- 學位論文
以系統動力學探索台灣論人計酬試辦計畫
A System Dynamics Approach to Exploring Capitation Payment Schemes in Taiwan
摘要
本研究以系統動力學以分析台灣全民健康保險制度下的健康照護服務系統，並模擬論人計酬試辦計畫的財務結構。對全民健保的執行當局而言，為求全民健保能永續經營，最重要的任務是提昇全民健康及醫療成本的控制，而這二者都需要在系統設計的思維下與其他行動者互動、合作與協商。在系統動力學的模擬下，本研究要確認在全民健保制度中論人計酬支付計畫對病人、醫療服務的供應者、健康推動者及政府的好處。模式的建立及驗證是根據可公開取得的統計數據，及服務提供者的交易資料，對論人計酬支付制度實驗，以評估在不同情境下系統財務的永續性。以20年模擬論人計酬支付制度來探究健康照護系統的主要三個角色（支付者、服務提供者及消費者）。主要的研究發現計有(1) 醫療支出可透過更多的病人使用論人計酬支付制度內而獲得減少；(2) 以健康促進為服務策略的論人計酬支付模式勝過以成本控制的論件計酬支付制度；(3) 論人計酬服務提供者的財務風險可透健保署支付管理成本而獲得分攤。模擬結果建議論人計酬模式應為基層醫療機構結合適當的風險評估，而於台灣發展更好的支付政策並符合成本效益的要求。
並列摘要
This study uses a system dynamics approach to analyzing the complexity of healthcare service system of Taiwan under the policy of the National Health Insurance (NHI), especially in modeling the financing scheme of the capitation pilot project. For NHI policy makers, the most important task is achieving NHI sustainability both in health promotion and medical cost containment that need to enable actors to interact (e.g., corporate, coordinate, negotiate) with other actors under the system design thinking. In the system dynamics modeling, this research identifies the benefits of capitation payment schemes under the NHI for patients, medical service providers, health promoters and the government. The model was built and validated based on publicly available statistical and transactional data of service providers experimenting capitation payment schemes to assess the system’s financial sustainability under different conditions. Three major sectors were explored in the experiments by simulating the capitation payment scheme over a period of 20 years. The main findings of this research can be summarized as follows: (1) medical expenditure per person can be reduced with more patients enrolled in the capitation payment schemes; (2) the Fee for Capitation model with health promotion service strategies will outperform fee-for-service (FFS) cost containments; (3) the financial risk of the service providers experimenting capitation payment schemes can be mitigated by administrative cost shared by NHIA These simulation results suggest that by combining the capitation model with proper risk estimates for primary care institutes, better payment policies can be formed in Taiwan which are cost effective.