全民健康保險系統代理問題之研究

The Agency Problems in the System of National Health Insurance

尹志峰(Chih-Feng Yin)

指導教授 ： 韓釗

淡江大學/管理學院/公共行政學系公共政策碩士班/碩士(2007年)

https://doi.org/10.6846/TKU.2007.00474

摘要

本研究之焦點係針對全民健康保險系統的財務問題，依據代理理論所提出的代理成本模型為架構，探討健保局與特約醫療院所間所形成之代理關係，並基於以行為為基礎的契約與以結果為基礎的契約，分析代理結構中監督成本、約束成本與剩餘損失之間的互動，提出以下四項主要發現及相關策略建議。

第一，健保財務系統的誘因結構是造成其收支失衡的主要原因之一，該結構導致醫療體系從事衝量服務行為，也使得醫療支出逐年上升。第二，在代理關係成立的基礎上，誘因結構愈符合健保局的利益，愈有助於降低其對於資訊系統的依賴程度。第三，健保局應提供正確且適當的誘因連結，以激勵代理人的約束行為。最後，在採行以行為為基礎的契約能夠正確衡量醫療院所之醫療服務行為前，健保局可考慮先使用以結果為基礎的契約規範代理關係，俟有能力增加相關資訊後，再修改成以行為為基礎的契約。

基於上述研究發現，本研究對於目前健保財務問題提出三項因應策略。首先，健保局可設立一套「違規標準」，在此標準以下的醫療院所表示較符合健保局之利益，可以用原先預定分配的總額加上安全準備金作為其總額分配基礎。其次，健保局可提供一定比例的檢舉服務量作為醫療院所從事檢舉行為的獎勵，以激勵同儕制約行為。最後，在指標管理的部份，對於醫療服務行為的衡量指標，可先考慮在無法增加相關資訊的情況下就其服務行為的結果加以規範，在累積相當資訊而能制定完整的指標後，再改為對服務行為的規範。

關鍵字

全民健康保險 ； 總額支付 ； 代理理論 ； 代理成本 ； 投機行為 ； 有限理性 ； 紮根理論

並列摘要

This research focused its efforts on probing the financial problems of the National Health Insurance (NHI) System. In accordance with the agency cost model proposed by agency theorists, this research investigated the agency relationship between the Bureau of National Health Insurance (BNHI) and the contracted medical care institutions. Moreover, this research analyzed the interactive effects among monitoring cost, bonding cost, and residual loss resulted from behavior-based contract and outcome-based contract, respectively. Based on the analyses of this research, four major findings and related strategies are stated as follows:

First, the incentive structure embedded in the financial system of NHI may be one of the major causes that result in financial deficits. The incentive structure tends to motivate overgrazing behaviors in the medical system that in turn, lead to the growth of medical care expenditures. Second, in light of current agency relationships, the more the incentive structure is aligned to the interest of BNHI, the less is the reliance of BNHI on its information system. Third, BNHI should provide correct and proper incentive links to encourage the agents’ bonding behaviors. Finally, before BNHI can correctly measure the behaviors of medical institutions by means of behavior-based contract, it may consider managing the agency relationships by using outcome-based contract instead, and replacing with behavior-based contract later when it has the ability to collect more information for monitoring the behaviors of the contracted medical care institutions.

Based on the research findings stated above, this research proposed the following three strategies for coping with the financial problems existed in the National Health Insurance System. First, BNHI may establish a set of “contravention standards”, and the budget for the medical institutions below those standards will include the negotiated amount plus the reserve. Second, BNHI may provide a certain proportion of service amount to reward those medical institutions which report fraudulent upcoding so as to encourage peer monitoring. Finally, BNHI may consider regulating the service outcome at present, and shift to behavior regulation after accumulating enough information for designing appropriate index that are able to accurately measure medical service behaviors.

並列關鍵字

National Health Insurance (NHI) ； Global Budget Payment System ； Agency Theory ； Agency Cost ； Opportunistic Behavior ； Bounded Rationality ； Grounded Theory

參考文獻

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