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題名：全民健保藥品支付制度與藥價差之探究
作者：陳世雄
作者(外文)：Chen, Shih-Hsiung
校院名稱：國立臺北大學
系所名稱：企業管理學系
指導教授：邱光輝
游志青
學位類別：博士
出版日期：2017
主題關鍵詞：三合一支付；藥價差；藥品支付制度；利害關係人理論；交易成本理論；Three-in-One Advanced Payment；Drug Price Difference；Pharmaceutical Benefits Scheme；Theory of Stakeholders；Theory of Transaction Costs
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臺灣全民健康保險為國家最重要的公共政策之一，健保署為長期監測民意，於2016年進行的民調顯示，民意對全民健保最不滿意是藥品不好。隨著老人化人口增加，慢性病與重症病患激增，醫療費用支出相對急劇上升；健保署受制於總額預算制度下，藥品執行「單一支付價」制度以控管藥費支出與成長；但此制度卻因醫院在藥品自行採購議價時以採購者的優勢，極力壓低藥商售價以取得健保藥品「單一支付價」之間的「藥價差」，從中獲取較高的價差利潤。形成藥品「單一支付價」所產生的「藥價差 (俗稱藥價黑洞)」問題，且有愈來愈擴大趨勢，已影響健保總額預算的合理分配。醫院仰賴「以藥養醫」扭曲了醫療行為，以及民眾對新科技醫藥無法快速引進，嚴重影響重症病患新藥治療的可及性與可近性而感到不滿。
本研究目的為探討健保署現行藥品「單一支付價」制度，所產生不當藥價差及新藥引進核價不合理等問題，並分析其發生原因，同時提出可能改善的支付制度與觀念架構。藉以文獻探討利害關係人及交易成本等理論，分析其支付制度的問題主因。並以專家深度訪談法提出藥品「三合一支付」構想配合制定藥價差合理規範的改革建議方案。再對藥品「三合一支付」構想分別進行相關議題的個別、交叉、焦點團體訪談，以及促成舉行多場藥品支付制度研討會、公聽會、產官學者座談會等，蒐集多方構面的資訊加以彙整與分析。
本研究結論實證，現行的健保藥品「單一支付價」制度與藥價調整無法降低「藥價差」有直接的相關。本研究建議之藥品「三合一支付」構想配合 (R-Zone) 藥價差合理規範，經專家證實可將不當的藥價差縮小與控制。希冀將藥價差節省管制資源回歸總額重新合理分配，用於引進新藥與不合理的醫療給付。促使醫療院所與藥商的營運正常化，確保民眾用藥品質、安全、有效的醫療環境，並提供政府主管機關與未來學術研究之參考。
National Health Insurance in Taiwan is one of the most important public policies in the country. To lead a long-term surveillance in public, NHIA (National Health Insurance Administration) conducted a survey in 2016. Some key findings from the survey showing that the greatest discontent with Nation Health Insurance is the poor quality of drugs. With the increasing number of elderly population and the sharply increasing number of patients with chronic diseases and severe diseases, medical expenditure is correspondently increasing; NHIA is subject to the constrained financial considerations of the global budget scheme, to effectively control the expenditure and growth of drugs, “Simplify Payment” scheme has been put in practice for all exiting drugs. However, the purchasers in hospitals take advantage of their priority position in the negotiations and decrease the drugs’ prices to earn the benefits from price differences between NHI reimbursement prices and actual pharmaceutical selling prices. The problem of "drug price difference" (known as the "black hole of drug price") arising from the "Simplify Payment" scheme has been enlarged and get more and more serious. Furthermore, the above mentioned has greatly affected reasonable allocation of reimbursement for global budget. The common “Drug-Maintaining-Medical cost” practice, i.e. hospitals’ operation relying on profits and revenue gained from drug dispensing the drug price difference to sustain themselves, has distorted medical practices. People are dissatisfied with the process of indolent import of new-tech medication, which has seriously affected the accessibility of new drugs treatment for patients with severe disease.
The purpose of the study is to explore the problem of improper Drug Price Difference and the unreasonable pricing of new drugs caused by "Simplify Payment" scheme (existing drugs) of NHIA, and analyze its causes, point out the possible improvement of the payment system and the conceptual structure at the same time. The study is to discuss the theories of stakeholders and transaction costs, analyzing the main problem of the reimbursement system. By using in-depth interview with experts, propose the concept of “Three-in-One Advanced Payment” scheme. Aligning with the suggestions in setting guidelines for reasonable drug price difference. Furthermore, based on the concepts of “Three-in-One Advanced Payment” scheme and separate related issues, arrange one-by-one or cross interviews with individual focus groups and facilitate as many events as possible; such as holding seminars, symposia and public hearings…, and so on. Finally, the study is to consolidate and analyze all the related information compiled from various processes.
This study concludes that there is a direct correlation between the existing reimbursed drugs applied with "Simplify Payment" scheme and the fact that the adjustment of drug prices cannot reduce the drug price difference. In this study, it is proposed to introduce the concept of “Three-in-One Advanced Payment” scheme aligning with (R-Zone) guidelines for reasonable drug price difference, which also being proved by experts can reduce improper drug price difference and have them in control. Aligning with reasonable guidelines, hope to have the given resources re-allocated from the saving of drug price difference use on the import of new drugs and adjustment of unreasonable medical benefits. Through normalizing the operation of medical institutions and pharmaceutical companies, ensure the quality of drugs, provide safe and effective medication for the public. Finally, the study provides reference for the government and further academic research.
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