健保，這個議題近來在美國與台灣都是熱門話題。歐巴馬因健保改革法案在民主黨的支持下，參眾兩院都安全過關，在歐巴馬簽署後，美國也會和台灣一樣，有全民健保。
美國的健保改革是要將全部的國民都納入健保範圍，台灣也要作健保改革，除了保費調漲之外，還不知有有甚麼革新。
本來對於美國的健保改革法案沒什麼興趣，畢竟那是美國人的事。我們自己的健保問題就一大堆了，電視上名嘴一堆，幾乎天天都會談這個議題。但是幾天前，得知因新的健保法案，AT&T將要在第一季的帳上認列十億美元的健保費用，讓我對美國健保制度感到好奇。後來去找出報導來看才發現，原來只是新的法案把一個漏洞填起來罷了：政府補貼28%的處方用藥的錢，但是企業又可以把支付員工處方用藥的錢全部(100%)從應稅所得中扣除；而新的法案只允許企業扣除支付員工處方用藥的72%的費用。所以這並不能算是費用的增加！
top marginal federal corporate rate for taxable income over $18.3 million is 35%（Wikipedia）
AT&T這種公司所得一定超過18.3M,所以稅少繳了支付員工處方用藥的全部花費的9.8%
28% * 35% = 9.8%
"AT&T plans $1 Billion charges for health care" 給人一種感覺：AT&T因為新健保制度需「多」支出十億美元。如果真是「多」支出，那麼AT&T所需支付的員工健保費總額則高達$10.204 Billion；相當於3,214億台幣。(二○○八年台灣健保給付醫療院所的支出為4221億)這個金額太誇張了！認列十億美元的費用只是聳動的新聞寫法，報導中並沒有提到AT&T原本帳上認列的費用是多少，也沒有報導增加多少錢的數字。
US$1 billion / 9.8% = US$10.204 billion
(US$1 = TW$31.5) = TW$321.426 billion
很有可能因為有這來自政府補貼，又可以扣抵稅額所多出來的錢，後來AT&T又加碼成為員工的福利支出了。所以報導才會說，AT&T也考慮縮減員工福利。
而國內的健保應該有許多要作的改革，其中我最期待的便是病歷電子化。相信這電子化不但可以省很多錢，還可以帶動相關的解決方案的系統整合商機，做好後可能只要略加修改就可以拓展國外市場呢！
現在的情形是：若是在甲醫院做了A檢查，後來到乙醫院，又要做A檢查。如果直接在乙醫院重做，健保出錢，病患了不起多個幾十元的自付額，但是健保可能要付出上千元，甚至是數千或上萬元的費用。如果你回到甲醫院拿A檢查報告，不但要花費自己的時間與舟車勞頓，還要付給甲醫院幾百元的手續費。我就有過這種經驗，因腹痛到附近醫院急診，因查不出原因，做了許多檢查，這些檢查花了健保近萬元。最後還是查不出原因，在打了許多止痛針後出院了。幾天後，到另一家醫院，醫生也開出處方要做同樣的檢查。我就搭了個計程車，回到急診的醫院，買每一份檢查報告，一份好像是200元的樣子。因為我想當天的檢查較能反映真實狀況，這些檢查又花許多錢，實在沒有必要。如果我在第二家醫院重做那些檢查，所花的時間大慨和回到急診醫院拿報告差不了多少，不過大概只需花300元左右，而且不必跑來跑去。而我選了一個最費時費力，也最花(我自己)錢的方法，車資加上檢查報告、Ｘ片要一千多，但是健保少支出了近萬元！
健保應"追求最大共同利益"！類似的案例，每天都在台灣各地的醫院發生，如果病歷互通，每天應該可省下數百萬重複檢驗的費用。健保局難道一直到去年才知道有這種醫療資源浪費的狀況嗎？我不願將放任這樣醫療資源的浪費歸因為公務員心態－不做不錯，或醫療療院所與健保局合謀賺政府和人民的錢；唯一的合理解是刺激經濟成長(增加GDP)。但是這種刺激經濟的方式也太墮落了吧！
26-Mar-10
AT&T Plans $1 Billion Charge for Health Care
By THE ASSOCIATED PRESS
The telecommunications giant AT&T said on Friday that it would take a $1 billion noncash accounting charge in the first quarter because of the health care overhaul and might cut benefits it offers.
The charge is the largest disclosed so far. Earlier this week, the AK Steel Corporation, Caterpillar, Deere & Company and Valero Energy announced similar accounting charges, saying the health care law that President Obama signed Tuesday would raise their expenses. On Friday, the 3M Company said it would take a charge of $85 million to $90 million.
All five are smaller than AT&T, and their combined charges are less than half of the $1 billion that AT&T is planning. The $1 billion is a third of AT&T’s most recent quarterly profit. In the fourth quarter of 2009, the company earned $3 billion on revenue of $30.9 billion.
AT&T said Friday that the charge reflected changes to how Medicare subsidies are taxed. Companies say the health care overhaul will require them to start paying taxes next year on a subsidy they receive for retiree drug coverage.
A White House spokesman, Robert Gibbs, said Thursday that the tax law closed a loophole.
Under the 2003 Medicare prescription drug program, companies that provide prescription drug benefits for retirees have been able to receive subsidies covering 28 percent of eligible costs. But they could deduct the entire amount they spent on these drug benefits — including the subsidies — from their taxable income.
The new law allows companies to deduct only the 72 percent they spent.
AT&T said that it was also looking into changing the health care benefits it offered because of the law. Analysts say retirees could lose the prescription drug coverage provided by their former employers as a result of the overhaul.
Changes to benefits are unlikely to take effect immediately. Rather, the issue would most likely come up as part of contract negotiations between the company and unions representing its employees and retirees. AT&T is the largest private employer of union workers in the United States.
Candice Johnson, a spokeswoman for the Communications Workers of America, which represents more than 160,000 AT&T workers, said these employees had contracts in place until 2012. An agreement covering retirees also runs through 2012.
http://www.nytimes.com/2010/03/27/technology/companies/27phone.html?scp=3&sq=AT&T%20drug%20subsidy&st=cse
While Democratic leaders and the White House ultimately persuaded 219members to support the bill -- three more than needed for passage --they clinched their victory only hours before the voting started onSunday. They agreed to a deal with opponents of abortion rights withintheir party to reiterate in an executive order that federal moneyprovided by the bill could not be used for abortions, securing forDemocrats the final handful of votes they needed to assure passage.
病歷電子化 5年內完成
【工商時報 呂雪彗／台北報導】2009.05.01
行政院長劉兆玄昨（30）日下午赴萬芳醫院視察遠距照護服務業務，期勉衛生署積極透過遠距照護創新服務模式，促進異業合作，帶動智慧醫療相關產業發展。智慧醫療產業是相當具亮點商機醫療產業，可結合ICT資通訊科技布局全球市場，5年內完成全國醫療機構病歷電子化。
行政院會昨日通過健康照護升值白金方案，衛生署長葉金川認為，整個計畫最大特色就是智慧醫療。他說，美國總統歐巴馬計畫投入新台幣約80億元進行病歷電子化，台灣只需花費近14億元，以5年時間，就能做到全台所有醫院病歷電子化，2年內建立影像交換中心，相關病人資料都能透過網路交換，使資訊流通訊無障礙。
智慧醫療包括健保IC卡改善計畫；醫院安全關懷RFID（電子辨識系統）計畫，遠距照護計畫等。醫院安全關懷RFID計畫是將RFID技術廣泛應用在老人照護、病人照護，針對植入人體儀器進行追蹤。遠距照護是透過醫療照護與資通訊科技結合應用，推動社區、居家、機構式等三種科技化照護模式。
葉金川認為，IT（資訊科技）產業是台灣強項，結合資訊技術與醫療整合，打破資源地域時空限制，商機無限，智慧醫療服務將能提升醫療服務品質及資源運用效能。他說，目前台灣500多家醫療院所，約42％已病歷電子化。
未來將可將RFID產業與醫療資訊的創新模式輸出，也可將醫療機構電子病歷化及影像傳輸等提供輸出，增加病患跨國就醫，搶食歐美等電子病歷化市場商機。推估4年內這塊市場國內約有1293億元。
劉揆期許衛生署帶領國內各級醫療照護機構，投入科技化健康照護服務發展，尤其遠距醫療結合醫療照護、電子化醫療器材、資通訊技術等跨領域專業，為民眾提供多元化的科技化照護服務。
中時健康：http://health.chinatimes.com/contents.aspx?cid=5,63&id=5994
The stories were taken from the websites of The New York Times and China Times (中國時報). The copyright remains with the original owners. The New YorkTimes and China Times (中國時報) do not endorse, nor are involved with the production ofthis blog.
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