全民健保實行總額支付制度之探討─以加拿大與台灣之施行現況為例

Implementation of the Global Budget Payment System under the National Health Insurance─Exploring the Current Status of Canada and Taiwan

黃品憲(Huang Pin Hsien)

指導教授 ： 賴沅暉

亞洲大學/管理學院/國際企業學系碩士班/碩士(2004年)

摘要

為保障全體國民均能獲得完善的醫療保健服務，現代進步國家皆透過實行全面性的醫療保健制度以貫徹此一宗旨，我國亦於1995年開辦「全民健保」。加拿大總額預算制度已行之有年，其醫療水平與品質屬於高度發展之國家，而總額支付制度可能產生之醫療品質下降之問題亦未在加國發生。因此，本文期望透過次級資料分析法與歷史制度分析法著手進行，以加拿大總額支付制度提供之經驗，借鏡國內實施總額支付制度可能面臨之問題，並提供建議改善之。
根據研究結果發現，我國實施全民健保支付制度出現包括支付制度論量計酬、標準結構、藥品支付制度、缺乏醫療費用抑制辦法與相關決策尚未建立完善模式等問題。而加國目前在健康保險制度上有著相對優異之表現。其健保體系以府際關係的制度環境為基礎，在「財政聯邦主義」帶動下，由醫院保險逐漸擴大到社區與藥品給付，並在每次的改革中，以漸進的方式，不斷修正其健保政策，為加國人民提供最佳健康照護服務。
事實上，總額支付制度並無所謂的標準，我國在實施總額支付制度的制度設計上應擷取加國優異之處，並依兩國體制結構、發展需求、實施對象及目標的差異，而制訂適宜之總額預算配套制度。透過有效節制醫療浪費、充分保障民眾就醫權益、抑制與調整過度醫療服務以及促使醫療執業行為正常等修正，促進醫療生態的平衡發展，達成民眾健康更有保障的目標。

關鍵字

全民健保 ； 總額支付制度 ； 加拿大

並列摘要

In order to achieve well-developed health care service, most industrialized countries have been practiced complete all-around health care systems. The new National Health Insurance Program in Taiwan was also implemented in 1995 which covers comprehensive health services for entire populations. Canada uses the global budget payment system for its health care service for many years; however, it does not encounter any problems with decreasing health care quality and standard by using such payment system. Therefore, the thesis will address all the challenges Taiwan will be facing by using global budget payment system for health care service through secondary data analysis and historical regulations analysis. The thesis will also discuss suggestions for improvement based on the experiences of health care payment system in Canada.
According to the results of my research, the new National Health Insurance Program in Taiwan is facing several challenges include payment systems, standardized structure, medicine payment system, etc. Canada uses intergovernmental relations regulation environment as the foundation under the fiscal federalism to expand health insurance plan from hospitalized insurance plan to community and medicine payment plan. It continues to improve and modify its health insurance policy in order to provide the best health care service.
In fact, there is no certain standard for the global budget payment system. Taiwan should adapt the excellence of Canadian health care insurance service to develop its suitable global budget payment system base on the differences between Canada and its country i.e. organization structure, development demand, implemented target and goal. The new policy should control the waste of health care resources, assure the right of public''s health care, control and adjust excessive health care service, and induce the normality of health care service behavior. It will encourage balanced-development in the health care environment and achieve the goal of assuring public''s health.

參考文獻

25. 楊志良。(2000)。健保實施五年之回顧與未來興革之道。「中華衛誌」，第十九卷第三期：159-160。

14. 李玉春。（2001）。全民健保西醫總額支付制度之推動政策─基層與醫院預算之分立或統合。「台灣醫界」，第四十四卷第七期：43-47。

32. 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研究所碩士在職專班碩士論文。

35. 張益誠。(2002)。「總額支付制度實施前後之差異分析：以台灣北部地區西醫基層診所為例」。台北醫學院醫務管理研究所碩士論文。

1. Arrow, Kenneth J. Uncertainty and the Welfare Economics of Medical