風險校正因子：論人計酬醫療費用預測之基礎

Risk Adjuster: The Basis for Capitation Payment

張睿詒(Ray-E Chang) ； 賴秋伶(Chiu-Ling Lai)

《台灣公共衛生雜誌》 23卷2期 (2004/04) Pp. 91-99

https://doi.org/10.6288/TJPH2004-23-02-01

摘要

為了有效控制醫療費用成長與強化社會公平，前瞻式預算支付設計已被許多先進國家的健康照護制度採用，在避免無效率及缺乏公平性存在於此預算額度的決定，近年來風險校正機制已逐漸導入。而多年來國際研究持續投入此一領域，提供許多政策制訂上之依據，其中發展風險校正因子，提升對未來醫療費用預測的研究，為數甚多。鑑於全民健康保險支付制度已全面採行前瞻式總額支付方式，而多項健保改革制度倡議均提及風險校正之必要性，而國內之風險校正相關研究仍處於萌芽階段，然初步結果顯示，我國風險校正因子預測力相較國際研究結果並不遜色，甚或有較佳之跡象。在檢視國內外文獻提出對台灣風險計價發展之下列建議：（１）風險計價與校正因子的發展，應考量本土保險制度與社會習性，方可提供有效訊息予政策規劃使用；（２）短期內，國內風險計價研究可利用完整診斷資訊，發展具預測力的風險因子並從事國際比較，中、長期而言，可藉由處方資訊的改善，發展用藥處方因子，全面與國際發展趨勢銜接。

關鍵字

風險校正因子 ； 風險校正 ； 論人計酬 ； 健康保險

並列摘要

In order to contain the escalation in health care expenditure and strengthen social equity ,most developed countries ,at least to a certain degree ,have introduced prospective budget mecha-nism into their health care systems. To avoid the carrying over of inefficiencies and any resulting unfairness into the current system, in recent years the determination of the prospective budget has been calculated more cautiously by employing risk adjustment. Many studies have been dedicated to this area and have provided a sound basis for policy making. Among these studies, a large number are related to the development of risk adjusters to increase the predictability of risk assessment. Taiwan’s NHI has fully implemented a prospective budget payment system, and many reform proposals have urged the necessity of risk adjustment. Although the research into risk adjustment is at an early stage, some risk assessment studies have reported promising results. After reviewing both Taiwan’s and international risk assessment studies, we recommend: (1) to provide valuable information to policy makers, the development of a risk assessment model must take Taiwan’s health care system and social characteristics into account; and (2) in the short term, a risk assessment model incorporating fully diagnostic information should be developed immediately, and in the long term, the prescription information in the claim data should be improved, which can be used in developing indigenous prescription drug adjusters. In this way, the research into risk assessment in Taiwan will be able to be used for cross-country comparisons and be compatible with the global trend.

並列關鍵字

risk adjuster ； risk adjustment ； capitation ； health insurance

參考文獻

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