Helping or harming the public healthcare systems?
George Cautherley, Convenor, Healthcare Policy Forum
The proposed private healthcare insurance scheme will benefit everyone, says the SAR government. The proposed scheme will benefit not only people who can afford private healthcare insurance (PHI) but also those who cannot, as well as the insurance industry. According to the government, the objective of the scheme which is relevant to those who cannot afford private healthcare insurance is this: through encouraging the uptake of PHI, the pressure on and thus the waiting lists in the public healthcare system can be eased. For those who cannot afford PHI then, it is entirely legitimate to ask whether the promise can be delivered, particularly when the uptake of PHI is going to be subsidized by public money. Given international experience, we are concerned that not only is PHI not likely to help the public healthcare system, but it may actually harm the system in time.
Indeed, one of the consultancy reports committed by the government has provided some evidence in this regard. Reviewing related literature, the consultancy reports that "there is as yet no concrete evidence" that PHI can relieve pressure on public hospitals. Citing Australia's PHI experience as an example, the consultancy says that the conclusions from different academic studies on the topic are mixed. Summarizing the findings of an OECD study on PHI, the consultancy writes: "PHI has not significantly assumed financing burdens from the public sector. Cost shifting from publicly to privately financed providers in systems with duplicate PHI has remained small."
In addition to the government consultancy's research findings just cited, we would like to supplement a couple of others here. Regarding Australia's experience, a study by an academic at La Trobe University is worth noting. The study concludes that it "has confirmed the findings of previous overseas studies that suggest that increased private sector activity is associated with increased public sector waiting times, the reverse of the rhetoric supporting policies to increase support for the private sector in order to take the burden off the public sector'." This study at the same time echoes the view of the Canadian Health Services Research Foundation that the hypothesis of reducing waiting time in the public sector through expanding the private sector is a "myth".
Concerning the experience of OECD nations, another study on five OECD nations by academics at the University of Toronto is equally important not to miss. It says: "International evidence provides no grounds for believing that the existence of a privately insured sector parallel to the public sector reduces overall waiting lists or times." "Waiting lists for publicly financed services are likely to respond to infusions of public, not private, finance." "Indeed, a resort to private finance is, on balance, more likely to harm than help publicly financed systems For those who would seek to improve publicly financed systems, the locus of reform efforts must remain the public system itself."
The findings that PHI cannot help but may in fact harm the public system are not difficult to explain. In the short to medium run, the supply of crucial medical resources, in particular medical personnel, is constrained and highly inelastic. Expanding the private sector will only draw resources out of the public sector and thereby reduce its capacity. Greater competition for limited supplies of medical resources between the two sectors will also bid up the prices of these resources. Cost inflation will result.
The private sector has an incentive to "cherry pick" the most profitable cases and less complicated cases while referring less profitable and more complicated cases to the public sector. If private wards and care services are available in the public sector, such perverse incentives will be further enhanced. Patients with PHI in this situation will also have an incentive to use private facilities in the public hospitals for more complicated illnesses. Given the general lack of critical-care facilities in private hospitals, public hospitals at the same time have to serve as a backup for all serious adverse contingencies in private hospitals. In the end, as an academic writes in the context of Australia, "nearly all emergencies and most of the oldest, poorest and sickest patients will be cared for publicly". There is evidence in Britain that length of stay in public hospitals is longer in areas with high levels of private inpatient services. Data from Australia also suggest that average complexity of cases is higher in public than in private hospitals. With shrunken capacity but increasing complexity of cases, that pressures on public hospitals will increase rather than reduce should be expected.
In systems where doctors can practise in both the public and private sectors simultaneously, there is yet another perverse incentive which bears on the length of waiting lists in the public sector. As payment levels are in general higher in the private sector, doctors may have an incentive to maintain lengthy waits or manipulate waiting lists in the public sector in order to increase demand for their private practice. Indeed, the OECD study studied by the government consultancy mentions this particular issue, as it writes: "In some countries, incentives created by higher payment levels in PHI markets have also encouraged providers to maintain long queues in the public system or refer patients to owned private facilities in order to sustain their private practice."
The government consultancy projects that PHI would relieve the patient load of public hospitals. However, it seems that its projection has neither modeled in the shift of medical personnel between the public and private sectors nor the long term supply of medical personnel. It is also unclear whether the projection has taken into account the perverse incentives of providers mentioned above - the perverse incentives of cherry picking and maintaining lengthy waits.
In the government consultation document, only the issue of healthcare manpower is discussed. There is no mention of the two perverse incentives of providers. The government even indicated recently that doctors might be allowed to practise in the private and public sectors simultaneously and expanding private facilities in public hospitals. All these add to our worry that the proposed private healthcare insurance scheme will only benefit people who can afford PHI and the insurance industry at the expense of the public system. The case that the proposed scheme will benefit everyone remains to be made by the government.
An abridged version of this article was published in SCMP on 25 October 2010.
The Chinese version of this article was published in Ming Pao on 26 January 2011.
私人醫保 減輕公營醫療負擔？
高德禮（George Cautherley），醫療政策論壇召集人
政府稱自願私人醫療保險計劃能令「人人受惠」，不管有沒有能力購買私人醫保的市民都會得益。政府解釋，沒有能力購買醫保而倚賴公營醫療的市民可從中得益，因為透過鼓勵有能力的市民購買醫保，可減輕公營系統的負擔，從而縮短輪候時間。然而，由於購買私人醫保會受公帑資助，沒有能力購買的市民質疑政府能否兌現以上的承諾是完全合理的。根據國際經驗，我們擔心私人醫保不單不能減輕公營系統的負擔，長遠而言，更有可能增加負擔。
事實上，政府的顧問報告為我們的憂慮提供了一些理據。報告綜述相關文獻，指出到目前為止，並未有確實證據證明私人醫保能減輕公營醫院的負擔。報告又以澳洲私人醫保經驗為例，指出就這課題的研究並沒有一致的結論。顧問綜合經濟合作與發展組織（OECD）的私人醫保研究，認為私人醫保未能有效分攤公營部門的財政負擔；在有「重複性」私人醫保的制度裏，醫療開支從公營部門轉移至私營部門的幅度有限。
兩項相關研究
除上述政府顧問提及的研究外，我們可再補充兩項相關研究。澳洲La Trobe University一位學者就澳洲經驗的研究有這樣的結論：研究再次證實其他國家早前的研究發現擴大私營醫療市場與公營醫療部門輪候時間的增加有關；這恰巧與支持擴大私營市場以減輕公營部門壓力的政治口號相反。
另外，多倫多大學學者就5個OECD國家的研究認為：1）國際證據未能證實有一個平行於公營部門的私營保險醫療市場能縮短整體輪候時間；2）公共而非私人資源的投入較能影響公營部門輪候名單的長短；3）總的來說，私人的融資方法很可能只會損害而不會改善公營部門；如要改善公營部門，改革重點須在公營部門本身。
私人醫保可能損害公營部門
私人醫保不會改善，甚至可能損害公營部門的原因並不難解釋。首先，重要的醫療資源，尤其是醫療人員，在中短期的供應都會變得非常有限。擴大私營部門只會抽走公營部門的資源，令它的能力萎縮。另外，公私營部門互相爭奪有限的資源只會使價格上升和造成醫療通脹。
其次，私營部門存在誘因只接收盈利較高及較簡單的病症，並將盈利較低及較複雜的病症轉介至公營部門。假如公營部門內設有私家設施，私營部門這不當的誘因（perverse incentives）會進一步加。在這情下，有私人醫保的病人亦有誘因選擇公營部門的私家設施醫治較複雜的病症。另外，由於私家醫院一般都缺乏處理危急病症的設施，公營部門會同時被迫充當私家醫院意外或嚴重併發事故的後援。最終，幾乎所有急症和大部分最老、最窮、最病的病人都會要由公營部門照顧。英國有證據顯示在私人住院服務較多的地區，公營醫院病人住院的日數會較長。澳洲數據也顯示公營醫院病例的平均複雜性較私營醫院的高。以萎縮了的能力照料越益複雜的病症，公營醫院的負擔不減反加應是意料之內的事。
「人人受惠」說法待政府證明
最後，假如容許醫生在公私營部門同時執業，這會誘發另一影響公營部門輪候時間長短的不當誘因。由於私營醫療的收費較高，醫生因此有誘因操控並加長公營部門的輪候時間，從而增加病人對自己私營服務的需求。其實，政府顧問所引述的OECD私人醫保研究就有提及這問題，並有以下的論述：在某些國家，私人醫保市場較高的收費是一個誘因，鼓勵醫療服務提供者繼續公營系統的冗長輪候時間，甚或將病人轉介至自己的私人診所，以維持自己的業務。
政府顧問推算私人醫保可減輕公營醫院的負擔。但這推算似乎沒有把醫療人員在公私營部門的轉移、醫療人員的長遠供應，以及兩種不當誘因所可能誘發的各種影響計算在內。政府諮詢文件只論及醫療人手問題，但兩種不當誘因的影響卻隻字不提。政府更表示會考慮容許醫生在公私營部門同時執業和擴充公營醫院的私家設施。凡此種種都令我們更憂慮私人醫保是否只會以犧牲公營部門的利益為代價來使有能力購買私人醫保的市民得益。私人醫保能令「人人受惠」這說法有待政府進一步證明。
文章刋登於2011年1月26日明報
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