明天过后---健保支付制度的未来~

明天過後---健保支付制度的未來~總額支付制度下醫院服務行為因應之實證研究明天過後:請問何謂總額支付?健保法規定:總額支付九十一年七月全國不分區總額九十二年因SARS影響全年單一點值結算九十三年第二季起分區分門住診結算但是參加醫院卓越計畫者固定點值結算九十四年各分局自行操作門住診分開結算年年難過年年過!健保局還會有什麼花招?GlobalBudget的理論與實務許多OECD國家採用globalbudget控制全部或部分醫療費用實證經驗上globalbudgets確實有效控制醫療費用的成長U.S.GeneralAccountingOffice證明在法國與德國globalbudgets確實減少9-17%的醫療支出但是在全民健保或公辦的健保方面大部分國家也出現了需多醫療資源耗用的無效率化之問題Table1.CharacteristicsofGlobalBudgetingSchemesUsedinOrganizationforEconomicCooperationandDevelopmentCountriesCountryProviderTypeExpenditureTypeServiceTypeBudgetProcessActionifBudgetExceededFinancingSourceGeographicSpecificsAustraliaPublichospitalsOperatingcosts－State-controlledRiseinprivatepatientrevenuesdecreasesState-fundedrevenuesStatetaxrevenuesandFederalgrantsState-specificBelgiumTeachinghospitalOperatingandcapitalcostsMagneticresonanceimagingSickness-fund-definedglobalbudgetingformagneticresonanceimagingamortization,operatingcosts,andradiologistfeeNoadditionalfundsSocialSecuritycontributions,Statesubsidies.NAPharmaceuticalcompanies－prescriptionsSicknessfundsetscapondrugconsumptionIfconsumptionexceedsestimatedlevel,unitpricesarereducedNANASeefootnotesatendoftableTable1.-continuedCharacteristicsofGlobalBudgetingSchemesUsedinOrganizationforEconomicCooperationandDevelopmentCountriesCountryProviderTypeExpenditureTypeServiceTypeBudgetProcessActionifBudgetExceededFinancingSourceGeographicSpecificsCanadaPhysicians－AmbulatorycareNegotiationFeesreducedfollowingyearNationalandprovincialtaxrevenuesProvince-specificHospitalOperating－NegotiationGovernmentmaintainssmallemergencybudgetingoverrunsSameProvince-specificFinlandHospital/clinicsOperatingcosts－MultiplereviewprocessNANationaltaxrevenuesProvince-specificFrancePublichospitalsOperatinganddebtservicecostsforconstructionandhigh-costequipment－Nationwidehospitaltargetguidesnegotiationbetweenhospital,found,andgovernmentSmallregional“maneuveringmargin”Payrolltax;hospitalspaidinmonthlyinstallmentsRegionalSeefootnotesatendoftableTable1.-continuedCharacteristicsofGlobalBudgetingSchemesUsedinOrganizationforEconomicCooperationandDevelopmentCountriesCountryProviderTypeExpenditureTypeServiceTypeBudgetProcessActionifBudgetExceededFinancingSourceGeographicSpecificsGermany1Physicians－AmbulatorycareNegotiationbetweensicknessfundassociationsandphysicianassociationNAPayrolltaxes,paidtophysicianassociations,whichdistributetophysiciansRegionalNetherlandHospitalOperatingandsomecapitalcostsInventoryandequipmentonlyNegotiationbetweenhospitalandsicknessfundsNonePayrolltax,premiums,catastrophicfundNASwedenHospitalOperatingcosts－NegotiationNACountryandnationaltaxesCountry-specificSwitzerlandHospitalOperatingcosts－NegotiationNAFederalGovernmentCantonofVaudonlyUnitedKingdomHospitalandphysicianOperatingandcapitalcostsAll,includingprescriptiondrugSetbytheMinistryofHealthNoexcessfoundGeneraltaxrevenuesImplementedthrough200districtHealthAuthorities1AsofSeptember1991,thesubstitutefundsremovedexpenditurecapsonexpendituresforphysicianservices.Note:NAisnotapplicableSOURCE:WolfeandMoran,Lewin-VHI,Fairfax,VA,1992.Table2.國際比較-醫療費用年平均成長率西元年國家1960-19701970-19801980-19901990-19951995-19961996-19971997-19981998-19991999-20002000-20012001-20022002-20032003-2004澳洲……8.06.56.45.96.47.16.69.6………加拿大12.212.49.33.4-1.24.36.82.43.87.55.45.33.8法國12.915.08.64.43.33.03.02.45.06.26.25.5…德國…14.56.27.46.51.21.62.34.63.64.52.6…義大利………4.24.65.83.82.010.44.95.01.68.8日本…………9.94.46.37.38.06.74.7……韓國………10.816.211.54.819.31.824.83.810.4…荷蘭……6.74.03.83.9-2.74.76.113.712.37.4…挪威………8.28.613.87.810.710.57.310.95.61.6美國11.113.711.06.14.84.74.54.25.78.28.17.0…台灣(全民健保)………………11.68.12.67.07.44.44.2※2004-2005年台灣(全民健保)醫療費用年成長率為4.0%。Table3.國際比較-每人年西醫門診次數西元年國家196019701980199019961997199819992000200120022003澳洲2.73.14.06.16.86.76.66.56.46.46.26.0加拿大……5.66.76.46.46.46.46.36.2……法國……4.25.96.56.46.66.66.96.96.9…德國…………6.76.97.17.27.3………義大利…………………6.06.1………日本………13.814.814.314.514.514.414.514.1…韓國…………………8.8……10.6…荷蘭……4.95.55.45.95.65.85.95.85.6…紐西蘭……3.7………………4.4…3.2英國……5.26.16.1…5.4…5.44.95.65.2美國……………10.010.110.48.99.08.98.9台灣(全民健保)…………10.311.211.912.211.811.611.711.4※2004、2005年台灣(全民健保)平均每人西醫門診次數分別為12.3次及12.4次。Table4.國際比較-每人國民醫療保健支出年平均成長率西元年國家1960-19701970-19801980-19901990-19951995-19961996-19971997-19981998-19991999-20002000-20012001-20022002-2003澳洲……6.66.05.95.66.56.88.24.97.1…加拿大9.110.38.33.40.14.17.54.44.38.34.95.6法國11.613.08.25.33.13.03.53.46.26.65.55.1德國…13.66.15.46.10.42.43.04.44.24.82.7義大利………2.05.56.05.23.110.15.14.40.4日本17.514.56.86.67.22.53.24.97.86.12.3…韓國………7.412.44.6-2.518.35.820.94.510.2荷蘭……6.64.93.22.55.84.45.811.510.17.2紐西蘭…9.27.04.62.06.66.85.05.46.08.82挪威11.116.87.76.39.213.58.310.69.56.610.05.3英國6.811.47.46.95.73.84.67.18.510.99.8…美國9.211.810.05.93.83.94.04.85.77.78.26.6台灣(全民健保)…………10.47.57.97.13.32.83.34.0※2003-2004年台灣每人國民醫療保健支出年成長率為3.53%。總額支付的功與過從結果論:確實把醫療費用控制下來了但是各國做法不同WaitingList問題相同是資源利用的效率問題嗎?---付費者的觀點或是資源投入的不足呢?---醫療提供者的觀點何謂資源耗用的效率節約醫療費用並不等於達到效率效率efficiency.staticefficiency,靜態的效率代表改善了金錢使用的價值dynamicefficiency,動態的效率以有限的人力或醫師資源不斷改進醫療及技術以提升機構的生產力W.P.M.M.VandeVeninhi