- 期刊
全民健保同病同酬之規定與診斷組合(DRGs)相關內容之探討
A Review on the Case Payment Design of the National Health Insurance Program in Taiwan, ROC
摘要
同病同酬是社會大眾為實現醫療價付公義而持有的一種觀念，但正如人類生而平等這一思想，在確定其含義上，不免又出現一些類詞，如齊頭式的平等、立足點的平等一樣，需要向學者或專業人員進一步發掘其內容，詮釋其真意，才能落實執行，不致以詞害義，反而妨害公義之實現。 民國八十四年實施之全民健保將同病同酬概念納入法律條文中，但未詳訂其內容及如何作到同酬。本文根據全民健保法及健保局有關規定，推定有關當局主張之同病同酬意義為“對ICD-9-CM前三碼相同之疾病，除藥品及藥事服務費外，支付同等金額之診療報酬制度”。 如所周知，全民健保法之立法及其實施不僅充滿變化，有些規定更未盡周全，同病同酬即其一端。本文參照美國DRGs/PPS制有關診療報酬支付之規定，檢視全民健保法實施之內容，認為後者最大問題在於只秉持了一個模糊的概念，未對不同的醫療狀況擬訂不同的報酬對策，簡言之，就是過於粗略，是引起混亂之根源。為健全制度之實施，不但要更精確的界定什麼是同病，而且要區別其是否同工，唯有同病又同工才同酬之支付制度，才能落實施行並實現公義。
並列摘要
The Taiwan National Health Insurance Program which enacted last year and enforced this March, 1995 carried out an article of ”one price for one category of diseases” or ”case payment” plan. According to the National Health Insurance Bureau's supplementary document, the ”case” means diseases having the same first three digits of ICD-9-CM code. This is not appropriate because factors of clinical practice and the patient's condition cannot be excluded if the regulation is to apply. Moreover, the whole structure of the so called ”case payment” in the program, does not like DRGs/ PPS in the Medicare, bears few supporting measures to assist its implementation. The main problem of the plan is its over primitive. Only cognation both in disease and patient category and in effort produced by health care providers can make a justifiable and workable payment device.
延伸閱讀
- 林詠蓉、曾家琳、湯澡薰（2008）。疾病分類人員對診斷編碼的建議對健保支付費用與DRG點數之初探性研究－以台某市某區域醫院爲例。醫務管理期刊，9(2)，83-87。https://doi.org/10.6174/JHM2008.9(2).83
- 莊逸洲、吳明彥（1996）。全民健康保險論病例計酬制審核模式之研究。中華公共衛生雜誌，15(1)，47-60。https://doi.org/10.6288/CJPH1996-15-01-04
- 韓揆（2001）。土、洋DRGs-全民健保論病例計酬如何為繼。醫務管理期刊，2(3)，27-46。https://doi.org/10.6174/JHM2001.2(3).27
- Chuang, L. (2007). THE EFFECT OF COST CONTAINMENT AND QUALITY AFTER THE NATIONAL HEALTH INSURANCE SYSTEM IN TAIWAN [doctoral dissertation, National Central University]. Airiti Library. https://www.airitilibrary.com/Article/Detail?DocID=U0031-0207200917351476
- 劉宜君（2001）。A Financial Analysis of Taiwan's National Health Insurance Policy。中國行政評論，10(4)，129-176。https://doi.org/10.6635/cpar.2001.10(4).05