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標題: | 區域總額預算與轉診制度之研究-臺灣健康保險制度新解 Study of Regional Global Budget with Referral System–A New Solution for Taiwan National Health Insurance Policy |
作者: | Ta-Liang Chen 陳大樑 |
指導教授: | 張重昭(Chung-Chau Chang) |
關鍵字: | 全民健保,中央健保局,供給與需求,區域總額制,轉診制度,財務, National Health Insurance System,Bureau of National Health Insurance,supply vs. demand,regional global budget,referral system,finance, |
出版年 : | 2007 |
學位: | 碩士 |
摘要: | 背景:臺灣實施全民健康保險以來,由於民眾對其依賴日深,然而健保整體財務及醫療品質卻日漸惡化。政府在制定政策之初,乃至於實施十二年的今天,對於財務規劃及內控機制,始終無法擺脫以醫療供應面為財務主體政策來設計。且醫療院所逐年增設,創造民眾醫療需求的浪潮下,造成醫療行為與財務需求,逐年成長居高不下,亦形成民間與政府論價議酬的政治角力。對醫療市場、行為、文化乃至於政策而言,亦偏離了應以民眾整體健康需求為考量的理念。
方法:如何設計出一個以民眾醫療需求面為主體,以預防醫學之民眾健康為醫療標的,且兼顧健保財務及醫療品質的醫療架構與環境,是本研究探討分析的主要目的。內容先從資料分析目前全民健保基本規範架構,論量計酬的用意及所面臨的難題,再與外國公醫健保制度比較做為基礎,剖析如採取以醫院或區域總額預算制的政策利弊。而後就中央健康保險局資料庫中,蒐集目前全國健保醫療之疾病種類、民眾地區性就醫型態分析以及未來就醫形態的轉變進行設計假說,研議以論人計酬區域預算架構下,設計以區域性醫療主體責任制的可行性;並探究在此醫療形態轉換下,與現行醫院個別總額預算制度,就醫療政策、財務策略、醫療品質及醫療資源整合等方面進行比較,並說明此制度實施時應有的相關制度配套為何,最後則對此制度的基本構思提出提醒與建議。 結果:在此區域總額預算制度規劃之下,將引導各地區不同等級之醫療院所、基層醫師與衛生單位產生下列轉變:1)從原先強調以水準整合降低成本的經營模式,轉變為注重垂直整合的醫療鏈;2)在財務資源的分配策略上,將由被動地調控醫療院所無止盡以量計酬的醫療供給面,轉變為主動宏觀調控以病患為中心需求面,並兼顧品質的醫療運作模式;3)同時在醫療衛生政策上,將導正目前醫學中心主導的治療醫學,逐步向面對疾病前端推進,改為以公共衛生體系的預防醫學為主體,以達到「預防勝於治療」之目的。 討論:在配套制度方面,則將決定制度轉換的成敗關鍵,其中包括:1)醫療制度垂直整合時,病患個人的醫療資訊檔案,是否能夠完整而安全地流通連結,方能適當地減少醫療資源的重複浪費;2)建立區域轉診及社區家庭醫師制度的規範,賦予區域各級醫院的分配性醫療,但仍容許病患部份的就醫選擇權及強化部份負擔制;3)財務資源分配、醫療品質評鑑以及醫療給付合理化調整,必須有足夠公開的資訊,並由公正的第三團體斡旋協商及仲裁,才能擁有既可掌握財務分配的透明、客觀與公正性,如此方能穩固政府醫療政策與財務操作的均衡,並同時兼顧醫療品質與病患的權益。 Background:The National Health Insurance System(NHIS)in Taiwan has been established since 1995. The high satisfaction ratio of the publicity pushes the government to the endless financial demand in medical care. The initial financial planning and internal regulation for budgeting was based on the basic principle of matching the need from the supply-side(hospitals and physicians vs. patients)of the medical market. However, the constant development for the new hospitals and medical innovations provoked the irreversible increases in the budget demand in the NHIS. In order to restrain the budget, the struggling between the private medical systems with the government seems to be inevitable. Methods: In order to design a budgeting system, matching with the demand-side of the publicity instead of the supply-side of the medical group, prevention-based instead of therapy-based, we suggest a new model of operation providing the possibility of financial balance of government with acceptable quality of medical service. First, we search the journals and analyzed the major restraints and present difficulties of NHIS facing the hospital global budget system in Taiwan and compared with the world-wide NHIS applied in other western developed countries. Secondly, according to the data bank from BNHI(Bureau of National Health Insurance)for the disease entities of patients in different levels of hospitals, the regional characteristics of the patient source of the medical centers, we proposed the possibility of the regional global budgeting system to replace the present individualized hospital global budget system. Results: The regional global budget system with the referral system would direct the future integration of regional medical system of different levels and function together. The major alterations of the health system would be: 1) The efficient profit-pursuing financial model for the future hospital development would change from the horizontal into the vertical integration; 2) The policy of financial distribution in this new system would convert the market from the supply-side(amount-centered)of medical service(physician-oriented)to the demand side(patient-centered)of general population(individual-oriented); 3)The health policy would shift from the therapeutic medicine(hospital-based)to the preventive medicine(public health-based). Discussion: There are several key successful factors in order to have a smooth operation, including: 1) To have vertical integration among the regional hospital and attending physicians, the availability and the accessibility of personal medical records from different health providers would be essential and important to avoid unnecessary repetition of medical consumption; 2) Community-based referral system with family physicians provides the background support for the completion of regional responsibility of medical care. However, the outlier’s free choice out of the regulation for special treatment is allowed but with extra-payment; 3) The independent auditing and negotiation system for the finance and quality evaluation between the contractors and the regional hospitals is needed as long as with the mutual transparency of information to secure the equity of the health system and the human right for the general population. |
URI: | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/25557 |
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