健保制度下的醫療體系

Health Care System Under National Health Insurance Scheme

全民健保已經實施18 年，明顯提升民眾的就醫可近性以及健康的公平性，普遍受到民眾的肯定，另一方面也對臺灣的醫療體系產生不少衝擊。本文從醫療服務的資源投入與支出著手，從國際比較與臺灣的發展趨勢做分析，接著討論臺灣醫療體系的特性與面對的挑戰。主要發現是臺灣醫療供給面有顯著成長、醫療保健費用成長快速、片段式的醫療服務、過度門診利用與藥品浪費，以及醫院規模大型化等，我們認為目前的醫療提供方式必須改變，否則醫療體系將難以支撐。最後我們提出臺灣健保與醫療體系改革的建議，包括促進醫療提供者間的聯繫、繼續推動健保論質計酬與診斷關聯群支付制度、讓醫院評鑑等級漸進地與健保脫鉤、研擬重症中心健保加成機制，以及醫學教育改革等，讓全民健保與醫療體系可以永續經營，繼續守護民眾的健康。

After 18 years of the National Health Insurance, the program has increased the accessibility to care and equity of health for Taiwanese population. On the other hand, it has also influenced the health care system. This article compared health care resources among selected countries and described the trend in Taiwan, and discussed the features of and challenges facing our health care system. We found that health resources as well as health care expenditure have increased significantly. Our system was featured by fragmented care, overuse of ambulatory care and prescribed medication, and increasing size of hospitals. We consider that the system would not be sustainable and significant changes have to be made. We recommended strategies to reform the health care system and the health insurance program which include promoting coordinated care among healthcare providers, implementing performance based or episode based payment, separating hospital accreditation from the National Health Insurance, designing critical care centers with enhanced insurance payment, and medical education reform etc. We hope these reforms can turn our health system into a sustainable one which will protect and promote the health of Taiwanese people.