| 摘要: | 我國總額支付制度的目標為透過前瞻性的協定與分配預算機制，合理控制醫療費用、促進醫療體系的整合與資源之合理分布。在總額預算協商過程中，政策利害關係人不僅得以陳述自身的訴求，並可發揮對於政策決議的影響力。本研究之主要目的為瞭解政策利害關係人對於我國醫療費用總額分配方式之觀點與看法，期能提供衛生主管機關及後續研究者，作為未來推動總額支付制度改革時，參酌各方政策利害關係人觀點，得以有效凝聚共識之參考。
本研究為一橫斷性研究，研究對象為總額支付制度之相關政策利害關係人，包含醫事團體、付費者、政府主管機關及專家學者，研究方法分為深度訪談與問卷調查兩部分。在深度訪談方面，選取行政院衛生署100年度委託科技研究計畫「全民健保醫療費用總額分配方式及其可能影響之評估」之具代表性的深度訪談為研究對象，以深入瞭解各方政策利害關係人對我國醫療費用總額分配方式之看法。在問卷調查方面，於民國100年10月1日至100年11月30日，以郵寄問卷方式，選取研究計畫「全民健保醫療費用總額分配方式及其可能影響之評估」之調查問卷為研究工具，針對上述四類政策利害關係人進行問卷調查，共發放400份問卷，回收之有效問卷共333份，回收率為83%。本研究之主要結果如下：
一、總額支付制度目標或產生的正向結果之重要性：政府主管機關、醫事團體與專家學者及付費者代表皆認為「控制醫療費用」為實施總額支付制度的最主要目標。
二、總額支付制度目標或產生的正向結果之執行成效：各方政策利害關係人皆認同總額支付制度已達到有效控制醫療費用的目標。此外，醫事團體與專家學者及付費者代表反應總額支付制度實施後，無法確實達到「醫療專業自主」的目標。
三、總額支付制度可能產生問題及負向結果之嚴重程度：各方政策利害關係人一致認同「科別人力配置失衡」問題的嚴重程度最高，其次為「轉診與分級醫療未落實」與「城鄉間醫療資源配置失衡」的問題。
四、總額支付制度可能產生問題及負向結果中需解決或處理之急迫程度：「科別人力配置失衡」為大部分政策利害關係人皆認為需儘快處理的問題，其次則為「轉診與分級醫療未落實」及「健保財務赤字」。
五、總額支付制度設計與執行的改善建議之贊成程度：各方政策利害關係人建議應檢討各方協商代表的比例，亦需提供各方總額協商代表教育訓練的機會，以及成立幕僚單位提供相關研究與分析資料。在民眾的教育方面，應加強宣導節約醫療資源的觀念，使民眾改變過度就醫的行為。
總額支付制度至今已實行十餘年，除了在控制醫療費用成長方面已有相當的成果之外，但同時也因此制度的實施，致使醫療提供者在財務壓力之下，改變其醫療服務行為。雖然不同政策利害關係人對總額支付制度各有褒貶，但最終皆期望透過醫療費用總額協商分配，達到合理分配醫療資源、提升疾病治療效率與醫療品質的目標，同時必須加強付費者之教育宣導，鼓勵其共同參與總額支付制度，皆有益於凝聚社會整體對於未來總額支付制度改革之共識。
Through this prospective agreement and medical expenditure budget allocation mechanism, hoping to do a great impact on the health care cost control, the distribution of medical resources, and promote the integration of the health care system under under Global Budget System in Taiwan. During the global budget negotiation process, policy stakeholders not only be a statement of its own demands, but can play to influence policy decisions. The aim of this study was to understand the medical expenditure allocation mechanisms from different stakeholders’ perceptions and opinions. This study presented the results of diverse perceptions, and was expected to offer the health authorities and researchers a effective cohesions in consensus from policy stakeholders.
This cross-sectional study is based on the policy stakeholders under Global Budget System, including medical service providers, healthcare payers, academic circle, and relevant government agencies, and also divided by in-depth interview and survey. In the in-depth interview study, the targets were selected from the in-depth interview subjects of 100 academic year DOH commissioned research program “Global Budget Allocation Mechanisms and the Impacts Assessment”, in order to well understand the opinions of medical expenditure budget allocation mechanism by the representatives of policy stakeholders. Otherwise, the questionnaires were executed by mail survey targeted at four kinds of policy stakeholders. A total of 400 questionnaires were distributed to interests group and individuals with 333 valid questionnaires returned for a response rate of 83%.
The major findings were summarized as follow:
1. Importance of Global Budget System goals or positive results: All representatives including government agencies, medical service providers, academic circle, and healthcare payers are under the impression that “health care cost control” is the most important goal of Global Budget System.
2. Execute effectivenessof Global Budget System goals or positive results: Different policy stakeholders endorse that it already reached the goal of effective control medical costs. Besides, medical service providers, academic circle, and healthcare payers make in response that it can not really achieve the goal of medical professional autonomy after the implementation of Global Budget System.
3. Severity of Global Budget System problems or negative results: Policy stakeholders unanimously agree “Medical Branch force average is the highest” is the most severe problem, followed by “referral and the hierarchy of medical services does not truly implement” and “medical resource allocation imbalance between urban and rural areas”.
4. Global Budget System problems or negative results need to be dealt with urgent degree: “Medical Branch force average is the highest” problem must be dealt with as soon as possible, followed by “referral and the hierarchy of medical services does not truly implement” and “health insurance financial deficit”.
5. Recommendations for improvements of Global Budget System in design and implementation:
Stakeholders suggested that a review of the proportion of medical expenses consultation representatives, also provided them education training opportunities, and establish the aides unit to support research and analysis data. Besides, another suggestion about public education is to strengthen the concept of advocacy to save medical resources, leading to change the behavior of excessive medical treatment.
The global budget payment system have been practiced for more than ten years, it already made considerable progress in controlling the growth of medical costs. Nevertheless, the implementation of the system cause health care providers under more financial pressure to change its medical services. Although different policy stakeholders have passed judgment on the global budget payment system, all expectations of medical expenditure budget allocation mechanism were to achieve a rational distribution of medical resources, and the efficiency and quality of medical care. The need to strengthen the propaganda of those healthcare payers for education, to encourage participating in the global budget payment system must be executed simultaneously. All these efforts are conducive to social cohesion and the overall consensus for Global Budget System reform. |
