全民健保實施總額預算制度之政策分析：制度規劃、導入與成效

Policy Analysis of Global Budget Program for Taiwan’s National Health Insurance:System Planning, Implementation and Performance

張鈺旋(Yu-Hsuan Chang)

指導教授 ： 鄭守夏

國立臺灣大學/公共衛生學院/健康政策與管理研究所/碩士(2019年)

https://doi.org/10.6342/NTU201900615

摘要

我國全民健保自1995年實施以來至今已近24年，在財源籌措的部分，全民健保以保險費為主要財源，且支付制度採用第三者付費機制。在健康保險改革的國際趨勢中，會面臨健康照護系統面臨財源有限的情況，並要求強化效率與效果的壓力，為因應總體層次的國家醫療費用控制，通常會採用目標制總額支付制度或上限制總額支付制度，以克服資源有限性及資源分配有效性，以提升醫療服務之品質，而且這些機制在總體層次的國家醫療費用控制效果相當明顯。我國參考其他健保制度國家的總額預算制度經驗，預算固定並透過同儕制約與共同管理，以精確控制預算並提升服務效率，又要兼顧民眾就醫之可近性暨全民醫療就醫之公平性。
總額預算制度為一宏觀（macro）調控手段，配合微觀（micro）支付基準的改革（如論人計酬或論病例計酬），鼓勵醫療提供者改變診療行為，使之趨於合理。從宏觀面而言，實施總額預算制度可以合理使用資源，以購買價值(value-based)為前提下，讓支出在可控制範圍(總支出)內；在微觀面而言，是支付給醫療院所的醫療費用要如何分配的問題。
在實施總額預算後需要進行不同面向的執行成效，包括有：一、實施總額預算對醫療費用控制之影響；二、對醫療院所營運之影響；三、對醫療服務品質之影響及民眾對醫療體系之滿意度。當然醫療保險體系無法由總額支付制度單一策略而可完全去除弊端，但總額預算制度建立協商機制、前瞻式預算及支付基礎檢討的經驗，仍具有相當正面意義。
本研究的結論有以下重點：一、健保總額支付制度目標，達到總體控制醫療費用效果；二、在健保總額制度之推動策略，在某個程度上透過菁英模式推動達成，並以團體主義形成各部門總額之協定分配；三、健保總額制度之發展歷程，各部門推動總額各有其要解決的問題，在運作上有其理念之一致性；四、總額支付制度有達到階段性成就，但支付基準的改革仍待努力；五、建立社會審議式民主機制，但要付出民主的代價；六、對於醫療利用情形及民眾醫療品質而言，不受影響或有微幅改善；七、地區預算分配爭議時有發生，透過協商討論方式去解決或政治力去解決。
但面臨台灣人口嚴重老化及疾病轉型問題，對於總額的結構性分配是否可以進一步思考，以及支付誘因設計上可以是否多多考量帶動整體照護模式之改變等，以激勵最佳照護模式，並進而帶到醫療體系建構之新思維，有待未來再深入研究。

關鍵字

全民健康保險 ； 總額預算 ； 支付制度 ； 政策分析 ； 公私協力

並列摘要

It has been nearly 24 years since the implementation of Taiwan’s National Health Insurance (NHI) in 1995. The NHI financing is mainly based on premium collection and payment system adopts the third-party reimbursement mechanism. Issues such as insufficient financing resources, pressures of improving health care efficiency and effects often be discussed when mentioning about the health insurance reform. In order to control national health expenditures from the macro level, a target or capped global budget (GB) payment system is usually adopted to deal with the problems of limited medical care resources, efficiency of resource allocation as well as enhancement of health care quality. The aforementioned mechanisms also demonstrate an obvious performance in health care expenditure containment. Taiwan refers other countries’ experiences on the design and implementation of GB system and develops its own system. By adopting a fixed GB through health care provider peer restriction and collaborative management, health care expenditures can be controlled precisely, at the meantime, to guarantee the accessibility and equality to health care services for the general public.

By implementing GB as a macro mechanism to control health care expenditures, several micro payment schemes such as fee-schedule reform, capitation or case payment etc. need to be adopted to encourage the behavior change of health care providers. Viewing from the macro perspective, the implementation of GB makes the utilization of medical resources be more reasonable and the total health care expenditures be contained under a manageable scope by purchasing value-based health care services. Viewing from the micro perspective, the key issue will be how to allocate the payment to health care providers through various payment schemes.

Different aspects of performances need to be assessed after the implementation of GB, such as:
1. The impact of health care expenditure containment.
2. The impact to the health care providers’ operation.
3. The impact on the health care service quality and the satisfaction of the general public towards the health care system.

Though the fraud and drawbacks of health care system cannot be eliminated by implementing a single strategy like GB, it stills demonstrate its positive value on establishing a good negotiation mechanism, perspective payment budget and fee-schedule review.

Major conclusions of this study are as follows:
1. The target GB achieves the objective of containing total health care expenditures.
2. The promotion strategy of GB mainly is executed by the elite group, and different sectors GB negotiation and allocation are also achieved through medical professional groups.
3. Though different sectors of GB have their problems to be solved, the philosophy for operation is consistent.
4. GB system has accomplished its periodic achievement, however, the reform of reimbursement fee-schedule need to be continued.
5. The establishment of deliberative democracy mechanism has its price to pay.
6. The implementation of GB has no impact or has slightly improvement on the utilization of medical resources and health care quality.
7. When disputes occur for district budget allocation, negotiation or the intervention of political power are common ways to solve them.

Taiwan is facing aged population and increased chronic diseases, the structural allocation of GB may be further reviewed of its propriety. In addition, the design of payment incentives can be further considered of driving the change of health care model and motivating the optimal health care model in order to have a brand new idea on the reconstruction of health care system. The aforementioned issues need to be further studied.

並列關鍵字

National Health Insarance ； Global Budget ； Payment System ； Policy Analysis ； Public Private Partnership

參考文獻

江東亮. (2015). 公共衛生與健康不平等：三個歷史的教訓. 台灣公共衛生雜誌, 34(1), 1-4. doi:10.6288/tjph201534103125

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