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原載《HKCER Letters》一九九九年五月至七月第五十六期
(Reprinted from HKCER Letters, Vol.56, May-July 1999)

             

Hong Kong Healthcare and Finance Reform
香港的醫療護理與融資改革

Y.C. Richard Wong 1
王于漸




        1. Introduction

        The study Improving Hong Kong's Health Care System: Why and For Whom?
        (the "Harvard Report") published earlier this year makes it clear that the Hong
        Kong health system and its financing require reform. The Report also identifies
        many of the reasons - which in my view deserve to be taken seriously - why this
        is necessary and should not be delayed. The Harvard Report proposes a new
        approach to financing health care that would entail a total reform of the system
        of health care provision. Its core proposal centres on creating a universal
        mandatory social insurance system that would allow patients to choose doctors,
        clinics and hospitals. As a consequence, dollars would follow patients instead of
        being given directly to health care providers, as is the case at present. The
        current distinction and separation between public and private care will also
        basically cease to exist. The social insurance premium would be financed jointly
        by the patient and the public purse, and the new programme would include
        built-in income redistribution features to achieve equity objectives. While the
        Harvard proposal has obvious strengths and addresses some of the
        shortcomings of the present system, the report's proposal has serious theoretical
        and practical difficulties. In this article we discuss why the Harvard Report is
        correct about the necessity for change, but we also explain why the core
        recommendation of the Harvard Report is not a good solution for the problems
        of Hong Kong's health care system and go on to propose an alternative scheme.
 

                    1. 引言

                    港府年初發表諮詢報告《香港醫護改革─為何要改?為誰而改?》
                    (下稱《報告》),建議設立全民強制性社會保險制度,由病人自由
                    選用服務,令公、私營服務得以公平競爭。保費由個人和政府分擔,
                    費率結構內含重新分配收入的因素以求平等。哈佛報告指出了現存的
                    弊病和改革的急迫性,惜有關建議香港並不適用。本文提供了另類的
                    選擇。

                     
        2. Why is reform necessary?

        The Hong Kong health care system requires reform for a number of reasons.
        From a government-policy perspective, the main concern is the system's
        long-term financial viability. From a user's perspective, the greatest problem is
        quality of service. There are probably few consumers of either public or private
        health services in Hong Kong who, if asked, would say that they are truly
        satisfied with the services they have received. Users of public services complain
        of long waiting times, an indifferent service attitude and lack of choice, while
        those who go to the private sector face high costs and variable service quality.
 

                    2. 非改不可?

                    香港的醫護制度確有改革的必要。在現行制度下,政府擔心長遠來說
                    財政上難以負擔﹔用者則不滿服務質素。公營服務輪候費時、服務態
                    度欠佳、缺乏選擇;私營服務則收費高昂、質素參差。
 

        Restrictions and barriers in the medical and health care professions seem to limit
        effective competition among private providers of health care. News reports of
        the barriers to entry of private clinics in public housing estates appear to be a
        case in point. While one should recognise the very visible improvements that
        have been made in the past few years in the public-hospital care sector, it is also
        important to note that the success has been achieved by means that are likely to
        be unsustainable. Many of the improvements have been facilitated by a generous
        provision of public funding that cannot be continued into the future. In a sense,
        the Hospital Authority (HA) has sown the seeds for its own future fall.
        Far-reaching health care financing reforms have to be introduced, and it is
        inconceivable that this can be achieved without reorganising the structure of
        health care provision in Hong Kong.

        Hong Kong's spending on health care has risen substantially in recent years.
        Public health spending rose from 1.7% of GDP in 1989 to 2.5% in 1996. This
        growth is projected to continue into the future. The Harvard Report projects that
        public health spending will rise to between 3.4% and 4.0% of GDP by 2016,
        assuming that real GDP grows at the rate of 5% a year. This implies that,
        assuming that the Basic Law provision requiring that the increase in government
        spending be in proportion to growth in GDP is adhered to, government health
        spending will absorb 20-23% of the total budget in 2016, compared to the
        current figure of 14%. According to this scenario, the government will have to
        reduce spending on other areas in order to maintain health care services at their
        present level.

                    不同醫護專業之間存在著藩籬,限制了私營服務的競爭。公立醫院服
                    務雖有改善,但用資源堆砌成就,長遠難以維持。公共醫護開支近年
                    步步高昇,在本地生產總值中的比例在1989年是1.7%,至1996年已上
                    升至2.5%。港府若堅守《基本法》「量入為出」的理財原則,隨著醫
                    護開支在政府預算中的比例上升,其他民生開支將被迫削減。
 

        One may argue with the Harvard projections, but this is unlikely to be a useful
        exercise given the paucity of detailed statistics available at present. For this
        reason, the Harvard Report's recommendation that an Institute for Health Policy
        and Economics be established has great merit, because such an institute could
        provide policy makers with the necessary empirical analysis they need to make
        prudent reform decisions and to implement reforms successfully. One should
        also note that the paucity of data available today should not serve as an excuse
        for not reforming the system, since delaying reform could also have costly
        consequences for society. The present lack of detailed quantitative data
        therefore mandates an evolutionary reform strategy designed with built-in
        feedback systems so that the initial effects and results of reform can be used to
        modify policy over time.

                    由於缺乏可靠數據,哈佛報告的預測難以作準。也正因此,該報告建
                    議設立醫療政策及經濟研究所實有必要。但不應以數據不足為由延遲
                    變革,否則只會增加社會的負擔。本文因應這項困難,建議在改革方
                    案內設置資訊回饋制度,初期循序漸進,視乎成效以修正其後的變
                    革。
 

        One of the main factors behind the need for changes in the financing of health
        care in Hong Kong is the changing nature of Hong Kong society and the type of
        health problems that it will have to deal with. As Hong Kong becomes more
        affluent, the diseases affecting its citizens are changing. While in the past, the
        most pressing health problems were infectious diseases, in the future the
        prevalent problems will increasingly be chronic diseases such as diabetes, heart
        disease, stroke and cancer and the care of the old. As Hong Kong's population
        ages as a result of lower birthrates and increased life expectancy, the proportion
        of medical services that the aged consume will rise significantly. The shift in
        demographics also means that greater emphasis should be given to prevention
        rather than to cure. Such an emphasis must be effected through
        patient-education, health-promotion, and disease-detection programmes. Early
        action to prepare for this trend is necessary.

                    醫護融資必須求變,原因是出生率低、壽命延長、社會富裕,糖尿病
                    、心臟病、中風、癌症等慢性病、以及長者護理日漸成為醫護主要的
                    負擔。服務重點應及早由治療轉向預防,開展教育,促進早期防治。
 

        While this may be the core long-term financial reason why reform is necessary,
        there are other pressing reasons for change. These mainly concern the quality of
        health care available in Hong Kong. In some respects Hong Kong can point to
        the high standard of health services provided to its citizens, but there are still
        many areas where the quality of service is variable and poor. To some extent this
        is the result of an inappropriate allocation of resources. Hong Kong has parallel
        public and private health systems that operate entirely separately and
        independently of each other. As a result, the overall delivery of health and
        medical services to patients is compromised. To a considerable extent, such
        compartment-alisation extends itself into the division between primary,
        secondary, and tertiary care. The fragmentation of service is highly inefficient
        and results in an overall deterioration of health care service quality.

                    與此同時,公、私營服務各自為政,造成醫療服務的某些領域質素參
                    差。哈佛報告所謂的「分裂隔離」(compartmentalisation)狀態亦存
                    在於基層醫療、secondary care和tertiary care之間。
 

        In the public system, resources are primarily allocated by administrative means
        within the HA, with little guarantee that they will be provided where patients want
        them and where they are genuinely needed. The HA has improved its
        management of hospitals and provision of services in recent years. In some
        respects this has perhaps tended only to reinforce its own difficulties, since there
        is evidence to suggest that improvement in the services provided by public
        hospitals has attracted patients away from the private sector. The share of bed
        days occupied in the public hospital sector has risen from 90% to 92% since
        1991.

                    公營服務方面,醫院管理局(簡稱「醫管局」)靠行政指令分配資源。
                    近年雖已改善了醫院的服務和管理,但也因而引來私營部門的病人,
                    增加本身的負荷。
 

        Access to government health services is in practice free at the point of delivery.
        This is not to say, however, that users face no costs. In fact, the main direct
        cost to users is the queuing time involved in the use of public facilities.
        Consultation with a doctor frequently requires hours of queuing, in effect
        allowing access to government facilities to those who have time on their hands,
        while those who do not are forced to go to the private sector until they can no
        longer afford it.

        The frequently poor standards of medical practice in Hong Kong can often be
        traced to the limited choices available to users. Within the government hospital
        system, patients are required to more or less accept what is given to them. Their
        only other option is to go to the private sector. Figures indicate that despite the
        "free" government outpatient services, the majority of consultations are with
        private doctors.

                    部分醫護服務質素低落,原因往往是選擇太少。市民使用公營服務,
                    只須付出象徵性費用,真正的代價是長時間輪候。趕時間者只能光顧
                    收費高得多的私營服務,否則只能對公營服務逆來順受。大多數人還
                    是光顧私家醫生。
 

        There is strong evidence that resources are poorly allocated even within the
        private sector. Private hospitals operate at well under capacity as a result of
        competition from a low-cost substitute available in the public sector. Since there
        is no meeting point between the public and private systems, there is often
        unnecessary duplication of effort. The private system also suffers from high
        costs, wide variation in the quality of treatment and inadequate competition
        caused by barriers to entry. The medical profession is highly protective of its
        interests everywhere in the world, and Hong Kong is no exception. Nevertheless,
        the possibility exists of reducing some of the barriers in order to redress the
        imbalance of market power in the private sector. For example, relaxing the
        restrictions on advertising of physician's service would enhance patients' ability
        to exercise their choice in a more informed manner. Allowing physicians free
        entry to practice in public housing estates would be in the interest of patients.
        Greater separation of patient consultations and the filling of drug prescriptions
        would benefit patients.

                    私營服務的資源也失調。由於公營服務廉宜,私家醫院空置率高。公
                    、私營服務經常重疊。私營服務則競爭不足,成本高、質素參差。應
                    降低市場屏障,放寬醫生刊登廣告的限制,讓醫生自由在公共屋村開
                    辦診所及增加醫與藥的分工。

                     
                    3. Financing possibilities
                    3. 融資方式
 

        In practice there are only three basic approaches to funding health expenditure.
        Each approach entails a rather different way of organising health care services,
        and has different consequences for equity and efficiency. They are:

                    已知的醫療融資方式不外三種。
 

        1. Direct public funding combined with public provision
                    1. 由公共直接資助與提供服務
 

        Health care is provided directly by government out of tax revenue. Although the
        system may incorporate user charges, the bulk of the costs are borne out of
        taxation. If the tax system is truly progressive, as is the case in Hong Kong, then
        it will meet equity objectives. However, Hong Kong's narrow tax base and low
        tax rates make it difficult for the government to expand health spending without
        compromising the fiscal system. Moreover, the direct provision of health care by
        government is usually inefficient and unresponsive to patient needs. In Hong
        Kong direct government funding provides most of the finance for the hospital
        system, although elements of the other systems also coexist side by side with
        this system. Outpatient treatment is mainly carried out in the private sector.

                    政府用稅收直接提供醫療服務。用者可能要支付部分費用,但大部分
                    成本由稅收承擔。在香港的漸進稅制下,政府直接提供服務能夠達到
                    平等的目的。但香港稅基狹窄而稅率低,政府若「量入為出」,也就
                    很難增加醫療開支。而且,政府提供服務通常效率低。香港公立醫院
                    大部分經費來自政府,但門診服務則主要由私營部門提供。
 

        The most significant point in favour of the existing system in Hong Kong is that
        it has a high degree of equity - no one is excluded from health care because of
        cost. The disadvantages of the government-funding approach are widely
        recognised. Hong Kong's government-run health care system is plagued by most
        of them and they are noted in the Harvard Report. Under this system, allocation
        of funds by administrative fiat leads to misdirection of resources, while access
        to the system at no financial cost at the point of use tends to create excessive
        demand for services. Without a proper monitoring mechanism it is difficult to
        control costs in such systems, and without financial incentives for staff service
        may be poor.

                    香港公營醫護最大的「優點」在於平等,沒有人因為無力付費而得不
                    到護理;但也存在著公營服務常見的弊端。用行政命令分配經費令資
                    源流向失當;用戶幾乎無須付費則導致需求過度。加上缺乏適當的監
                    察機制,難以控制成本。而員工一旦缺乏經濟誘因,服務很可能下
                    降。
 

        2. Fee for doctor with selective private insurance
                    2. 由私營保險付費給供應者
 

        Under this system, fees are paid to providers, either directly by users for
        services provided, or indirectly through private insurers out of premiums. Private
        insurance is unlikely to provide full coverage to all patient groups because of the
        problem of adverse selection, which makes private insurance financially not
        viable. A purely private fee-based system also faces problems; not least of
        which is restricted access to those without means. Demand is limited to those
        who can afford the fees charged. Resources are directed to those who can pay
        for the services, but at the cost of considerable inequity, since those without the
        means to pay are excluded from the system.

                    醫護費用或直接由用者支付給提供者,或間接由私營保險公司從保金
                    支付。但為免用者逆向選擇(adverse selection),私營保險通常不
                    會毫無選擇地接受所有人投保,也不會承擔全部醫護費用。而全私營
                    的保險凡事靠收費,老弱殘疾和經濟欠佳者受到排斥,資源流向有能
                    力付費者,造成差距。
 

        3. Insurance schemes funded fully or partly by public money
                    3. 由公帑全部或部份承擔保金
 

        With funding under an insurance scheme, the cost of health care is covered by
        insurance premiums paid by users, perhaps supported partly or fully by
        government funds. Payments are made to health care providers by insurers to
        cover the cost of care provided. Under this system, which for the most part
        characterises the United States health care system, users pay for medical costs
        indirectly through their insurance premiums. An insurance-based scheme can be
        designed in principle to meet both equity and efficiency objectives and is
        therefore popular with most economists.

        Insurance-based funding has its own drawbacks, however. One of the greatest
        difficulties associated with insurance systems is that they tend to increase costs
        as a result of the moral hazard problem. The use of deductibles and
        co-payments can mitigate some of the problems of overuse. In practice, though,
        it is unlikely that the problem of moral hazard can be entirely mitigated, because
        these systems do not operate in a vacuum and cannot be made immune from the
        reality of political tampering from powerful interest groups and misguided
        politicians. As a consequence, controlling cost can be a big problem. The
        examples of the United States and Taiwan are cases in point.

                    保險制度仍有資金時,醫護開支由用者繳付的保費承擔。但其中可能
                    部分或全部由政府承擔。保險公司直接對服務提供者支付用戶的費
                    用。美國即主要用這種方法,用戶透過支付保金,間接支付醫護費
                    用。原則上,利用保險以融資可以做到既平等又有效益,有很多國家
                    採用。但弊病是容易有道德危險,推高成本。利用扣除額
                    (deductible)和共同支付(co-payment)能夠減少濫用服務,但難以完
                    全避免。原因是保險制度無法避免利益團體和政客從中左右,以致難
                    以控制成本。美國和台灣都是箇中例子。
 

            Moral hazard

             One of the most difficult problems that the provision of health care
             financed by insurance must face is that the insured may change his
             or her behaviour as a result of being insured. Moral hazard refers to
             the reduction in the incentive to take precautions as a result of
             having insurance. Insurance is intended to protect against the
             consequences of a possible undesirable outcome, such as illness.
             However, if an individual is protected against the outcome of an
             event, he has less incentive to take precautions to prevent the
             outcome occurring.

             For example, let us suppose that a person develops a slight cough.
             This person knows that he is susceptible to bronchitis, and that the
             treatment for bronchitis is somewhat costly. If this person does not
             have insurance, he is likely to take precautions against aggravation
             of his illness in the hope that he will not have to pay for the
             expensive drugs that will be required should his cough develop into
             bronchitis. On the other hand, if the same individual, in the same
             situation, has insurance he is more likely to continue his normal
             behaviour, knowing that, should his cough develop into something
             worse, his doctor's visit and any necessary medication will be paid
             for by insurance.

             The consequence of this type of behaviour for the insurer is that it
             raises the cost of providing insurance. If the premium is calculated
             on the basis of estimates of the probability of the undesirable
             outcome occurring prior to provision of the insurance, the actual
             probability will be higher, with the result that the insurer will lose
             money. The results of moral hazard can be reduced by various
             mechanisms, for example, by requiring the insured to pay the first
             part of any claim up to a specified amount, or by offering
             no-claims bonuses, which create an incentive for insureds to
             protect themselves from illness.
 

        Adverse selection is another potential problem with voluntary schemes. A
        compulsory system can reduce the problems of adverse selection by spreading
        risk over the whole population. But one should note that the public health system
        is also prone to overuse by virtue of being a free service. Cost control is
        maintained through an inefficient rationing mechanism that eliminates patient
        choice.

                    這類用者自願選擇的計劃另一種問題是逆向選擇。強制性計劃由全民
                    分擔風險,減少了逆向選擇。但公共醫護服務是免費的,容易濫用。
                    要控制成本就只能配給,不但效益低,也限制用者的選擇。
 

        Insurers, since they operate primarily for profit, have strong incentives to control
        quality and cost of services and to prevent overcharging for and overuse of
        services. A body of private insurers will also form an informed counterbalance
        to the dominance of doctors. In fact, when the insurance system was first
        introduced in the United States, cost control and preventing overuse was not a
        problem, because the insurers provided an effective check against the perverse
        incentive of doctors to abuse usage and overcharge patients. However, in a
        landmark United States court case, the power of insurers to challenge the
        judgments of doctors in treating patients was severely curtailed. Since then it has
        been almost impossible to control health care costs in the United States.

                    承保者為了圖利,會力求控制服務的質素和成本,以免服務提供者收
                    費過高和濫用服務。美國最初推行私營醫護保險時,濫用服務和控制
                    成本還不是問題。但其後一宗歷史性的法庭判例大大削弱了承保者挑
                    戰醫生專業判斷的權利,此後幾乎無法控制醫療成本。
 

          Adverse selection

             The provision of insurance is complicated by the problem of
             adverse selection. If a person is healthy and believes there is little
             likelihood that she will become ill, she has little incentive to buy
             insurance. If she believes that she is likely to become ill, she has
             more incentive to buy insurance. This is a problem for insurers
             because, despite their best efforts to find out as much as they can
             about insureds' health prospects, individuals tend to know more
             about their own health than an insurer possibly can. As a result,
             adverse selection will take place, so that those insured will be more
             likely to suffer illness than the general population. One way to solve
             this problem is for insurance to be compulsory, so that risk is
             spread over the whole population, good and bad risks together. In
             a voluntary system, the effects of adverse selection can be
             countered by varying premiums based on the level of risk. Thus,
             health insurance premiums are in most cases determined according
             to the insured's age.

        The main concern with a compulsory government subsidised and managed
        insurance scheme is that it is not a genuine market system organised from the
        bottom up, but a contrived socialist market system organised from the top down
        and controlled from the centre by a board consisting of politicians, bureaucrats,
        professionals and experts. The welfare of the public is entirely dependent on the
        decisions of this board, and any error it makes will be propagated throughout the
        system. It is a universal compulsory scheme from which the patient has no
        escape. As previously mentioned, however, a scheme based entirely on a private
        insurance market, however, cannot work either, because of the problem of
        adverse selection and its limited ability to address equity concerns. Furthermore,
        private insurance is unlikely to provide comprehensive coverage for those with
        bad health risks.

                    由政府津貼和管理的強制性保險,最大的弊病是一種中央操縱的社會
                    主義市場制度,由政界和專業人士組成董事局自上而下控制,操縱公
                    眾的命運,一子錯滿盤皆落索。而作為全民制度,市民別無選擇。
 

        Theoretically, health care should be financed by an insurance scheme because
        the incidence of disease in the population is uncertain. Without insurance the
        burden of health care expenditure may fall on those who cannot afford it. An
        ideal insurance scheme should pool cross-sectional risks across the population
        and be able to move resources intertemporally over an individual's life cycle.

            Overuse of services

             Insurance-based health financing in countries such as the US has
             suffered from severe difficulties associated with overprovisioning
             of services. Since the provider is paid by the insurer according to
             the procedures provided, it has an incentive to carry out as many
             procedures as possible, even when these are unnecessary. The
             user, who sees no direct relationship between his premium and the
             services provided, is unlikely to object to unnecessary services,
             such as tests. In the US, government insurance-based provision of
             medical services through Medicare and Medicaid led to the
             ballooning of medical costs for just these reasons.

             This tendency can be countered by insurers taking steps to ensure
             that costs are controlled. Since under our proposal most insurance
             would be offered on a private commercial basis, there would be a
             strong incentive to control costs. This could be achieved through
             mechanisms such as fee schedules that limit maximum charges, or
             by requiring a second opinion before certain procedures are carried
             out. Insurers could also provide lists of preferred providers, known
             as preferred-provider organisations, which abide by cost schedules
             set by insurers. Individuals using those providers would enjoy
             cheaper insurance policies. Costs will also be kept in line by
             competition between insurers. Those that provided excessive
             services will find their costs and consequently their premiums
             rising, making them less attractive than other insurance schemes.

        In a sense, all the three systems described above can be considered as forms of
        insurance scheme insofar as they all pool risks within the population, although in
        different ways and to varying degrees. In reality, all three systems coexist to
        some extent in every modern society. In part this reflects the complexity and
        difficult of finding a single system to meet the sometimes conflicting objectives
        of equity and efficiency in providing health care to different groups of patient
        populations. In health care the problems arising from (1) information asymmetry,
        (2) the many well-organised and powerful interest groups, and (3) the often
        emotionally charged nature of the subject, create numerous political stress points
        that make it difficult for society to adopt a rationally designed system that meets
        the standards of professionalism and is politically and financially sustainable in
        the long run. Each of the three systems we have discussed has its comparative
        advantages and disadvantages when serving different population groups. The
        presence of mixed systems throughout the world reflects the enduring relevance
        of this important observation. For this reason, it is unwise to try to create a
        single universal health care system. Indeed, it may be sensible to consciously
        design an institutional arrangement that is mixed in nature, which would in effect
        allow patients to choose among alternatives, and which would let each system
        compete with the others.

                    上述三類融資都是為了分擔全體人口的風險,可說是不同的保險計
                    劃。但不同的人口組別有不同的需要,三類融資應用於不同的人口組
                    別時,各有利弊,故在其他國家都混合使用。加上醫療問題存在著
                    (1)資訊失衡,病人所掌握的醫學知識與醫生有差距,(2)利益集團
                    多,以及(3)討論時容易情緒化等特殊問題,難以達成一種既有專業
                    水平、在政治和財政上都能長期維持的合理制度。設立單一的全民制
                    度既不明智,還不如搞混合制,讓病人有所選擇,也鼓勵各種制度彼
                    此競爭。

                     
        4. The Harvard proposal
                    4. 哈佛報告的建議
 

        Given the difficulties with each of the three systems discussed above, and the
        problems of the present health care system in Hong Kong, what is the way
        forward? The preferred option offered in the Harvard Report is a compulsory
        jointly funded insurance scheme with an expanded role for patient choice and
        market forces. Both the government and the patient will contribute to the cost of
        the premium. The proportion of cost sharing will vary with the economic
        situation of the patient in question.

        In essence, the Harvard Report proposes two insurance plans. The first is the
        Health Security Plan (HSPs), which covers major unexpected medical costs and
        pools risks within the population through a pay-as-you-go mechanism. The
        second is the Savings Accounts for Long Term Care (Medisage), which
        provides an individualised accumulative fund for purchasing long-term insurance
        coverage for old age or disability. A Health Security Fund (HSF) will be
        established to run the HSPs as a quasi-governmental body, and will be
        supervised and managed by a board with representatives of government,
        employers, employees and patients. This board will purchase health services
        from provider groups in both the public and private sectors.

                    哈佛報告建議設立強制性聯合保險計劃,由政府和用者分擔保費,分
                    攤比率視乎用者的經濟能力。建議中的兩種保險,一是「聯合保健」
                    (簡稱「HSP」),涵蓋意外的大筆開支,透過隨收隨支
                    (pay-as-you-go)方式由全港市民分攤風險。二是「護老儲蓄戶口」
                    (簡稱「MEDISAGE」),每人長期累積一筆資金,用來購買長期護理保
                    險,以備年老或不幸傷殘之需。聯合保險的資金由半官方機構「聯合
                    保健基金」(HSF)經營,由政府、僱主、僱員和病人代表合組董事局
                    監管,由董事局負責選購公私營醫護服務。
 

           Information asymmetry

             From the point of view of the user of medical services, one of the
             biggest problems with health care in general is obtaining
             information. The complexity of medicine and its technical nature
             tend to make it difficult for most patients to fully understand the
             treatment they are being offered. This, it is argued, prevents
             patients from making informed decisions, the basis of any
             workable market. Decisions are better left to those with the
             knowledge to make them, that is, doctors. The reverse side of this
             coin is that the monopoly of knowledge in the hands of doctors
             places them in a position to dominate the decisions-making process
             throughout the health system. In Hong Kong the lack of access to
             medical information is more acute than in many other parts of the
             world. It is frequently the case that doctors fail to explain
             treatments and medicines to their patients. User education is almost
             entirely lacking. And, of course, there is virtually no way that
             patients can access information on the quality of treatment offered
             by hospitals or doctors, except through word of mouth.

             In order to create effective competition, more information will have
             to be made available to patients. It is often argued that one of the
             reasons doctors must dominate health care decision making is
             because the consumers of health care, unlike purchasers of other
             goods, are unable to fully understand the good they are receiving.
             Since the choice of medical care may be a life-and-death issue, it is
             vital that only the technically competent make decisions. Against
             this it can be argued that users do not need to fully understand
             medicine in order to make reasonably informed decisions.
             Consumers also make life-and-death decisions when, for instance,
             they purchase a car or buy a plane ticket. In both cases, consumers
             rarely fully understand the engineering of cars and aircraft. They are
             however, able to form a judgment of the reputation for safety of the
             make of car they purchase or the airline they fly with. In Hong
             Kong consumers could make much more informed medical
             decisions if the government were to collect and publish a far greater
             amount of information on the costs and outcomes of heath care
             providers than it currently does. Steps could also be taken to relax
             restrictions on advertising by the medical profession.

        The Harvard Report offers a second stage of reform to be built on the basic
        reform of financing. Under this option, the HA will be reorganised into 12 to 18
        regional Health Integrated Systems (HISs). The HISs would include regional
        public hospitals, which would be allowed to contract with private general
        practitioners and specialists to provide benefit packages covering preventive,
        primary, outpatient and hospital care. Private hospitals and physicians groups
        will also be allowed to participate in an HIS to provide benefit packages. The
        HISs are providers but they are not health maintenance organisations (HMOs)
        because the latter employ third-party managers to oversee and monitor
        providers' treatment decisions. The aim of forming these HISs is to overcome
        the existing compartmentalisation of health services by offering integrated
        services.

                    哈佛報告建議,完成上述改革後,再把醫管局重組為12-18個「地區
                    性醫療一體化系統」(簡稱「HIS」)。各HIS屬下的地區性公立醫院可
                    與私家執業者和專家簽約,由後者提供預防、基層、門診和住院等服
                    務。私家醫院和醫生組合也可以直接參加HIS以提供服務。HIS雖然提
                    供服務,但並非美國的保健組織(簡稱「HMO」)。後者另僱專家以查
                    驗服務提供者的診治。成立HIS是為了打破醫護界服務的分裂隔離,
                    提供全套服務。
 

        It is argued that such a scheme will offer a number of advantages over the
        existing system. It is a simple scheme with a coherent concept that puts funds in
        the hands of the patient rather than the health care provider.

                    哈佛方案認為新制度簡單,目標首尾一致,而且由用者掌握開支。此
                    外,還有下列優點:
 

        Maintaining and improving efficiency.

        The Harvard scheme promotes risk pooling and provides equal insurance
        coverage to every resident, so that all are assured of health care.  Subsidies are
        provided for those who cannot pay.

                    (i)更加平等:分攤了風險,為所有市民提供同等的保險給付,確保
                    所有人獲得服務。無力付費者可獲津貼。
 

        Improving quality and efficiency.

        The principle of "money following patients" creates equality for public and
        private-sector providers. Compartmentalisation of health services in the parallel
        public and private sectors would be removed. The HSF provides accountability
        to patients and the public, and a counterbalance to the dominance of doctors.

                    (ii)改善質素,提高效益:「錢跟病人走」使公營與私營部門得以公
                    平競爭,公、私營不再各自為政、分裂隔離。HSF對病人和公眾負
                    責,減少了醫生利用專業知識對病人享有的優勢。
 

        Improving financial sustainability.

        Built-in controls such as negotiated payment rates and demand-side cost sharing
        will help manage the government budget.  Separation of purchasing and
        provision lays the foundation for competition between public and private
        providers and raises accountability and efficiency.

                    (iii)財政上更穩定:有關計劃內含機制,例如洽商釐訂支付率、由
                    需求方分享成本,從而控制政府預算。分開服務的一買一賣,使公、
                    私營部門得以競爭,增加問責性和效益。
 

        Targeting subsidies.

        Government resources can be targeted to areas where they are needed.
        Resources will be targeted through subsidies for premiums to benefit those who
        cannot afford health care, unlike the present system where the heavily subsidised
        public sector benefits rich and poor alike.

                    (iv)有需要才津貼:透過津貼無力付費者的保費,把公共資源用在最
                    有需要的地方,而非目前那樣不論貧富一視同仁。
 

        Meeting the future needs of the population.

        The MEDISAGE scheme provides for care of the elderly by funding the future
        costs of their care.  These individualised accounts will be used to purchase
        insurance plans in old age, and if they are unspent will become a part of an
        individual's estate.  In principle this is similar to Singapore's MEDISAVE
        account.

                    (v)滿足未來人口的需要:人人有自己的MEDISAGE戶口,以備他日購
                    買長期護理保險用,確保能支付年老的護理開支。到時若無須動用,
                    則作為該人的遺產。這基本上像新加坡的MEDISAVE戶口。
 

        Managing health expenditure inflation.

        The Harvard scheme helps control inflation of health costs by separating
        purchasing and provision and by negotiating on payment rates.   The "money
        follows patients" principle promotes efficiency through increasing competition,
        while deductibles and co-payments limit consumer demand.

                    (vi)控制開支漲勢:分開服務的買和賣和洽商釐訂支付率,均有助於
                    控制成本。「錢跟病人走」增加競爭,提高效率。保險設置扣除額和
                    共同支付,限制了需求。

                     
        5. The difficulties
                    5. 哈佛報告實行的困難
 

        A top-down market system.

        Under the Harvard scheme, it is suggested that a central HSF be established to
        act as a purchaser for health services on behalf of the patient. The central role of
        the HA as both a buyer and provider of services would be changed to one where
        it is only a provider. It is not clear that this solution would necessarily result in
        any significant improvement in terms of competition among health service
        provider organisations, since the creation of a single central purchasing organ
        would in effect impose another administrative solution at the core of the new
        system. Rather than consumers, it would be this administrative body that
        decides what services should be covered by insurance, the rate of
        reimbursement and premium payments. In effect, the board would dominate the
        purchase of health services in Hong Kong, and would be able to impose its view
        of the health needs of Hong Kong's population on service providers. While
        patients might have a choice of doctors, they would not be able to choose an
        alternative system of health care providers; HISs would provide all health care
        services.

                    (i)自上以下的市場:哈佛報告建議由中央設置HSF,代表用者選購服
                    務,相當於用HSF取代集買賣於一身的醫管局,也就是由這個行政機
                    關而不是用者來決定保費、賠償率和哪些服務屬於承保範圍。這能夠
                    增加服務提供者之間的競爭?屆時HSF董事會將會壟斷買家市場,將
                    本身對公眾需要的看法強加於服務提供者。用者縱使有權選擇醫生,
                    卻無權選擇另一套制度。
 

        Yugoslav labour cooperatives.

        In the Harvard Report it is explicitly stated that the HISs are not HMOs because
        they do not employ third-party managers.  One should note that the reason why
        United States HMOs employ third-party managers is that they are a business.
        Many HMOs are publicly listed companies.  Third-party managers are employed
        to ensure that shareholder value is maximised and that the HMO is efficiently
        managed.   If the 12 to18 HISs are really not HMOs, then what are they?  The
        best way to characterise a quasi-governmental health service organisation is as a
        Yugoslav-style labour cooperative.  Such organisations seek to maximise the
        wage bill per worker, rather than profits.  They will not result in overall economic
        efficiency.   Competition amony regional HISs, which, unlike corporations, do
        not seek to maximise profits, will not generate optimal savings for society.  One
        should note that private hospitals in Hong Kong are not really business
        corporations either; rather they behave as labour cooperatives responsible to
        self-perpetuating management boards dominated by senior doctors and do not
        have shareholders to whom they are accountable.

                    (ii)南斯拉夫式勞工合作社:哈佛報告指明,HIS並非HMO,因為並不
                    僱用第三方管理人員以查核名下的醫護服務。美國的HMO是商營的,
                    不少是上市公司。這樣做是為了確保效益和股東的利益。如果香港屆
                    時的12-18個HIS並非HMO,那又是甚麼?半官方醫護組織的最佳例子
                    是南斯拉夫的勞工合作社,目的是為工人爭取最大的人均工資,而非
                    所屬機構的利潤。這對增進整體效益無助。HIS並非牟利性,彼此競
                    爭並不能為社會節省最多的資源。香港的私家醫院也類似勞工合作
                    社,向上負責的是以資深醫生為主的長青管理委員會。
 

        Under ideal conditions and if implemented as envisaged, the Harvard
        recommendations would create a Yugoslav-style socialist market system, the
        problems of which are well documented in the comparative economics literature.
        Such problems include inefficiency from a systemwide perspective, investment
        decisions being made to maximise per capita wages, labour mobility being
        minimised to protect the interests of the existing workers, and lack of innovation
        because property rights over innovations are not well defined. It is therefore not
        surprising to find that medical doctors working in United States HMOs are
        highly critical of their own system. Indeed, they would prefer a Harvard-style
        HIS.

                    (iii)哈佛建議若付諸實施,很可能導致南斯拉夫式的社會主義市場
                    經濟。弊病包括:投資時求取最大的人均工資;為了保護既有工人的
                    利益,不鼓勵工人轉換工作;由於知識產權定義不明,缺乏創新。難
                    怪美國HMO屬下的醫護人員對本身的制度大為不滿,寧取哈佛式的
                    HIS。

                     
        6. Political Economy of Reform
                    6. 改革的政治經濟學
 

        For the Harvard recommendations to be implemented as envisaged it would
        require a total reorganisation of the system of health care provision and the
        creation of a radically different set of institutions. The provision of health care
        anywhere in the world is the locus of powerful conflicts of interest where
        entrenched groups are strongly motivated to look after their own interests in the
        name of the public good. Doctors, administrators and politicians are all in a
        position to significantly influence the way in which health care is provided.
        Health care provision is also a highly emotional issue, touching as it does on the
        fundamental interests of every member of the community. The fear of even
        relatively minor illness and its financial costs - not to mention of life-threatening
        medical conditions - is almost universal.

                    要實施哈佛的建議,須翻轉現行的服務供應方式,另設一組截然不同
                    的機構。世上各地的醫護制度都是社會利益的戰場,各派人士都假公
                    眾利益之名爭一己之利。醫生、醫護行政人員和政客各據有利的地
                    位,力求左右醫護服務的方向。而對病痛老死的恐懼是與生俱來的,
                    加上對鉅額醫藥費用的憂慮,因此,醫護的議題往往十分情緒化。
 

        Given these powerful interests and fears, it is highly unlikely that any major
        reform of health care financing such as that envisaged by the Harvard Report will
        be accepted by all parties involved without strong resistance from certain
        quarters. Whatever its merits, acceptance of the Harvard proposal will require
        that interest groups be mollified with concessions, which will weaken financial
        controls and expand budgets. Such concessions may have the effect of fatally
        weakening the reformed system and of defeating one of its main objectives -
        effective control of the health care budget. This will lead to a situation in which
        costs can potentially escalate rapidly under the reformed system, so that within a
        short time it will become insolvent. This in effect has been the experience in
        Taiwan, where health financing has undergone a wide-ranging reform similar to
        that suggested by the Harvard Report for Hong Kong and where costs have
        increased sharply in a few years' time. The same is likely to happen in Hong
        Kong, given the absence of good health care statistics, which will give free rein
        to "informed prejudice".

                    由此觀之,像哈佛建議這種全面性的改革要成為社會共識機會不大。
                    不論該報告有理與否,這種改革須對各種利益集團作出讓步,包括增
                    加預算、削弱對財務的控制,以致動搖新制度,抵消有效控制醫護預
                    算的改革原意。台灣即曾實施類似哈佛報告的改革,結果成本在數年
                    內大幅飆升。
 

        If this happens in Hong Kong, the system will have to be refinanced by
        increasing premium contributions that will become politically divisive. As a
        consequence, service quality will begin to deteriorate, and eventually it may not
        be possible to allow for unrestricted patient choice. If this unfortunate outcome
        occurs, the entire reform effort would have been defeated, and the system of
        social insurance would have degenerated into nothing more than a scheme of
        earmarked taxes. In essence, the old system will be revived, and some of the key
        objectives of the reform - increasing user choice and controlling costs - will be
        lost. The public, however, will have been lured into paying more for its health
        care, although the system - and, within it, the type and quality of care available to
        them - will remain fundamentally unchanged.

                    香港缺乏可靠的醫護數據,易受「有識的偏見」左右。萬一因而重蹈
                    台灣的覆轍,就只能提高保費,造成政治分化,損害服務質素,最終
                    令用者的選擇再度受到限制。屆時改革將付諸東流。這項社會保險制
                    度只不過是另一種特定的稅項。至此又將回到舊制,差別只是公眾須
                    付出更多的費用才能獲得同樣的服務。

                     
        7. ChoiceCare: an alternative proposal
                    7. 「選擇多」醫療保險方案:另類選擇
 

        With these reservations in mind, a more gradualist, but nevertheless fundamental,
        approach may be more appropriate for Hong Kong. This approach will retain
        elements of the existing system, while attempting to create a greater balance
        between the various elements, so that no one sector dominates, as is the case at
        present. Creating a better balance between the private and public sector will
        enhance competition among health care providers, providing them with an
        incentive to continuously improve the quality of health care service. It will also
        achieve the goals sought by the Harvard proposal - sustainable financing,
        enhanced user choice, and improved quality of service - without the political
        costs and with less of a chance of reform failure.

                    基於上述原因,香港的改革應從根本上著手,但更為循序漸進。本文
                    建議保留現制度的各方面,而嘗試在期間求取平衡,以免像目前由某
                    些方面支配大局。公、私營部門若較為均衡,有利於促進競爭,改善
                    服務質素。本建議同樣能達成哈佛報告的目標-財政穩定、增加選擇
                    、改善質素,卻得免箇中的政治成本,成功機會較高。
 

        The key elements in our proposed reform would be (1) a system of voluntary
        subsidised insurance rather than a universal compulsory system and (2) a gradual
        integration of the public and private sectors. The voluntary subsidised insurance
        scheme will be called ChoiceCare.

                    本文建議設立名為「選擇多」醫療保險方案(ChoiceCare)的自願受津
                    貼保險計劃,而非哈佛報告的全民強制性保險,並逐步結合公、私營
                    部門,打破「分裂隔離」。
 

        Those who join the ChoiceCare scheme will receive a government subsidy on
        their basic-level premiums. The basic insurance plan will cover a fixed set of
        services that must be made available to all who wish to join. Should users require
        a greater range of services, they will be able to upgrade their coverage by making
        additional premium payments for additional services. Under this proposal,
        individuals will be permitted to purchase health insurance not from one central
        supplier as they would under the Harvard proposal, but from any number of
        possible suppliers. These could include not only hospitals and doctors' groups,
        but also insurance companies. The insureds will be permitted to choose their
        health care provider from among a number of options. These could include
        public hospitals, private hospitals, independent doctors or doctors' groups.
        Unlike the Harvard proposal, the creation of HMOs would not be precluded.
        Insurance companies that participate in the scheme could maintain a list of
        preferred doctors similar to preferred provider organisations (PPOs) in the
        United States. Since there is an element of government subsidy in this voluntary
        insurance scheme, health care providers and insurers will not be able to refuse to
        cover patients on a selective basis. Those individuals who do not join the
        government-subsidised scheme will have two choices - to use either the public
        or private systems.
 

                    市民若選擇參加「選擇多」醫療保險方案,基本保費獲政府津貼。基
                    本投保範圍包括一系列特定服務。若希望享有更多服務,可選擇增加
                    保費以擴大投保範圍。市民有權同時向數家承保人投保,而非像哈佛
                    報告,全港的保險由政府包辦。服務提供者可以是醫院、聯營的醫
                    生,也可以是保險公司。投保人在一定範圍內有權選擇服務提供者,
                    包括公立醫院、私家醫院、獨自或聯營執業的醫生。與哈佛報告不
                    同,本文認為毋須排除美國式HMO(保健組織)的可能性。參與本計劃
                    的保險公司可選定某些醫生,供投保人優先選用,類似美國「優先供
                    應商組織」(preferred provider organisation,簡稱“PPO”)的做
                    法。由於「選擇多」醫療保險方案享有政府津貼,服務提供者和承保
                    人也就不能挑選投保人。不參加計劃的市民可自行付費使用公、私營
                    服務。
 

        Under this proposal, the public health system will continue to exist, but it will be
        open to a number of new competitive forces. Its budget will be reduced in
        proportion to the number of people who join the voluntary subsidised insurance
        scheme. But hospitals belonging to the HA will be able to recapture this lost
        financing by competing to provide services to those who have joined the
        voluntary insurance scheme, by, for instance, offering their own health care
        services and insurance plans. To create a level playing field the public hospitals
        will also be permitted and required to give access to private doctors to provide
        services to patients on a fee-charging basis. This will effectively transform HA
        hospitals into a system that provides two types of service. The first service type
        is a publicly funded free service similar to the service offered under the present
        system. It will be provided to those patients who did not join the voluntary
        insurance scheme. The second service is provided on a competitive basis, with
        providers charging market fees to fee-paying and ChoiceCare covered patients.

                    在本方案下,公營制度繼續運作,但接受新的競爭。公營部門預算視
                    乎「選擇多」醫療保險方案投保的人數,按比例削減。但公立醫院透
                    過提供服務和承保,只要能成功爭取投保的市民,完全可以彌補所削
                    減的資助。為了營造公平的競爭環境,私家醫生可在公立醫院範圍
                    內,收費診治病人。醫管局自此實行「一局兩制」。所提供的第一種
                    服務類似現行的政府免費服務,供未曾加入「選擇多」醫療保險方案
                    的市民享用。第二種服務透過競爭提供,服務提供者按市價對自費和
                    「選擇多」醫療保險方案投保人收費。
 

        By forcing HA hospitals to compete with the private sector directly for patients
        the system will put in place a real and effective mechanism that will improve
        efficiency in what is otherwise a bureaucratically managed system. Most
        importantly, the HA will be changed from being a bureaucratic purchaser and
        provider of services to being the administrator of a system in which user demand
        will play a much greater role in financing. The HA would be subject to
        competition from other providers within a framework in which users will be able
        to choose their providers. Different forms of organising health care provision,
        such as doctors panels, PPOs, and HMOs, which are currently nonexistent or
        very limited in Hong Kong, could become available and will be able to compete
        in the market for clients.

                    醫管局直接與私營部門競爭病人後,才有真正有效的機制以改善效
                    益,不必再用資源堆砌成就。由於用者得以選擇服務,用者需求對醫
                    院的財務狀況舉足輕重,醫管局的角色將會由官僚的採購者和服務提
                    供者變成新制度的管理者。醫生小組(doctors panel)、PPO和HMO等
                    香港較為罕見的醫護服務提供方式,屆時均可以在市場上競爭,為市
                    民提供選擇。
 

        The fundamental attraction of the ChoiceCare scheme is twofold. First, the
        scheme allows for more efficient allocation of resources among providers. As
        users will be able to choose both their providers and how to finance their health
        care, finance will follow the patients rather than being allocated on purely
        bureaucratic principles. Such a system imposes discipline on HA hospitals and
        also on the private sector because it too will be competing against a liberated HA
        sector. Second, the traditional role of the HA as provider of last resort for those
        without means will continue without fear of service disruption. These changes
        will not only provide an improved quality of service, but will translate into overall
        efficiency gains for the health care system and will result in net savings for
        society.

        Since the subsidised insurance scheme is purely voluntary, there will be no
        coercive pressure to join, making it politically more feasible. Under this proposal
        insurers will be required to insure all those wishing to join, but insurers will be
        permitted to vary the premium depending on risk. Some people outside the
        scheme will find joining the ChoiceCare scheme very attractive. Those who rely
        on the existing public health system will be attracted to the higher-quality service
        and the possibility of choosing providers, such as hospitals and doctors. For
        those using the current private system, there will be the attraction of subsidised
        insurance. This will permit the user to choose not only his health care provider,
        but also his health care system. The option of moving from one system to
        another will help create a better greater balance between the different sectors.

                    這有兩大好處。一是更有效地在各服務提供者之間分配資源。用者同
                    時得以選擇服務提供者和融資方式,所謂「錢跟病人走」而非按官僚
                    的意願分配。醫管局固然受到牽制,但醫管局進一步開放後,私營部
                    門亦面對更強的競爭。二是醫管局將繼續擔當醫護服務的最後提供
                    者,確保無力付費者也能獲得服務。
 

        The level of financing withdrawn from the public health system and the amount
        of subsidy provided to ChoiceCare participants will have to be estimated
        carefully so that the overall financial commitments of the public purse is known
        and controlled. In particular, the transfer of public funds from the public health
        system to ChoiceCare patients has to take into account the characteristics of the
        patients that join the ChoiceCare scheme. Caution may be necessary initially in
        determining the proper level at which to subsidise the ChoiceCare scheme, given
        that detailed medical and health cost figures are not available at present. Over
        time it will be possible to revise the commitment as experience is gained. It was
        pointed out at the very outset of this paper that the paucity of available detailed
        statistics mandates an evolutionary reform strategy. A strategy designed with
        built-in feedback systems so that the initial effects and results of reform can be
        used to modify policy parameters over time will be most effective in light of the
        small amount of data currently available.

                    至於應從公營醫護中抽取多少撥款,對「選擇多」醫療保險方案投保
                    人應提供多少津貼,務須仔細估算,以確切掌握預算中和實際的公帑
                    開支。尤其當抽出部份公營服務撥款用來津貼「選擇多」醫療保險方
                    案時,必須考慮到「選擇多」醫療保險方案投保者的人口組合。由於
                    缺乏醫護成本的數據,「選擇多」醫療保險方案初期就政府的津貼釐
                    訂最合適的水平時,須倍加謹慎。待累積了數據和經驗後,再修正原
                    先的水平。本文一開頭即指出,由於缺乏數據,醫護改革必須循序漸
                    進。本建議內含回饋機制,利用初期實施的成效修正政策參數,最能
                    針對這項缺失。
 

        A major attraction of such a reform strategy is that the relative desirableness of
        the ChoiceCare scheme versus the public health system can be controlled by the
        government through the relative generosity with which each sector is funded.
        The balance between the two systems can be maintained and changed over time
        through differential funding. Maintaining such a balance is desirable not only in
        terms of improving service quality, but also in terms of controlling the overall
        cost.

                    「選擇多」醫療保險方案的另一個優點是「選擇多」醫療保險方案和
                    公營服務同時受政府資助,市民相對歡迎哪一種,透過兩者受資助的
                    多少而操諸政府之手。利用這項差別可以改變兩種服務的對比,從而
                    改善服務、控制成本。
 

        Patients who join the ChoiceCare scheme will not have the option of falling back
        on the public health sector. This is an important feature for controlling overall
        cost and avoiding the abuse of the public health system, which is probably
        pervasive at present. Currently, as a result of perverse incentives, many patients
        turn to the private sector for the treatment of major illnesses for as long as they
        can afford it, and when their money runs out they are shoved into the public
        sector. This is of course the extreme manifestation of the major weakness of the
        present health care system, under which over 80% of outpatient treatment is
        undertaken by the private sector, but over 90% of inpatient treatment takes place
        in the public sector.

                    市民參加「選擇多」醫療保險方案後,不得再依賴公營服務。這對於
                    控制成本、防止濫用公營服務十分重要。後一弊病目前十分普遍。不
                    少人出於負面誘因,只要尚有經濟能力,患病時大都先向私家醫生求
                    診。錢一旦用光就轉介給公營部門,以致私家醫生佔了八成多的門診
                    「生意」,但公立醫院須負擔九成以上的住院服務。公營之弊莫過於
                    此。
 

        Unlike the Harvard scheme, ChoiceCare would not require that insurance be
        offered by a central body. Rather, multiple providers will offer insurance
        policies. The precise terms and conditions of services provided will be
        determined by the market of patients, providers, and insurers, not by any central
        administrative body. There will be an element of government oversight of the
        insurance system to ensure order in the market and fairness to consumers.
        Insurance schemes will be regulated and monitored by the government to
        guarantee that they meet minimum standards of coverage, service, financing and
        reimbursements.

            ChoiceCare

                 1. voluntary subsidised insurance
                 2. government subsidy of basic insurance premiums
                 3.  upgrading of insurance coverage possible at higher premiums
                 4.  many sellers of insurance permitted, including hospitals,
                 5.  doctors' groups and insurance companies
                 6.  patients have choice of providers, including public and private
                 7.  hospitals, doctors' groups or individual doctors
                 8.  public and private systems will coexist with ChoiceCare
                 9.  regulation of system by government to ensure high standards
                 10. possibility to introduce medical savings for serious illness and
                      old age
                 11. flexibility allows for policy adjustment as system evolves

                   與哈佛報告建議由中央經營保險相比,「選擇多」醫療保險方案容許
                    不同的保險計劃。承保的條件由用者、提供者和投保者構成的市場決
                    定,避免中央式的指令經濟。但由政府監管「選擇多」醫療保險方案
                    保險,確保市場秩序、以及用戶獲得公平的對待,特別是承保範圍、
                    服務質素、融資和賠償各方面須達到最低的要求。
 

        In the future, it may be necessary to introduce a system of pre-funding health
        care expenditure through the creation of individual savings accounts to meet the
        needs of long-term care for old age and disability, and to meet catastrophic
        needs. But pre-funding should only be introduced after the entire health care
        system has achieved a better balance between and greater integration of the
        public and private sectors. Such a development would be appropriate after the
        ChoiceCare scheme has become a significant factor in promoting the
        transformation of health care provision. At that point, the public will then be
        more readily convinced that pre-funding is not a pretext for raising taxes in the
        absence of any patient representation in determining the kind of care they
        demand.

                    今後或須設立預付醫護開支用的個人儲蓄戶口,應付長者和傷殘人士
                    的長期護理需要或意外的大筆醫護開支。但只能當「選擇多」醫療保
                    險方案在改革中有了明顯的成效,公、私營部門逐步融合後,才宜引
                    進。屆時病人有了代表參與決策,公眾才不會誤以為設立預付的戶口
                    是政府巧立名目,變相加稅。
 

        There is no single ready-made answer to any of society's health care problems.
        As Hong Kong changes and becomes more affluent, rather than becoming
        simpler, its health problems will become more complex and difficult to resolve.
        In this respect, a diversified system that offers a number of options is the best
        solution. Not only will Hong Kong need to provide hospital and outpatient
        services, it will also have to pay much greater attention to health education,
        prevention, and community medicine. This proposal will maintain equity while
        enhancing quality and efficiency by diversifying the health care system, and
        creating a situation in which the various elements in the system are more
        balanced. It would also pave the way for pre-funding health care expenditure so
        that Hong Kong at some point will not have to rely solely on a pay-as-you-go
        system for financing health care services. Above all, this option offers a
        gradualist programme of change that reduces the risk of failure as a result of
        initial miscalculation of costs and permits policy adjustments as the system
        evolves.

             Diagram 1 shows the current situation with parallel public and
             private health care systems. The user has the choice of either the
             free public sector or the fee-paying private sector.

             Diagram 2 shows the Harvard proposal. The patient will choose
             among various HIS plans, although all patients will be within the
             same compulsory system. Fees will follow the patient to whichever
             provider he chooses. All providers will operate under the same
             system, with the HSF as the single purchaser of services.
 
 

             Diagram 3 shows the ChoiceCare Proposal. Patients will choose
             from a range of subsidised insurance schemes. These may be
             offered by both public and private providers as well as insurance
             companies. Public and private sector providers will be integrated,
             although not completely. Fees will follow the patient in the
             ChoiceCare system, who will also have the option of going to the
             traditional public or private sectors. ChoiceCare plans will be
             regulated by the government.



                    談到醫護問題,不論哪個社會都沒有現成的答案。香港日益富裕,人
                    口發生變化,醫護問題只會愈來愈複雜。多元化方為上策。在治療外
                    兼顧健康教育、預防和社會醫療。本建議即提倡醫護制度多元化,讓
                    各種服務提供者得以在接近均勢下經營,在平等之餘提高服務質素和
                    效益。本建議同時為預付醫護開支鋪路,使市民終有一天毋須靠隨用
                    隨付的方式應付醫護開支。我們主張循序漸進的改革,以降低實施初
                    期因成本估算出錯而功敗垂成的風險,也為其後視乎初期成效而調整
                   政策留下了餘地。
 
 

        Notes:

        1 Professor of Economics at the University of Hong Kong and Director of the
        Hong Kong Centre for Economic Research.
        2 This scheme was originally proposed in the study by Joel W. Hay, Health
        Care in Hong Kong: An Economic Policy Assessment, Hong Kong Centre for
        Economic Research, Chinese University Press, 1992
 
 
 

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