從政策執行觀點分析全民健康保險轉診制度 : 以某醫學中心耳鼻喉科為例

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Title:	從政策執行觀點分析全民健康保險轉診制度 : 以某醫學中心耳鼻喉科為例
Other Titles:	Analysis of policy implementation of referral system under national health insurance in Taiwan : a case study of otolaryngology department of a medical center
Authors:	余慶華;Yu, Ching-Hua
Contributors:	淡江大學公共行政學系公共政策碩士在職專班陳志瑋;Chen, Chih-Wei
Keywords:	轉診制度;政策執行;就醫經濟障礙;醫療可近性;Referral System;Policy implementation;Economic Barrier of Medical Care;Accessibility of Medical Care
Date:	2013
Issue Date:	2014-01-23 14:11:45 (UTC+8)
Abstract:	我國實施全民健康保險制度以來，健保財務赤字始終是個難解的習題，歷經多次調漲部分負擔或調高保費，結果都只是杯水車薪，仍舊無法填補日益擴大的財政缺口，導致健保經營陷入危機。多數健保政策的研究者，會直接以財務面為探討對象，其終極目標多鎖定在為健保財政尋求解套的方法。然影響政策執行成敗的因子，不會只有一個單一面向，有鑑於此，本研究則以政策面為研究對象，自既有的政策本身為研究起點，依據政策執行的理論架構，從健保轉診政策本身的屬性面與非健保轉診政策本身的屬性面，分析影響政策執行之相關因子，期能在健保政策之運作機制中，找出可能影響健保政策執行成敗的關鍵所在，並釐出能解決健保財務最具經濟效益、最具可行性的方法，期使健保得以永續經營。本研究採文獻研究法、個案研究法及深度訪談法。首先自文獻中整理分析前人所研究之成果，以為本文論述之依據，其次再就個案5年之轉診記錄資料進行統計分析，最後以深度訪談法進行實證研究，並據此研究結果與文獻資料及個案統計資料彙整對照，進行綜合分析並提出結論與建議。研究發現，在先進國家之醫療體系中，轉診皆扮演著重要的角色，其中愈是醫療科技發達的國家，就醫轉診愈是普遍，且轉診較具成效的國家，其醫療支出也會相較其他先進國家減少近1/2。若再以我國健保資料庫統計分析來看，國人每年應轉診而未轉診，直接逕赴醫學中心就醫者，粗估高達2,400萬人次，健保每年就會因此多支出近300億元，由此看來，要改善健保財務赤字，與其大費周章的計算保費，倒不如徹底執行轉診政策來得更具成效。結論：健保制度實踐了「降低病患就醫的經濟障礙，提升病患醫療的可近性」，並以低消費高品質的醫療服務享譽國際。但在這榮耀的背後，其實是嚴重的健保財務黑洞。健保不能倒應是全民共識，以各國醫療保健制度之實施看來，要節約醫療資源，控制醫療費用，徹底實施轉診，比增加部分負擔，更具成效。建議主管機關要改善健保財務虧損，調漲部分負擔，僅為政策工具之一，應考慮從醫療體系實質面著手，提升基層院所之醫療品質，病患就醫權益才能獲得保障，再談落實轉診制度才更具意義。 The fiscal deficit of National Health Insurance（NHI） has been a worrisome topic since the launch of National Health Insurance System in Taiwan. In spite of several times of copayment and premium hikes, just like a drop in the ocean, the widening fiscal gap of NHI still has not been filled up; and this dilemma has involved NHI in an operational crisis. Most researches on NHI policy have focused on exploration and solution of its fiscal issue. However, the success of policy implementation depends on several aspects not just one factor. Thus, the key point of this research is on the aspect of policy, and the research attempts to probe the present policy. In accordance with the theoretical framework of policy implementation; from the referral policy attribute itself and none referral policy attribute, the research analyzes the related factors that influence policy implementation. The purpose of this research, from the operational mechanism of NHI, is to find major factors that may impact on the performance of NHI policy. Furthermore, the research also tries to find the most feasibility with the best economic efficiency for the sustainable operation of NHI. The methods used in this research included Literature-Review Method, Case-Study Method, and Interviews Method. Firstly, the research results of related literatures were reviewed and analyzed so as to establish the discourse of this research; the second step was to conduct a statistic analysis on a five-year case study of referral records; lastly, interviews method was used to conduct an empirical study. All of the empirical study, literatures information, and case statistic were collected and checked to conclude suggestions and summarizations. The research found that referral system played an essential role in the medical care system of the advanced countries; and, the more advance in medical technology, the more referral cases in operation; compared with other advanced countries, a country with a well-established referral system, whose medical expenditures was nearly a half of the other countries’. According to Taiwan NHI statistical analyzing data, every year, there was 24-million-number of outpatients, who should have been referral, went directly to academic medical centers for health care. Because of the failure in referral, the NHI had to pay other NT$30 billions for the cost. Figures told a truth, to improve the fiscal deficit of NHI, practically fulfill referral policy may be an efficient solution rather than focusing on premium calculation. In conclusion, Taiwan’s NHI performs the spirit of “reduction of economic barrier of medical care, promotion of accessibility of medical care” for patients; this insurance system has received well reputation in the world because of its high-quality-but-low-consumption policy. However, behind the glory, a severe insurance fiscal “black hole” is deteriorating the policy. Everyone agrees that the NHI must be existence; and in the viewpoint of international health care policy implementation, medical resources saving, medical expenditure control, and referral system implementation, all of which are useful solutions for securing NHI rather than just a copayment addition. To raise copayment of NHI to improve fiscal loss is one of tools; the result of the research suggests that the competent authority should take the specific medical system into account, strengthen the medical quality of physician clinics and dental clinics so that patients’ health care interests can be protected, then referral system implementation can be meaningful.
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