多元保險人經營策略－經營組織之品質保證及財務管理

Strategic Plan for Multi-Carrier Health Insurance Organization-Quality Assurance and Financial Management

王炳龍(Bill Binglong Wang) ； 林四海(Szu-Hai Lin) ； 張耀懋(Yao-Mao Chang) ； 鄭讚源(Tsan-Yuang Cheng) ； 陳辭修(Benson Chen) ； 戴蘭祺(Lan-Chi Tai)

《醫務管理期刊》 3卷1期 (2002/03) Pp. 49-67

摘要

全民健康保險制度誰動在減輕民眾醫療負擔、提供適切醫療照護、落實平等就醫權利等方面獲得顯著的成果。就健保制度而言，許多先進國家永於健保財務和醫療品質的考量，部分採行多元保險人制度，鼓勵保險人透過市場競爭機制，強化民眾參與經營與監督機制，提昇保險經營績效，俾確保保險財務之平衡，以奠定永續經營之賺礎。當前，雖然全民健保之改革方向已暫緩實施多元保險人制度，但從整體趨勢而言，多元保險人制度仍然是未來健保改革的參考之一。本研究之目的可分為三方面來探討，第一方面探討多元保險人之經營組織型態；第二方面探討多元保險人醫療服務品質之監控；第三方面探討多元保險人經營之支付方式及財務管理。最後，進一步透過文獻蒐集與分析及德菲法專家意見調查方式，規劃多元保險人組織有關品質與財務之經營策略。

關鍵字

全民健康保險 ； 多元保險人 ； 品質保證 ； 財務管理

並列摘要

The purposes for this study are: (1) to explore the different organization types of multi-carrier system, (2) to explore the quality assurance under the multi-carrier system, (3) to explore the financial management for multi-carrier systems. Lastly, three categories of conclusions and suggestions from this study are as follows:
The Managed Care Organizations (MCOs) are the organization types for multi- carries. The major groups consist of NHI and academic medical center (AMC) and their medical systems.
In quality assurance, the top priority issues are implementing credential reviewing, setting up clinical guidelines, medical and operation standard procedures, quality assurance monitoring, and evidenced-based medicine. In addition to set up prevention and health promotion index, and patient satisfaction survey. In the evaluation, the best way is to build up a Joint Commission for quality assurance or the National Commission of Quality Assurance (NCQA). Other accreditation organizations include the Department of Health that coordinates experts as accreditation commission, wel1-kno consumer organization, third party, or special medical group peer review committees.
The premium for health insurance supposes to be set by four different groups: insurer, beneficiary, health provider, and government, in order to providing high quality and reasonable cost for each of the participants. According to the compensation for physician, one of the top payment types is capitation. Next is global payment mixed with fee for service payment system. For hospital compensation, the result showed that the main payments could be case payment, capitation, global payment, respectively. In the share of insurer, there are several ways to allocate the shares: pooling foundation, lowering premium or raising the premium while shorting the shares.

並列關鍵字

National Health Insurance ； Multi-Carriers ； Management Strategies

參考文獻

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