全民健保不同支付制度對醫師執業行為之影響及比較

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

10.6504/JOM.2004.21.02.05

陳耀東(Yao-Tung Chen)

總額預算制 ； 回溯計點支付制 ； 論量計酬支付制 ； 醫師執業行為 ； Global budget ； Expenditure cap ； Fee-for-Service ； Professional behaviors of physicians

管理學報

21卷2期（2004 / 04 / 01）

237 - 255

繁體中文

政府於民國八十四年三月一日正式實施全民健保以來，一直為健保財務所苦。為此，健保局針對醫療費用之支付制度，已於民國九十一年七月一日起全面對各醫院實施「醫院總額預算管制」。就回顧健保局已實施之各種不同支付制度方式而言，主要有兩種支付方式，一為原農、勞保所採行的無總額預算限制之「論服務量計酬」支付制度（fee-for-service），另一則為現行所實施之「總額預算」（global budget）制度中的「支出上限制」（expenditure cap），此也名為總額預算回溯計點支付制度。本研究主要是建構一個分析模型探討於政府的最適預算支出下，上述兩種不同支付制度對醫師的醫療執業行為產生何種影響，並且以醫療服務消費者的角度，進行此兩種支付制度的比較。從分析結果得知：不同支付制度對醫師執業行為的影響與醫師提供醫療服務的成本結構有關。以醫療服務消費者福利的觀點，不同支付制度比較的結果顯示：當醫師提供醫療服務的邊際成本為遞增時，沒有採行總額預算制之必要。當醫師提供醫療服務的邊際成本為固定時，在某些條件成立下，則有必要採行總額預算制。但是於相同的總額預算限制下，定支出目標（expenditure target）的支付制度則會比定支出上限的支付制度好。

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.

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