醫院對全民健康保險藥價政策之因應策略研究

Abstract

台灣的全民健康保險係屬一種強制性之社會保險，採用單一保險人支付制度。近年來，由於人口高齡化、新醫療科技進步，治療成本隨之增加，導致整體醫療費用逐年提昇。藥費支出佔台灣整體醫療費用約1/4，為了減緩整體健保醫療費用增加速度，健保署針對藥品實施許多政策包括：「藥價基準」、「藥品費用分配比例目標制」及「健保學名藥三同」等。由於健保署採用「單一支付價」控管藥品支出，醫院藥品進價與健保給付之差額即為「藥價差」，被大眾媒體描述為「藥價黑洞」(Black Hole of Pharmaceutical Costs)，致使民眾對醫院經營產生負面觀感。然而在自由經濟市場上，此說法並非事實。 因此，本研究之目的在於分析系列個案醫院經營者在此藥價政策下，透過適當營運及管理模式，於當前健保制度限制下創造價值並兼顧醫療品質。研究透過訪談醫院決策管理者取得關鍵初級資料並佐以次級資料分析醫療機構同業的採購制度及營運模式。研究結果指出在健保署採取藥價給付限制下，將驅使醫院經營者針對內部管理藥品措施更為積極並依據自身條件尋找不同經營模式，包括在社區紮根及發展特色醫療等。在政策上，健保應該設立評估藥價政策調整，造成民眾用藥型態改變，及其長期療效的監測與評估，落實「以病人為中心」之醫療本質。

The National Health Insurance (NHI) in Taiwan is a compulsory program with a single-payer benefit package. The cost of pharmaceutical services is almost 25% of the total expenditure of the NHI. To decelerate the growth rate of NHI expenditures, several pharmaceutical pricing policies were established, including a drug list, drug expenditure target (DET), and policy for equal components, packages, and prices of generic drugs. The National Health Insurance Administration (NHIA) initiated a payment simplification scheme to control medical expenditures under the constrained financial considerations of the global budget scheme. However, this has resulted in phenomena related to differences in drug prices. Mass media describes the margin between drug purchases and NHI payments as a 'black hole of pharmaceutical costs,' which has concluded to be the main reason for declining medical quality for the people. However, this statement is not the truth in a market-oriented economy. The aim of this study is to analyze how hospital operators create value while taking into account the quality of medical care through appropriate modes of operation and management under constraints from the NHI. This study conducted a secondary data analysis of the procurement system and operating mode within hospitals and accessed key firsthand information through interviews with hospital executives. The findings indicate that the existence of drug price differences shapes managerial and operation model, including community relationship management and special medical services for hospital operators. To achieve patient-centered medicine, the government should evaluate the long-term prognosis of patients since enacting these pharmaceutical pricing policies.