全民健康保險價量協議法律問題分析

Legal Issues of Price-Volume Agreements in National Health Insurance

價量協議是全民健康保險制度下新型態契約。當藥品銷售超過約定數量時，藥商必須降價或將超額銷售金額歸還政府或保險人。價量協議有助於兼顧健保財務健全及維護人民用藥權利，但因在國內屬於新型態契約類型，現行法律沒有完整規定，以致在學說及實務上具有各種實際與潛在爭議。根據現行全民健康保險法相關規定，以及健保署及藥商在藥品收載及核定價格之互動關係，本文認為價量協議屬於行政程序法第137條之「互負給付義務行政契約」。價量協議影響被保險人用藥權利，且涉及政商關係龐大經濟利益，如將價量協議契約解釋為私法契約，將導致公權力遁入私法，不受行政法原則及行政程序法相關限制所規範，可能引發行政機關濫用職權傷害公共利益之流弊，而另一方面也可能引發適用公平交易法潛在法律疑義。為使價量協議之法律地位與合法要件更加明確，便利相關法律爭執解決，本文建議由衛生福利部或健保署依職權將價量協議定義為行政契約，且應重新檢討目前條款內容，以免契約條款違法無效而導致健保署對藥商喪失請求權。

Price-volume agreements （PVAs） are negotiations between pharmaceutical companies and the government or payer in a national healthcare system. The government or payer can ask price cuts or rebates when the actual sales exceed a forecasted volume. PVAs have been adopted internationally in recent years. In Taiwan, PVAs are still in an early stage of development, and their legal status has not been clearly defined by the National Health Insurance Act. This essay argues that PVAs should be regarded as a subtype of administrative contracts from legal and policy perspectives. To ensure PVAs' legal validity, the National Health Insurance Administration should reexamine existing PVAs and correct some clauses.