我國實施自負額制度之可行性－－預期成效及面臨的問題

The practicability, expected effectiveness and possible issues for implementing the Deductible System in Taiwan

民眾對醫療需求不斷的增加，導致醫療費用呈現節節上升的趨勢，為解決健保財務問題，全民健康保險法第34條規定，連續2年如全國平均每人每年門診次數超過12次，即應採行之自負額制度，再度引人關注。若健保將採行自負額制度，不但可以提升病人成本意識，節制保險醫療資源使用的誘因，同時也有加重民眾對自己身體保健、衛生之功能。惟從國外研究得知，在實施社會保險的國家，自負額制度並不多見，多實施於商業保險中。我國若欲從保險給付過渡到自負額制度，需有完整配套措施，才能達到資源有效運用及社會公平的雙重目標。為瞭解自負額制度，本文嘗試以國外實施自負額制度情形、國內自負額制度建議方案，以及我國實施自負額制度之可行性等進行研析，並就現有制度提出建議。本文採用蒐集國外自負額制度之實施經驗及國內各界曾提之建議方案等文獻回顧方式，對我國實施自負額制度之可行性進行探討。研究結果顯示，大多數國家之健保制度均未採行自負額制度，有實施自負額制度國家多採行醫療需求彈性較大的項目。實施自負額制度可與其他醫療費用部分負擔制配合使用，但須考慮弱勢團體的經濟負擔。考量造成弱勢團體較大之衝擊等因素，本文建議目前健保不宜全面採行門診或住診之自負額制度，我國若欲實施自負額制度，應慎重選擇項目，且採行小幅度改革，並與其他醫療費用部分負擔或差額負擔配合使用。

Background: There was the trend of continually demand in healthcare and resulting in gradually increasing medical expenditure. Experts from diverse fields suggested many kinds of financial proposals and the deductible system regulated in the National Health Insurance Act (NHIA) is again discussed. Objectives: In order to understand the deductible system regulated in the article 34 of NHIA, this article has introduced the deductible system in western countries and proposals for domestic deductible system, analylized the practicability of the deductible system implementing in Taiwan, and to propose suggestions under current system. Methodology: The study was to collect the details of deductible systems implemented by the western countries and past proposals suggested by experts by literature review in order to discuss the practicability of applying the deductible system in Taiwan. Findings: The results shown that most countries with national health insurance have not introduced the deductible system while those which adopting the deductible system have applied the deductible system to healthcare items with relative large demand elasticity. The implementation of deductible system is suggested to combine with other copayment systems. However, whether it is affordable for the minority should be taken into consideration.