九十年度全民健保年度醫療費用總額範圍之擬定及其政策意函

The Development and the Implication of Annual Health Care Expenditure Target for Global Budget Payment System of National Health Insurance in Taiwan-The First Year's (2001) Experience

李玉春(Yue-Chune Lee) ； 賴美淑(Mei-Shu Lai) ； 盛培珠(Pei-Chu Sheng)

《醫務管理期刊》 2卷2期 (2001/06) Pp. 72-86

https://doi.org/10.6174/JHM2001.2(2).72

摘要

為利健保局費用之控制、落實財務責任制度、並促使西醫加速實施總額，衛生署爰於九十年開始訂定年度醫療費用總額支出目標。本文目的在簡介支出目標研擬過程、擬定的方法，並討論其對健保財務與醫院之意函。
九十年度衛生署所研擬之每人醫療給付費用成長率範圍為2.21%-4.54%（投保人口及八十九年度醫療費用屆時依實際發生數計算），其下限(2.21%)，係年齡別結構改變對醫療費用之影響(0.80%)，加上醫療服務成本指數改變率(1.41%)，而後者係參考劉順仁等之研究，以相關經濟指標反映各項醫療服務成本，並利用後者之成本佔率為權重加權計算之。上限(4.54%)之擬定係以下限加調整因素，後者考量因素包括：給付範圍或支付項目之改變（高科技或藥品）、醫療品質之提升、其他服務利用及密集度改變、健保局精算報告、健保局八十九年及九十年節流措施預期成效、經濟成長率等。
上述範圍經行政院核定後由費協會據以協商，協定結果每人年醫療費用成長率目標值為4.11%（約3406億元），其中牙醫與中醫每人年醫療費用成長率分別為3.32%與3%，西醫在尚未實施總額前成長率則為2.21-3.97%（加上人口成長為4.93%，加軍人納保則為6.9%），若西醫超出或未達預定目標時，健保局需將因應措施（如打折支付），提報費協會協定。
因此就費用控制而言，九十年度以後全民健保已實際全面進入目標總額制，惟醫院部門尚未實施總額支付制度，目前醫療生態扭曲，專業自主性受箝制，以及效率不彰的現象可能更為嚴重，盼醫界早日凝聚共識，以真正落實總額支付制。

關鍵字

總額支付制度 ； 醫療費用支出目標 ； 全民健保

並列摘要

To facilitate the Bureau of National Health Insurance (BNHI) to set annual budget, control cost, enhance the financial accountability, and also to urge hospitals and clinics to participate in global budget payment system, total expenditure target (TET) for 2001 was set by the Department of Health (DOH). The purposes of this paper were to describe the methods and to discuss the implications of this policy.
The Process of setting TET began with the formulation of a reasonable range of TET by DOH and its approval by Executive Yuan, followed by the actual negotiation of TET by Health Care Expenditure Negotiation Committee (HCENC). The lower limit of TET per capital (2.21% increase) was computed by adding (1) impact of the change of population age structure on expenditures (0.80%), and (2) the medical care price index (1.41%). The latter was a composite index weighted by costing structure (%) of input factors and associated price indices proposed by Shuen-Zen Liu et al. The upper limit (4.54% increase) of TET was set based on the allowance for the above factors with some additional adjustment, including the impact of the benefits change (high tech or drug), incentive to promote quality, changing patterns of health care use, the actuarial report of the NHI, the potential saving of the intervention proposed by NHI in 2000-2001, and the economic growth rate, etc. Within the range of TET, recommended by DOH and approved by Executive Yuan, TET per capita, negotiated by HCENC, was 4.11% increase (about 340.6 billions N.T.) over and above 2000 expenditures. Among them, the annual per capita expenditure cap for dental and Chinese Medicine were 3.32% and 3% increase respectively. The per capita expenditures of the western clinics and hospital were required by HCENC to be controlled within the range of 2.21-3.97%, (4.93% if population growth was added or 6.90% if new enrollees from military sector were considered). During the fiscal year, BNHI should monitor and fix a solution (e.g. pro-ration, or setting a temporary discount on fee schedule) if the expected growth rate exceeds 3.97% orunder2.21%. To prevent from over-run, BNHI will introduce a lot of cost containment strategies. Some financial adjustment will also be proposed by DOH by the time when the reserved fund of NHI was less than one month of health care expenditures. Therefore, from 2001, hospitals will no longer be exempted from global budget. However, to be able to enhance professional autonomy, quality, and efficiency, hospitals have to participate in global budget payment system as early as possible.

並列關鍵字

Global Budget ； Health Care Expenditure Target ； and National Health Insurance