我國西醫醫療院所為何不願釋出門診處方箋？一個藥價差的解釋

Why Do Hospitals and Clinics in Taiwan Not Release Prescriptions? An Explanation of the Pharmaceutical Price Gap

我國政府雖自1990年代起已宣示推動醫藥分業，但卻一直未能立法強制要求醫療院所須釋出處方箋，以致多年來僅能依賴醫師的自願配合來落實此項政策；這也就使得「如何引導醫師釋出處方」成為藥政實務上的重要課題。本研究由診所醫師的行為出發，討論因藥價差而產生的藥品利潤，如何影響醫師的處方釋出行為。我們以全民健保資料庫為基礎，檢視2008年與2010年西醫的門診紀錄，並比對2009年與2011年第6次與第7次年度藥價調整資料，推算出各年各處方中藥價差總值的多寡。本研究證實，若某處方所開立的藥物，隔年遭調降藥價的總幅度越大，或依健保給付價所計算的總藥費越高，一般也將伴隨著醫師較低的處方釋出意願。此意味著醫師的處方釋出行為，確實會考慮到自藥品所得的利潤。這也意味著，一旦造成藥價差的藥價給付制度有所調整，醫藥分業將較易落實。

Although the policy regarding the separation of dispensing and prescribing drugs has been in force since 1990s, the authorities in Taiwan have not yet enacted rules requiring hospitals or clinics to release prescriptions, which a patient can take to the pharmacy to get the filling, as for many years, the government has relied on only physicians' voluntary cooperation to realize this policy. In order to help motivate physicians to release more prescriptions, this study examines their behavior and discusses how the profit from the pharmaceutical price gap (whereby the pharmaceutical reimbursement by National Health Insurance is higher than the actual expenditure) affects physicians' willingness to release prescriptions. Based on the National Health Insurance Research Database, we analyze clinic records in 2008 and 2010, compare them with information of the 6th and 7th adjustments in the pharmaceutical reimbursement schedule, and estimate the profit from the pharmaceutical price gap in each clinic record. The findings show that physicians statistically significantly tend to keep prescriptions, including for drugs whose reimbursement prices have been reduced in the two adjustments or for prescriptions with higher drug reimbursement. This implies that physicians do consider pharmaceutical profit when prescribing. It also means that if the government can amend the reimbursement policy that is causing the pharmaceutical price gap, then physicians will release more prescriptions to pharmacists.