全民健康保險藥品給付制度方案選擇之研究

Abstract

全民健康保險自民國八十四年三月一日開辦至九十一年十月三十一日，納保率已達96%。統計資料顯示，藥品費用支出高達總醫療費用的24.8%。藥品費用的支出逐年上漲，固然與民眾對醫療需求的增加、醫療品質的要求提升、人口結構的老化、疾病結構的改變、…等等因素有關，但是，健保藥品給付制度仍存在一些問題，導致「藥價黑洞」的議題週而復始的被廣泛的議論。 本研究的方法是參考英國、日本、美國、加拿大..等先進國家的保險藥品給付制度，再以問卷訪談的方式與國內相關業者、學者、專家與消費者訪談，歸納篩選五種藥品給付制度；以AHP法建構我國「全民健康保險藥品給付制度方案評選結構圖」，再採用模糊多準則決策評量方法(Fuzzy MCDM )，針我國全民健保藥品給付制度策略方案進行實證研究評量分析。本研究的目的在評選我國最適健康保險藥品給付制度方案，達到以下四個目標（1）達到政府藥品給付政策目標；（2）達到醫療提供者的期望目標；（3）滿足消費者的需求目標；（4）達到藥品供應者經營規劃目標。供我國健保相關決策機關擬定藥品給付制度的參考。研究結果與建議： 1.四類目標構面之重要性順序：最重要為「達到醫療提供者的期望目標」、其次為「滿足消費者的期望目標」、「達到政府藥品給付政策目標」、最後才是「達到藥品供應者經營規劃之目標」。四個構面權重差異不大，重要性相近。 2.全體受訪者對藥品給付制度方案評選的平均效用值大小依序為「藥效比較制」，「藥價參考制」，「成本結構制」，「藥價基準制」，「總額預算制」。 3.單一一種的藥品給付制度不足以兼顧到政府（保險人）、醫療提供者、消費者以及藥品供應者的期望目標。我國健保單位在評選藥品給付制度時應依據重點目標選擇「藥價參考制」為基礎，併用其他藥品給付制度。 4.現階段不宜採用「成本結構制」。 5.「藥品給付總額預算」由「醫療給付總額預算」中獨立出來。 中央健康保險局對全民健康保險藥品給付制度的任何舉措，都應該以民眾的健康權益為依歸，避免民眾暴露於不可知的用藥風險中，同時使健保醫、藥費支出合理化，並減輕政府財政上的負擔，讓全民健保得以永續經營。

ABSTRACT The National Health Insurance Program was implemented in March 1, 1995 and this program covers 96% of population in October 31, 2002. According to the statistic data, 24.8 percent of medical treatment payment is the expenditure of drug. The causes for growing up of expenditure of drug including the increasing need for medical treatment from people, the need for upgrading the quality of medical treatment, aging of the population, change of nature of disease… etc. However, the drug reimbursement system still has some problems to induce the topic of ‘Black Hole of Price of Drug’ to be widely discussed over and over again. This study method is referred to the drug imbursement system in developed countries such as British, Japan, Unites States of America and Canada, and by using the questionnaire to interview with local related businesspeople, scholars, professionals and patients. The results are concluded and selected for five drug reimbursement systems. Based on the AHP method to build up Taiwan’s ‘Evaluation Structure Diagram for Schemes of National Health Insurance Drug Reimbursement System’. Then adopt Fuzzy MCDM to precede the practical study and evaluation on the Schemes of National Health Insurance Drug Reimbursement System. The purpose of this study is to select the most suitable scheme for National Health Insurance Drug Reimbursement System to attain the following four targets. 1. To accomplish the drug reimbursement strategy of government 2. To meet the expectations of medical treatment providers 3. To satisfy the requirements of customers 4. To meet the business planning of suppliers of pharmaceutical products’ The results of study will be offered to National Health Insurance related decision-making department for reference to draft the drug reimbursement system. The results and suggestions of the study: 1. The sequence of importance for four category’s aspect: The most important is ‘To meet the expectations of medical treatment providers’, then ‘To satisfy the requirements of customers’, ‘To accomplish the drug reimbursement strategy of government’ and the last is ‘To meet the pharmaceutical products suppliers’ business planning’. The deviation of balancing weight of these four aspects is little and the importance is very similar. 2. According to score of the average effective value of drug reimbursement system, which is evaluated and selected by whole interviewers, the sequence from large to small is ‘System of drug effect comparison’, ‘System of Drug Price Reference’, ‘System of Cost Structure’, ‘System of Drug Price Baseline’, ‘System of Global Budget’. 3. It does not meet the expectations from government (insurer), providers of medical treatment, customers and suppliers of pharmaceutical products if there is only one drug reimbursement system. The Bureau of National Health Insurance should based on the key point to select ‘System of Drug Price Reference’ as the basis to evaluate the drug reimbursement system and combine with other drug reimbursement systems. 4. The ‘System of Cost Structure’ is not suitable to adopt at current stage. 5. ‘Global Budget for Drug Reimbursement’ is independent from ‘Total Budget for Medical Treatment Reimbursement’. Any manners for Drug Reimbursement System of National Health Insurance that conducted by Bureau of National Health Insurance should consider the privilege of people’s health. The people should avoid to be exposed to the risk of using unknown medicines. Meanwhile, the expenditure of medical and drug should be reasonable to reduce the financial burden of government. Thus the National Insurance can be run forever.