我國全民健保組織體制之研究

Abstract

本文分析我國現行健保組織體制之優缺點及組織問題，透過文獻分析及學者專家菁英訪談，以綜合性角度檢討我國健保組織之可能改革方案。研究結論認為，綜合各項組織制度變革方案之優缺點，及衡量我國目前之行政生態與法制發展，健保組織之體制以現制改革最為可行。 健保制度實施13年以來，一直存在健保收支不連動、財務嚴重失衡、績效欠佳、民眾、政府與醫療院所互不信任、民眾參與程度低、組織定位不明、權責不符、政治力介入等問題。本研究經過全面性文獻檢討後，彙整出現制改革、改制為行政機關、行政法人化、政署、多元保險人、民營化等6項改革方案。 本研究發現，6項改革方案中，最受支持方案依序為現制改革、改制為行政機關、行政法人化。雖然受訪者認為目前最適之改革方案係「現制改革－兩會合一」，但各主張獨特之配套方法。本研究發現行政作用法（健保法）之改革方向確定，則行政組織法（健保局組織法）問題就能迎刃而解。健保組織改制為行政機關則應於確定健保法修正草案後再議。 本研究之建議包括：(1).行政及立法機關均應積極研修通過健保法修正草案及行政法人法草案，以為後續改革法制依據；(2).積極推動兩會合一，促使健保收支連動，改善財務收支失衡問題；(3).建置長期監督之外部審計機制或專責機構，以重建社會信任；(4).衛生署及健保局應積極依法行政及改革，以紓解財務危機；(5).將行政法人化列為長遠可行之目標，積極規劃行政法人化相關之配套措施並行宣導；(6).組織體制應長遠規劃，於健保法修正定位後，再確立改制與否，並注意評估組織轉換成本及對國庫造成之負擔；(7).擴大社會多元參與健保政策，全民一起監督健保，避免健保黑箱決策過程；(8).現行健保局奬金制度可先行改革；(9).擬訂健保現制改革之基本原則。

This study reviews the organizational problems of Taiwan’s present National Health Insurance (NHI) structure and its functioning. Literature review and in-depth interviews are conducted. Six possible forms of organizational reform are critically reviewed. Six reform options include: reform of the current health insurance system, a traditional administrative organization, an independent administrative Institution, agency, multiple insurers, and privatization. The first three options are preferred during the interviews. Taiwan’s NHI system was established in 1995. Although the system is highly praised around the world, problems of the system have attracted serious public attention. Functional and organizational problems include: serious financial imbalance, inadequate linkage of premiums and expenses, unsatisfactory performance, lack of trust among stakeholders, low level of public participation, ambiguous organizational status, incompatible governance structure, and political interference. This study offers the following suggestions for the NHI organizational reform strategies: (1) The Health Insurance Act should be amended and Independent Administrative Institution Bill enacted; (2) committees governing premium revenues and medical expenses should be integrated to relieve the financial imbalance; (3) an external auditing organization should be established to rebuild the public confidence; (4) Department of Health and Bureau of National Health Insurance should reform their administrative systems to solve financial crisis; (5) organizational form of Independent Administrative Institution should be considered for the long term reform goal; (6) any reform measure of the NHI organization should consider its long term financial impact; (7) public involvement on NHI policy and budget should be encouraged; (8) the present performance bonus policy needs an overhaul; (9) general guidelines of organizational reform should be established.