現行總額預算支付制度下地區醫院因應之策略

Abstract

總額預算支付制度為控制醫療健康保險費用過度成長的有效方法，然而其本質在合理的醫療資源分配、醫療效率的提昇及醫療品質的保障。總額制度的實施，並非放任醫療院所於自由市場上競爭，而是應以制度面引導民眾走向適當的醫療，進而受到分層級的照護。如沒有適當的配套措施下，各大小型醫院將陷入賽局理論下的囚犯困境，只能盲目擴充服務量以增加收入，如此反而使得給支付點値下滑，再加上行政干預下，讓原本競爭力薄弱的地區醫院雪上加霜。健保局於92年度曾經挑選少數醫院試辦個別醫院總額計劃，再於93年度第3、4季全面開放各層級醫院加入個別醫院總額計劃，本研究卽以此二階段的數據來衡量分析個別醫院總額計畫之成效。 經本研究所得資料分析與比較發現：（一）總額預算支付制度在沒有配套措施下，引導醫院進入賽局競爭造成點値持續下滑，扭曲醫療生態。（二）個別總額支付制度可以有效限制醫療費用成長，而實施後各種品質指標監控及民眾滿意度均呈現較佳表現。（三）對地區醫院而言，相對競爭力薄弱下，應設法加入個別醫院總額計劃，以確保財務面的穩定，避免與大醫院正面競爭。（四）在沒有其他選擇之前，健保局仍應持續推行個別醫院總額計劃，以避免醫療產業崩盤。

The Global budget payment system is an effective method for controlling medical insurance expenditure from blowing out, however, the constitution of the system is designed to achieve a reasonable allocation of medical resources, enhance hospital efficiency, and ensure healthcare quality. The implementation of a global budgeting system is not intended to loose medical institutions to compete with each other in a free market, it should conduct the public seeking for proper healthcare and being cared by level. Without appropriate coordinating measures, large and small hospitals can become caught in a prisoner’s dilemma of game theory, and be left with no option but to blindly expand utilization for more income, which will instead only drive down conversion factor. Besides, the whole situation is further compounded by administrative intervention that makes less competitive area hospitals could stand in an even weaker position. In 2003, the Bureau of National Health Insurance (BNHI) ran a trial implementation of a hospital-based global budget plan in a limited number of hospitals and fully launched into all levels of hospitals in Q3 and Q4 in 2004. The statistics of the aforementioned two phases formed the base of this study with its results evaluation of the hospital-based global budget plan.

Analyses and comparisons of this study indicate that： 1. Without coordinating measures, the current global budget payment system led hospitals to enter the competition of game theory and that resulted in continuously lowering conversion factor. It has also deformed the medical ecology. 2. The Hospital-based global budget payment system functions to effectively limit medical expenditure growth. After the implementation, various quality index monitors and user satisfaction surveys have shown better results. 3. In order to ensure their financial stability and avoid a head-on confrontation with larger hospitals, it is advisable that regional hospitals, which are less competitive, seek to take part in the hospital-based global budget plan. 4. To prevent the medical industry from experiencing a full-scale crisis, the BNHI should continue to carry out the hospital-based global budget plan until a superior alternative appears.