臺灣與韓國健康保險制度之比較

Abstract

本研究主要是瞭解及比較臺灣及韓國健康保險制度，針對於兩國健康保險制度之保險人及保險對象、財務制度、給付制度、支付制度等議題進行探討，採用的研究方法是文獻内容比較研究，並利用OECD統計及臺灣與韓國相關當局之資料，同時蒐集相關法規及文獻，加以分析比較，希望給可深入互相瞭解兩國的健康保險制度，給未來的研究者及兩國健保政策者有幫助參考。 本研究主要結果如下: 一、保險對象 台灣健保納保率達到99％，韓國健保可區分兩大區分：健保納保人口(占96.29%)、低收入戶占(3.71%、2006年)。臺灣被保險人分爲六類、韓國分為職場保險對象者及地區保險對象者。救濟欠保險費及滯納金無法繳納之民衆，臺灣用分期攤繳、紓困貸款、愛心轉介；韓國則由缺損處分(Disposition on Loss)、分期攤繳來協助。 二、財務制度 兩國主要財源皆為保險費收入，臺灣目前保險費率是4.55%、韓國職場被保險人之保險費比率為4.77%。臺灣開辦全民健保以來只有一次調整過保險費(2002)，而韓國每年調整。臺灣保險費收入比例被保險人占38％、投保單位占36%、政府補助占26%，韓國國家僅補助地區對象者之健保給付費用及地區加入者之健康保險事業經營管理費用之40%金額。兩國都面臨財務危機，為解決健康保險制財務赤字及財務收支平衡缺口，韓國用菸捐補助金及調整保險費率和健保支付點數值，臺灣用總額預算控制醫療費用之上漲、調整投保金額上限、調整軍公教人員投保金額占全薪比率、調整菸品健康捐之金額、擴大基層門診與各級醫院門診部分負擔之差額等方法克服困境。 三、給付制度 臺灣每人每年平均門診次數每年大約為14次，韓國14.13次。臺灣部分負擔規定區分各層級別及有無經過轉診住院日數，採用不同的部分負擔，而且重大傷病、分娩等免部分負擔。反觀韓國住院及慢性洗腎病人等門診者負擔總金額之20％，自然分娩及未滿6歲兒童之住院時免部分負擔，癌症病人等重大傷病之部分負擔為醫療給付費用之10％。韓國還存在因病而窮問題。臺灣由重大傷病制度，保障防止因病而窮之困境，為重大傷病病人健保投入總醫療支出的26％，韓國於2005年9月起開始實施“癌症患者登錄制度”結果，癌症醫療費用之部分負擔大幅減少。 四、支付制度 兩國支付方式為都基於論服務計酬，臺灣自2002年起全面實施總額預算制度後，每年醫療支出成長率控制在5%以下，而且透過「品質確保方案」的執行，建立醫療服務品質指標。臺灣目前採用總額預算制度下之論服務計酬，亦實施53項目之論病例計酬方式，預定2008年1月起實施住院診斷關聯群(Tw-DRGs)。韓國全面實施DRG失敗後，於2001年醫事服務機構選擇方式來使用。 五、建議 本研究針對韓國與臺灣健康保險制度未來發展，提出以下幾項研究建議。在韓國部份：第一，應早日導入健保IC卡或全面使用身份證替代；第二，對於低收入戶應實施補助保險費及減輕部分負擔的方案；第三，應規劃救濟重大傷病者方案；第四，需要考慮多方課徵及政府補助的辦法；第五，規劃實施新政策前，事先考慮未來可行性。在臺灣部份：第一，用保健教育及宣傳方法改善民眾逛醫院行為；第二，可考慮調整保險費率；第三，為未來所需要之預防保健進行宣傳及教育。

The purpose of this study was to understand and compare the Health Insurance Systems between Taiwan and Korea. The discussion focused on issues of the insurers, the insured, financial policy, benefits packages, and payment systems. The study method was literature review, and further analyze using data provided by OECD, Taiwan, and Korea governments. Important results are as follows: 1.The insured In Taiwan, the insurance rate was 99%; in Korea, health insurance is divided into two parts: 1. health insurance population (96.29%), 2. low-income population (3.71%, 2006). The insured are divided into six categories in Taiwan, but into only the employee insured and the self-employed insured in Korea. Citizens who are unable to pay the premium and the overdue charge pay through installments for individual overdue payment, NHI Relief Funds Loan, or Referral Services in Taiwan, and through Disposition on Loss in Korea. 2.Financial policies The financial resources for Taiwan and Korea are both premiums. The premium rate in Taiwan is 4.55%, and 4.77% for the working insured in Korea. Premium adjustment was made once in Taiwan (2002), but adjusts each year in Korea. In Taiwan, 38% of the total premium income is from the insured, 36% from the group insurance applicants, and 26% from government subsidies. In Korea, subsidies are 40% for the self-employed insured’s health insurance coverage and operation and management expenses for their health insurance business. Both countries are facing financial crisis. In order to solve the deficit problem, Korean government uses health surcharge on tobacco, adjustment of premium rate, and health insurance payment claims. In Taiwan, global budgeting is used to control increase of medical expenses. Also, adjusting the ceiling of enrollment cost, public officials and servicemen’s enrollment rate, amount of health surcharge on tobacco, and expanding the payment difference between basic outpatient service and outpatient service in each class of hospitals were applied. 3. Benefits packages Average number of outpatient visits per person each year is about 14 times in Taiwan and 14.13 times in Korea. In Taiwan, different co-payment methods are applied to all classes of hospitals based on with or without referral and the inpatient days. No co-payment is applied in catastrophic illness and childbirth. In Korea, inpatient and chronic dialysis patients pay 20% of the total amount. No co-payment is applied on natural childbirth and inpatient children under six. Cancer patients and patients with catastrophic illness pay 10% of the medical costs. The problem of destitution due to sickness still exists in Korea. The catastrophic illness systems in Taiwan protects citizens from destitution due to sickness. About 26% of the total medical expenses are on patients with catastrophic illness. Since September, 2005, Korean applied the “Cancer patient registration system”, and results in a large number of decrease in co-payments. 4.Payment Systems The payment methods of both countries are based on fee for service. In Taiwan, after global budgeting payment system comes into effect, the growth rate of medical expenses each year is under 5%. Also, medical service quality indicator was established through the quality ensuring policy. There are 53 items of case payment currently used in Taiwan. TW-DRGs will be carried out from January, 2008. After the failure of DRGs in Korea, medical service institutions chose different methods to use since year of 2001. 5.Suggestions To Korea: Lead in the health insurance IC card or Personal Identification card, subsidies programs for low-income households, programs for patients with catastrophic illness, more programs on government’s subsidies and taxation, and take into consideration of the effects decade-later before carrying out a new policy. To Taiwan: Use health education and advertising programs to improve the behavior of “hospital shopping”, adjusting premium rate, and disseminate and educate preventive health care.