醫療政策與醫療行為差異之分析：以署立醫院選擇經營透析方式為例

Abstract

從民國八十四年開始實施全民健保以來，全民享受到了全世界最廉價但最完整的醫療照顧，民眾的滿意度一直居高不下，經常為持在百分之七十以上。但在健保初期以量計價的時代，所有的醫療院所無不卯足全力衝量，導致醫療費用節節高升。雖然健保法內有明文規定在健保實施滿五年後，健保局得依照財務狀況，在授權範圍內做健保費率適度的調整，但是在國內紛亂的政局下，任何對民眾多收費用的舉動都會招來極大的反彈，所以健保費率在健保實施第十二個年頭的今天遲遲無法調整，而健保局在無法開源的情況下，只能從節流方面多下工夫。雖然經過多方的努力，健保局的財務狀況仍未獲得改善，處在破產邊緣。 衛生署自民國九十四年起，宣示要用多元微調的方式來挽救健保危機。而佔了健保費用高達百分之七的透析費用，自然是需要調整的對象。透析方式可分為血液透析和腹膜透析兩大類，在臺灣的健保制度中，以血液透析的給付較高，而且所獲得的利潤也較佳，再加上之前只准許腹膜透析在醫院實施，所以血液透析在臺灣佔了極大的比例，達百分之九十三。為了解決健保的財務狀況，衛生署和健保局開始要推展腹膜透析，希望提高腹膜透析所佔的比例，減少健保支出。而屬於衛生署管轄的三十五家各級署立醫院，自當響應政府政策。但到目前為止，仍然只有三家署立醫院有腹膜透析病患，而且病患人數並未顯著成長。到底問題發生在那裡呢？本研究分別從政府、醫院、醫師、藥師、以及病患等多方的角度分別加以分析探討，找出一些問題的徵結所在，並希望找出解決之道，進而能讓署立醫院盡情發展腹膜透析，替搖搖欲墜的健保財政赤字盡一份心力。 一、政府得制定醫療政策，要求醫院及醫師遵循，但不得違背實証 醫學所獲得的醫療選擇性。 二、署立醫院負有社會責任，理當執行政府政策，但也須考量讓醫 師在選擇不同透析模式時，能獲得相同的報酬，如此醫師才不 會出現偏見。 三、醫師對不同的透析模式，應以公正客觀的角度詳細對病患及家 屬解釋其好處、壞處，除非在特殊狀況外，應把決定權交給病 患或其家屬。 四、藥事法第三十七條有關藥品調劑之規定應予釐清，否則現行腹 膜透析調劑模式恐有觸法之虞，讓藥師提心弔膽。 五、病患是醫療照顧的接受者，若獲得不完全的或偏頗的資訊，自 然無法獲得最適合病患自己的治療模式。如何讓病患獲得完整 的醫療資訊是一項重大的議題。

Taiwan’s national health insurance (NHI) program implemented since 1995 delivers the most affordable yet most comprehensive healthcare in the world to practically all citizens and has attained consistently high level of satisfaction over 70%. In the initial period of NHI that paid the providers on a fee-for-service basis, all hospitals endeavored to build up volume of services, which resulted in escalating healthcare expenses. Under the National Health Insurance Act, the Bureau of National Health Insurance (BNHI) may adjust the premium rate by its vested authority in view of the financial status of the NHI program five years after inception. But given the domestic political atmosphere, any attempt of fee increase beckons loud protest. This is why the NHI premium rate has never been adjusted even as the NHI enters its twelfth year. Handicapped by the inability to tap new funding, BNHI could only resort to cost control. However, after considerable efforts, BNHI has not seen improvement in its financial status, and the NHI program is on the brink of bankruptcy. The Department of Health (DOH) and BNHI have declared the use of series of microadjustment to save the NHI from financial ruins since 2005. An apparent target of adjustment is dialysis treatment that accounts for 7% of the NHI expenses. There are two options for patients on dialysis - hemodialysis (HD) and peritoneal dialysis (PD). The NHI pays more for HD and the procedure is more profitable. Plus the fact that previously PD could only be performed in hospitals, HD has been the preferred choice of treatment, accounting for 93% of all dialysis modalities. As part of the measures to address the financial woe of NHI, the DOH and BNHI plan to embark on the promotion of PD, hoping to raise its proportion and cut NHI expenses. Since it is a government policy, we would assume at least the thirty-five hospitals under the administration of DOH would vigorously promote PD. But up to now, only three DOH-administered hospitals have PD patients and the number of PD patients has not grown significantly. So what is the problem? This study explores the issue from the angles of government, hospital, doctor, pharmacist, and patient in the hope to identify the crux of the problem and find solutions. By helping the DOH-administered hospitals to develop PD service, it is our way to make a contribution to the crumbling national health insurance system. 1. The government should formulate healthcare policy and demand adherence by hospitals and doctors without compromising medical options proffered by empirical medicine. 2. DOH-administered hospitals have the social responsibility to carry out government policy, but should also consider equal pay to doctors selecting different dialysis modalities so as to free the doctors from making money-driven biased decision. 3. Doctors should explain in a fair and objective manner to the patient and his/her family the benefits and disadvantages of respective dialysis modality, and unless under special circumstances, let the patient or his/her family decide which system to use. 4. Article 37 of the Pharmaceutical Affairs Act should clarify the provisions for drug preparations. Otherwise, pharmacists might have concern over breaching the law under the current mode of preparing peritoneal analysis agents. 5. Medically patients are service recipients who are unable to decide the most appropriate treatment for themselves if the information they obtain is incomplete or biased. How to let patients access comprehensive medical information is a major issue to be addressed.