我國健康保險制度永續性之研究

Abstract

台灣自1995年實施全民健康保險制度以來，成功達成「全民納保、平等給付」之初衷，顯著提升醫療可近性與民眾滿意度。然而，隨著人口快速老化、少子化趨勢加劇，以及醫療科技的進步，健保制度逐漸面臨財務壓力與結構性挑戰。健保財源長期依賴保費收入，公共醫療支出占GDP比率偏低，加上新藥給付延宕與總額預算副作用等問題，均對制度永續性構成威脅。本研究旨在探討台灣全民健康保險制度之永續發展，並針對「財源不足」、「新藥審查與核價機制」、「總額預算制度副作用」三大核心議題進行分析。 研究方法採文獻分析與深度訪談並行。文獻部分蒐集台灣健保發展歷程、國內外相關研究及英國、加拿大、日本、南韓、澳洲等先進國家的制度比較；訪談部分則針對製藥產業高階主管、醫療院所醫師及醫藥相關學者共11位專家，蒐集其對我國健保制度現況與改革方向的專業見解。 研究結果顯示：第一，台灣健保財源結構過於單一，政府公共支出占比下降，應建立長期調整機制並提高財政挹注比重，使公共醫療支出逐步接近OECD平均水準。第二，現行新藥審查與核價制度偏重成本控制，導致藥價低估與給付時程延宕，建議引入健康科技評估（HTA）與風險分攤機制，並設置創新藥基金以保障病人可近性與鼓勵產業創新。第三，總額預算制度雖能有效控費，但長期壓縮醫療點值，促使醫療機構仰賴藥價差維持營運，形成「以藥養醫」與「藥價黑洞」現象，建議導入成果導向支付（Pay for Performance）及合理化診療報酬，以改善制度扭曲。 綜上所述，健保制度永續發展需兼顧財務穩定、醫療品質與公平性。本研究建議政府除強化中長期財務規劃與透明治理外，亦應深化跨部會協作，推動以價值為導向之支付制度，確保全民健康保險在財政可負擔下持續提供高品質醫療服務，達成「全民可近、永續經營」之目標。

Since the implementation of Taiwan’s National Health Insurance (NHI) in 1995, the system has successfully achieved its goals of universal coverage and equal access to medical services, significantly improving healthcare accessibility and public satisfaction. However, Taiwan’s NHI now faces severe financial and structural challenges due to rapid population aging, declining fertility, and medical technology advancement. The system’s overreliance on premium income, the declining share of public health expenditure in GDP, prolonged delays in new drug reimbursement, and side effects of the global budgeting mechanism have all threatened its long-term sustainability. This study aims to explore the sustainability of Taiwan’s NHI system, focusing on three key issues: (1) insufficient funding resources, (2) the review and pricing mechanisms for new drugs, and (3) the unintended consequences of the global budgeting system. The research adopts both literature review and in-depth interviews. The literature analysis covers Taiwan’s NHI development, domestic research, and comparative studies of advanced health insurance systems in the United Kingdom, Canada, Japan, South Korea, and Australia. The interview component involves eleven experts, including senior executives from the pharmaceutical industry, physicians from major hospitals, and academic scholars in medical and health policy fields. The findings indicate that: Financial insufficiency - Taiwan’s NHI revenue structure is overly dependent on premiums, with declining public financial input. The study suggests establishing a long-term fiscal adjustment mechanism and increasing the proportion of government funding to gradually align public health expenditure with the OECD average. New drug reimbursement and pricing - The current cost-centered approach undervalues innovation and causes delays in patient access. The study recommends incorporating Health Technology Assessment (HTA), risk-sharing mechanisms, and a dedicated innovation drug fund to enhance accessibility and promote medical innovation. Global budgeting distortions - Although effective for cost control, the system has compressed medical service payments, leading to “drug margin dependence” and distorted hospital operations. The study proposes outcome-based payment models and rationalized physician fee adjustments to correct structural imbalances. In conclusion, ensuring the sustainability of Taiwan’s NHI requires a balance between financial stability, service quality, and fairness. The government should strengthen medium- to long-term fiscal planning, enhance transparency, and promote value-based payment reforms to maintain a high-quality and financially sustainable universal healthcare system.