健保藥價政策與藥價黑洞之探討 ─藥品費用分配比率目標制分析性研究─

NHI Drug Price Policy and Probe into the Black Hole of Pharmaceutical Costs -Drug expenditure target analytical studies-

陳世雄(Chen, Shih-Hsiung)

指導教授 ： 古永嘉博士

國立臺北大學/商學院/企業管理學系/碩士(2013年)

摘要

本文結合專訪產、官、學者、專家與問卷調查方式，探討中央健康保險局現行之藥品政策所產生的藥價差（藥價黑洞）問題，以及二代健保法2013年1月1日正式公告實施後，藉由本法中第62條應預先設定之「藥品費用分配比率目標制」（Drug Expenditure Target, DET）等條文，是否有助於健保局解決或縮小藥價差（藥價黑洞）的問題，進行深入分析與探討。
藥價差現象的產生為健保局制定的藥品「統一支付價」有直接關聯，如將現行藥品「統一支付價」制度，改以「三合一」配套方案，可否徹底處理不當的藥價差？以及DET制度與第46條市場交易、合理價格、藥價調查與合理調整所產生之變化探討與建議未來因應對策。
本研究綜合專訪產、官、學者、專家與問卷彙整分析後，結論與建議如下：
1.新的 DET 制度與藥價差進行研究分析，同意此制度的實施可使藥價調整之額度具有透明性、明確性、可預測性，減少對醫、藥界之衝擊，達到有效控管藥費支出與浪費，但在現行的藥品「統一支付價」制度下，已證明無法改善縮小藥價差之目的，因此，目前DET制度對促進藥業合理經營與發展其效能仍產生負面的影響。
2.以訪問與問卷調查為基礎，結果顯示對藥品供應鏈的穩定度、醫院換藥頻率，個別產品或整體價格調整而言能發揮其立法旨意與精神；該政策之推動與落實執行有助於提供政府與醫、藥界實務的參考依據或借鏡。
3.本研究歸納結果，達到有效控管藥費支出與運用，但藥品「統一支付價」制度所產生的藥價差，已證明無法阻止或解決醫療院所索取不合理的藥價差與「以藥養醫」之扭曲事實，也無法回歸醫師專業處方權，更無法確保病患『合理/安全/有效』的用藥權益。
4.本研究顯示，受訪者大多數同意現階段為使健保藥品政策更行完臻，必須制定藥品合理價格、停損點、合理的藥價差規範，且應將現行的藥品「統一支付價」制度改以「三合一」支付制度等量化指標，雖無法徹底解決藥價差，但可規範及處理不當的藥價差，杜絕民眾詬病的「藥價黑洞」污名，改善藥品不當的浪費，消除以藥養醫及有助於健保局落實「醫藥分業」制度。
本研究之意涵重點在於建立一套公平、合理、效率的健保藥品政策，讓產業

得以永續經營、鼓勵以『品質』取代目前『價格』上的競爭，確保國人『用藥品質』的把關，達到『合理/安全/有效』的『用藥保障/環境』。唯有健保藥品政策支付制度持續改革，終極目標是徹底縮減/解決藥價差的問題，逐步提高處方簽釋出率，才能實現醫藥分業制度，使台灣邁向先進的文明國家行列。

關鍵字

藥價基準、藥價調查、藥價差、三合一配套

並列摘要

The purpose of this study is to investigate the drug price balance problem (drug price black hole) caused by the existing drug policy of Bureau of National Health Insurance(BNHI) with integrated opinions of industrial practitioners, officers, scholars, and experts. In additions, this study would also investigates if the Article 62 (referring as Drugs Expenditure Target, or DET), of the 2nd Generation of NHI, effective on January 1, 2013, could help BNHI to reduce drug price balance problem (drug price black hole).
It is well-known that the cause of drug price balance has directly associated with the “Unified Drug Price” system set up by BNHI. Using questionnaire survey, this analysis mainly aimed at if we could change Unified Drug Price system into “Three in One” system for solving the inappropriate drug price balance, and to give strategic suggestions on how to modify the DET and Article 46 regulations (referring to transaction in market, reasonable drugs price value survey, and reasonable price adjustment).
The results of this study are summarized as follows:
1. This research showed that the implementation of new DET can make the amount of drug price adjustment bearing transparency, accuracy, and predictability. It also can reduce the impact on medical and pharmaceutical industries, and achieves effective control of drugs expenditure. However, the new DET with the existing unified drug price system is incapable of improving of narrowing down the drug price balance. Consequently, the existing system may have negative influences on the development of reasonable operation in pharmaceutical industry.
2. The results agreed that the implementation of new DET policy can stabilize the supply chain, the frequency of switching drugs, and reasonable adjustments of overall and individual products. It means the new system legislation would be useful for providing insightful example for government, medical and pharmaceutical industries.
3. This research shows the new system could achieve effective control of drugs expenditure and waste. However, the unified drug price system could not prevent that hospitals asked for unreasonable drug price in order to use drug price balance to support hospital expenses. It would distort the professional prescription right to doctors, and could not assure the patients’ reasonable, safe and effective dosing right.
4. The respondents all unanimously agreed that in order to make NHI drug policy even better, BNHI should establish quantified indicators for reasonable drug price, floor price, and reasonable drug price balance, “Three in One” system and so on. It is suggested that the existing “unified drug price” system should be changed into “Three in One” system. Even though it cannot solve drug price balance, it could reduce the inappropriate uses on drug price. It could also reduce the criticism of “drug price black hole”, and improve the unsuitable drug waste, remove financial dependency of hospitals on drug usage, and help BNHI implement the separation of drug prescribing and dispensing system.
The main implication of this research is to establish a fair, reasonable, and efficient NHI drugs policy so that the industry will be able to operate continuously. A well-designed NHI policy should encourage competitiveness in quality instead of price in order to assure the public of drugs quality, and to achieve a reasonable, safe, and effective drugs security/environment. With the continuing reform of the NHI drugs policy, we can achieve the final target of completely narrowing of solving drug price balance, and gradually raise the prescription release ratio. Furthermore, the fulfillment of the separation of drug prescribing and dispensing system would make Taiwan become a better civilized country.

並列關鍵字

Drug List, Drug Price Survey, Drug Price Balance, Three-in-One System, DET, R-zone, Floor price, and Claw back

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