風險校正：健康保險市場的效率與公平之關鍵

Risk Adjustment: A Key to Efficiency and Equity in the Health Insurance Market

張睿詒(Ray-E Chang) ； 江東亮(Tung-Liang Chiang)

《中華公共衛生雜誌》 17卷5期 (1998/10) Pp. 373-380

https://doi.org/10.6288/CJPH1998-17-05-02

摘要

在傳統的健康保險市場，醫療效率與就醫公平是二個相互衝突的目標，多年來學者與政策制定者均致力於研究如何設計兼顧公平與效率的健康照護制度。近期在解決此一難題的發展，是建立於風險校正的設計。理論上，風險校正藉由風險平凖基金的機制使保險人得收取風險計價之保費，而被保險人則是依其財務能力繳交保費。目前，一些西方國家已將風險校正應用於其市場導向之醫療改革上；台灣值此全民健保朝多元化保險人體制發展之際，實有必要對風險校正加以深入探討。在檢視風險校正理論以及國際實施風險校正經驗之後建議：(1)經修正後之荷蘭風險校正模式或可適合台灣全民健保體制改革之需要，以及(2)台灣應立即加強風險校正相關議題之本土研究，以為制訂醫療改革政策之參考。

關鍵字

風險校正 ； 健康保險市場 ； 健康保險改革

並列摘要

Efficiency and equity are conflicting objectives under the traditional health insurance market, and for many years researchers and policy makers have striven to achieve both goals at the same time. Recent developments to resolve this dichotomy have been based on risk adjustment. In principle, risk adjustment works through the mechanism of equalization fund so that health plans are able to collect risk-adjusted premiums while the contribution of the insured is in accordance with their abilities to pay. Some Western nations have already introduced risk adjustment to their market-oriented health care reforms. In Taiwan, where market-oriented health insurance proposals are under consideration by the government, it is timely to open the debate on the issue of risk adjustment prior to being implemented. After reviewing the theory of risk adjustment and international experiences on the application of risk adjustment, we recommend: (1) Netherlands' model may be modifiable and adapted to meet the need of Taiwan's health care reform, and (2) more indigenous efforts should be immediately undertaken to study issues related to the introduction of risk adjustment in Taiwan.

並列關鍵字

risk adjustment ； health insurance market ； health care reforms