健保核刪變革之行政透明研究：以診所醫師與醫院醫師觀點

Abstract

為了避免健保資源過度地浪費，健保署透過醫療服務審查（核刪）的方式，針對醫療院所在處方與服務選擇上進行約束。基於上述，本文以2017年核刪改革作為政策參照基準點，由資訊不對稱與行政透明的角度進而審視變革前後之反饋，改革面向包括公開具名、回推放大、專業雙審以及電子醫療平台等措施，並且評估變革是否符合期待，以提出後續可持續改革之方向。\n\n本文研究方法的採用上，透過質化研究之深度訪談法的方式，探討診所與醫院醫師的觀點，了解核刪對於醫師在醫療單位經營、病人處方選擇以及相關健保政策的影響之態度。綜合研究結果發現，多數醫師對於回推放大設定上限表示高度認同，特別是在自身的處方選擇上產生了相對穩定的作用。然而公開具名反而出現高度的分歧，多數醫師在是否公開具名持相對保留的態度。專業雙審雖然立意良善，但需要提升的是臨床醫師對於該政策的感知程度。醫療電子化在提升溝通效率上具有立即性的幫助，然而執行可行性依然有持續進步的空間。\n\n本文的政策建議為，建立臨床醫師與其他醫療相關單位在資訊流通上的暢通為當務之急。邁向電子化醫療的方向下，幫助弭平距離上的限制，達到傳遞資訊的即時性與提升醫患關係。在審查過程中，提升審查專業一致性為化解醫師對於核刪政策缺少信任的解方之一。最後，對於給付制度提出的建議有，在醫療端更為細緻化的建立審查機制，以及加強培養民眾對於自費醫療的觀念。

Preventing the overusing of medical resources, the National Health Insurance Administration (NHIA) developed the medical review system to supervise whether the prescriptions` choice is right or not. However, some physicians argued that the medical review presented the contretemps of unfairness, asymmetry of information, and communication block. To fix up those issues, NHIA decided to launch a reform in 2017, which contains openness to identity, control for magnification of point value, professional double review, and set-up for the electronic medical platform. In this disquisition, the 2017 reform is the cynosure, accompanying with prior reform as a reference.\n\nAs for the research method, it adopts an in-depth review to discuss the topics of medical claims review with 10 physicians from clinics and hospitals and to understand how the medical review system affects medical finance, the prescription choice for patients, and other NHIA policies. The conclusions are that most interviewees compliment the control for minatory magnification of NHIA point value is sanguine, especially enhancing the flexibility of prescriptions choice, but they think that openness to identity is not a crucial step for reform because it may lead to more mistrust, suspicion, and aloofness between doctors. On the other hand, the launch of the professional double review receives positive feedbacks but unfortunately, most doctors did not quite realize the main idea of this policy. Also, although electronic medical platform accelerates the communication power for target audiences, the feasibility for doctors in remotes parts needs to be intensified.\n\nThere are some suggestions for the policy amelioration in the future. Firstly, building up the puissant commutation mechanisms between doctors and other medical units is a must-do. Secondly, advancing toward digital medical services can alleviate the limitation of messaging to reinforce the doctor-patient relationship. The presence of knowledge asymmetry in the medical review process will be the low trust factor for the NHIA system. Lastly, improving the benefits package to be more precise allow the citizens to cultivate a better attitude toward self-pay medical services.