醫療管制與俘虜理論的動態分析-總額預算下的管理式醫療

Dynamic Analysis of Medical Regulation and Capture Theory-Managed Care in Global Budget System

林毓琦(Yuh-Chyi Lin)

指導教授 ： 劉靜怡

國立臺灣大學/社會科學院/國家發展研究所/碩士(2007年)

https://doi.org/10.6342/NTU.2007.03047

摘要

作者認為，制定醫療公共政策，必須以審議式民主理念，讓人民公平地參與討論，在說理和議論的主導下，尋求解決利益衝突之道。然而現實環境中舉凡與有關健保之高度技術性政策，即使全部符合正當程序與資訊公開的要求，也不可能事事全部都讓一般人民經公民論壇解決爭議，所以國家管制機關（衛生署）必須以相關審議委員會之行政制度監督途徑，經由合議制方式，解決多方利益的衝突；在審議委員會中，醫療資源使用者是以公民身分，要求國家制定對他們有利的醫療政策；台灣醫療資源分配實際上是經由國家政策、編預算決定執行，而非由市場經濟決定，健保預算既屬於國家資產，就應該公有共享，所以醫療提供者的任務，不但要執行醫療專業，還要協助醫療資源使用者善用公有的醫療資源。但是若前述程序組織失靈，司法系統即扮演司法監督機制，藉由判決與司法審查，改正國家管制的脫軌行為。
本文是從現實面切入，將上述理論以實例闡述，由結果面出發，提出組織失靈的現實問題，並從國家管制的俘虜理論解釋一連串社會保險失控的背景，再檢討管制主體、社會福利國的理想、公共利益與現行總額預算下管理式醫療的衝突。當國家管制沒有落實民主程序，利益團體不可避免地將假藉公共利益之名，行追求私利之實。
合理的健保制度，是要允許醫師盡其所能給與病人最完善的照顧。但是醫療專家專斷之制度設計，反而會誘發了人性醜陋的一面，這容易使醫師將利潤的考量放在病人的福祉之前。現行牙醫或核子醫學方面的游離輻射診斷，醫療霸權認為不會傷害到病患，因此在制度上無形中提供了誘因，並隨著醫療商業化及形式化同儕審查標準的發展，動搖了醫師「以病人的福祉為優先考量」的專業態度。當醫療制度隱藏著讓醫師增加所得之不當誘因，在棒子與蘿蔔的威脅利誘下，最終將導致醫療提供者濫用X光片攝影檢查，而增加了醫療游離輻射設備不必要的使用。
因此本文檢討醫療專家專斷制定政策時，未加考量的重要事項︰諸如實質面上，同儕審查的迷思、告知後同意、保護病患隱私權與隱私自主權等問題。並從醫療訴訟與二代健保修法中，檢討司法與行政機關的實務發展，結論上我國在告知後同意與隱私自主權的實踐，尚有許多努力改進的空間。
另外在程序制度面上，本文從正當程序出發，檢討衛生署四個審議委員會，仍舊逃不出醫療霸權的專斷，因此相形之下，我國司法審查有必要對全民健保制度最後一道防線負責把關，以維護全民健保的公益目的。
然而我國的社會脈絡在與行政、與司法的監督機制，因為其獨特的醫療霸權發展脈絡，造成了我國空有社會福利國理想之制度，卻又無從以審議委員會或司法機關的途徑，糾正組織失靈的現實缺失。因此本文認為醫療公共事務的制定程序中，必須落實審議式民主、以及審議委員會與司法審查制度，社會福利國的理想才可能完全實現。

關鍵字

社會福利國 ； 審議式民主 ； 全民健康保險 ； 牙醫 ； 告知後同意 ； 國家管制 ； 俘虜理論 ； 管理式醫療

並列摘要

This paper is to explain the procedure of policy-making about medical public affairs. First with the idea of deliberative democracy let people fairly participate and discuss. Then after argument and discussion, people find the way that can solve the problem. However it is unrealistic and impractical to appeal every issue - especially complex, technically oriented issues of National Health Insurance policy to a public process. Therefore regulatory agency (Department of Health) establishes institutional review board (IRB) as inner supervision arrangement. Through the commission negotiation, government settles the impact of vary interest groups. Residents, users of medical resource, urge government make the best policy that they want. Though the medical resource, those will be shared to people equally and justly, belong to country estate, the medical providers not only deliver professional medical care, but also help users allocate and make the best of the medical resource. While IRB function is failure, courts of justice department act as external supervision arrangement. Through decision and justice review, they can correct the arbitrary and abusive discretion of executive agencies.
This paper was written and described from the positive aspect. Retrospectively it initiated the beginning by the issue of government failure and argued the capture theory of regulation. Then it explained the background about lose control of the social insurance and checked regulation entity, ideal of the social welfare, and conflict between public benefits and medical managed care in global budget system. If regulation not fit with requirement of democracy process, unavoidably the interest group will grasp private benefit in the name of public goods.
A reasonable healthcare system grants doctor do his best and deliver perfect medical care as possibly. However the current healthcare policies designed by medical imperialism lead to a manner of corruption because doctors more care their income than benefit of the patient. Even if the radiography is considered not definitely harmful in the dentistry and the other image diagnosis of medicine, in the healthcare system we can not offer the incentives that persuade doctors give up their professional attitude with which they do best for the patient. If there are unjust incentives in the wake of medical commercialization and formalization, finally doctors will abuse radiography and providers will be encouraged to overuse unnecessary radiation.
Therefore in the last half of this paper specially considered are issues related to policy-making of which medical imperialism takes no account.
Substantially there are issues involved with myth of peer review, informed consent, protection of patient private right and privacy autonomy. Through practice of medical lawsuit and analysis of secondary generation National Health Insurance, we can understand there are some spaces in these for further progress in the future.
This paper describes due process and four institutional review boards in the Department of Health, Taiwan. Because medical imperialism takes over the commission, justice review, external supervision arrangement, acts as gatekeepers of National Health Insurance.
However there are special social context with external and inner supervision arrangements. Therefore it is vain for both supervision arrangements to correct market and government failure.
This paper accents a standard procedure of policy-making about medical public affairs. With deliberative democracy and both supervision arrangements the idea of social welfare will come true.

並列關鍵字

social welfare ； deliberative democracy ； National Health Insurance ； dentistry ； informed consent ； government regulation ； capture theory ； managed care

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