全民健保各項改革議題評析―以德菲法專家意見調查為基礎

An Evaluation on the Proposed Plans for the National Health Insurance Reform-A Study Based on a Delphi Survey

陳歆華(Hsin-Hua Chen) ； 陳孝平(Michael S. Chen)

《臺大社會工作學刊》 1期 (1999/05) Pp. 35-75

摘要

全民健保實施二年後依法屆臨改革，面對政院亟思多元化與民營化的潮流、及立院討論中的諸多版本，健保體制蘊釀重大之變革。本文的目的，在於將健保改革的各項可能的改革方案，歸納成若干項主要議題以及若干類方案，採用德菲法(Delphi)，針對國內醫療衛生政策領域專家學者進行二輪回之問卷調查，對全民健保改革之重要議題提供意見，並以五類改制方案達成政策目標之程度進行評估。本文調查的結果發現：多數專家對縮減現行健保基本給付範圍具有共識，也能認同健保法業已規定之總額預算、DRGs制之實施；而對「論人計酬」支付方式改革、甚而民營類似HMOs機構的引入亦有相當比例的支持。整體方案的評估上，現制改革及永金會應是阻力最小的方案；醫院組合相較於診所組合雖節制費用效果較佳，但在可進性及醫療品質相對減損。多元市場模式在「效率面」的成效最高，但卻因風險套利或就醫限制而有「可進性」的顧應。在縮減派本給付的前提下過半數專家贊同建立個人的「醫療專用儲蓄帳户」，但因降低社會連帶責任而有「公平性」的質疑，從而抵消其促進個人選擇的正面意義。

關鍵字

全民健保

並列摘要

The Executive Yuan has submitted a proposal calling for a number of fundamental changes in the NHI, such as a NHI foundation, and more importantly, a system with plural insurers (or, more accurately, carriers). To evaluate those proposals, this study applies the Delphi method, surveying on health-policy scholars and specialists for a series of issues, including changes in the benefit package, payment scheme, cost sharing, and assessments for plans in the entirely. We found that a majority of the surveyed seemed to come to a consensus that the current benefit package must be reduced, and the Chinese medicine was oh the top of the list to be cut. They also supported the idea if introducing institutions akin to HMOs, implementing a global budget which had been legislated, introducing DRGs for hospital services, A Capitation system was also supported, and so were medical savings accounts (MSAs), though by a slightly smaller majority. As for the proposals in their entirety, the surveyed considered a piecemeal reform plan based on the current system would face resistance; provider groups (a preferred name for HMOs here in Taiwan) based on hospitals would be more powerful in containing costs than that based on clinics; accessibility and quality, however, might be compromised. A plural model might enhance efficiency, accessibility, though, become a concern because of cream skimming practiced by the carriers. MSAs might promote choices, but equity might be hurt.

並列關鍵字

national health insurance