我國全民健保財務平衡機制之研究

A study on the financial balance mechanism of National Health Insurance in Taiwan

李進益(Chin-Yi Lee)

指導教授 ： 簡俱揚 ； 鄒翊

中原大學/商學院/會計學系/碩士(2006年)

https://doi.org/10.6840/cycu200600124

摘要

民國八十四年三月我國全民健康保險正式成立，為提供醫療給付為主的強制性社會健康保險體制。全民健保擔負二大政治使命而上路：促進社會健康保險普遍性(與世界衛生組織 Health for All的宣言相同)與改革社會保險財務。目前納保率已達99%，所以Health for All的普世使命已達成，但第二項：「改革社會保險財務」的使命，由於至今健保仍面臨嚴重赤字財務，所以仍為公共政策上急待解決的問題，也依然是決策者與執行者必須慎重面對的重要財政問題。因此，本文之研究目的是對現行全民健保的財務責任制度，作系統化的檢視與探討，分析健保財務陷入困境的問題所在，並且找出健保財務平衡的相關變項與主要的調節機制，提出較可行的財務改革策略，讓各利害關係人在享受健保照護的同時，也應負擔相對的財務責任。
基本上，影響我國健保財務平衡之因素，大致可以分為自然因素及人為因素兩項，經本文探討、分析可將自然、人為因素之各項影響因子，歸納為財務收支構面、醫療供需構面及健保體制構面等三個面向來探討其改革策略。綜合學者專家之見解及實務上之經驗，目前我國全民健康保險面臨了下列的困境，直接或間接影響健保財務狀況：
一、財務失衡嚴重。
二、保費負擔不公平。
三、健保收支缺乏連動。
四、資源配置缺乏機制。
五、醫療資訊不夠透明。
六、支付標準不合理。
面對上述健保財務的挑戰，必須從支出和收入面進行檢討，除此之外，醫療市場供需及健保體制是否配合革新，也將成為影響財務改革成功與否的重要因素。本文針對上述的財務收支、醫療供需及健保體制等構面，提出了下列改革策略：
一、財務收支構面：改變保費徵收及計繳方式，以擴大保費基礎的彈性、加強部份負擔制度功能，以爭取民眾的接受與認同、積極催收各級政府積欠健保補助款、設立整合性紓困基金，以加強景氣循環之財務整備、嚴格控制醫療資源浪費、強化總額支付制度功能等。
二、醫療供需構面：進行醫療供給者之行為新規範、提高醫療需求者之公平參與等。
三、健保體制構面：依據我國全民健康保險未來的定位，建議健保組織之可選擇方案，如：設立全國健康保險委員會及改制為獨立政府機關、衛生署下設單一健保局、衛生署內設健保處及健保局、衛生署下設行政法人健保基金會、衛生署下設健保局與六個健保公司、衛生署下設單一行政法人基金會並開放多元保險人等。
健全的財務結構是維持整個健保制度賴以運作的基礎，如何使健保財務狀況穩定，收支能達到平衡，肯定是政府及健保組織當前及未來努力的重要課題；我國健保期望永續經營，進行財務的改革是絕對必需的，本文希望上述改革建議能供健保政策規劃者參考，以求全民健保財務長期的健全與穩定。

關鍵字

財務責任 ； 財務平衡機制 ； 全民健保

並列摘要

The National Health Insurance was established formally in March of 1995 to provide a mandatory social health insurance system specializing in payment of medical treatment. The National Health Insurance launched with two great political missions: Promote the universal coverage of social health insurance (in accordance with the declaration, ' Health for All ', of World Health Organization) and reform the social insurance finance. As of today the NHI coverage rate has reached 99% already, and the universal mission of ' Health for All' has been achieved at present. However, because of the current serious financial deficit that NHI is facing, the second political mission, ' financial reform of the social insurance ' is still an urgent problem to be solved on public policy, and it is still the important financial problem that policymakers and executors must face cautiously.
Therefore, the research purpose of this text is to systematically investigate and study the financial responsibility of NHI system currently in effect, to analyze why the NHI financial condition was mired in difficulties, and to find out the factors which affect the NHI financial balance and its main regulation mechanism relevantly. Then we' all propose more feasible financial reform tactics that let every stakeholders while having the benefit of NHI, bear relative financial responsibility too.
Basically, the factors that influence NHI financial balance can roughly be divided into two categories, natural factor and human factor. According to the study and analysis of this research, we can categorize the human and natural factors into three constructs, the financial revenue and expenditure, medical supply and demand, and NHI system, to sum up good reform tactics. This article summarizes the scholars' and experts' opinions and practical experience and concludes that the NHI has faced the following predicaments at present, which have influenced the financial situation of NHI directly or indirectly:
First, the financial status is seriously out-of-balance.
Second, the insurance premium is unfairly distributed.
Third, NHI revenue and expenditure are not reasonably correlated.
Fourth, the resource distribution lacks of good mechanism;
Fifth, the medical information is not transparent enough.
Sixth, the Payment standard policy is unreasonable.
In the face of the above-mentioned financial challenge of NHI, we must make a self-criticism of the expenditure and revenue. In addition, supply and demand in medical market and innovation of NHI system are decisive factors to the success of NHI financial reform. In this article, we proposed the following reform tactics pertinent to the above-mentioned three constructs, the financial revenue and expenditure, medical supply and demand, and NHI system:
(1) In respect of financial revenue and expenditure: Adjust the insurance premium and payment scheme to expand the flexibility of insurance premium base, and enhance the function of deductible policy and system, Strive for the people's acceptance and recognition, press for the NHI subsidy arrears of governments at all levels, set up the NHI Poverty-relief Fund, reorganize the financial outfit to cope with different economic cycles, strictly control and reduce waste of medical resources, strengthen the function of global budget system .
(2) In respect of medical supply and demand: establish and comply with all the regulations related to medical practitioners and suppliers, promote the fair participation of all people in demand of medical treatments.
(3) In respect of NHI system: We propose the optional schemes of NHI system according to future NHI positioning policy, for instance: Set up the national health insurance committee and reform the system to be independent groups of government bodies; Under Department of Health there can be an unitary Bureau of National Health Insurance; Set up Division of NHI and Bureau of National Health Insurance inside the Department of Health; Set up a corporatization NHI foundation under Department of Health; Under Department of Health, there can be a Bureau of National Health Insurance and six NHI coperations;or set up a single corporatization NHI foundation under Department of Health and make multiple-purpose insurances open to public access in the meantime.
Whether the NHI can be ever lasting definitely depends on whether we carry on financial reform. This article is to propose the above reform tactics for reference of the NHI planners and policymakers so as to achieve the long term financial healthiness and stability of NHI system.

並列關鍵字

National Health Insurance ； Financial balance mechanism ； Financial responsibility

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