前路迢迢：全民健保實施論人計酬制度之經驗探討

Abstract

全民健保的願景為購買健康而非購買醫療，然而，健保實施至今 25 年來，持續面臨醫療費用上漲等種種困境，各項支付制度政策亟待轉型與改革，以落實使用者共同負擔之精神。台灣自 2011 年起，即進行為期 3 年的論人計酬試辦計畫，期望藉由制度的設計，改善論量計酬所衍生的諸多問題，唯後續未再有相關計畫進行。若理想得以由此實現，那麼實施論人計酬的經驗，真正帶給政策規畫者及醫療供給者什麼樣的歷練與啟發？ 本研究的目的包括：一、瞭解健保署推動論人計酬的脈絡和演變緣由。二、探討醫療院所參與論人計酬試辦計畫的內容和執行經驗。三、剖析台灣實施論人計酬制度的前瞻與啟示。根據各項研究目的，透過資料收集、文獻分析與深度訪談法，自不同利害關係人之觀點進行分析，運用管理循環模式作為分析流程，包括政策規畫者、承作醫療團隊及學者之三方經驗為研究基礎，探討制度實施的目的及產生的影響。 實施論人計酬不僅為支付制度的改變，還有醫療生態改革的意義，以及促進民眾的健康行為，研究發現，如政府各級部門未共同參與，風險校正的方式缺乏真正公平的考量，則後續擴大試辦的可能性將大幅降低；對於承辦的醫療團隊，若採區域整合模式亦較為適合，而基層診所或社區醫療群要向上整合則相對困難，照護人數不足也具有較大的財務風險；另外，也建議相關單位加強對民眾宣導，以增加其主動參與健康促進的意願。

The concept of National Health Insurance is “purchasing health for people instead of purchasing medical services”. Since the implementation of NHI for 25 years, it has continued to face various difficulties such as rising medical costs. Various payment systems and policies urgently need to be transformed and reformed to implement the spirit of shared burdens for users. Since 2011, Taiwan has been conducting a three-year trial program of capitation. It was hoped that through the design of the system, many problems arising from FFS will be improved. However, no further relevant plans have been implemented in the future. If the ideal can be realized from this, what kind of experience and inspiration does it bring to policy planners and health providers? The purposes of this study are listed below: 1. To understand the context and evolution of the National Health Insurance Agency's promotion of capitation. 2. Discuss the content and implementation experiences of the trial program for capitation by medical institutions. 3. Analyze the foresight and enlightenment of Taiwan's implementation of capitation payment program. According to various research purposes, through data collection, literature analysis and in-depth interviews, analysis from the perspectives of different stakeholders, using the management cycle model as the analysis process, including the tripartite experience of policy planners, health providers and scholars. The implementation of capitation is not only for the change of the payment system, but also the significance of the medical ecological reform and the promotion of people’s healthy behavior. The study found that if the government departments at all levels did not participate together and the risk adjustment method lacks true fairness considerations, the possibility of expanding the trial will be greatly reduced. For the medical team undertaking, it is more suitable if the regional integration model is adopted. If the community general practioners are to be integrated upwards, it will be difficult, and if the number of people is insufficient, there will also be greater financial risks. In addition, it is recommended that relevant units strengthen public awareness to increase the willingness to actively participate in health promotion.