台灣全民健保總額預算支付制度對醫院市場結構與績效之影響

Abstract

台灣於民國84年3月1日開辦全民健保，然而由於支付制度之設計配套不足，促使健保財務失衡，為抑制醫療費用不斷成長，民國91年7月實施醫院總額預算後，至此全民健保醫療體系進入全面總額預算制度，財務風險移轉由醫療服務提供者自行承擔，提升營運困境，也改變醫療產業生態。 本研究發現，實施醫院總額預算制度並未降低醫療需求，由於健保涵蓋範圍廣泛、民眾自付額低、人口老化與科技發展等因素，反而逐年增長醫療服務費用；小型醫院因資金、人才、規模不經濟，使其家數逐年萎縮，15年間減少34%，但存在醫院有大型化趨勢，17.7%的大型醫院市場佔有率接近80%。就健保劃分六轄區觀之，東區與北區之市場集中度較高，高屏區、南區、台北區、中區之市場集中度較為分散。為降低健保總額預算之衝擊，醫院相繼發展自費市場，為維持競爭力，投入更多非價格競爭的醫療服務。

Taiwan's NHI (national health insurance) program was launched on March 1, 1995. However, the finance of NHI (national health insurance ) is imbalances due to the incomplete medical payment system. In order to control the increasing of medical costs, the National health insurance medical system bring global budget payment system into hospital from July 2002. Hence, the medical service providers have to take the responsibility of financial risk and therefore increase their operating challenge and change the medical ecology. Actually, we found that the implementation of hospital global budget payment system does not reduce the medical demand from the study. On the contrary, the medical service cost is increasing year by year as the wide coverage of National health insurance, low co-payment of patient, aging of population, and the development of science and technology, etc. For this reason, the number of small hospital decrease 34% in 15 years due to the small scale, lack of capital and talent. On the other hand, the existing hospitals tend to large-scale. There are17.7% of the large hospital with around 80% of market share. In the view of the six districts divided by Health insurance division, there is a higher degree of market concentration in Eastern Division and Northern Division while Kaoping Division, Southern Division, Taipei Division and Central Division have dispersive market concentration. In order to reduce the impact of the global budget payment system, the hospitals have been developing the self-paying market and put more effort on medical service with non-price competition to maintain competitive advantage.