差額負擔：公平、效率與醫療品質間之衝突

Balance Billing: Conflicts among Equity, Efficiency and Quality of Health Care

賴辛癸(Shin-Goei Lai) ； 藍忠孚(Chung-Fu Lan)

《中華民國公共衛生學會雜誌》 12卷2期 (1993/06) Pp. 107-120

https://doi.org/10.6288/JNPHARC1993-12-02-01

摘要

本文旨在探討全民健康保險時代來臨後，差額負擔應否存在？是否一套標準化的支付制度，可以滿足所有被保險人的醫療需求？是否允許被保險人在保險給付之外，爲追求不同醫療品質而付出額外的費用。
本文從不同的角度，來檢視實施差額負擔所可能帶來的衝擊，在考量就醫可近性時，會造成低所得民眾的就醫意願降低；在品質的改善方面，差額負擔雖提供提高品質的誘因，但成本的投入與品質的改善之間並沒有一定的正面關係；在醫療費用的控制方面，差額負擔所強調的市場競爭會導致醫師費用高漲；在另一方面，醫師自主權透過差額負擔的機制保障下，並不可能兼顧民眾的利益。而且行政成本的增加，造成醫療資源的浪費。此外，本文將就美國及加拿大實施差額負擔的現況，及台灣目前公勞農保制度下，差額負擔的實施的現象，提出檢討。最後結論：在強制性的全民健康保險制度下，不應透過差額負擔的方法來達成不同醫療品質的追求，因其所帶來的負面影響將大過於正面影響。

關鍵字

差額負擔 ； 國家健康保險 ； 健康政策 ； 支付制度

並列摘要

The primary purpose of this paper is to discuss whether or not balanced billing should be allowed after implementation of the National Health Insurance plan? Can a standardized reimbursement system satisfy the health care demands of all beneficiaries? Should beneficiaries be allowed to pay extra money for different levels of quality of health care beyond those provided by this insurance plan?
In this paper, the possible impacts of implementing balanced billing are examined from different perspectives. Considering access to health care, balanced billing will decrease the willingness of low-income groups to use health services. In impoving the quality of health care, however balanced billing will provide incentives for higher quality. The relationship between the input of cost and quality of health care is not always positive. In the control of medical expenditures, market competition, which balanced billing will emphsize will result in the inflation of costs. On the other hand, the autonomy of physicians will be protected by the mechanism of balanced billing. However, it may not provide optimal public care. Moreover, the increase in administrative cost will result in a waste of medical resources. Additionally, this paper discusses the implementation of balanced billing in American, Canada, and the existing insurance plans in Taiwan.
The conclusion is that different levels of health care quality under the statuatory National Health Insurance should not be pursued by balanced billing, as it will have more negative effects than positive effects.

並列關鍵字

balance billing ； national health insurance ； health policy ； reimbursement system