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Inte rimReviewof
ElderlyHealthCareVoucher
PilotScheme
FoodandHealthBureau
DepartmentofHealth
February2011
GovernmentofHongKong SpecialAdministrativeRegion
ElderlyHealthCareVoucherPilotScheme:AnInterimReview
Cont en t
EXECUTIVESUMMARY I
PURPOSE 1
BACKGROUND 1
POLICYADDRE SS
1
SCHEMEOBJECTIVE S
1
IMPLEMENTATION 2
SCHEMEDESIGNANDFEATURES
2
ElderlypersonseligibletoparticipateintheScheme 2
Healthcare serviceproviderseligibletoparticipateintheScheme 2
Restrictionsontheuseofhealthcarevouchers 2
SCHEMEOPERATION
3
Mechanismforissuingandusinghealthcarevouchers 3
Arrangementforreimbursementofhealthcarevouchers 4
eHealthSystem 4
PrivacyImpactAssessmentandPrivacyComplianceAssessment 5
SecurityRiskAssessmentandAudit 6
Theelectronic platformpilotingamodelforschemeadministration 6
IMPROVEMENTMEASURES
7
Datainputofclaimtransactions 7
ModificationtoConsentForm 7
NoneedtoarrangeVoucherAccountCreationForm 8
UseofSmartIdentityCardReader 8
PUBLICITYANDPROMO T IO N
9
REIMBURSEM E NT
10
POST‐CLAIMCHECKINGANDAUDITING
10
MeasurestopreventabuseoftheScheme 11
TheCorruptionPreventionDepartmentofIndependentCommissionAgainstCorruption 12
TheAuditCommission 12
INTERIMREVIEW
13
Objectivesoftheinterimreview 13
Methodologyandsourceoffindings 13
ElderlyHealthCareVoucherPilotScheme:AnInterimReview
STATISTICSONPA RTICIPATIONANDUTILIZATION 15
METHODOLOGY
15
RESULT S
15
(A)
Statisticsonhealthcareservicepro viders 15
Numberofenrolledhealthcareserviceproviders
15
Distributionofplacesofpractice
15
Enrolmentamonghealthcareprofessionals
18
Participationamonghealthcareprofessionals
20
Enrolmentandwithdrawalofhealthcareprofessionals
21
(B)Sta tisticsontheelderly 23
NumberofelderlypeoplejoiningtheScheme
23
(C)Voucherutilizationpattern 23
NumberofeHealthaccountscreated
23
Numberofclaimtransactionsmade
25
NumberofeHealthaccountswithzerobalanceofvoucher
25
Distributionofclaimtransactionsamonghealthprofessions
25
Distributionofclaimtransactionsbyreasonofvisit
27
Numberofvouchersusedpertransactionbytheelderly
29
Numberofvouchersclaimedbyhealthprofession
31
Medianofvouchersclaimedpertransactionbyhealthprofession
33
Distributionofvouchersclaimedandtransactionsmadebymedicalpractitioners
34
Doctor‐patientrelationship
35
FEEDBACKFR OMTHEELDERLY 37
OPINIONSURV EY
37
METHODOLOGY 37
RESULT S 37
(A) Reasonsforusingvouchers 38
(B) Schemeawareness 40
(C) Schemescope 43
a.
Subsidyamount 43
b.
Ageeligibility 44
c.
Coverageofhealthservices 44
(D) Scheme delivery 45
(E) Schemeimpact 46
a.
ChoiceofhealthcareservicesafterSchemelaunch
46
b.
ChangeinservicefeesafterSchemelaunch
47
ElderlyHealthCareVoucherPilotScheme:AnInterimReview
WILLINGNESS‐TO‐PAY
STUDY
49
METHODOLOGY 49
RESULT S 49
(A) Willingnesstopay 50
(B) Willingnesstoco‐pay 52
(C) Subsidy 54
FEEDBACKFR OMHE ALTHCARESERVICEPROVIDERS 56
METHODOLOGY
56
RESULT S
56
(A)
Reasonsforchoiceofparticipation 56
(B)
Schemedelivery 56
(C)
Schemeimpact 57
(D)
Suggestionsfr o mhealthcareserviceproviders 57
CONCLUSIONSANDRECOMMENDATIONS 58
KEYOBSERVATIONSONTHESCHEME
58
(i) Schemeawarenessandparticipation 58
(ii) SatisfactionwiththeScheme 59
(iii) Impactonhealthcareseekingbehaviour 60
(iv) Priceandsubsidyforhealthcareservices 62
(v) Coverageofhealthcareserviceproviders 63
RECOMMENDATIONS
63
APPENDIX1‐“FULLVERSION”AND“COND E NSEDVERSION”OFCONSENTFORMSINEHEALTHSYSTEM
68
APPENDIX2‐LISTOFDISTRICTELDERLYCOMMUNITYCENTRESANDNEIGHBOURHOODELDERLY
CENTRESHOMES 72
APPENDIX3–PROTOCOLSONMONITORINGANDINVES TIG ATIONOFTRANS ACTIO N CLAIMSMADE
THROUGHTHEEHE ALTHSYSTEM 77
APPENDIX4‐LISTOF“REASONOFVISIT”INRESPE CTOFTHEHEALTHCAREPROFESSIONALSELIGIBLETO
JOINTHESCHEME 86
APPENDIX5–FREQUENCYDISTRIBUTIONOFAVERAGENUMBEROFVOUCHERSCLAIMEDPER
TRANSACTIONBYHEALTHPROFESSION 92
APPENDIX6–FREQUENCYDISTRIBUTIONOFVOUCHERSCLAIMEDBYHEALTHPROFESSION 102
ElderlyHealthCareVoucherPilotScheme:AnInterimReview–ExecutiveSummary
i
EXECUTIVE SUMMAR Y
TheElderlyHealthCareVoucherPilotScheme(theScheme)hasbeen
in place for two years since its implementation in 2009.To assess the
effectiveness of the Scheme in enhancing primary care for the elderly, the
Government initiated an interim review in the second half of 2010.The
operationof
theSchemeandutilizationofthevoucherswereexamined.The
opinions and feedback of the elderly and healthcare service providers were
collected.Thisexecutivesummaryhighlightsthemajorfindingsofthereview,
ourevaluationoftheextenttowhichtheSchemehasachieveditsobjectives,
andourrecommendationsontheway
forwardwhenthecurrentpilotperiod
endson31December2011.
SchemeObjectives
2. The Chief Executive announced in the 200 7‐08 Policy Address that
the Government would launch a three‐year pilot scheme in the 2008‐09
financial year under which elderly people aged 70 or above would be
given
annually five health care vouchers worth $50 each to subsidise the primary
healthcare servicestheypurchasefromthe private sector.The Schemewas
launched on 1January 2009.It aims at providing partial subsidies for the
elderly to receive private primary healthcare services in the community, as
additional choices on
top of the existing public primary healthcare services,
with a view to enhancing primary healthcare services for the elderly.The
Scheme implements the “money follows patient” concept on a trial basis,
enablingelderlypeopletochoosewithintheirneighbourhoodprivateprimary
healthcareserv icesthatbestsuittheirneeds.
3. By
providing partial subsidies for the elderly to choose priva te
primary healthcare in the community, it is expected that the Scheme could
help promote key ingredients of good primary care among the elderly and
healthcare service providers, including: continued relationship between the
elderly and their healthcare providers, more provision and utilization of
preventivehealthcareservices,andpromotionofwell‐beingamongtheelderly.
With better access and a continuum of care from participating healthcare
serviceproviders,weexpectthatmoreelderlypeoplewouldbeabletochoose
private primary healthcare services close to their homes, and those elderly
peoplewhoneedto
relyonpublichealthcareservicesmightalsobenefitfrom
ElderlyHealthCareVoucherPilotScheme:AnInterimReview–ExecutiveSummary
ii
thelessburdenedpublicprimarycareservices.
ScopeandMethodologyoftheInterimRevie w
4. The interim review was conducted when the Scheme has been
implementedforitsfirst halfofthepilotperiod.Effortshave been madeto
show the position up to 31 December 2010, save for situations where
only
dataup to31October2010wereavailableforanalysispurposes.
5. Thescopeoftheinterimre viewcoverstheoperationof theScheme,
participation in the Scheme, utilization of vouchers, and feedback on the
Schemeingeneralandspecificaspects.Inparticular,theinterimre viewhas
coveredthe
followingaspectsby–
(a)examiningvoucherutilizationbytheelderlyandparticipationof
healthcareserv iceprovidersintheScheme;
(b) collecting feedback from the elderly (both participating and
non‐participating) about the Scheme, including their awareness
of the Scheme, means to get to know the Scheme, reasons for
Scheme
participation / non‐participation, desirable subsidy
amount, ag e eligibility, healthcare services coverage, service
deliveryandperceptionaboutchangeinservicefeesandchoice
ofhealthcareser viceafterSchemelaunch;and
(c) collecting feedback from healthcare service providers (both
enrolledandnon‐enrolled)abouttheScheme,includingscheme
operation, service delivery, barriers
of non‐participation and
reasonsforwithdrawal.
6. Data collected for analysis and examination include statistical data
capturedin the databaseof theeHealthSystem and purposelycollecteddata
throughstructuredquestionnaires and focusgroupdiscussions.To this end,
studies were conducted by the School of Public Health and Primary
Care of
FacultyofMedicineoftheChineseUniversityofHongKongtocollectfeedback
from the elderly and healthcare service providers, viz. the opinion survey,
focusgroupdiscussionsandthewillingness‐to‐pa ystudy.
ElderlyHealthCareVoucherPilotScheme:AnInterimReview–ExecutiveSummary
iii
SchemeOperationandIm plementatio n
eHealthSystem
7. The Scheme is administered through an electronic platform, viz. the
eHealth System.It is a web‐based system on which voucher‐based and
subsidy schemes operate.There is no need to issue or carry vouchers in
paper form as vouchers are issued and used through the electronic system.
The
eHealthSystemperformsthefollowingfunctions‐
(a) managing information on healthcare service providers and
enrolment;
(b) managing health care voucher accounts, including registering
eligible elderly people under the Scheme, issuing vouchers,
processingclaimsandrecordingusage;
(c)managingreimbursementof healthcare vouchersonamonthly
basis;and
(d) monitoring
the Scheme by producing statistical reports to
facilitate planning and management of dai l y operation, and
generatingalertmessageswheneveranirregularityintheuseof
vouchers is det ected to facilitate follow‐up actions and
investigations.
UseofSmartIdentityCardReader
8. Tofurtherstreamlineproceduresandprovidegreaterconvenienceto
healthcare service providers, arrangements have been made in late 2010 to
makeuseofthe“cardfacedata”functioninthechipsoftheSmartHongKong
Identity Card (HKID) for registration and authentication.It provides an
alternative means to
participating healthcare service providers to register
persons eligi b le for vouchers and to access their accounts for claiming
vouchers,obviatingmanualinputandensuringdataaccuracy.
ElderlyHealthCareVoucherPilotScheme:AnInterimReview–ExecutiveSummary
iv
PrivacyImpactAssessmentandPrivacyComplianceAssessment
9. Measurestoprotectpersonaldataprivacyandtopreventabusehave
been instigated prior to and during Scheme implementation.A Privacy
Impact Assessment (PIA) and a Privacy Compliance Assessment (PCA) on the
design and operational procedure s of the Scheme (phase I) were conducted
between July and December 2008 by
Deloitte Touche Tohmatsu.This
ensuresthattheeHealthSystemhasbuilt‐infeaturestosafeguardthesecurity
of personal data transferred and stored within it in compliance with the
relevantlegislationandgovernmentguidelinesonprotectionofpersonaldata
privacy.Prior to full launch of Smart HKID deployment for eHealth account
creationandvoucherclaimsinO ctober2010,PIAandPCAonphaseII ofthe
eHealthSystemwereconductedbetweenAprilandJuly2010.
SecurityRiskAssessmentandAudit
10. In addition, the Department of Health (DH) engaged Computer and
TechnologicalSolutionsLimited(C&T)toconductSecurityRiskAssessmentsof
phaseIandIIoftheeHealthSysteminMay2008andJune2010respectively.
The current security risk level of eHealth System was found satisfactory, and
compliedwith
theGovernment’sITSecurityPolicyandSecurityRegulations.
Post‐claimcheckingandAuditing
11. As at 31 December 2010, a total of 852,721 claim transactions
involving2,136,630voucherswereprocessedforreimbursementandatotalof
about $106 million have been reimbursed to enrolled healthcare service
providers.Toensureproperdisbursementoffundingforvoucherclaims,DH
has put in place a mechanism
for checking and auditing voucher claims.It
involves (a) routine checking, (b) monitoring and investigation of aberrant
patterns of transactions, and (c) investigation of complaints.By end
December 2010, a total of 1,711 inspection visits were conducted, having
30,241claimscheckedwhichre presents4%ofclaimtransactionsmade.The
checkingcovers
77%ofenrolledhealthcareserviceproviderswithclaimsmade.
The post‐claim checking and auditing revealed 25 cases of wrong claims,
representing 4% of the checked claims.These claims involved error s in
procedures or documentation.So far, two medical practitioners and one
Chinesemedicinepractitionerhavebeendelistedfromthe
Scheme.
ElderlyHealthCareVoucherPilotScheme:AnInterimReview–ExecutiveSummary
v
12. In mid 2008, the Corruption Prevention Department of the
Independent Commission Against Corruption offered corruption prevention
advicetoDHontheadministrationoftheSchemepriortoitslaunch.Also,to
ascertainwhethertherearepotentialriskstoregularity,proprietyorfinancial
controlinthemanagementoftheScheme
anditsoperationalmechanism,the
AuditCommissionconductedariskauditoftheSchemein2009‐10.DHhas
taken into account their suggestions and observations in fine‐tuning the
modusoperandioftheScheme.
Sta tisticsonSchemeParticipationandU t ilization
Healthcareserviceproviders:distributionofplacesofpractice
13. Asat31December2010,thereareatotalof2,736healthcareservice
providersenrolledintheScheme,involving3,438placesof practice.Among
them, 39.6% (1,363) are in Kowloon, 23.4% (803) Hon g Kong Island, 19.8%
(681)theNewTerritoriesWest,16.0%(549)theNewTerritoriesEastand1.2%
(42)Islandsdistrict.Ofthe18districts,YauTsimMongdistrict(549)hasthe
highestnumberofplacesofpractice.
Healthcareserviceproviders:Enrolmentandparticipationrate
14. Nine categories of healthcare professional who are registered in
HongKong are eligible to participate in the Scheme.They are medical
practitioners, Chinese medicine practitioner s, dentists, chiropractors,
registered and enrolled nurses, physiotherapists, occupational therapists,
radiographers and medical laboratory technologists.Medical practitioners
account for the highest percentage of enrolled healthcare
service providers
(52.3%)(1,431),followedby Chinesemedicinepractitioners(27.9%)(762)and
dentists(8.7%)(239).
15. We estimate that the participation of medical practitioners, which
formed the majority of the enrolled healthcare services providers, is about
34.1% of the potential pool of medical practitioners actively providing
healthcareservicesintheprivate
sector.Theparticipationrateisonparwith
other public‐private partnership schemes launched by the Government (e.g.
vaccination subsidy schemes).Participation among other eligible health
ElderlyHealthCareVoucherPilotScheme:AnInterimReview–ExecutiveSummary
vi
professions is relatively lower, at 16.1% for dentists and 12.5% for Chinese
medicinepractitioners.
ElderlypeoplejoiningtheSchemeandclaimingvouchers
16. As at 31 December 2010, a total of 385,657 eHealth accounts
(representing 57% of eligible elderly people) were created and 300,292
eHealth accounts made voucher claims (representing 45% of eligible elderly
people).Thenumberof eligibleelderlypeoplewhohaveregisteredwiththe
Scheme has increased from 42% in
end 2009 to 57% in end 2010.The
number of eligible elderly people who have registered with the Scheme and
made voucher claims has increased from 29% to 45% over the same period.
By the end ofthesecondyear ofthe pilotperiod,131,801elderlypeople,or
34%ofelderly
peoplewhohaveregisteredwiththeScheme(some20%ofthe
eligibleelderlypeople),usedupthevoucherstheywereentitledtobythen.
Claim transactions made: distribution among health professions, vouchers
claimpatternandusage
17. With regard to the distribution of claim transactions among the
different professions, the majority (88.1%) (751,212 out of 852,721) of the
claim transactions are made by medical practitioners.Chinese medicine
practitioners (9.3%) (79,377) and dentists (1.9%) (16,396) rank second and
third in terms of utilization of vouchers.In terms
of number of vouchers
claimed, medical practitioners constitute the largest proportion (87.1%)
(1,861,348 out of 2,136,630 vouchers), followed by Chinese medicine
practitioners(8.4%)(180,324)anddentists(3.5%)(74,751).
18. Amongtheninehealthprof essions,dentist shavethehighestaverage
number of voucher claimed per transaction (4.56 vo uchers per transaction)
whereas the
two lowest are medical practitioners (2.48 vouchers per
transaction) and Chinese medicine practitioners (2.27 vouchers per
transaction).Themedianofvouchersclaimedpertransactionfor dentistsis
4.75whereasformedicalpractitionersandChinesemedicinepractitionersare
2.77and2.43respectively.
19. Fordistributionofclaimsbyreasonofvisit,
ahighproportionofclaim
transactions (69.4%) are madefor managementof acuteepisodic conditions.
[...]... further review of the Scheme especially voucher utilization over the extended pilot period. xxi Elderly Health Care Voucher Pilot Scheme: An Interim Review PURPOSE The objective of this interim review is to examine the operation and utilization of the Elderly Health Care Voucher Pilot Scheme ( the Scheme) and to collect feedback from the elderly and healthcare service providers in order ... electronic platform for administrating targeted subsidization for healthcare services (i.e. the Elderly Health Care Voucher Pilot Scheme in this case) which are low in amount ($250 per year per eligible elderly person) and high in volume (about an average of 400,000 claim Page 6 Elderly Health Care Voucher Pilot Scheme: An Interim Review transactions involving an average of about 1,000,000 electronic vouchers per ... felt that the information was insufficient, 53% would like to learn more on how to use the vouchers and 43% would like to know the channels where they could obtain the list of viii Elderly Health Care Voucher Pilot Scheme: An Interim Review – Executive Summary enrolled healthcare professionals. Scheme scope: subsidy amount 27. Of the 1,026 elderly people who participated in the survey, 17% (35% ... In addition, the elderly were also asked on whether they considered 31. the vouchers were convenient to use. Some 64% of the interviewees (including both voucher users and non‐voucher users) considered the ix Elderly Health Care Voucher Pilot Scheme: An Interim Review – Executive Summary vouchers were convenient to use. Among the 359 voucher users, 80% considered the vouchers convenient to use. ... the private sector. The results show that their willingness to pay (WTP) and the amounts they were willing to co‐pay for private primary care services varied by type of diseases and services. x Elderly Health Care Voucher Pilot Scheme: An Interim Review – Executive Summary 36. The average WTP amounts for general health conditions and acute condition were within the current price range in private sector. ... checks and dental check. In other words, the elderly were more willing to pay for management of acute episodic diseases than chronic conditions and preventive care. xi Elderly Health Care Voucher Pilot Scheme: An Interim Review – Executive Summary Conclusion and Recommendations 39. The interim review brings to light points worth noting regarding the Scheme over the past two years through its initial operation, and at the same ... provides a good basis for furthering the objectives of the pilot to enhance primary care for the elderly and also for the promotion of other public‐private partnership schemes in xii Elderly Health Care Voucher Pilot Scheme: An Interim Review – Executive Summary healthcare. 42. The participation rate of the elderly (57% eligible elderly people registered in the ... problems at the initial phase of the Scheme, mostly concerning the use of the electronic platform and the procedures for making claims. These have soon been identified and addressed through the concerted efforts of parties xiii Elderly Health Care Voucher Pilot Scheme: An Interim Review – Executive Summary concerned, and the operation details of the Scheme have been streamlined significantly since. Improvements ... model and platform that is necessary to enable change of healthcare seeking and providing behaviour among users and providers. (iii) Impact on healthcare seeking behaviour 48. Broadly speaking, the Scheme has so far failed to induce any xiv Elderly Health Care Voucher Pilot Scheme: An Interim Review – Executive Summary noticeable behavioural change on the part of both users and providers of primary healthcare services, during the first two years of the pilot period. ... family doctor providing comprehensive care to them. With the right design and incentive, it is still possible for the Scheme to initiate the desired behavioural changes essential to the development of comprehensive and xv Elderly Health Care Voucher Pilot Scheme: An Interim Review – Executive Summary holistic primary healthcare. However, further and more in‐depth monitoring and analysis would be needed to assess
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