全民健保門診藥品不給付對各利害關係者財務之影響

The impact on the related stakeholders'' financial status under the National Health Insurance outpatient drug non-reimbursement program

鄒佩倫(Tsou Pei-Lun)

指導教授 ： 楊志良

亞洲大學/健康學院/健康產業管理學系健康管理組/碩士(2004年)

摘要

台灣健保費用每年收不敷出，開源不易之情形下，唯有從節流著手，每年全民健保門診藥品支出約700億元，佔總醫療費用支出1/4，對健保財務影響甚鉅，本研究援引若干國外先進國家之政策，探討門診診療無部分負擔而藥品由民眾自行購買（以下簡稱為新制）之可行性。
本研究的目的為：1.探討主要辦理社會醫療保險或全民健康照護之國家，其藥品給付及支付制度。2.若比照加拿大等國家，研擬門診診療取消部分負擔調整為藥品民眾自行購買時，對健保局、民眾及醫院之影響。3.綜合研判此項興革在各層面中，包括健保局、民眾、醫療提供者及藥品供應商及製造商，對於此項措施之態度，以評估其可行性。4.藉由本研究的結果整理，以玆未來研擬全民健保政策參考。
除國際上之文獻探討外，主要是針對健保局、民眾及提供者（包括醫界及藥界）進行分析，以能達成三贏為可行之前提，採用分為2部分：第1部分首先將2001年國內各健保特約醫療院所申報之醫療費用資料，以現況分析及模擬法將健保局之門診支付費用、民眾的門診負擔及醫療院所的門診申報收入資料，區分為現況組及研擬組（研擬新制實施後之情形），探討研擬新制後其財務影響差異情形，再進一步深入瞭解，研討此項措施對醫療機構層級別、權屬別及就醫科別之醫院收入及不同性別、疾病別及年齡別之民眾財務負擔的變化；第2部分以健保局、民眾、醫界及藥界之利害關係團體（stakeholder）為對象，採問卷方式，探討對此方案之接受程度及各層面之影響，進而瞭解新制之可行性；最後進行資料整理及結果探討。期能提供未來全民健保政策之參考。

關鍵字

門診藥品 ； 部分負擔 ； 醫療給付

並列摘要

The Bureau of National Health Insurance paid about 70 billion NT dollars per year for drugs for outpatients, which accounted about one-fourth of the total medical expenses, and brought a very great effect to the financial condition of the national health insurance program. This project is to study the feasibility of having the outpatients to buy drugs by themselves without cost sharing by referring to the policies adopted in the advanced nations.
The purposes of the study are: (1) reviewing the payment for drugs and the payment system in the advanced nations with social medical insurance or national health care programs; (2) discussing the effect of readjusting out-patients to purchasing the drug by themselves like Canada to the Bureau of National Health Insurance, the public, and the hospital medical and pharmaceutical industries; and (3) evaluating the feasibility of such a change from the Bureau of National Health Insurance, the pharmaceutical industry, medical care providers and the public.（4）the results are discussed to provide a reference for determining the policy in the national health insurance program.
In addition to review on literatures published by some international publications, the study mainly include analysis on the Bureau of National Health Insurance, the public and the medical care/drugs providers for a feasibility that can benefit all of them. First, descriptive analysis is used first by referring to the data about medical expenses applied by the contracted hospitals and clinics under the National Health Insurance data base during 2001 September to December in order to review the effect of such change to the financial condition of the Bureau of National Health Insurance, the change the medical care providers’ income in different diseases and in different classes of hospital/clinic, and the change on financial burden of the public. Second, the insured, medical and pharmaceutical industry’s degree of acceptance to this change is then discussed by questionaire method. Finally, the data are sorted and the results are discussed to provide a reference for determining the policy in the national health insurance program.

並列關鍵字

Drug ； Cost Sharing ； Medical Benefit

參考文獻

16. 林惠雯、薛亞聖 (2003)：醫療消費者及醫療提供者對全民健保新制門診藥品部分負擔的認知、態度及行為之研究。台灣衛生公共雜誌，22（1）：33-42。

48. 黃曉萍(2000)：探討全民健保之藥價差額負擔制度成效之經濟分析。國立中山大學中山學術研究所，未出版，高雄。

15. 林惠雯（2001）：醫療醫療消費者及醫療提供者對全民健保門診藥品部分負擔制度的認知、態度及行為之研究。國立臺灣大學醫療機構管理研究所碩士論文，台北。

40. 陳楚杰（2000）：德國健康照護制度改革的經驗回顧。醫務管理期刊，1（1）：12-19。

51. 楊全斌（1997）：德國醫療費用抑制之經驗。台灣經濟研究月刊，20（11）：81-98。