全民健保支付制度改革之回顧與展望

The Review and Prospect of the National Health Insurance Payment System Reform

台灣在1995 年實施全民健康保險，成功的完成全民納保，再加上其醫療費用低廉、就醫可近性與滿意度高，因此聞名國際。自開辦以來，全民健保即引進多元的支付制度改革以提升醫療品質與民眾健康，強化醫療服務效率與價值，控制醫療費用。這些策略—包括總額支付制度、（診斷關聯群為基礎的）論病例計酬、依據資源耗用相對值表調整支付標準表、依據市場調查與成分別訂價調整藥價基準、論質支付、整合性照護體系（家庭醫師制度、論人計酬）等，已部分達成上述支付制度改革之目標。這篇文章將回顧並評估健保開辦以來推動的支付制度改革策略，並依據上述回顧，對未來支付制度改革方向提出具體建議。

National Health Insurance (NHI) was launched in 1995 and has been internationally well-known for its success in achieving universal coverage, low cost, high accessibility and satisfaction. Since its inception, NHI has introduced many payment system reform strategies to improve quality of care & population health, to enhance efficiency and value of health care provision, and to control costs. These strategies, including global budgeting, (TW-DRG-based) case payment system¸ Fee Schedules revision based on Taiwan Relative Value Scales (TW-RVS), Pharmaceutical price adjustment based on market survey and generic grouping, pay-for-performance and integrated delivery system (family physician system and capitation), have partially fulfilled the goals of payment system reform mentioned above. This paper reviews and evaluates these reform strategies and draws recommendation on the future directions of NHI payment system reform.