全民健保實施總額預算制度之政策分析

Abstract

動機與目的 全民健保總額預算制度是一種預先以協商方式決定未來一段時間內醫療服務總支出的預算制度。我國推動總額預算制度之主要目的為控制醫療費用支出於合理的範圍內、促進醫療資源均衡分布、利用同儕制約使醫療服務提供更趨合理、幫助專業自主提升。然而此一新制度，自1998年七月一日由牙醫門診開始實施，並在健保實施後第七年(2002)才得以全面實施，實施至今已屆滿六年，財務問題仍為全民健保現今面臨的最重要問題，醫界也仍然訴求廢除總額。因此，探究總額預算制度之肇因、內容和結果甚為必要，故本研究之目的在於描述全民健保實施總額預算制度之過程與內容，並分析總額預算制度實施後的影響。 研究方法 為達上述研究目的，本研究將主要以檔案文獻分析法，進行總額預算制度之政策背景、肇因、內容與影響等資料收集，至於文獻資料不足之處，則輔以重要人物訪談，以獲取關鍵資訊。 結論與建議 研究結果顯示，總額預算制度係參與規劃全民健保之菁英，為求全民健保永續經營而倡議與設計。該制度之內涵亦試圖同時解決國內長期以來存在之問題：醫療費用之快速成長、醫療資源之分布不均、支付制度設計不良、保險人對醫療專業深度介入、醫療浪費造成醫療效率不彰。總額預算實施後，在實施成效方面：對醫療費用的控制最具成效；對同儕制約的機制建立與專業自主能力之提升皆有明顯助益；在醫療資源分布方面，則由於「錢跟著人走」之原則未能落實，目前僅牙醫部門達成此項政策目標。對醫療供給者的影響方面：醫界「衝量」行為仍為其優勢選擇；醫療生態的兩極化現象持續擴大；健保特約機構之牙醫師與中醫師每人平均收入有下降趨勢，而診所與醫院的醫師每人平均收入則呈現上升趨勢。對民眾影響方面：民眾對健保滿意度仍維持在七成以上，尚未有實證顯示就醫可近性與醫療品質受到不利影響，但自費項目有越來越多的趨勢，其影響值得後續觀察與研究。在政策建議方面：宜儘速發展以論病例計酬(DRGs)或論人計酬作為支付基準，以避免論量計酬提供錯誤誘因；此外，以地區預算分配促進醫療資源合理分布之政策效果已獲牙醫部門之證實，建議調整策略繼續努力。

Research purpose The global budget program of National Health Insurance is a prospective payment system which determines the future medical expenditures. The purpose of the global budget program for the health care in our nation includes keeping medical expenditure under control, assuring fair medical resource allocation and reasonable medical service through peer review, and strengthening professional groups self-governing. This new health reform starting on the first of July, 1998 from dental outpatient services began to cover all medical services in 2002. Six years after the implementation of the new NHI, finance has remained to be the major problem among all. Even medical professionals have urged to abolish the global budget program. Thus, it is critical to investigate the underlined principles, the contents, and the consequences of the global budget system. The study was intended to describe the implementation of the global budget program and its contents and to analyze the impact after its implementation. Methodology In order to thoroughly describe the system and conduct the analysis, the researcher incorporated archive research and literature review to collect information on the global budget program regarding the background, the underlined principles, the contents, and its impact. Interview with key-opinion leaders was also used to acquire further information as a supplement to collected data. Results The results of the study indicated that the global budget program was determined by a group of national health care experts for continuous success in the management of the health care. This program has solved the long-standing problems including the fast-growing medical expenditure, uneven allocation of medical resources, ill-designed payment plan, insurers’ interference with professional care, and inefficiency caused by medical waste. The most noticeable effect after the implementation of the global budget program was the efficient control in medical expenditures. Because of the program, there was an apparent improvement in peer review and professional groups self-governing. In regard to the allocation of medical resources, only dentistry was able to accomplish the goal; unfortunately, all others failed because the allocation of the medical budget was not based on population. As for the effect on medical service providers, increasing its revenue is still its priority. In addition, medical industry is also increasingly dichotomized. Moreover, the average income of dentists and doctors of traditional Chinese medicine under the health care plan has decreased whereas the average income of other doctors has increased. Overall, the public satisfaction toward National Health Care has remained in the 70 percent range. So far there is no evidence indicating any negative effect on medical care in quality or proximity. However, there is an increase on the number of out-of-pocket medical service items, which needs to be further investigated. As for the policy, it is advised to adopt DRGs or capitation payment as payment method to avoid inappropriate incentive from fee-for-service. Furthermore, the local budget allocation system has helped to improve medical resource allocation in dental practice, which requires attention and continuous effort.