全民健康保險會運作效能之評估研究：健保會委員之觀點

Evaluation Research of National Health Insurance Committee: The Perspectives of Committee Members

10.6785/SPSW.201606_20(1).0003

劉宜君(I-Chun Liu)

全民健康保險 ； 全民健康保險會 ； 委員會 ； 過程評估 ； 運作效能 ； National Health Insurance policy ； National Health Insurance committee ； committee ； process evaluation ； operational effectiveness

社會政策與社會工作學刊

20卷1期（2016 / 06 / 01）

85 - 128

繁體中文

自2000年開始，政府提出二代健保的改革構想，其中在組織體制最主要的變革是將「健保監理會」與「健保費用協定會」兩會合一，成立健保會，負責審議健保費率、給付範圍、決定5,000多億健保醫療費用的分配。研究目的透過文獻資料蒐集、深度訪談法，從健保會委員觀點評估健保會實際運作過程與效能，提出改善建議。研究發現健保會雖然有少數委員對於角色認知不足、會議效率有待增進、委員專業知識不對等、委員互動仍在磨合等問題。但整體而言，健保會的確擴大社會多元化參與健保政策，並完成法定任務。研究建議衛福部可建立各類型組成團體之委員聘任原則、訂定專家學者與公正人士代表的遴選委員會設置及作業要點、衛福部提供行政資源，協助委員分析健保相關資料，促進委員的專業表達能力，強化付費者代表監督能量，以及委員之間的實質對等協商能力。

Since 2000, the second generation National Health Insurance policy has focused on reforming its financial balancing mechanism. The key to reaching a balanced budget is to build a mechanism for 'integrating two committees governing premium revenues and medical expenses into National Health Insurance Committee (here after NHIC) to coordinate the decisions of revenues and expenses closer with each other.' A year-round procedure is established to connect global budget consultations, global budget negotiations, and premium rate negotiations under the integrated NHIC. However, this new mechanism's ability to achieve the reform goal must be evaluated. The research is an operational process evaluation that explores effectiveness and the possible NHIC problems from the committee members' perspectives. It also analyzes operational problems including the cognitive bias of committee members' roles, the loopholes in the operational processes and lack of professional knowledge of some members. The advantages of the committee include expanding participation and complete legislative missions. This research recommends that the government can present the appointees' principles, provide administrative resources to help members analyze healthcare-related information, and promote members' professional skills.

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