從國際經驗省思全民健保地區預算之分配方法

Geographical allocation of the healthcare budget in the National Health Insurance program: what can we learn from other countries?

全民健保自1998年陸續實施牙醫門診、中醫、西醫基層、醫院等部門之總額支付制度，在此制度下將預算分配到健保署各業務分組，以促進各地區醫療資源之有效自主管理。然而目前各總額部門之地區預算分配方式互異，雖遭致許多批評但應如何修訂迄今仍難凝聚各方共識。部分醫界代表及專家學者認為，除了現行地區預算分配方式中納入的分配參數，也應將各地區醫療需求程度差異、人口風險因子、醫療服務提供者之執業成本、醫療服務供給等因素納入考量。因此本研究經由文獻探討，瞭解實施總額支付制度或醫療先進之國家，其地區醫療預算分配方式、參考因素、發展趨勢與經驗，以提出臺灣全民健保總額支付制度下地區預算分配方式之改善方向及具體建議，提供主管機關作為未來政策修訂之參考。本研究經由文獻探討發現，英國、澳洲、紐西蘭等國有進行地區醫療預算之分配，且均採用「以人口為基礎」（population-based）、或稱為「以需求為基礎」（need-based）之預算分配方法。分配預算的參考因素或校正因子除了基本的年齡、性別組成，多數國家也納入民眾罹病狀態、社經特性以反映不同地區民眾對醫療需求的差異；有些國家亦將供給面的成本差異或未被滿足的醫療需求等因素納入分配預算的條件。各國預算分配機制除了反映醫療需求的差異，也期望透過地區預算的分配降低地區間的醫療資源分配不公平。本研究建議於未來的地區預算分配機制中，納入罹病狀態與社經特性等參考因子，並建議發展本土化、共通性的社經特性測量工具，並進行調查研究以瞭解現況下民眾有多少未被滿足的醫療需求。 In 1998, the National Health Insurance program of Taiwan implemented a global budget payment system for dental outpatient services, followed by traditional Chinese medicine, primary care, and hospitals. Under this scheme, the annual healthcare budget is distributed among six regional service areas for enhancing self-management within each area. However, the formulas used in the allocation of the annual budgets differ across sectors. This situation has drawn criticism from healthcare providers, and stakeholders have yet to reach a consensus regarding the types of revisions that should be implemented. For the formulation of healthcare budgets, many medical professionals and researchers are demanding the inclusion of factors such as the variations in healthcare needs, personal risk factors, costs involved in the healthcare service provision, and distribution of healthcare providers in the region. In this study, we review the methods employed in other countries for the distribution of budgets as well as the factors included in their formulas, trends in the development of the budget allocation systems, and their experiences following implementation. Our literature review revealed that the United Kingdom, Australia, and New Zealand allocate healthcare funds according to population-based (also referred to as “needs-based”) distribution formulas. These formulas include factors pertaining to age and gender, morbidity, and socioeconomic status. Some of these formulas also account for differences in the supply-side costs and “unmet needs” in the healthcare provision. The methods in question are ostensibly highly effective in accounting for regional healthcare variations and also aim to reduce inequity in healthcare resource distribution. We suggest that morbidity and socioeconomic status should be included in the resource allocation formula in the future. According to the literature review findings, the government should develop localized measures of socioeconomic status that can be applied across Taiwan. The government should also investigate the status quo in relation to “unmet needs” in Taiwan.