我國全民健保制度之探討

Study of the National Health Insurance system

陳美娟(Mei-Chuan Chin)

指導教授 ： 鄭雅穗

元智大學/管理學院/管理碩士在職專班/碩士(2012年)

摘要

本研究針對我國健保制度，探討保險組織體制、財源、醫療資源分配與OECD國家（參與經濟合作暨開發組織）比較，採個案分析法瞭解我國健保制度之特色及危機，因健保制度是各國發展及國家穩固的基石，制度的延續及保費的公平性？一直是民眾在意與關心的議題，保費收繳合理性與醫療照護適切性？政府政策與保險制度配套措施，如何使制度能更健全？反觀各國健保制度，財源不足一直是關鍵議題，因應財源短絀問題，各國制度改革持續漸進，本研究以各國健保改革方向，並透過其國家制度施行成效，討論我國健保制度下組織體制及財務來源等面向，檢視政策變遷過程影響因素，歸納我國全民健保制度之特色與缺失。提出建議如下：1.保費收入預算與支出連動，以量入為出的方式，維持財務平衡。2.醫療服務項目規劃責任院所，醫療院所分級，減少醫療浪費。3.健保制度財務來源採稅制較保費收入，更健全與穩定。4.設立保費回饋制，鼓勵民眾健康促進，減緩醫療費用成長。5.健保財務透明化，社會參與讓民眾對於全民健保政策更了解。6. 加強藥物審核機制，建立評議小組。7.利用健保IC卡增加病人就醫安全，減少重複檢查及用藥。

關鍵字

全民健保制度 ； 社會保險 ； 支付制度

並列摘要

Aimed at our national health system, this study explores the organization of the insurance system, financial resources and a comparison of the allocation of medical resources in OECD countries (participation in the Organization of Economic Cooperation and Development). It also examines the features and crises facing our national health system through a case study as this system is the cornerstone of development for each country and enhances the stability of national security. The extension of policies and the fairness of insurance premiums is a topic that the majority of people care about. In addition, they are also eager to know the rationality behind insurance charges and the applicability of medical care. In particular, they are interested in whether or not the governmental policies and supplementary policies of the insurance system can make the insurance system complete. Having reviewed the national insurance system of each worldwide, the main problem is insufficient financial resources. In accordance with this problem, the reform in policies and regulations for each country continues to make progress.
This study is aimed at the reform of the national health care system of each country and explores the construction of the organizational mechanisms and financial resources under the national health care system through examples of the operational effectiveness of other countries. It reviews influential factors in the process and concludes with the features and drawbacks of the national insurance system. Suggestions for improvement are as follows: 1. Regarding premium income budget and expenses linked to living, we could use the way to live within the means to maintain financial balance. 2. We shall assign certain institutes with responsibilities in the medical services program by grading the hospitals and reducing medical waste. 3. The income of the insurance care system is much more stable and consistent than that of the financial resources. 4. An insurance feedback mechanism should be established to encourage the public to enhance their health and inhibit the growth of medical expenses. 5. The insurance care financial system should be transparent and social involvement should educate the public about the insurance policies. 6. The medicine review mechanism should be strengthened and consultation teams established. 7. The health insurance IC Card should be used to enhance the medical safety of patients and reduce the duplication of checks and medication.

並列關鍵字

National Insurance System ； Social Insurance ； Payment Mechanism

參考文獻

5.江盈儀（2011），「全民健康保險監理委員會之監督機制探討」，淡江大學公共行政學系公共政策碩士論文。

17.黃昱朣（2001），「全民健保實施牙醫總額預算制度對醫療資源分布的影響評估」，國立台北護理學院醫護管理研究所碩士論文。

25.劉金鎮（2010），「社會保險之被保險人財務負擔研究--以健保為中心」，國立中正大學法律學研究所碩士論文。

中央健保局：二代健保政策說明網站、網址：

1.王秀蕙(2002)，「全民健保實施西醫基層總額支付制度成效評估-以高屏分局為例」，國立高雄醫學大學公共衛生學研究所碩士論文。