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    Title: 影響全民健康保險醫療費用因素之探討(供給面)
    Authors: 周麗芳;陳孝平;紀駿輝
    Contributors: 中央健康保險局
    國立中正大學社會福利學系;國立政治大學財政系
    Keywords: 全民健保;健保費用;醫療生態;公共衛生學
    Date: 1999
    Issue Date: 2010-10-05 16:08:43 (UTC+8)
    Abstract: 我國全民健保的財務?i健保財務已呈現赤字,而由於受到經濟衰退以及政治環境的限制,此項赤字有更加擴大之可能。?j全民健保費用上漲來自於門診的部份達八成以上,而其中以就診次數的增加為主因。住院則主要在於醫療密度的增加。 ?Z我國醫療資源與醫療利用的特點?i與OECD國家比較,我國醫師密度低,但門診次數之高,接近世界第一的水準,惟住院次數並不因此而較低。?j住院與門診費用之比例與其它國家大相逕庭。?k台灣人口的年齡結構尚稱年輕,故醫療費用占GDP的比例不高。但若經年齡結構的調整,則我國已可算是中度醫療費用國家。?l台灣經濟成長相對於多數國家仍屬穩定,因此掩蓋了醫療費用的若干問題;然而整個經濟體系資源配置仍然大幅向醫療產業傾斜。 影響全民健保費用供給面的因素?i醫師密度或病床密度較高的地區,醫療服務利用有偏高的趨向,似乎有供給誘發需求的跡象。?j我國醫師的收入相對於一般人的倍數,要高於大多數其它國家。?k外科醫師的手術費用之支付標準(即單價)其實並不偏低。外科醫師之所以感覺收入不佳,其原因可能是因為其它醫師藉量的擴大而提高所得,故外科醫師產生相對之被剝奪感。?l先進國家對醫療的「量」有所控制。台灣雖藉「合理門診量」抑制門診醫療次數,但對住院醫療使用的密度則無控制機制。?m然而住院費用在同級醫院中卻呈現相當大的變異性,暗示有相當的問題存在。?n台灣高科技醫療儀器的普及性相當高,過去數年之間成長幅度又極為迅速。?o為提升醫療品質並節省醫療費用,臨床路徑的研發是醫院革新的重要一環。相關研究指出,臨床路徑確有提升品質及降低費用的功能。?p若干國家在不等程度上使用醫師替代人力。研究顯示醫師替代人力的使用,並不降低醫療品質,且有節省醫療費用的作用。?q由於門診費用上漲頗快,而且對大眾之就醫可近性在大多數情況之下並不構成嚴重之影響。因此,考量對醫療費用的控制機能,可以考慮將一般門診改成附加保險。 醫療體系的重整?i有些改革項目,若無相適應的醫療體系的重整,將無法克竟全功。而就本研究的目的而言,「整合」是醫療體系重整的核心概念。?j整合的目的,在於以經濟合理的方式,提供民眾連續性的照護,而其內容包含功能的整合,醫師與體系的整合以及醫療服務的整合。?k整合的模式包括建立在管理式照護體系之上的整合,以及以社區營造為基礎的整合。?l我國的醫療體系在財務、協調與規劃等功能上欠缺協調的機制,而現行的論量計酬制並不能提供整合的誘因。?m健保法的「再修正案」中,型式上雖接近管理式競爭的策略,但缺乏管理式競爭藉以發揮作用的機制。 主要政策建議?i降低門診次數實為一切改革的起點。門診次數若不下降,不但醫療品質無法提升、支付標準不可能調整,而且使其它改革的空間均受到擠壓。?j在現行醫療輸送制度之下,門診次數下降不易,可考慮在重整醫療體系時,導進類似HMOs的機構,以限制門診的濫用。?k醫療費用支出的額度,宜維持現行占GDP之比例,而後隨著人口老化緩慢自動上升。至於醫師的支付標準,可在預算中立的前提下,在科別之間依每項服務的時間為主要根據來調整;至於手術費用相對於其它服務項目,其支付標準並不偏低。?l供給者誘發的需求根據本研究似乎在台灣地區也獲得印證,因此,若有考慮擴充醫療資源,宜仔細評估其對於健保財務乃至於整體醫療費用支出的影響。在醫事人力的政策方面,可考慮培養醫師之替代性人力,使之負擔一部份之醫療功能,除有助於醫療費用的控制外,對偏遠地區的醫療資源亦有一定充實的作用。?m住院費用的增加,主要來自於服務使用的密度,而且同一層級的醫療機構其每次住院的資源使用也有相當大的變異,因此,似宜設計適當的機制,藉著縮減這些變異的幅度來控制醫療使用的密度。?n相對於其它國家,台灣的高科技醫療設備的普及率是屬於較高者,而在現行支付制度之下,應有相當高濫用的可能性。因此,在醫療科技政策上,應有成本效益分析及客觀明確的使用規範。?o伴隨論病例計酬的擴大實施,宜促成各醫療機構建立臨床路徑,或其它類似之執業規範。?p給付制度仍有調整的空間。可考慮將醫療費用控制不易、對家戶影響較低者另列為附加方案。?q若要實施「再修正案」,則應使保險人得以拒絕相當比例之醫療機構的加入,以促成醫療機構之競爭。?r在考量實施論人計酬制之同時,宜制訂規範,使醫療機構之間產生整合,以在節約成本之下提供連續性的照護。 The National Health Insurance (NHI) program ran into deficit as it entered the fifth year, and the deficit might become larger unless the economy takes an upturn in the near future. This study identifies some of the factors on the supply side that might have contributed to the cost escalation. Drawing on the OECD database, we found that Taiwan, while has very low physician density, has virtually the highest number of outpatient visits per person, and the outpatient service takes up a lion share of the total expenditure ?V rather contrary to the OECD experience in general. On the surface, Taiwan??s health expenditure seems low, only 5.3% that of GDP, the percentage was actually near that of Japan or the United Kingdom if adjusted for the relative younger population. Rapid economic growth must have made health expenditure low relative to the national income. We found that Roemer??s law seemed to be confirmed in Taiwan. Physician income in Taiwan, in terms relative to that of the average wage-earners, was higher than most of the OECD countries. Our study did not support the widely believed thesis that the number of surgeons decreased because of an unfavorable payment level. If anything, the internists, taken together, chewed off most of the pie by encouraging more visits. Unusually high number of visits was arguably the core of the whole problem of cost escalation. Inpatient costs did not appear so much a problem as outpatient costs, yet the unit costs demonstrated a great variance among the hospitals of the same category , suggesting potential problems in this area. High-tech medical appliances might have also been a source of the cost inflation. The development of clinical pathways must be encouraged as a way of cutting costs and maintaining quality. This deserves more attention as the payment scheme will swing toward one based on case payment. Alternative medical manpower, if introduced prudently, may be a positive factor in terms of containing the NHI expenditure. We call for restructuring of the medical delivery system, so as to provide continuum of care at a lower total health expenditure.
    Relation: DOH87-NH-028
    應用研究
    委託研究
    研究期間: 870301~880331
    研究經費: 855 千元
    Data Type: report
    Appears in Collections:[財政學系] 研究報告

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