全民健保外科手術項目支付標準訂定之研究

Abstract

我國全民健康保險於民國八十四年三月開始實施，制度設計屬於社會保險。全民健保的實施後，對我國醫療生態的影響很大，其中較為重大者，為沿用勞保時期之支付標準，許多項目自民國78年至今，未做合理調整，造成醫學界很大的衝擊。由於支付制度規劃上的限制，導致全體外科系所佔給付費用比率相當低。目前的支付標準訂定仍有許多問題存在，為了改善這些問題及有效凝聚外科專家對支付標準訂定之意見，以制訂合理的支付標準，本研究結合德菲法、專家名義團體法、層級分析法（AHP）、及模糊多準則決策法（FMCDM）之系統化的科學方法，來架構全民健保外科手術項目支付標準訂定之分析模型，以達到下列二項研究目的： （1）整合外科各次專科專家對於健保手術項目支付標準值訂定之意見，達成外科界之共識，方便與健保局協商； （2）建立外科各次專科健保手術項目支付標準訂定之分析模型，作為我國全民健保醫療費用支付標準訂定及費用調整時之參考。 本研究流程包括既有文獻分析、外科專家共識整合、建立AHP與FMCDM模型、及模型實證分析等，以有效整合外科專家之意見，及訂定外科手術項目支付標準。其中外科專家共識整合是以德菲法與專家名義團體法進行；與訂定支付標準相關之考量因素權重值是由AHP模型求出；FMCDM模型用於計算各次專科手術基準項的相對值；最後計算出整體外科手術項目之支付標準總表。 本研究總共舉行19場次的會議，外科九個次專科共214人參與研究。研究結果顯示，外科各次專科專家可以接受此方法，有效達成共識及建立協商基礎。完整且客觀的參考資料、科學化的分析方法與理性的思考模式，是訂定合理外科手術項目支付標準的關鍵。

Taiwan’s National Health Insurance (NHI) program was established on March, 1995. The payment system design for Taiwan’s NHI belongs to social insurance. The payment system of Taiwan’s NHI is followed that of the era of previous Government Employee/Labor Health Insurance. Many items issued from 1989 were not rationally adjusted. The inherent structures make irrational fee schedule biases and have affected the medical ecosystem. Following the implementation of NHI, the ratio of overall payments to surgical specialties was quite low due to many innate restrictions of the fee schedule in the payment system. For improving the weaknesses and establishing a rational fee schedule by precisely capture surgical experts’ opinions, this study aims to design a systemic scientific framework, which including: Delphi method, nominal group technique, analytical hierarchy process (AHP), and fuzzy multiple criteria decision-making (FMCDM) for contructing the analytic models, to achieve the following two purposes: （1） Integrate the opinions of surgical specialties about the establishment of NHI’s fee schedule for surgical procedures. （2） Construct the analytic models for surgical specilities to establishing the rational fee schedule of surgical procedures in the NHI’s program. The main processes of this study including: literatures review, survey and integrate experts’ opinions, build the AHP and FMCDM models, and empirical study of the models. Through theses processes, we can condense the surgical experts’ opinion by using Delphi method and nominal group technique. The AHP model was constructed for getting the relative weighting of each considering factors. For establishing fee schedule for surgical procedures in a NHI program, we use the FMCDM model. Finally, a new fee schedule for surgical department was completed. Nineteen meetings were held, and three were 214 surgical experts participated in this study. The results of our study strongly support that the models constructed are effective in forming a consensus among surgical specialists. The key success factors of establishing the rational fee schedule for surgical procedures depend on complete and objective data, scientific analytic methods and rational thinking process.