全民健保制度與醫療院所經營關聯之研究 －以病人為中心之多贏策略

Abstract

全民健保自21世紀以後，健保費用成長迅速，財務陸續惡化，至2004年底時短期借款已達900億元，流動比率（=流動資產/流動負債）由2000年的1.82；升到2004年的1.99，嚴重違背即收集付的精神。健保醫療成本2000年至2004年間增加約15﹪，民眾健保受益並未增加，健保受益比（=健保費用/家庭保費）由2000年的3.02降至2004年的2.98，五年間家庭醫療自負額也成長26﹪，而1995年（健保實施年）至1999年僅成長10﹪，也拉大貧富間醫療就醫的公平性。 而造成民眾就醫更加不公的原因，與醫療院所的經營日益困頓有關，以醫院為例，醫院的健保收入增加了15﹪，204盈餘卻減少50﹪，醫院為經營所需，只能提高自費項目並減少成本支出，此等作為是造成民眾就醫不公與醫療品質下降的主因，而健保局為減輕財務壓力，增加不少管控作為，但無意間卻傷害了對醫療專業的尊重，也間接傷害就醫的公平性與醫療品質。 因此如何在有限的資源下，使醫療院所能保有一定的盈餘，使需要就醫的民眾得到合適的照護，健保支付制度的改變是必須的，而論人計酬是可以加以考量的。 本研究的中心思維就是如何使需要醫療的民眾得到應有且合適的照護，但健保制度直接影響醫療院所的經營模式，因此架構一合理的健保給付制度，除能使醫療院所穩定經營，並重視民眾就醫的需要，與健保財務的平衡，這是本研究希望達成的目標。 本研究建議利用病人健保就醫場所的資料，將有共同病患交集的醫療院所予以整合成一健康管理聯盟，健保局就醫療院所的核心能力及其所照護病患人數，依據以往醫療院所收入與病患醫療費用（個人價值），予以一定的給付（論人計酬）與應有的照護責任（健康管理制），民眾則有主動選擇醫療院所聯盟的權利，病患從A聯盟換到B聯盟時，病患在B聯盟所需的照護費用由A聯盟給付，但A聯盟有審查之權，使民眾與聯盟間、或聯盟與聯盟間的權責可以平衡，聯盟需以加強品質與服務爭取民眾的忠誠度，醫療院所可發揮其醫療專業，以健康整合照護代替以往的純醫療服務，引導民眾從購買醫療走向購買健康，醫療院所也可獲得穩定的收入與盈餘，減少不必要的競爭，整體健保費用的成長也可得到較佳的控制。 本研究從健保資料可知，歷年醫療費用之疾病結構別差異不大，病患對醫療院所也具有一定的忠誠度，因此以論人計酬為主的支付制度應屬可行，本研究建議可將健保相關資料作更深入的探討，掌握各項變數的變動趨勢，並針對新制的需要加以必要的模擬，將有助於未來論人計酬致的進行。

Since the 21st century, the Medical Care Expenditure (MCE) from National Health Insurance (NHI) has increased very quickly. Until 2004, the short–term borrowing was nearly NT 90 billion. The current assets to debt ratio increased from 1.82 in 2000 to 1.99 in 2004. This ratio shows that we have violated the principle of turnover rate. The cost of medical care increased 15% between 2000 and 2004, but the ratio of MCE to premiums decreased from 3.02 in 2000 to 2.98 in 2004. During these five years, the out-of-pocket MCE for each family increased 26%, whereas the out-of-pocket MCE for each family increased only 10% from 1995 to 1999. This phenomenon shows that the inequity of MCE has increased. One reason for the inequity of MCE is the operational performance of hospitals. In 2004, the hospital’s total income from the NHI increased 15%, but the total surplus decreased 50%. Based on this data, the hospital strategy is to create a new service, which is the out-of-pocket MCE, and decrease the cost. The results of the hospital strategy are that inequity of MCE has increased, and medical care quality has suffered. At the same time, the Bureau of NHI’s (BNHI) strategies do not respect the medical professional, hence lowering medical care quality and violating the equity of MCE. How does one maintain a constant surplus for hospitals and keep quality of patient care with limited resources? One of the solutions is to reforming the payment system of the NHI is capitation—everyone pays the same fee. The central thinking process of this research is to make the patients, who really need medical care, get the right medical care. The goal is to maintain not only a constant surplus for the hospitals but also financial solvency of the NHI, while valuing the medical demands of patients. This research studies the medical utilization history of patients, and then it allies all the intersections of hospitals that patients have visited before into a coalition-health-management-hospital (CHMH). The BNHI analyzes the core-competition-ability of each hospital and the total number of patients for each hospital. Utilizeding the above data which containeds the income of the hospital and the MCE of each patient, the BNHI can set a modified capitation payment system.Under this modified system, hospitals have the responsibility offer each patient’s health. Patients can choose any CHMHs which patients they like, and patients can switch their hospital from A to B. When a patient decides to stay at B hospital, hospital A has to pay the MCE to hospital B, but hospital A has the right to audit the quality of hospital B.. The responsibility of different CHMHs and the responsibility between the patient and his CHMH will be balanced. The CHMH will focus on qualities and services: it will perform the best professional services, substitute managed health for medical care, induce patients to buy health, rather than treatment. If so, all the hospitals will get stable incomes and constant surpluses. Also, unnecessary competition will be diminished, and the growth of the MCE will be under control. This research reveals that there are correlations between disease patterns and the number of hospitals that a patient visits each year. Based on the above phenomenon, the modified capitation payment system is available. This research suggests that we have to simulate more modified capitation models.