診斷關聯群附加支付的發展與應用

The Development and Application of Add-On Payments in a DRG System

李卓倫(Jwo-Leun Lee) ； 洪錦墩(Chin-Tun Hung) ； 陳文意(Wen-Yi Chen) ； 蔡梓鑫(Tzu-Hsin Tsai) ； 紀駿輝(Chun-Huei Chi)

《台灣公共衛生雜誌》 32卷3期 (2013/06) Pp. 205-219

https://doi.org/10.6288/TJPH2013-32-03-01

摘要

新興醫療科技通常會先應用在住院病人身上，當新科技已經上市但還未納入健保給付時，這項新科技不會在診斷關聯群的支付名單內，因此醫院比較不願意使用。理想上，經政府核准的新興醫療科技必須先經過醫療科技評估，以確定其用途、療效、及成本效果後才能正式由全民健保給付，但目前在缺乏醫療科技評估機制的情況下，新醫療科技與現有醫療科技的相對優勢，仍處於模糊的階段。在論量計酬支付制度使用新醫療科技通常會讓醫療支出上升，而導入診斷關聯群可能同時減緩醫療費用上漲和新科技的引進速度。這當中最大的挑戰，在如何透過支付制度設計，來達到一方面控制醫療支出，同時也提供足夠的誘因來促進醫療科技進步的雙重目標。本文之主要目標在描述介紹主要工業化國家對於社會健康保險或國民醫療服務為引進新興醫療科技時，在診斷關聯群支付制度上所做的誘因安排，進而提出其對台灣實施診斷關聯群支付制度的政策啟示。本文介紹的國家包括美國、德國、法國、義大利、和英國。這些國家附加支付的共同性包括制度的銜接、強調醫療自主性、以主診斷碼為依據、建構協商公式、及以科技評估為依據（義大利除外）。同時這些國家的制度也在下列方面有差異：以費用控制為目標（德、法、義）、對申請資格的限制（德、法）、以委員會議為審查機構（德、法）、建構醫療科技成本基準（美、德、英）、及強調資訊透明（美、德、英）。由這些國家實施附加支付經驗之分析，本文歸納出附加支付制度對台灣全民健保的重要啟示包括有助於支付制度的銜接、長期醫療費用控制、及控制家戶自付醫療費用占率。此外，為使附加支付制度達成其政策目的，台灣有必要建構醫療科技評估制度，及標準化客觀的醫療成本估算方式。

關鍵字

診斷關聯群 ； 附加支付 ； 新興醫療科技 ； 健康保險

並列摘要

New medical technologies have often been applied to inpatient care; however, when a new medical technology becomes available in the market but is not yet covered by national health insurance, such a technology is excluded from the Diagnosis-Related Group (DRG) list. Consequently, hospitals may be reluctant to use it. Ideally, once a new medical technology is approved by the government, it should undergo a health technology assessment (HTA) to ascertain its applicability, effectiveness, and cost-effectiveness before it is covered by a national health system. At present, however, the lack of HTAs makes the relative advantage of a new medical technology unclear. The adoption and use of a new technology in a fee-for-service payment system usually leads to increased medical expenditure. This is where the introduction of DRG add-ons plays an important role in regulating the rates of adoption of technology and rising expenditures. The major challenge in dealing with a new medical technology is how to design a payment system that will achieve the goal of controlling expenditure while providing adequate incentives for technological improvement. The purpose of this article is to compare how several industrialized nations designed their DRG add-on payment incentives in order to regulate the adoption of new medical technologies by their national health care systems, and to provide policy implications for Taiwan. We summarized the DRG add-on payment systems implemented in the United States (U.S.), Germany, France, Italy, and the United Kingdom (U.K.). Their systems share several common features in that they are consistent with the existing payment system, emphasize professional autonomy, use primary diagnostic codes as the foundation, provide formulas for negotiation, and are based on technology assessment (except Italy). There are unique features in some countries, such as an emphasis on cost control (Germany, France and Italy), restrictions on who can apply (Germany and France), setting up review committees (Germany and France), a cost-based foundation for medical technology (U.S., Germany and U.K.), and an emphasis on transparency (U.S., Germany and U.K.). For Taiwan, the lessons we learned from these countries include the importance of DRG add-on payments in providing consistency in the payment system, control of long-term health care costs and control of household out-of-pocket payments for health care. In order for DRG add-ons to achieve policy goals, Taiwan needs to establish systems for medical technology assessment and standardized medical cost accounting.

並列關鍵字

DRGs ； add-on payment ； new medical technology ； health insurance

參考文獻

The Medicare, Medicaid, and State Children's Health Insurance Program (SCHIP). Benefits Improvement and Protection Act of 2000 (BIPA), Section 533(b), Final rule 66 FR 46902, 2001

KHEntgG. Krankenhausentgeltgesetz 2010. Hospital Reimbursement Act, Dec. 22, 2010 Reichsgesetzblatt I [RGBl. I] as amended, at § 6, 2309 (Ger.), 2010.

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Martin TD. Relating diagnosis-related groups: what Germany and the United States can learn from each other about acute-care payment systems. Available at: http://works.bepress.com/timothy_martin/6/. Accessed July 4, 2012

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