民眾對全民健保給付合理論責機制之態度調查

Employing accountability for reasonableness in Taiwan’s National Health Insurance: exploration of public opinions

目標：合理論責機制（accountability for reasonableness, A4R）為健康照護分配正義評估提供完整連貫之理論架構，本研究目的便係瞭解民眾（作為重要利害關係人）對於將A4R要件納入全民健保給付決策機制之態度與認知，並探討可歸因性之相關因素。方法：研究對象為20歲以上全國民眾，採隨機抽樣並輔以電話訪問，樣本數為1,140位，以多項式邏輯斯迴歸探討可歸因性與民眾特性、公開性、參與性及可修正性之關聯性。結果：多數受訪者認為可歸因性、公開性、參與性與可修正性為健保給付決策機制之重要要素，但僅少數受訪者認識相關機制。就健保給付決定因素分析，重視藥物／醫療服務價格勝於治療效果者，與年齡、教育程度、收入、醫療利用、公開性及參與性有關；重視疾病負擔勝於治療效果者，與年齡、收入、慢性病及參與性有關。結論：民眾普遍認為健保給付決策機制納入A4R要件有其重要性，但認知與態度存在差距；且可歸因性與民眾特性、公開性、參與性有關。

Objectives: Accountability for reasonableness (A4R) provides a coherent theoretical framework to evaluate healthcare distributive justice as part of healthcare policy. This study aimed to analyze people’s knowledge about and attitudes toward employing A4R (including relevance of decisions, transparency, involvement of stakeholders, and revisability) in the National Health Insurance (NHI) treatment/drug reimbursement decision-making process, and to explore factors associated with the relevance of such decisions. Methods: A total of 1,140 adults aged 20 and over were randomly sampled from a nationwide population and interviewed by telephone. Multinomial logistic regression was used to examine the associations of individual characteristics, transparency, involvement of stakeholders, and revisability with the relevance of decisions. Results: Most respondents regarded A4R as essential to the NHI reimbursement decision-making process, but only few recognized how A4R was implemented. Additionally, with regard to considerations about setting healthcare priorities - (medical efficacy, disease burden, treatment/drug price), respondents’ concerns about price were associated with age, education, income, medical utilization, and their subjective perspectives about transparency and the involvement of stakeholders. Their concerns about disease burden were associated with age, income, chronic disease status, and subjective perspective about the involvement of stakeholders. Conclusions: Even though most people agree on employing A4R to support fair priority-setting in NHI’s reimbursement decision-making, a gap exists between their attitudes and knowledge. Additionally, public attitudes about the relevance of decisions are associated with socio-economic characteristics and concerns about transparency and the involvement of stakeholders. (Taiwan J Public Health. 2018;37(2):166-181).