全民健保不同支付制度對醫師執業行為之影響及比較

陳耀東

doi:10.6504/JOM.2004.21.02.05

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社会科学 > 管理学

DOI： 10.6504/JOM

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全民健保不同支付制度对医师执业行为之影响及比较

The Effects of Payment Systems under NHI on Professional Behaviors of Physicians and Consumer Welfare Comparisons

陈耀东(Yao-Tung Chen)

管理学报； 21 卷 2 期 (2004 / 04 / 01) ， P237 - 255

繁体中文 DOI： 10.6504/JOM.2004.21.02.05

总额预算制；回溯计点支付制；论量计酬支付制；医师执业行为； Global budget ； Expenditure cap ； Fee-for-Service ； Professional behaviors of physicians

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摘要 │ 参考文献 (13) │ 被引用文献 (2) │ 国际计量

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To curb the widening budget deficit of the formerly adopted payment system, namely 「fee-for-service」, the Bureau of National Health Insurance has executed the method of 「expenditure cap」under 「global budget」 for all the suppliers of medical services in Taiwan, since July 1, 2002. This study tries to construct an analytic model based on the viewpoint of maximizing medical service consumer’s welfare to discuss the effect of the change in the payment system on professional behaviors of physicians and to know whether there is a need for the government to set a constraint of global budget on payment systems under national health insurance. 
In contrast with Fan (1998), our analysis is not confined to comparing different payment systems under the presumption that there must be a constraint of global budget. There are two payment systems mainly adopted under global budget: expenditure cap and expenditure target. Based on the criterion of supplied quantities of medical services, Fan (1998) considered that expenditure cap is always better than expenditure target. But there are two questions arising from this result: one is whether more quantities of medical services supplied mean better allocation of scarce resources for the society or worse, as pointed out in Chou (2001); the other is whether there is a need to impose the constraint of global budget on payment systems or not, if the marginal cost of supplying medical services is increasing, that is a major assumption in Fan (1998). To deal with these two questions mentioned above is the major motivation behind this paper’s discussion. 
The analytic model in this study is solved in three stages through backward induction. At the first stage, it is up to the consumers to decide the optimal demand for quantities of medical services, after receiving cure suggestion from physicians. At the second stage, given a payment system designed by the government and confronting the demand function for medical services, the physicians must determine an optimal threshold for profit maximization against which to decide whether to give the consumers cure suggestions. At the third stage, given the derived optimal professional behaviors from physicians at second stage, the government will pick the optimal payment system arranged to maximize the welfare of medical service consumers. The professional behaviors of physicians and consumer welfare comparisons among different payment systems will be analyzed after the optimization problems are solved in these three stages. 
Our analysis showed that the different professional behaviors of physicians under the two payment systems mentioned above are related to the cost structure of supplying medical services. If the marginal cost of supplying medical services is increasing, both fee-for-service payment system and expenditure cap under global budget will induce the physicians to get stricter in giving the consumers cure suggestions. If the marginal cost of supplying medical services is constant, fee-for-service payment system will induce the physicians to get looser in giving the consumers cure suggestions, while expenditure cap under global budget still induces the physicians to get stricter in giving cure suggestions. As for consumer welfare comparisons among different payment systems, we also found that there is no need to adopt the constraint of global budget, if the marginal cost of supplying medical services is increasing; otherwise, there should be. But with the need to impose the constraint of global budget being justified, expenditure target will result in better consumer welfare than expenditure cap.

参考文献 ( 13 ) 〈TOP〉

Aas, I.H.M.(1995).Incentives and Financing Methods.Health Policy,34,205-220.
Arrow, K.(1963).Uncertainty and the Welfare Economics of Medical Care.American Economic Review,53,941-973.
Blomqvist, A.(1991).The Doctor as Double Agent: Information Asymmetry, Health Insurance and Medical Care.Journal of Health Economics,5,129-151.
Chen, M. C.,Huang, C. C.(2001).A Comparative Analysis of the Impacts of Payment Systems of NHI on Quantities of Medical Services and Medical Benefits.Journal of Contemporary Accounting,2(2),169-194.
Chou, L. F,Chen, T.J.(2001).An Economic Perspective on Payment Systems of NHI.Taiwan Medical Journal,44(1),45-50.

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