論人計酬支付制度之綜論－－以美國Medicare制度為例

A Literature Review of Capitation System: Taking US Medicare System as an Example

全民健係開辦以來，由於醫療費用高居不下，健保局除了施行部分負擔 制度、合理門診量等相關措施來避免門診量過度擴張以外，另一方面亦採漸 進方式，逐步改革支付制度以抑制持續上漲的醫療費用。而論人計酬支付制 度亦為健保局改革之重要措施之一，因此其實施對於民眾就醫的影響亦應、為 各界所關心。本文將介紹論人計酬支付制度、美國論人計酬支付制度的實施 情形及其實施論人計酬支付制度之經驗，以瞭解論人計酬支付制度實施對民 眾就醫所造成之影響。 論人計酬靜、指按被保險人的人數及其醫療需求（如被保險人的性別、年 齡、診斷別、健康狀況等風險因子），事先決定該年度支付給醫療服務提供者 的費用，而不考慮被係險人實際醫療服務的利用，故又稱「預付制度」（prepayment） 。論人計酬支付制度之重要議題為風險校正，其為決定論人計酬支 付標準的重要因素。美國為最早實施論人計酬支付制度的國家，但其實施至 今仍有風險選擇的現象存在。而從文獻中得知，論人計酬支付制度對美國民 眾就醫的影響是：醫療服務量減少、入院率降低、平均住院日降低、醫療成 本減少、預防性醫療服務增加。 美國論人計酬實施經驗可作為台灣之借鏡。然而，台灣之醫療體采分級 特性及保險制度皆與美國不盡相同，因此不能單就美國之經驗來斷定台灣是 否適用論人計酬支付制度。本文僅提供以上關於論人計酬支付制度之相關論 述，希望對未來政策之制定有所幫助。

In response to the escalating health expenditures resulted from the implementation of the National Health Insurance, the Bureau of the National Health Insurance adopted capitation system as well as co-payment and reasonable amount of outpatients to contain costs. The purpose of this article is to introduce the capitation system, the US experience with the implementation of capitation, and the possible impacts of the capitation on consumers' medical behaviors. The payment amounts of capitation system are predetermined by the number of the insured and their medical needs (i.e., gender, age, diagnosis, and risk factors), so this system is also named as 'prepayment' system. The most important issue regarding capitation system is risk adjustment. The problem of risk selection still exists in the US health delivery system. Based on the literature review, the possible impacts of the capitation system on consumers are the decreases in service volumes, admission rates, lengths of stay, medical costs, and increases in services of preventive care. Taiwan can learn from the US experience on the capitation system although the health structure and insurance system in Taiwan is different from the US. It is hoped that this article can help p