been a political football for as long as anyone can remember. For a long time, it has worked out pretty well. However, in the past decade, with the participation of private insurance plans, it has become a maze for both the patients and the doctors. And the doctors usually are the financial losers. A doctor can see Medicare patients either directly or as a provider for the private insurers. The reimbursement rates are higher with the former. That is why there is pressure from physician groups looking to restore the cuts in direct Medicare payments. However, if Medicare cuts payments to the insurers, the doctors lose out as well. It is, sadly, a lose-lose situation for the doctors.
The lure of the private insurers is a promise of better drug coverage and routine exams that are now not covered by Medicare. They were able to convince the Congress that they could deliver more benefits at zero or very low costs to Medicare beneficiaries. This is in effect an invasion of the HMOs that have become popular previously also under false promises.
Under the HMOs, the drug coverage is based on a three-tier system and while routine exams maybe covered, they must be performed by network providers. And the network doctors are paid at a fraction of the Medicare rates. Plus, not only the amount of paperwork is astounding, the denials are usually for trivial reasons, for example, wrong dates of birth, missing zip codes, “incorrect" diagnostic codes or procedure codes, ineligible dates of services, etc. This does not include the time spent for the doctors to write letters asking for approval for top-tier medicine and expensive diagnostic imaging. So a lot of the resources are wasted on insurance administration. And the HMOs have become very good at finding ways of NOT paying the doctors.
To be fair, some insurance plans are much better than others. Nonetheless, for a doctor in the traditional private practice mode, there is simply no way of absorbing close to 70% overhead and still survive. So the only way to be a doctor, which you have spent years training for, is to join a huge physician group or work for the hospitals; only they have the bargaining power with the insurers. Unfortunately, to generate more income, more patients must be seen (hence less time spent on each patient).
The American healthcare system is one that on the surface appears great until you probe deeper into it. Now you have over-worked doctors and sicker patients. Sicker, because the system emphasis is on surgical repairs (more income fo the hospitals) not for preventive care (e.g., in a private office/clinic).
Unfortunately, no one has the solution. From what I have read, the system in Taiwan has also put a lot of pressure on the physicians. The only saving grace is probably this: at least Taiwan has not (yet) adopted the HMO system. Please don’t. And for the Taiwan system to remain successful, educating the patients is the only way to avoid abuses. Of course, this is easier said than done.