本文自健保險總額支付制度之運作中，依現行的西醫專業審查「專業審查」之依據，自醫療品質與法律的觀點切入，分析「專業審查」意義，並著重在「逕用高價藥品不予給付」核刪條款，進而針對該條款進行醫療品質與法律觀點的評價與討論，並提出因應改善之建議，以確保西醫醫療專業審查品質。本文結論包括，健保局依法訂定藥價基準，醫事服務機構依此基準申報藥品給付，全民健康保險法第39條有關全民健康保險給付範圍之排除條款之規定，並不包括逕用高價藥品之給付；同法第41條規定承保範圍之例外條款中，也沒有限制被保險人不能要求醫事服務機構在兼顧醫療品質情況下開立「較高價藥品」或「高價藥品」。總額支付制度之審查醫師與爭議審議委員會醫療案件審查專家，並無藥品財務管理分析的專業背景，從而面對違反行政行爲明確性原則的「不予支付理由代碼」―逕用高價藥品爲醫療專業審查核刪理由之案件或爭議之審查或處理，本質上既傷害醫療專業審查品質，也令人對專業審查制度產生質疑。本文建議，所謂「逕用高價藥品」應屬管理指標，性質歸屬於「同儕制約」；此管理指標既非屬法律，亦非屬命令，無法律效力，應直接刪去「不予支付理由代碼323A-『逕用高價藥品』」爲醫療專業審查核刪理由，因爲依該代碼非自全民健康保險醫事服務機構醫療服務審查辦法第15條第4款「治療內容與保險支付標準規定不符」之所謂「法源」基礎。本文並建議健保局與醫師公會全聯會另成立藥品給付專家小組，定義高貴藥品後，研擬增列爲調整參數，並進行分析並建立預估模型，以期適度調控點值萎縮與成長。

Based on ideal financial operation of medical payment of National Health Insurance (NHI), the Global Budget System promoted the efficiency and quality by the medical professional review for the mediation approval of the medical expenditure cases. This study was set up to assess the reimbursement disputes by legal evaluation, and focused on those disputes about the payment subtraction of high-priced drugs by the regulating review based on the Reference List for Drug and the Fee Schedule for Medical Service of NHI Act. This study concluded that, because of the non-relevant consideration, the review regulation, mentioning about the payment subtraction under ”Code 323A: High-priced Drugs” lacked the legal clarity, and would lessen the contribution of medical professional review system and influence the healthcare quality of NHI. Besides, the Guideline of Coding System of Payment Subtraction on Professional Review was technical and critical for the medical professional reviewers, and was non-regulating. It was not a kind of the ”administrative rule” used in the Administrative Procedure Act, but just a kind of ”peer constrain.” Finally, this study recommended to develop a special pharmacoeconomic council to set up a prediction model by adjusting the related parameters to moderate the growth on NHI expenditures after the definition of ”High-priced Drugs.”