論健保體系下醫藥費用的分攤時間點：當期扣抵與遠期補償

A Study for the Cost-sharing in Health Insurance: Discount Directly or Rebate Later

洪乙禎(Yi-Chen Hong) ； 林錦鴻(George Linn)

《社會科學論叢》 3卷2期 (2009/10) Pp. 79-118

https://doi.org/10.30401/RSS.200910_3(2).0004

摘要

健康保險中常見的部分負擔，是在就醫當時為被保險人分攤費用，被保險人的支出僅是部分負擔，是屬於「當期扣抵」的形式。私部門銷售的醫療保險或特定疾病險，被保險人必須在醫療事件發生時先自墊費用，事後再提出理賠申請，是屬於「遠期補償」的形式，被保險人獲得費用分攤，距離就醫已有一段時間落差。本文利用完全訊息代表性個人的兩期決策模型，分析健康保險採行傳統「當期扣抵」或「遠期補償」兩種型態下，被保險人的醫藥需求、費用與風險承擔，藉此分析兩種制度型態對於節制道德危險與風險保護等政策目標，可能產生的差異效果。
研究結果顯示，在相同部分負擔下，「遠期補償」因為補償時間的延遲，以及被保險人獲得給付的不確定性，具有抑制需求面道德危險的效果。但同時「遠期補償」因為自墊費用的現金流出，使被保險人面對較大疾病財務風險，也可能形成就醫障礙。所以，「當期扣抵」和「遠期補償」各自存在政策執行的優劣勢，考量台灣藥品費用長久偏高，而醫療服務與藥品有本質上的差異，本文提出醫療服務採行「當期扣抵」、藥品予以「遠期補償」的混合型態，可以不需全面加重部分負擔，但在藥品部分加強被保險人成本意識，適度地兼顧健康保險的不同政策目標。

關鍵字

醫療需求 ； 藥品需求 ； 部分負擔 ； 道德危險

並列摘要

Coinsurance and co-payment are usually adopted as the cost-sharing methods in health insurance. Under these two ways, the insurers immediately share the medical expenditures with the insured. The insured only pays the coinsurance or co-payment as utilizing medical services. This kind of cost-sharing mechanism belongs to ”discount directly”. ”Rebate later”, however, is another kind of mechanism, which is usually adopted in supplementary health insurance. The insured has to pay the total expenditures first and then applies for the insurance reimbursement later. This study adopts a two-period model of the representative agent with perfect information to discuss the agent's demand for medical services and pharmaceuticals. Using the theoretical analyses, this study compares the medical utilization and financial burden of the insured and shows the efficiency under these two mechanisms, ”discount directly” and ”rebate later”.
Compared with ”discount directly”, ”rebate later” could reduce moral hazard from demand side because of delayed and uncertain reimbursement but the cash flow exposes the insured to higher financial risk and it would become a barrier to medical access. Considering the utilization of medical services and pharmaceuticals in Taiwan, this study proposes a mixed mechanism, which immediately shares the cost of medical services and rebates the pharmaceutical expenses later. This mixed method could induce the insured's cost-saving incentives for pharmaceuticals without increasing the insurance copayment.

並列關鍵字

Medical Demand ； Pharmaceutical Demand ； Co-payment ； Moral Hazard