歐洲各國總額支付制度之跨國比較－－以德國、英國與荷蘭為例

A Comparative Research of Global Budgeting in Germany, England and Netherlands

總額支付制度是目前許多國家為有效控制醫療費用上漲的策略方法之一，總額制度的設計改變過去從需求面來抑制醫療費用上漲之策略，使醫療服務供給面必須承擔醫療費用上漲責任。總額支付制度成為許多國家爭相仿效採行，但仿效之國家往往忽略許多實施總額制度國家的歷史背景及其制度變更之配套措施，只攫取其他國家部分設計或忽略本國特殊文化背景，如此稼接的總額支付制度往往事倍功半，無法真正達到抑制醫療費用之目的，反而衍生出傷害醫療服務品質或劣幣逐良幣之現象，因此本文的目的在介紹實施總額支付制度較成功之國家之現況如德國、英國及荷蘭等國，透過各國制度發展的歷史和政治變遷邏輯，對總額支付制度作一脈絡化的分析。本研究以文獻分析法作為主要的研究方法。為求完整，研究者蒐集多元的文獻資料，其中包括各國的主要官方資料和相關的學術研究成果。綜合分析的內容，本研究主要發現如下：各國總額支付制度常因歷史背景及既有制度的經驗，而對制度的發展構成關鍵的影響。德國健保體制的形成主要是秉持聯邦主義及社團主義的精神，此外政府、疾病基金會及醫事團體三方權力平衡運作的成功經驗，更是其總額預算實施的重要條件。英國濟貧法，不僅形塑了政策受益者的行為慣性，更使得制度產生自我增強的效果，成為英國國家化醫療福利體制繼續得以存續的主要原因。荷蘭的健康保險制度，主要是構築在管理式競爭模式的基礎之上。世界各國在積極提升國民健康之際同時也面對醫療費用高漲的問題，因此必須讓醫療資源有效利用與分配，總額支付制度實施不僅能有效分配醫療資源使有限的經費用在刀口上、減少政府過度介入干涉、提昇專業價值和尊嚴，更能促使醫療院所重視民眾健康的提昇而非提供更多醫療服務量為目的。不同的國家有不同之醫療保健制度，各國特殊的政治結構將是影響該國醫療福利改制成敗的關鍵因素之一。

The aim of this study was to provide up-to-date information on the health care systems of three countries outside Taiwan to help the policy makers appropriately respond the pressures and challenges caused by the global budget system. We undertake historical institutionalism perspective to compare the historical mid political logic of global budgets in Germany, England mid Netherlands through contextualizing analysis. This study includes a selection of three countries representing the diversity of international experience of both funding mid delivering health care. Literatures analysis was the math research method. To have comprehensive exploration, multiple literatures were collected, including significant official document for each country and related academic research. The major results of this study include: First, we found that the current global budgets did not come from vacuum, they inevitable embraced in the experience even in some broken remains, which ere already exist. Secondary, this research found that particular politic structure for each country was crucial factor for success or failure of health care system. Last, global budgets allow governments to control costs while at the same time granting hospital management a great deal of discretion in the allocation of fluids among a hospital various operations. Global budgets also allow the delivery of comprehensive, integrated health care, which in the long run, ca reduce overall health care costs. This study highlight that despite significant differences in how health systems are financed, organized and provided, three countries face a number of similar challenges. These include ensuring equity of access to health services raising quality: improving health outcomes sustainable financing improving efficiency greater responsiveness: citizen involvement in decision making and reducing barriers between health and social care. How ever, the responses to these challenges differ as each country adopts the most appropriate approach based on its historical, political, social and cultural context. By understanding how different countries respond contemporary health care system and challenges, we hope, this study will inform the debate in Taiwan on the future of health care.