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研究生:黃敏玲
研究生(外文):Huang, Min Ling
論文名稱:全民健保多元化制度下基本健康給付項目之範籌與附加保險之研議
論文名稱(外文):The Study of Basic Health care Services and Supplemental Health Insurance Under Proposed NHI of Multiple Carrier System
指導教授:楊教授志良
指導教授(外文):Yaung Chih-Liang
學位類別:碩士
校院名稱:國立臺灣大學
系所名稱:醫療機構管理研究所
學門:商業及管理學門
學類:醫管學類
論文種類:學術論文
論文出版年:1998
畢業學年度:86
語文別:中文
論文頁數:138
中文關鍵詞:健保多元化制度基本健康給付項目附加保險
外文關鍵詞:NHI Multiple Carrier SystemBasic Health Care ServicesSupplemental Health Insurance
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為彙整當前國內外醫療支付項目之現況與相關問題,以為多元化健保體制下各保險人醫
療給付範疇之研究參考基礎,本研究之多元健保體制設計以楊氏等人改制版本為主,而醫
療給付範疇參考各國給付項目現況以及美國奧勒崗州健康計畫,附加保險方面則參酌美國
Medigap之設計。問卷樣本以立意抽樣出各類社會賢達與醫學專家探討其對多元化健保體
制下給付項目及附加保險議題之態度;社會賢達分為學界、工商界、勞工領袖、醫院主管
代表、醫師公會及民意代表等六組採行德菲法問卷;醫學專家中將面訪三位具代表性家庭
醫師結果彙成問卷主軸,再以家庭醫學醫學會代表(事長、理、監事)為問卷樣本。
研究結果如下:
一. 樣本回收率:社會賢達兩梯次中兩輪問卷皆在四成與八成之間。醫學專家則為54.17
﹪,全為男性且皆畢業於醫學系。
二. 對HMO制度之立場:社會賢達見解有互異之處,學者專家、工商界、勞工領袖比醫療
提供者(尤其是基層醫師)對於HMO制度持有較正面態度。醫學專家為有條件性贊同。
三. 贊成HMO得減少目前全民健保給付項目,而以增加其他給付項目或頻率的方式替補之
議題:社會賢達獲得近七成支持率,只有民意代表一直維持為反對態度,醫學專家多為不
贊成減少給付項目。
四. 基本健康給付項目之範疇:將急診、門診(包含預防保健)與住院列為基本給付項目

五. 附加保險之內容:社會賢達有86.8﹪贊成將「中醫服務」列入附加保險,而在「牙醫
服務」方面看法較不一致,但在第二梯次中支持率為54.8﹪,其他選項(例如:「只提供
住診及重大傷病,不提供一般門診」、「只提供門診不提供住院」、「可以不提供急診服
務」、「可以不提供門診藥物」)在後期皆未能獲得認同。醫學專家有條件性(需限定非
治療性及非預防保健性項目)贊成附加保險項目為「中醫服務」(100﹪支持率)、「牙
醫服務」(81.8﹪支持率)以及「門診服務」(90.0﹪支持率),後者「門診服務」若條
件限定為消費者自行決定則有90.9﹪支持率。
依據研究結果對主管機關建議制訂適用國內的醫療照護優先次序表(Prioritized Li
st of Services)。醫療提供者應評估未來中醫服務列入附加保險時之因應策略。對未來
研究者建議1.應偏重周全性照護議題2.對基本健康給付項目範疇之研議,可考量將各國給
付項目總數加以列表,敬會學者專家參考並依序排序之,以獲得更具體結果3.可說明不限
於「全民健保採多元制度」條件下,以減少負面回應。4.可考慮繼續舉辦質性研究中,利
用焦點團體法、專家座談會及公聽會以獲得深入且廣泛性意見。
In order to analyze the current domestic and international situation of healt
h services payments, we have designed a fundamental study of the National Heal
th Insurance of Multiple-Carrier System using Dr. Young et al revised version.
Medical treatment coverage is referenced to other foreign systems (e g ., Ore
gon Health Plan), supplemental medical insurance while the development of insu
rance policy is structured upon the Medigap system in the United States. The
questionnaire uses convenience sampling to cmmunity representatives and medic
al experts to discuss the National Health Insurance of Multiple-Carrier System
reimbursement methods and their attitudes toward the addition of insurance co
verage. Using the Delphi method, community representatives including academia
scholars, entrepreneurs, union leaders, hospital administrators, physician lo
bbyists, and parliamentarians are selected. Medical experts include three aut
horitative family physicians who helped formulate the questionnaire; other fam
ily physici representatives (chairman, members, and supervisors) participated
in the survey.
Results:
1.compltion rate: Responses received from the two sets of questionnaires (each
including two sample groups) ranges from 40% to 80%. Medical experts (all ma
le and medical school graduates) completing the questionnaires make up 54.17%
of the sample size.
2. Viewpoint of HMO: Specialists hold conflicting attitudes toward the presenc
e of HMO. Compared to health care providers (especially primary care physicia
ns), academia scholars, entrepreneurs, and union leaders have a more positive
attitude toward the institution of HMO. Medical specialists give only conditi
onal support.
3. We have suggested the use of HMO to reduce the overall number of health ser
vices covered by the National Health Insurance Program. Consequently, the sav
ed fund can be transferred to other reimbursement items or increase the freque
ncy of reimbursement. According to the survey, there is a 70% endorse rate, o
nly the parliamentarians maintained an opposing voice. Likewise, the majority
of medical experts disagree with the cutback on the number of reimbursement i
tems.
4. The addition of acute care, outpatient services (including prevention medic
ine), and inpatient care into basic health care reimbursement items.
5. Annexation of the National Health Insurance Program: According to the surve
y, 86.8% of the community representatives agree to include coverage of Orienta
l medical services into the National Health Insurance Program. There is less
agreement in terms of dental health care, only 54.8% of the responses in the s
econdary survey support its reimbursement. Other options: (1) to fund hospita
l stay and traumatic injuries and not outpatient care, (2) to fund outpatient
and not inpatient care, (3) the choice to rese the offering of critical care,
and (4) the choice to refuse the supplying of outpatient medicine were all rej
ected in the later stage. Medical experts gave their conditional support (e.g
., the need to limit non-treatment and non-preventive health care) to the adde
ndum of Oriental medical services (100%), dental health care (81.8%), and outp
atient care (90.9%). When the contingency for outpatient services is changed
to consumer''s autonomy, than the support rate increases to 90.9%.
Using the result from this study, we are able to suggest a Prioritized Li
st of Services tailored to the use of responsible organizations within the nat
ion. Health care providers should assess whether or not, and if so, to what e
xtent Oriental medical services be cover by the National Health Insurance Prog
ram. Future research can include: (1) discussions that emphasize overall heal
th care provisions, (2) studies using foreign references to categorize the rei
mbursement of basic health care services, (3) measures that eliminate negative
feedback by establishing National Health Insurance of Multiple-Carrier System
conditions, and (4) evaluations of the quality of health care using focus gro
up, professional and public hearings to capture profound and diversified opini
ons.
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