The Development of Ambulatory Patient GroupsAPGsfor the　National Health Insurance-An application of tree analysis

Abstract

The National Health Insurance program (NHI) has been in place for more than 5 years. To reduce the financial impact on the providers, Fee-for Service is still the pre-dominant payment system at early stage of NHI implementation. Regarding the cost containment, total ambulatory care cost accounted for more than two-third of the total health care expenditures, annual growth rate of outpatient care being up to 11%, with the growth on the utilization rate (9%) as the major contributor of health care cost inflation. The cost control on ambulatory care, especially for physician visit becomes a crucial issue for NHI. In addition to utilization review, reference price system of Labor Insurance and/or the use of "Simple claim form" (fix drug payment per diem) of NHI were the major strategies to be used to control the cost of ambulatory care. However neither of them take patients' case-mix into account. Besides, both strategies tended to encourage providers to increase the volume of physician visits. Therefore, It is crucial to develop a payment system, which will reflect the case-mix of ambulatory care and also has the potential to be used as a tool to control ambulatory cost. In this presentation, I will introduce briefly the payment issues that NHI is currently facing, followed by the introduction of the methodology and preliminary results of this on-going study. The application of the results to the design of the payment system reform for NHI will also be discussed.