衛生福利部全民健康保險會第1屆103年第9次委員會議議事錄中華民國103年9月27日衛生福利部全民健康保險會第1屆103年第9次委員會議紀錄壹、時間：中華民國103年9月27日上午10時30分貳、地點：中央健康保險署大禮堂(台北市信義路3段140號18樓)參、出席委員：干委員文男曲委員同光何委員永成中華民國中醫師公會全國聯合會李常務理事豐裕(代)何委員語 吳委員玉琴吳委員肖琪李委員永振李委員蜀平林委員至美林委員啟滄中華民國全國漁會陳秘書健民(代)林委員錫維侯委員彩鳳翁委員文能林口長庚醫院郭特助正全(代) 連委員瑞猛張委員永成中華民國農會林主任敏華(代)張委員煥禎中華民國區域醫院協會劉副秘書長碧珠(代)莊委員志強陳委員川青陳委員幸敏陳委員宗獻陳委員錦煌陳委員義聰中華民國牙醫師公會全國聯合會陳常務理事彥廷(代) 楊委員芸蘋楊委員漢湶楊委員麗珠葉委員宗義蔡委員明忠 蔡委員登順謝委員天仁謝委員武吉肆、請假委員：李委員成家周委員麗芳柴委員松林蔡委員圖晉伍、列席人員：本部社會保險司梁組長淑政中央健康保險署黃署長三桂蔡副署長魯蔡主任秘書淑鈴林組長阿明本會柯執行秘書桂女吳組長秀玲張組長友珊魏組長璽倫陸、主席：鄭主任委員守夏 紀錄：黃偉益、彭美熒、邱臻麗、方瓊惠、馬文娟柒、主席致詞(略)捌、議程確認決定：確定。玖、例行報告第一案案由：確認本會上(第8)次委員會議紀錄，請 鑒察。決定：確定。第二案案由：本會上(第8)次委員會議決議(定)事項辦理情形及重要業務報告，請 鑒察。決定：一、上次委員會議決議(定)事項辦理情形洽悉。二、針對中央健康保險署所提供96年新增33項胸腹腔鏡手術之替代效應分析資料，委員關心其中部分新增項目之平均每件醫療費用及平均住院天數，高於既有支付項目，似有違常理，爰請該署先提供書面說明資料，再視需要安排專題報告。第三案案由：中央健康保險署「103年8月份全民健康保險業務執行報告」，請 鑒察。決定：洽悉。 拾、討論事項第一案提案單位：本會第三組案由：104年度中醫門診、牙醫門診、醫院、西醫基層醫療給付費用總額協商因素項目與成長率及其他預算案，提請 討論。決議：一、104年度中醫門診醫療給付費用總額及其分配(一)總額設定公式：104年度中醫門診醫療給付費用總額=校正後103年度中醫門診一般服務醫療給付費用×(1＋104年度一般服務成長率)＋104年度專款項目經費註：校正後103年度中醫門診一般服務醫療給付費用，係依全民健康保險會103年第5次委員會議決議，校正投保人口數成長率差值。(二)總額協定結果：1.一般服務成長率為1.662%。其中，醫療服務成本及人口因素成長率0.978%，協商因素成長率0.684%。2.專款項目全年經費為241.5百萬元。3.前述二項額度經換算，104年度中醫門診醫療給付費用總額，較103年度所核定總額成長2.124%；而於校正投保人口數後，成長率估計值為1.897%。各細項成長率及金額如表1。(三)總額分配相關事項：1.一般服務(上限制)：(1)品質保證保留款(0%)： eq \o\ac(○,1)依中醫門診總額品質保證保留款實施方案支付，並以品質相關指標作為獎勵依據。該方案請於103年11月底前完成相關程序，並於104年6月底前提送前一年度執行成果。 eq \o\ac(○,2)金額應全數用於鼓勵提升醫療品質，並以最近2年(103、104年)該保留款成長率之累計額度為限，其餘額度回歸一般服務預算。(2)調整藥事服務費(0.135%)：請於104年6月底前提送執行情形。(3)其他醫療服務利用及密集度之改變(0.557%)： eq \o\ac(○,1)傷科支付點數調整不另增預算。 eq \o\ac(○,2)傷科合理門診量規定不得變更。 eq \o\ac(○,3)104年度地區預算分配，參數中之人口占率(R值)必須往前進，否則本項預算收回。 (4)違反全民健康保險醫事服務機構特約及管理辦法之扣款(-0.008%)。2.專款項目全年經費為241.5百萬元：具體實施方案(含預定達成目標及評估指標)由中央健康保險署會同中醫門診總額相關團體訂定後，依相關程序辦理，並送全民健康保險會備查。前述方案之作業時程，延續型計畫應於103年11月底前完成，新增計畫原則於103年12月底前完成，並於104年6月底前提報執行成果及成效評估報告(新增計畫僅需提供初步執行結果)；實施成效並納入下年度總額協商考量。(1)醫療資源不足地區改善方案：全年經費96.5百萬元，辦理無中醫鄉巡迴醫療服務計畫及開業計畫。(2)西醫住院病患中醫特定疾病輔助醫療試辦計畫：全年經費113.0百萬元，包含腦血管疾病、顱腦損傷，及腫瘤患者手術、化療、放射線療法後照護。(3)提升孕產期照護品質計畫：全年經費32.0百萬元。二、104年度牙醫門診醫療給付費用總額及其分配(一)總額設定公式：104年度牙醫門診醫療給付費用總額=校正後103年度牙醫門診一般服務醫療給付費用×(1＋104年度一般服務成長率)＋104年度專款項目經費註：校正後103年度牙醫門診一般服務醫療給付費用，係依全民健康保險會103年第5次委員會議決議，校正投保人口數成長率差值。(二)總額協定結果：1.一般服務成長率為1.319%。其中，醫療服務成本及人口因素成長率0.373%，協商因素成長率0.946%。2.專款項目全年經費為1,817.6百萬元。3.前述二項額度經換算，104年度牙醫門診醫療給付費用總額，較103年度所核定總額成長2.140%；而於校正投保人口數後，成長率估計值為1.916%。各細項成長率及金額如表2。(三)總額分配相關事項：1.一般服務(上限制)：(1)品質保證保留款(0.300%)： eq \o\ac(○,1)依牙醫門診總額品質保證保留款實施方案支付，並以品質相關指標作為獎勵依據。該方案請於103年11月底前完成相關程序，並於104年6月底前提送前一年度執行成果。 eq \o\ac(○,2)金額應全數用於鼓勵提升醫療品質，並以最近2年(103、104年)該保留款成長率之累計額度為限，其餘額度回歸一般服務預算。(2)牙周顧本計畫(0.4%)：請於104年6月底前提送執行情形。(3)調整藥事服務費(0.008%)：請於104年6月底前提送執行情形。(4)特殊口腔黏膜疾病統合照護計畫(0.027%)：請於104年6月底前提送執行情形。(5)懷孕婦女照護(0.217%)：請於104年6月底前提送執行情形。(6)調整診察費(0%)： eq \o\ac(○,1)104年擬調整診察費支付點數20點，以預算中平為調整原則，不另編列預算。 eq \o\ac(○,2)請於下年度總額協商前完成並提出執行情形。(7)違反全民健康保險醫事服務機構特約及管理辦法之扣款(-0.006%)。2.專款項目全年經費為1,817.6百萬元：具體實施方案(含預定達成目標及評估指標)由中央健康保險署會同牙醫門診總額相關團體訂定後，依相關程序辦理，並送全民健康保險會備查。前述方案之作業時程，延續型計畫應於103年11月底前完成，並於104年6月底前提報執行成果及成效評估報告；實施成效並納入下年度總額協商考量。(1)醫療資源不足地區改善方案：全年經費280.0百萬元，辦理牙醫師至無牙醫鄉執業及巡迴醫療計畫。(2)牙醫特殊服務計畫：全年經費443.0百萬元，辦理先天性唇顎裂與顱顏畸形患者、特定障別之身心障礙者及在宅牙醫醫療服務。(3)牙周病統合照護計畫： eq \o\ac(○,1)第1、2階段，全年經費850.0百萬元；第3階段，全年經費244.6百萬元。 eq \o\ac(○,2)第1、2階段照護目標數為125,000人；第3階段服務人數為90,000人。 eq \o\ac(○,3)請加強宣導本項已屬全民健康保險給付項目，若有民眾檢舉另收費用經查屬實，即屬違規，下年度將不再增加任何預算，違規處理原則並請中央健康保險署研議(例如扣款)。三、104年度醫院醫療給付費用總額及其分配(一)總額設定公式：104年度醫院醫療給付費用總額＝校正後103年度醫院一般服務醫療給付費用×(1＋104年度一般服務成長率)＋104年度專款項目經費＋104年度醫院門診透析服務費用104年度醫院門診透析服務費用＝103年度醫院門診透析服務費用×(1+成長率)註：校正後103年度醫院一般服務醫療給付費用，係依全民健康保險會103年第5次委員會議決議，校正投保人口數成長率差值。(二)總額協定結果：1.一般服務成長率為4.343%。其中，醫療服務成本及人口因素成長率2.128%，協商因素成長率2.215%。2.專款項目全年經費為13,840.8百萬元。3.門診透析服務成長率2.341%。4.前述三項額度經換算，104年度醫院醫療給付費用總額，較103年度所核定總額成長3.659%；而於校正投保人口數後，成長率估計值為3.453%。各細項成長率及金額如表3。(三)總額分配相關事項：1.一般服務(上限制)：(1)品質保證保留款(0.1%)： eq \o\ac(○,1)依醫院總額品質保證保留款實施方案支付，並以品質相關指標作為獎勵依據。該方案請於103年11月底前完成相關程序，並於104年6月底前提送前一年度執行成果。 eq \o\ac(○,2)金額應全數用於鼓勵提升醫療品質，並以最近2年(103、104年)該保留款成長率之累計額度為限，其餘額度回歸一般服務預算。(2)新醫療科技(包括新增診療項目、新藥及新特材等)(0.646%)： eq \o\ac(○,1)請中央健康保險署於103年12月委員會議說明擬調整之相關項目與作業時程，及於104年6月底前提送執行結果(含新增項目及申報費用/點數)。若未於時程內導入，則扣減該額度。 eq \o\ac(○,2)資源有限，對給付項目之新增或適應症之調整，請中央健康保險署於額度內，依全民健康保險法第42條精神，善用醫療科技評估工具，並考量人體健康、醫療倫理、醫療成本效益及保險財務，排定納入健保給付之優先順序。(3)強化醫療資源支付合理性(0.100%)： eq \o\ac(○,1)請中央健康保險署於103年12月委員會議說明擬調整支付標準項目與作業時程，依時程導入，並於104年6月底前提送執行情形。 eq \o\ac(○,2)依醫療資源耗用相對值表(RBRVS)調整支付標準部分，不另編列預算，請於104年持續推動。(4)第2階段住院診斷關聯群(DRGs)之持續推動費用(0.110%)：103年導入第2階段，相關專款預算已併入103年醫院總額一般服務費用結算，爰104年於一般服務計列成長率。(5)配合安全針具推動政策之費用(0.057%)： eq \o\ac(○,1)配合安全針具推動政策，5年內按比例逐步完成全面提供安全針具。本項自102年起開始分5年編列，104年為第3年。 eq \o\ac(○,2)請於104年6月底前提送執行情形(含安全針具之申報量與價格)。(6)提升住院護理照護品質(0.568%)：本項自專款項目移列至一般服務，經費並用於調增住院護理之支付標準，除支付方式應依護病比訂定外，尚須訂定護理人力相關監理指標，並請中央健康保險署於104年6月前提經全民健康保險會同意後動支預算，及於104年6月底前提送執行情形。(7)其他醫療服務利用及密集度之改變(0.624%)：在合理預期支出範圍內，應含放寬藥品適應症所增之費用；若有全民健康保險法第26條之情事，則不適用。(8)配合結核病防治政策改變之費用(0.010%)： eq \o\ac(○,1)用於「抗結核病藥物副作用個案住院≦30天」住院醫療費用。 eq \o\ac(○,2)請於104年6月底前提送執行情形。(9)違反全民健康保險醫事服務機構特約及管理辦法之扣款(-0.0003%)。2.專款項目全年經費為13,840.8百萬元：具體實施方案(含預定達成目標及評估指標)由中央健康保險署會同醫院總額相關團體訂定後，依相關程序辦理，並送全民健康保險會備查。前述方案之作業時程，延續型計畫應於103年11月底前完成，新增計畫原則於103年12月底前完成，並於104年6月底前提報執行成果及成效評估報告(新增計畫僅需提供初步執行結果)；實施成效並納入下年度總額協商考量。(1)鼓勵器官移植並確保術後追蹤照護品質：全年經費3,972百萬元，不足部分由其他預算支應。(2)罕見疾病、血友病藥費及新增罕見疾病特材： eq \o\ac(○,1)全年經費7,827.5百萬元。 eq \o\ac(○,2)罕見疾病、血友病藥費，全年經費7,815百萬元，不足部分由其他預算支應。 eq \o\ac(○,3)104年新增罕見疾病特材，全年經費12.5百萬元。 eq \o\ac(○,4)為檢視本項費用成長之合理性，請中央健康保險署於104年6月底前，提出專案報告。(3)醫療給付改善方案： eq \o\ac(○,1)全年經費741.3百萬元。 eq \o\ac(○,2)辦理原有之糖尿病、氣喘、乳癌、思覺失調症、B型肝炎帶原者及C型肝炎感染者個案追蹤、早期療育等6項方案，並新增孕產婦方案。 eq \o\ac(○,3)宜提升涵蓋率，照護更多相同疾病的患者；屬成效明確的方案，應將該類病患全部納入，以避免選擇性偏差的問題。並整合各方案，朝以病人為中心的整合性服務發展，以提升醫療資源的使用效益。(4)急診品質提升方案： eq \o\ac(○,1)全年經費160百萬元。 eq \o\ac(○,2)請中央健康保險署檢討方案執行內容，以提升急診照護品質。(5)鼓勵繼續推動住院診斷關聯群(DRGs)： eq \o\ac(○,1)全年經費280百萬元，導入第3階段DRGs項目。 eq \o\ac(○,2)本項經費應依實際導入施行之項目與季別，併醫院總額一般服務費用結算。(6)醫院支援西醫基層總額醫療資源不足地區改善方案： eq \o\ac(○,1)全年經費60百萬元。 eq \o\ac(○,2)配合支援西醫基層醫療資源不足地區所需，提供專科巡迴醫療等服務。本項經費得與西醫基層總額同項專款相互流用。(7)全民健康保險醫療資源不足地區醫療服務提升計畫：全年經費800百萬元。3.門診透析服務：(1)合併西醫基層及醫院兩總額部門所協定之年度門診透析服務費用，並統為運用。(2)門診透析服務費用於醫院及西醫基層總額之計算方式：先協定新年度門診透析服務費用成長率，再依協商當年第1季醫院及西醫基層之門診透析費用點數占率分配預算，而得新年度醫院及西醫基層門診透析費用及其成長率。(3)門診透析服務總費用成長率為3.7%；醫院部門本項服務費用成長率為2.341%，含偏遠地區門診透析服務保障每點1元支付。(4)門診透析院所前提報台灣腎臟醫學會之所有資料，嗣後改以全數上傳至中央健康保險署健保資訊網服務系統(VPN)，並將院所上傳情形納入「慢性腎衰竭病人門診透析服務品質提升獎勵計畫」之指標。四、104年度西醫基層醫療給付費用總額及其分配(一)總額設定公式：104年度西醫基層醫療給付費用總額＝校正後103年度西醫基層一般服務醫療給付費用×(1＋104年度一般服務成長率)＋104年度專款項目經費＋104年度西醫基層門診透析服務費用104年度西醫基層門診透析服務費用＝103年度西醫基層門診透析服務費用×(1+成長率)註：校正後103年度西醫基層一般服務醫療給付費用，係依全民健康保險會103年第5次委員會議決議，校正投保人口數成長率差值。(二)總額協定結果：1.一般服務成長率為2.447%。其中，醫療服務成本及人口因素成長率1.154%，協商因素成長率1.293%。2.專款項目全年經費為1,984.4百萬元。3.門診透析服務成長率5.557%。4.前述三項額度經換算，104年度西醫基層醫療給付費用總額，較103年度所核定總額成長3.191%；而於校正投保人口數後，成長率估計值為2.991%。各細項成長率及金額如表4。(三)總額分配相關事項：1.一般服務(上限制)：(1)品質保證保留款(0.1%)： eq \o\ac(○,1)依西醫基層總額品質保證保留款實施方案支付，並以品質相關指標作為獎勵依據。該方案請於103年11月底前完成相關程序，並於104年6月底前提送前一年度執行成果。 eq \o\ac(○,2)金額應全數用於鼓勵提升醫療品質，並以最近2年(103、104年)該保留款成長率之累計額度為限，其餘額度回歸一般服務預算。(2)新醫療科技(包括新增診療項目、新藥及新特材等)(0.122 %)： eq \o\ac(○,1)請中央健康保險署於103年12月委員會議說明擬調整之相關項目與作業時程，及於104年6月底前提送執行結果(含新增項目及申報費用/點數)。若未於時程內導入，則扣減該額度。 eq \o\ac(○,2)資源有限，對給付項目之新增或適應症之調整，請中央健康保險署於額度內，依全民健康保險法第42條精神，善用醫療科技評估工具，並考量人體健康、醫療倫理、醫療成本效益及保險財務，排定納入健保給付之優先順序。(3)調整藥事服務費及語言治療診療項目(0.399%)：請中央健康保險署於103年12月委員會議說明擬調整支付標準項目與作業時程，依時程導入，並於104年6月底前提送執行情形。(4)配合安全針具推動政策之費用(0.004%)： eq \o\ac(○,1)配合安全針具推動政策，5年內按比例逐步完成全面提供安全針具。本項自102年起開始分5年編列，104年為第3年。 eq \o\ac(○,2)請於104年6月底前提送執行情形(含安全針具之申報量與價格)。(5)其他醫療服務利用及密集度之改變(0.713%)：在合理預期支出範圍內，應含放寬藥品適應症所增之費用；若有全民健康保險法第26條之情事，則不適用。(6)違反全民健康保險醫事服務機構特約及管理辦法之扣款(-0.045%)。2.專款項目全年經費為1,984.4百萬元：具體實施方案(含預定達成目標及評估指標)由中央健康保險署會同西醫基層總額相關團體訂定後，依相關程序辦理，並送全民健康保險會備查。前述方案之作業時程，延續型計畫應於103年11月底前完成，新增計畫原則於103年12月底前完成，並於104年6月底前提報執行成果及成效評估報告(新增計畫僅需提供初步執行結果)；實施成效並納入下年度總額協商考量。(1)醫療資源不足地區改善方案：全年經費150百萬元，本項經費得與醫院總額同項專款相互流用。(2)慢性B型及C型肝炎治療計畫： eq \o\ac(○,1)全年經費400百萬元，不足部分，由其他預算支應。 eq \o\ac(○,2)請中央健康保險署研議成效評估指標。(3)醫療給付改善方案： eq \o\ac(○,1)全年經費254.4百萬元。 eq \o\ac(○,2)辦理原有之糖尿病、氣喘、思覺失調症、B型肝炎帶原者及C型肝炎感染者個案追蹤、早期療育等5項方案，並新增孕產婦方案。 eq \o\ac(○,3)宜提升涵蓋率，照護更多相同疾病的患者；屬成效明確的方案，應將該類病患全部納入，以避免選擇性偏差的問題。並整合各方案，朝以病人為中心的整合性服務發展，以提升醫療資源的使用效益。(4)家庭醫師整合性照護計畫：全年經費1,180百萬元，應確實評估成效，並訂定嚴格之退場機制。3.門診透析服務：(1)合併西醫基層及醫院兩總額部門所協定之年度門診透析服務費用，並統為運用。(2)門診透析服務費用於醫院及西醫基層總額之計算方式：先協定新年度門診透析服務費用成長率，再依協商當年第1季醫院及西醫基層之門診透析費用點數占率分配預算，而得新年度醫院及西醫基層門診透析費用及其成長率。(3)門診透析服務總費用成長率為3.7%；西醫基層部門本項服務費用成長率為5.557%，含偏遠地區門診透析服務保障每點1元支付。(4)門診透析院所前提報台灣腎臟醫學會之所有資料，嗣後改以全數上傳至中央健康保險署健保資訊網服務系統(VPN)，並將院所上傳情形納入「慢性腎衰竭病人門診透析服務品質提升獎勵計畫」之指標。五、104年度全民健康保險其他預算及其分配(一)104年度其他預算增加534.5百萬元，預算總額度為 =SUM(ABOVE) 11,316.9百萬元，採支出目標制，由中央健康保險署管控，各細項分配如表5。(二)預算分配相關事項：1.山地離島地區醫療給付效益提昇計畫：全年經費605.4百萬元，請於104年6月底前提送執行成果。2.非屬各部門總額支付制度範圍之服務：(1)全年經費3,714百萬元，用於助產所、護理之家照護、居家照護、在宅醫療、精神疾病社區復健及安寧居家療護等所需經費。(2)請於103年12月委員會議說明擬調整支付標準項目與作業時程，並於104年6月底前提送執行情形。3.全民健保高診次民眾就醫行為改善方案-藥師居家照護：(1)全年經費54百萬元，以輔導至少7,000人為目標。(2)請於104年6月底前提送執行成果及成效評估報告。4.支應醫院總額罕見疾病與血友病藥費及器官移植、西醫基層總額慢性B型及C型肝炎治療計畫專款不足之經費，及狂犬病治療藥費：(1)全年經費300百萬元。 (2)所列狂犬病治療藥費係用於治療被動物咬傷患者，防止狂犬病之發生。5.推動促進醫療體系整合計畫：(1)全年經費1,100百萬元，用於「醫院以病人為中心門診整合照護試辦計畫」3億元、「論人計酬試辦計畫」3億元，「跨層級醫院合作計畫」1億元，及「提升急性後期照護品質試辦計畫」4億元。(2)新增方案原則於103年12月底前完成相關程序，各計畫請於104年6月底前提送執行成果及成效評估報告(新增方案僅需提供初步執行結果)。6.其他預期政策改變及調節非預期風險所需經費：(1)全年經費1,000百萬元。(2)含新增醫藥分業地區所增加之費用。(3)經費之支用，依費協會第178次委員會議通過之適用範圍與動支程序原則辦理。7.ICD-10-CM/PCS編碼：(1)全年經費250百萬元，應於105年全面以ICD-10-CM/PCS申報。(2)計畫請於103年12月底前完成相關程序，並於104年6月底前提送執行成果。8.鼓勵醫療院所即時查詢病患就醫資訊措施：(1)全年經費2,200百萬元。(2)本計畫原則以5年為期程，用於網路費用、相關系統開發及獎勵院所上傳重要檢查、檢驗結果。(3)請於104年6月底前提送執行成果及成效評估報告。9.提供保險對象收容於矯正機關者醫療服務計畫：(1)全年經費1,404.5百萬元。(2)請於104年6月底前提送執行成果及成效評估報告。10.慢性腎臟病照護及病人衛教計畫：(1)全年經費404百萬元。(2)用於繼續推動末期腎臟病前期(Pre-ESRD)之病人照護與衛教計畫、初期慢性腎臟病醫療給付改善方案，及慢性腎衰竭病人門診透析服務品質提升獎勵計畫。(3)請於104年6月底前提送執行成果及成效評估報告。11.提升保險人管理效率：(1)全年經費285百萬元。(2)本計畫須報經衛生福利部法制單位通過後始得動支。(3)請於104年6月底前提送初步執行結果。第二案提案人：謝委員武吉案由：攸關731高雄石化氣爆事件對健保財務及轄區預算分配之影響的因應措施，提請 討論。主席裁定：保留至下次委員會議討論。第三案提案單位：中央健康保險署案由：104年度全民健康保險抑制資源不當耗用改善方案，提請 討論。主席裁定：保留至下次委員會議討論。拾壹、專案報告報告單位：中央健康保險署案由：102及103年全民健康保險抑制資源不當耗用改善方案之執行情形及成效報告，請 鑒察。主席裁定：保留至下次委員會議報告。拾貳、臨時提案(如附件)提案人：干委員文男連署人：何委員永成、何委員語、吳委員玉琴、吳委員肖琪、李委員永振、李委員蜀平、陳代理委員健民(林委員啟滄代理人)、林委員錫維、侯委員彩鳳、郭代理委員正全(翁委員文能代理人)、 連委員瑞猛、林代理委員敏華(張委員永成代理人)、劉代理委員碧珠(張委員煥禎代理人)、莊委員志強、陳委員川青、陳委員宗獻、陳委員錦煌、陳代理委員彥廷(陳委員義聰代理人)、楊委員芸蘋、楊委員漢湶、楊委員麗珠、葉委員宗義、蔡委員明忠、蔡委員登順、謝委員天仁、謝委員武吉代表類別：保險付費者代表、保險醫事服務提供者代表、專家學者及公正人士案由：有關中央健康保險署與主計總處核算全民健康保險法規定政府負擔36%比率見解不同案，提請 討論。決議：一、法律之解釋權責按理屬該管主管機關，本案源自全民健康保險法之援引，爰建請由衛生福利部回歸立法意旨，妥為解釋及處理。二、本會絕大多數委員認同中央健康保險署對「政府應負擔全民健康保險總經費不足36%部分」的計算方式，建請衛生福利部轉陳行政院參酌。拾參、散會：下午1時30分。表1 104年度中醫門診醫療給付費用協定項目表項 目成長率(%)或金額(百萬元)增加金額(百萬元)協 定 事 項一般服務醫療服務成本及人口因素成長率0.978%210.6計算公式：醫療服務成本及人口因素成長率 =[(1+投保人口數年增率)(1+人口結構改變率+醫療服務成本指數改變率)]-1投保人口數年增率0.175%人口結構改變率0.325%醫療服務成本指數改變率0.477%協商因素成長率0.684%147.3鼓勵提升醫療品質及促進保險對象健康品質保證保留款0.000%01.依中醫門診總額品質保證保留款實施方案支付，並以品質相關指標作為獎勵依據。該方案請於103年11月底前完成相關程序，並於104年6月底前提送前一年度執行成果。2.金額應全數用於鼓勵提升醫療品質，並以最近2年(103、104年)該保留款成長率之累計額度為限，其餘額度回歸一般服務預算。保險給付項目及支付標準之改變調整藥事服務費0.135 %29.0請於104年6月底前提送執行情形。其他醫療服務利用及密集度之改變0.557%120.01.傷科支付點數調整不另增預算。2.傷科合理門診量規定不得變更。3.104年度地區預算分配，參數中之人口占率(R值)必須往前進，否則本項預算收回。其他議定項目違反全民健保醫事服務機構特約及管理辦法之扣款-0.008%-1.7一般服務成長率1.662%357.9項 目成長率(%)或金額(百萬元)增加金額(百萬元)協 定 事 項專款項目(全年計畫經費)醫療資源不足地區改善方案96.522.1辦理無中醫鄉巡迴醫療服務計畫及開業計畫。西醫住院病患中醫特定疾病輔助醫療試辦計畫1.腦血管疾病2.顱腦損傷3.腫瘤患者手術、化療、放射線療法後照護 113.00.0提升孕產期照護品質計畫32.032.0專款金額241.554.1總成長率(註1)(一般服務+專款)增加金額1.897%412.0總金額22,129.3較103年度核定總額成長率2.124%－註：1.計算總成長率所用之基期費用，一般服務含校正投保人口數成長率差值。2.本表除專款項目金額外，餘各項金額為預估值。表2 104年度牙醫門診醫療給付費用協定項目表項 目成長率(%)或金額(百萬元)增加金額(百萬元)協 定 事 項一般服務醫療服務成本及人口因素成長率0.373%137.5計算公式：醫療服務成本及人口因素成長率 =[(1+投保人口數年增率)(1+人口結構改變率+醫療服務成本指數改變率)]-1投保人口數年增率0.175%人口結構改變率-0.062%醫療服務成本指數改變率0.260%協商因素成長率0.946%348.9鼓勵提升醫療品質及促進保險對象健康品質保證保留款0.300%110.61.依牙醫門診總額品質保證保留款實施方案支付，並以品質相關指標作為獎勵依據。該方案請於103年11月底前完成相關程序，並於104年6月底前提送前一年度執行成果。2.金額應全數用於鼓勵提升醫療品質，並以最近2年(103、104年)該保留款成長率之累計額度為限，其餘額度回歸一般服務預算。牙周顧本計畫0.400%147.5請於104年6月底前提送執行情形。保險給付項目及支付標準之改變調整藥事服務費0.008%2.9請於104年6月底前提送執行情形。調整診察費0.000%0.01.104年擬調整診察費支付點數20點，以預算中平為調整原則，不另編列預算。2.請於下年度總額協商前完成並提出執行情形。其他醫療服務利用及密集度之改變特殊口腔黏膜疾病統合照護計畫0.027%10.0請於104年6月底前提送執行情形。懷孕婦女照護0.217%80.0請於104年6月底前提送執行情形。其他議定項目違反全民健保醫事服務機構特約及管理辦法之扣款-0.006%-2.1一般服務成長率1.319%486.4項 目成長率(%)或金額(百萬元)增加金額(百萬元)協 定 事 項專款項目(全年計畫經費)醫療資源不足地區改善方案280.00.0辦理牙醫師至無牙醫鄉執業及巡迴醫療計畫。牙醫特殊醫療服務試辦計畫443.00.0辦理先天性唇顎裂與顱顏畸形患者、特定障別之身心障礙者及在宅牙醫醫療服務。牙周病統合照護計畫(第1、2階段)850.0170.01.第1、2階段照護目標數為125,000人；第3階段服務人數為90,000人。2.請加強宣導本項已屬全民健康保險給付項目，若有民眾檢舉另收費用經查屬實，即屬違規，下年度將不再增加任何預算，違規處理原則並請中央健康保險署研議(例如扣款)。牙周病統合照護計畫(第3階段)244.680.0專款金額1,817.6250.0總成長率(註1)(一般服務+專款)增加金額1.916%736.4總金額39,175.6較103年度核定總額成長率2.140%－註：1.計算總成長率所用之基期費用，一般服務含校正投保人口數成長率差值。2.本表除專款項目金額外，餘各項金額為預估值。表3 104年度醫院醫療給付費用協定項目表項 目成長率(%)或金額(百萬元)增加金額(百萬元)協 定 事 項一般服務醫療服務成本及人口因素成長率2.128%7,497.6計算公式：醫療服務成本及人口因素成長率 =[(1+投保人口數年增率)(1+人口結構改變率+醫療服務成本指數改變率)]-1投保人口數年增率0.175%人口結構改變率1.859%醫療服務成本指數改變率0.091%協商因素成長率2.215%7,800.9鼓勵提升醫療品質及促進保險對象健康品質保證保留款0.100%352.31.依醫院總額品質保證保留款實施方案支付，並以品質相關指標作為獎勵依據。該方案請於103年11月底前完成相關程序，並於104年6月底前提送前一年度執行成果。2.金額應全數用於鼓勵提升醫療品質，並以最近2年(103、104年)該保留款成長率之累計額度為限，其餘額度回歸一般服務預算。保險給付項目及支付標準之改變新醫療科技(包括新增診療項目、新藥及新特材等)0.646%2,275.51.請中央健康保險署於103年12月委員會議說明擬調整之相關項目與作業時程，及於104年6月底前提送執行結果(含新增項目及申報費用/點數)。若未於時程內導入，則扣減該額度。2.資源有限，對給付項目之新增或適應症之調整，請中央健康保險署於額度內，依全民健康保險法第42條精神，善用醫療科技評估工具，並考量人體健康、醫療倫理、醫療成本效益及保險財務，排定納入健保給付之優先順序。保險給付項目及支付標準之改變強化醫療資源支付合理性0.100%351.01.請中央健康保險署於103年12月委員會議說明擬調整支付標準項目與作業時程，依時程導入，並於104年6月底前提送執行情形。2.依醫療資源耗用相對值表(RBRVS)調整支付標準部分，不另編列預算，請於104年持續推動。第2階段住院診斷關聯群(DRGs)之持續推動費用0.110%387.0103年導入第2階段，相關專款預算已併入103年醫院總額一般服務費用結算，爰104年於一般服務計列成長率。配合安全針具推動政策之費用0.057%200.01.配合安全針具推動政策，5年內按比例逐步完成全面提供安全針具。本項自102年起開始分5年編列，104年為第3年。2.請於104年6月底前提送執行情形(含安全針具之申報量與價格)。提升住院護理照護品質0.568%2,000.0本項自專款項目移列至一般服務，經費並用於調增住院護理之支付標準，除支付方式應依護病比訂定外，尚須訂定護理人力相關監理指標，並請中央健康保險署於104年6月前提經全民健康保險會同意後動支預算，及於104年6月底前提送執行情形。其他醫療服務利用及密集度之改變0.624%2,200.0在合理預期支出範圍內，應含放寬藥品適應症所增之費用；若有全民健康保險法第26條之情事，則不適用。其他預期之法令或政策改變配合結核病防治政策改變之費用0.010%36.01.用於「抗結核病藥物副作用個案住院≦30天」住院醫療費用。2.請於104年6月底前提送執行情形。其他議定項目違反全民健保醫事服務機構特約及管理辦法之扣款-0.0003%-0.9一般服務成長率4.343%15,298.5專款項目(全年計畫經費)鼓勵器官移植並確保術後追蹤照護品質3,972.00.0不足部分由其他預算支應。罕見疾病、血友病藥費及新增罕見疾病特材7,827.512.51.罕見疾病、血友病藥費全年經費7,815百萬元，不足部分由其他預算支應。2.104年新增罕見疾病特材12.5百萬元。3.為檢視本項費用成長之合理性，請中央健康保險署於104年6月底前，提出專案報告。醫療給付改善方案741.3174.01.辦理原有之糖尿病、氣喘、乳癌、思覺失調症、B型肝炎帶原者及C型肝炎感染者個案追蹤、早期療育等6項方案，並新增孕產婦方案。2.宜提升涵蓋率，照護更多相同疾病的患者；屬成效明確的方案，應將該類病患全部納入，以避免選擇性偏差的問題。並整合各方案，朝以病人為中心的整合性服務發展，以提升醫療資源的使用效益。急診品質提升方案160.0-160.0請中央健康保險署檢討方案執行內容，以提升急診照護品質。鼓勵繼續推動住院診斷關聯群(DRGs) 280.0-387.01.導入第3階段DRGs項目。2.本項經費應依實際導入施行之項目與季別，併醫院總額一般服務費用結算。醫院支援西醫基層總額醫療資源不足地區改善方案60.00.01.配合支援西醫基層醫療資源不足地區所需，提供專科巡迴醫療等服務。2.本項經費得與西醫基層總額同項專款相互流用。全民健康保險醫療資源不足地區醫療服務提升計畫800.00.0提升住院護理照護品質0.0-2,000.0移列至一般服務項目。專款金額13,840.8-2,360.5成長率(一般服務+專款)增加金額3.511%12,938.0總金額381,472.3門診透析服務成長率增加金額2.341%445.81.門診透析服務總費用成長率為3.7%；本項與西醫基層總額門診透析服務費用合併，並統為運用。2.含偏遠地區門診透析服務保障每點1元支付。3.門診透析院所前提報台灣腎臟醫學會之所有資料，嗣後改以全數上傳至中央健康保險署健保資訊網服務系統(VPN)，並將院所上傳情形納入「慢性腎衰竭病人門診透析服務品質提升獎勵計畫」之指標。總金額19,487.4總成長率 (註1)(一般服務+專款+門診透析)增加金額3.453%13,383.8總金額400,959.7較103年度核定總額成長率3.659%－註：1.計算總成長率所用之基期費用，一般服務含校正投保人口數成長率差值。2.本表除專款項目金額外，餘各項金額為預估值。表4 104年度西醫基層醫療給付費用協定項目表項 目成長率(%)或金額(百萬元)增加金額(百萬元)協 定 事 項一般服務醫療服務成本及人口因素成長率1.154%1,132.7計算公式：醫療服務成本及人口因素成長率 =[(1+投保人口數年增率)(1+人口結構改變率+醫療服務成本指數改變率)]-1投保人口數年增率0.175%人口結構改變率0.997%醫療服務成本指數改變率-0.020%協商因素成長率1.293%1,269.8鼓勵提升醫療品質及促進保險對象健康品質保證保留款0.100%98.21.依西醫基層總額品質保證保留款實施方案支付，並以品質相關指標作為獎勵依據。該方案請於103年11月底前完成相關程序，並於104年6月底前提送前一年度執行成果。2.金額應全數用於鼓勵提升醫療品質，並以最近2年(103、104年)該保留款成長率之累計額度為限，其餘額度回歸一般服務預算。保險給付項目及支付標準之改變新醫療科技(包括新增診療項目、新藥及新特材等)0.122%120.01.請中央健康保險署於103年12月委員會議說明擬調整之相關項目與作業時程，及於104年6月底前提送執行結果(含新增項目及申報費用/點數)。若未於時程內導入，則扣減該額度。2.資源有限，對給付項目之新增或適應症之調整，請中央健康保險署於額度內，依全民健康保險法第42條精神，善用醫療科技評估工具，並考量人體健康、醫療倫理、醫療成本效益及保險財務，排定納入健保給付之優先順序。保險給付項目及支付標準之改變調整藥事服務費及語言治療診療項目0.399%391.6請中央健康保險署於103年12月委員會議說明擬調整支付標準項目與作業時程，依時程導入，並於104年6月底前提送執行情形。配合安全針具推動政策之費用0.004%3.91.配合安全針具推動政策，5年內按比例逐步完成全面提供安全針具。本項自102年起開始分5年編列，104年為第3年。2.請於104年6月底前提送執行情形(含安全針具之申報量與價格)。其他醫療服務利用及密集度之改變0.713%700.0在合理預期支出範圍內，應含放寬藥品適應症所增之費用；若有全民健康保險法第26條之情事，則不適用。其他議定項目違反全民健保醫事服務機構特約及管理辦法之扣款-0.045%-43.9一般服務成長率2.447%2,402.5專款項目(全年計畫經費)醫療資源不足地區改善方案150.00.0本項經費得與醫院總額同項專款相互流用。慢性B型及C型肝炎治療計畫400.0200.01.不足部分由其他預算支應。2.請中央健康保險署研議成效評估指標。醫療給付改善方案254.448.91.辦理原有之糖尿病、氣喘、思覺失調症、B型肝炎帶原者及C型肝炎感染者個案追蹤、早期療育等5項方案，並新增孕產婦方案。2.宜提升涵蓋率，照護更多相同疾病的患者；屬成效明確的方案，應將該類病患全部納入，以避免選擇性偏差的問題。並整合各方案，朝以病人為中心的整合性服務發展，以提升醫療資源的使用效益。家庭醫師整合性照護計畫1,180.0-20.0應確實評估成效，並訂定嚴格之退場機制。專款金額1,984.4228.9成長率(一般服務+專款)增加金額2.633%2,631.4總金額102,545.5門診透析服務成長率增加金額5.557%774.41.門診透析服務總費用成長率為3.7%；本項與醫院總額門診透析服務費用合併，並統為運用。2.含偏遠地區門診透析服務保障每點1元支付。3.門診透析院所前提報台灣腎臟醫學會之所有資料，嗣後改以全數上傳至中央健康保險署健保資訊網服務系統(VPN)，並將院所上傳情形納入「慢性腎衰竭病人門診透析服務品質提升獎勵計畫」之指標。總金額14,709.4總成長率 (註1)(一般服務+專款+門診透析)增加金額2.991%3,405.8總金額117,254.9較103年度核定總額成長率3.191%－註：1.計算總成長率所用之基期費用，一般服務含校正投保人口數成長率差值。2.本表除專款項目金額外，餘各項金額為預估值。表5 104年度其他預算協定項目表項目金額(百萬元)增加金額(百萬元)協 定 事 項山地離島地區醫療給付效益提昇計畫605.40.0請於104年6月底前提送執行成果。非屬各部門總額支付制度範圍之服務3,714-541.用於助產所、護理之家照護、居家照護、在宅醫療、精神疾病社區復健及安寧居家療護等所需經費。2.請於103年12月委員會議說明擬調整支付標準項目與作業時程，並於104年6月底前提送執行情形。全民健保高診次民眾就醫行為改善方案-藥師居家照護54541.以輔導至少7,000人為目標。2.請於104年6月底前提送執行成果及成效評估報告。支應醫院總額罕見疾病與血友病藥費及器官移植、西醫基層總額慢性B型及C型肝炎治療計畫專款不足之經費，及狂犬病治療藥費300.00.0所列狂犬病治療藥費係用於治療被動物咬傷患者，防止狂犬病之發生。推動促進醫療體系整合計畫1,100.0100.01.用於「醫院以病人為中心門診整合照護試辦計畫」3億元、「論人計酬試辦計畫」3億元，「跨層級醫院合作計畫」1億元，及「提升急性後期照護品質試辦計畫」4億元。2.新增方案原則於103年12月底前完成相關程序，各計畫請於104年6月底前提送執行成果及成效評估報告(新增方案僅需提供初步執行結果)。其他預期政策改變及調節非預期風險所需經費1,000.00.01.含新增醫藥分業地區所增加之費用。2.經費之支用，依費協會第178次委員會議通過之適用範圍與動支程序原則辦理。ICD-10-CM/PCS編碼250149.51.應於105年全面以ICD-10-CM/PCS申報。2.計畫請於103年12月底前完成相關程序，並於104年6月底前提送執行成果。鼓勵醫療院所即時查詢病患就醫資訊措施2,200.00.01.本計畫原則以5年為期程，用於網路費用、相關系統開發及獎勵院所上傳重要檢查、檢驗結果。 2.請於104年6月底前提送執行成果及成效評估報告。提供保險對象收容於矯正機關者醫療服務計畫1,404.5 0.0請於104年6月底前提送執行成果及成效評估報告。慢性腎臟病照護及病人衛教計畫 404.00.01.用於繼續推動末期腎臟病前期(Pre-ESRD)之病人照護與衛教計畫、初期慢性腎臟病醫療給付改善方案，及慢性腎衰竭病人門診透析服務品質提升獎勵計畫。2.請於104年6月底前提送執行成果及成效評估報告。提升保險人管理效率285.0285.01.本計畫須報經衛生福利部法制單位通過後始得動支。2.請於104年6月底前提送初步執行結果。總 計 =SUM(ABOVE) 11,316.9 =SUM(ABOVE) 534.5 註：採支出目標制，由中央健康保險署管控。附件第1屆103年第9次委員會議與會人員發言實錄壹、「議程確認」、例行報告第一案「確認本會上(第8)次委員會議紀錄」、例行報告第二案「本會上(第8)次委員會議決議(定)事項辦理情形及重要業務報告」與會人員發言實錄鄭主任委員守夏一、現在開始進行本會第9次委員會議，請委員翻開昨天協商時參用的104年度總額協商暨第9次委員會議資料。今天會議議程共有例行報告3案、討論事項3案、專案報告1案，其中最重要的就是確認104年度各部門總額及其他預算之協商結果。委員對議程的安排有無意見？(未有委員表示意見)若無意見，則按照既定的程序進行。二、請同仁宣讀上(第8)次委員會議紀錄。同仁宣讀鄭主任委員守夏謝謝同仁宣讀，請問委員對上(第8)次會議紀錄內容有無修正意見？請謝委員武吉。謝委員武吉為何專案報告第一案「健保法第43條推動自行負擔費用及轉診之執行報告」的決定為「洽悉」，而臨時提案則有決議內容？兩案的決議文字不是應該一致？鄭主任委員守夏通常委員對報告案(含專案報告)若無特別意見，則會議決定文字為「洽悉」；而對討論事項(含臨時動議)則會列決議文字。一般報告案與討論案的用詞會不同，報告案的決定，有時為退回或要求再次報告，若委員無特別意見，則決定通常為「洽悉」；上次會議的臨時提案，因有討論並獲致結論，所以列有決議文字。謝委員武吉我知道，剛才我是提出「洽悉」是否恰當的建議，若主委覺得恰當，我也無意見。鄭主任委員守夏這是習慣用詞，報告案若委員無特別意見，決定文字就是「洽悉」；如有意見而變成討論議案，則會列入討論事項，並有決議。謝委員武吉也會將報告案保留至下次委員會議報告的情形，是嗎？鄭主任委員守夏對，有時因會議時間不夠，部分報告案會來不及報告。謝委員武吉若時間來不及，建議會議趕快進行。干委員文男主席！鄭主任委員守夏請干委員文男。干委員文男經謝委員武吉提出意見，我才想到一件事，不然又忘記了！健保署很認真地分析新增項目的替代效果資料，若經委員會議報告通過，可否再提出意見。柯執行秘書桂女干委員關心的事項，在例行報告第二案上次委員會議決議(定)事項辦理情形中，會做說明。鄭主任委員守夏一、若會議紀錄文字沒問題，先予確認。(未有委員表示意見)二、接下來進行上(第8)次委員會議決議(定)事項辦理情形及重要業務報告，請柯執行秘書桂女。柯執行秘書桂女一、各位委員及所有與會者，大家早！二、上次委員會議決議(定)事項辦理情形及重要業務報告，分為兩部分，第一部份為上次委員會議決議(定)事項辦理情形之追蹤，建議其中3項解除追蹤，5項繼續追蹤。請大家翻到議程資料第109頁。因時間關係，主席交代報告儘量精簡，因此簡要說明解除追蹤項目。(一)第1項，請衛福部於103年6月前制訂地區預算分配之具體政策供本會參據案，社保司回復之說明如議程資料第111~113頁，因已處理完畢，且其回復內容將納入10月份地區預算分配的討論案，所以建議解除追蹤。(二)第6項，即干委員文男剛剛所提，請健保署進一步分析新增醫療科技項目對醫療費用之影響案。上次委員會議健保署已提報96年新增之3項支付標準項目的分析結果，後經決定請健保署提供另30項的分析資料，以利了解全貌；另並參照新增支付標準項目計算替代效應的方式，分析新增藥品對醫療費用之影響。健保署提供的資料在議程第143頁之附錄一，請委員參考，其已針對96年新增之33項支付標準項目進行分析，惟表示藥品部分無法比照支付標準項目進行分析。由於健保署已提供分析資料，本項建議解除追蹤。干委員文男對分析內容如有意見，稍後可再提出。(三)第7項，臨時提案之決議，因社保司回復業錄案參辦，並承諾以後會召開會議討論，本項建議解除追蹤。至其餘5項幕僚均建議繼續追蹤。三、第二部分為衛福部與健保署於6月至9月發布相關資訊，如附錄二(第161頁)至附錄九(第199頁)，請委員參考。鄭主任委員守夏謝謝柯執行秘書的報告，請問委員有無垂詢。請干委員文男。干委員文男健保署提供的分析資料，多項新增支付標準項目之費用及天數均較原支付項目高，請說明原因。例如：議程資料第148頁，良性複雜縱膈腔腫瘤切除，平均每件醫療費用13.3萬元、平均住院天數9.6天，新的胸腔鏡縱膈腔腫瘤切除術，平均每件醫療費用14.9萬元、平均住院天數9.7天，醫令數也較多；議程資料第149頁，食道瘤及囊腫切除術，平均每件醫療費用、住院天數分別為11.3萬元、10.1天，新的胸腔鏡食道瘤及囊腫切除術，則為14.9萬元、16.0天，醫令量較少，可能還在試驗階段；議程資料第150頁，食道肌切開術為7.1萬元、9.9天，新的胸腔鏡食道肌肉切開術則為16.5萬元、13.1天；議程資料第155頁，膽管截石術為10.2萬元、7.9天，新的胸腔鏡膽管截石術則為11.1萬元、9.4天；議程資料第157、158頁，很多項目都有類似情形，按理，新技術應較優，但費用與住院天數卻反而增加。對費用、住院天數有進步的項目表示肯定，但退步的項目，健保署應解釋。鄭主任委員守夏因這部分較為細節，項目也很多，請教干委員文男，可否同意請健保署彙整後提供書面資料，例如那些項目的費用呈現下降趨勢、那些費用愈來愈高，屆時委員若仍不清楚，再安排專題報告。我擔心今天會議時間有限，健保署無法說明清楚。干委員文男剛提及的幾頁已有相關數據，請健保署書面答復。鄭主任委員守夏一、好，請健保署提供書面資料，如委員還是無法理解，再安排專題報告。二、委員有無其他垂詢(未有委員表示意見)。接下來進行下一案，健保署的例行業務執行報告，因本次為9月份，請委員參閱書面資料。接下來進行討論事項。貳、討論事項第一案「104年度中醫門診、牙醫門診、醫院、西醫基層醫療給付費用總額協商因素項目與成長率及其他預算案」與會人員發言實錄鄭主任委員守夏一、本案最主要是確認昨天到今天早上的協商結果，就照協商的抽籤順序進行確認。請問中醫部門來得及嗎？若來不及，就先從牙醫部門開始。二、為能在今天一早的委員會議確認昨天協商結果，幕僚同仁昨晚會後即趕工整理。早上總額相關團體、健保署看到書面資料後，有提出修正意見，因此委員桌上的書面資料，部分與螢幕出現的文字不同，故文字以螢幕呈現者為主。文字難免會有修正，因昨晚開到近十一點，幕僚要將所有結論立即整理出來，並不容易。請同仁宣讀。同仁宣讀104年度牙醫門診醫療給付費用總額及其分配一、總額設定公式：104年度牙醫門診醫療給付費用總額=校正後103年度牙醫門診一般服務醫療給付費用×(1＋104年度一般服務成長率)＋104年度專款項目經費註：校正後103年度牙醫門診一般服務醫療給付費用，係依全民健康保險會103年第5次委員會議決議，校正投保人口數成長率差值。二、總額協商結論：(一)一般服務成長率為1.319%。其中，醫療服務成本及人口因素成長率0.373%，協商因素成長率0.946%。(二)專款項目全年經費為1,817.6百萬元。(三)前述二項額度經換算，104年度牙醫門診醫療給付費用總額，較103年度所核定總額成長2.140%；而於校正投保人口數後，成長率估計值為1.916%。各細項成長率及金額如表2。三、總額分配相關事項：(一)一般服務(上限制)：1.品質保證保留款(0.300%)：(1)依牙醫門診總額品質保證保留款實施方案支付，並以品質相關指標作為獎勵依據，該方案請於103年11月底前完成相關程序，並於104年6月底前提送前一年度執行成果。(2)金額應全數用於鼓勵提升醫療品質，並以最近2年(103、104年)該保留款成長率之累計額度為限，其餘額度回歸一般服務預算。2.牙周顧本計畫(0.4%)，請於104年6月底前提送執行情形。3.調整藥事服務費(0.008%)，請於104年6月底前提送執行情形。4.同意比照西醫基層調整診察費20點，請於下年度總額協商前完成並提出執行情形，惟本項成長率為0%。5.特殊口腔黏膜疾病統合照護計畫(0.027%)，請於104年6月底前提送執行情形。6.懷孕婦女照護(0.217%)，請於104年6月底前提送執行情形。7.違反全民健康保險醫事服務機構特約及管理辦法之扣款(-0.006%)。(二)專款項目：具體實施方案(含預定達成目標及評估指標)由中央健康保險署會同牙醫門診總額相關團體訂定後，依相關程序辦理，並送全民健康保險會備查。前述方案之作業時程，延續型計畫應於103年11月底前完成，並於104年6月底前提報執行成果及成效評估報告；實施成效並納入下年度總額協商考量。1.醫療資源不足地區改善方案：全年經費280.0百萬元，辦理牙醫師至無牙醫鄉執業與巡迴醫療計畫，及新增牙醫門診總額鼓勵偏遠地區牙醫師長期進駐服務試辦計畫。2.牙醫特殊醫療服務試辦計畫：全年經費443.0百萬元，辦理先天性唇顎裂及顱顏畸形患者、特定障別之身心障礙者及在宅牙醫醫療服務。3.牙周病統合照護計畫：(1)第1、2階段：全年經費850.0百萬元。(2)第3階段：全年經費244.6百萬元。(3)第1、2階段照護目標數為125,000人，第3階段服務人數為95,000人。(4)請加強宣導本項已屬健保給付項目，若有民眾檢舉即屬違規，請中央健康保險署研議處理原則(例如扣款)，下年度且不再增加任何預算。鄭主任委員守夏謝謝同仁宣讀，委員可以參看表2的數字。請問牙醫部門代表有無問題？請陳代理委員彥廷。陳代理委員彥廷(陳委員義聰代理人)謝謝委員對牙醫部門的支持，對文字內容有三點修正建議：一、專款項目第1項，醫療資源不足地區改善方案：「全年經費280百萬元，辦理牙醫師至無牙醫鄉執業及巡迴醫療計畫，及新增牙醫門診總額鼓勵偏遠地區牙醫師長期進駐服務試辦計畫」，其中「，及新增…試辦計畫」文字為誤植，建請刪除，因與現行的計畫名稱不同。二、專款項目第2項，牙醫特殊醫療服務試辦計畫：「全年經費443百萬元，辦理先天性唇顎裂與顱顏畸形患者、特定障別之身心障礙者及在宅牙醫醫療服務」，建議改為「…特定障別之身心障礙者，老人及在宅牙醫醫療服務」。三、專款項目第3項，牙周病統合照護計畫：「(3)第1、2階段照護目標數125,000人，第3階段服務人數95,000人」，其中第3階段之服務人數，103年係以服務人數應達7成為目標，能否考慮此情況再酌予調整，基於125,000人的70%為87,500人，建議104年提高至90,000人，讓我們在實務上可做到。鄭主任委員守夏牙醫部門有三點建議，專款項目第1項，建議刪除「及新增牙醫門診總額鼓勵偏遠地區牙醫師長期進駐服務試辦計畫」乙段文字，請問是因支用其他項目的經費嗎？陳代理委員彥廷(陳委員義聰代理人)不是，是名稱已改為「牙醫師至牙醫醫療資源不足地區執業服務計畫」。鄭主任委員守夏所以與協商的內容無關。專款項目第2項，在特定障別之身心障礙者及在宅牙醫醫療服務，中間要增列「老人」兩字之用意為何？協商時並未特別提出。吳委員玉琴本項原先希望新增老人口腔醫療服務部分，協商當時幾位付費者委員都有共識，將牙醫部門所提的另一項專款項目「老人口腔醫療照護計畫」併入牙醫特殊醫療服務試辦計畫中，但不增加預算，故文字須落款，惟僅增列「老人」兩字似未能完整表達，與昨天的共識略有差異。鄭主任委員守夏僅列「老人」好像係指正常老人。吳委員玉琴對啊！鄭主任委員守夏如要落款，須有較明確的文字。請吳委員肖琪。吳委員肖琪我也認為不能僅列「老人」，因健康的老人可自行就醫，並無在宅醫療的需求，所以應係指失能的老人，例如比照身心障礙者僅列重度失能老人，這樣落款才能達實質意義。鄭主任委員守夏昨天協商時似未特別提出？吳委員玉琴昨天協商時，牙醫部門提出「老人口腔醫療照護計畫」，我們建議併入牙醫特殊醫療服務試辦計畫執行，結論也是這樣。鄭主任委員守夏若是這樣，應寫出原來建議的計畫名稱。吳委員玉琴原提出的名稱為「老人口腔醫療照護計畫」。鄭主任委員守夏請林組長阿明。林組長阿明老人口腔照護分為兩部分，一為提供在宅醫療服務，另一為至養護機構提供醫療服務。醫院與西醫基層部門至養護機構提供醫療服務時，其費用均由一般服務預算支應，並未特別增編預算。建議僅保留在宅醫療即可，且「牙醫特殊醫療服務試辦計畫」的預算約只剩3~4千萬元，若納入恐擠壓原來牙醫特殊醫療服務提供的項目。吳委員玉琴可加「重症」兩字。鄭主任委員守夏一、不建議加「重症」兩字，需要醫療照護的老人，一部分是在宅接受服務，一部分是到養護機構提供，若限定為重症老人，須再花費諸多行政資源定義何謂「重症老人」。剛林組長阿明已說明，無須特別寫「老人」，以免壓縮現行計畫照護的對象。昨天協商時並未提出，健保署也建議不要特別列出「老人」，以避免影響原已提供的服務，付費者是否同意？二、牙醫至養護機構提供老人口腔醫療照護，與西醫基層、醫院部門相同，已涵括在一般服務預算中，牙醫部門也可依現行「牙醫特殊醫療服務試辦計畫」提供在宅服務，請問付費者委員有無其他意見？請何委員語。何委員語昨天的原意是要將「老人口腔醫療照護計畫」併入「牙醫特殊醫療服務試辦計畫」中，若健保署認為規範上有困難，能否改為「老人在宅及機構牙醫醫療服務」，就是吳委員玉琴一直強調老人機構服務這部分。鄭主任委員守夏健康的老人非常多，「老人」很難定義，若規範的是在宅或住在機構者，則較明確，但其與是否為老人無關，因住在機構內的可能是身心障礙者，而接受在宅服務者也不一定是老人。建議應看健保署可否執行。何委員語若寫「老人在宅及機構牙醫醫療服務」是否可行？鄭主任委員守夏那麼，「非老人」在宅接受服務呢？有時訂了反而失卻原意…。請吳委員玉琴。吳委員玉琴這部分可請健保署會同牙醫部門討論執行細節，包含「老人」是昨天的共識，要執行老人口腔醫療照護，只是不增加預算，且併入「牙醫特殊醫療服務試辦計畫」中，故文字要落款。至如何執行，可請健保署與牙醫部門再討論。鄭主任委員守夏請林組長阿明說明。林組長阿明其實在宅醫療服務，已包含老人及其他無法出來就醫者。目前西醫有至養護機構提供醫療服務，牙醫要進入機構提供服務也可，並不需在此增列文字。李副組長純馥「牙醫特殊醫療服務試辦計畫」是照顧身心障礙者，我們擔心若擴大涵蓋範圍，會擠壓到原來提供身心障礙者醫療服務的預算，且現行計畫也包含有在宅牙醫醫療服務，其實已考量到外出就醫困難者，所以建議無須增加文字。另外，計畫的增修，健保署都會與牙醫部門再討論。鄭主任委員守夏還有個重點，本項並未增加預算，建議不宜要求太多。吳委員玉琴昨天的資訊，讓我們誤以為「牙醫特殊醫療服務試辦計畫」還剩7~8千萬元，以為預算還夠用，故同意將其併入。但今天聽到剩3~4千萬元，如此確實會擠壓到原有計畫，這也不是我們樂見。謝委員武吉請教一個問題，「在宅牙醫醫療服務」文字很奇怪，係指生病的老人？或健康的老人？宅男的在宅？抑或宅女的在宅？是有宅男代表、宅女代表嗎？應要規定清楚。鄭主任委員守夏相信健保署與牙醫部門在執行面會訂得很清楚，不可能是提供宅男服務。陳代理委員彥廷(陳委員義聰代理人)文字上我們不堅持，重點是之後至老人照護機構提供牙醫醫療服務時，是否准用本專案計畫，或支用一般服務預算。昨天與付費者協商時，是同意用本專案計畫，我想只要落實此精神即可。鄭主任委員守夏西醫部門至養護機構提供的醫療服務，費用係由一般服務預算支應，牙醫部門若再新增項目，恐壓縮原來難度較高的身心障礙者及先天性唇顎裂患者的醫療服務，故健保署建議不要增加「老人」文字，且本項未增編預算，若不增加文字，可確保原來的計畫順利執行。這樣可以接受嗎？吳委員肖琪長期失能者可領身心障礙手冊，但短期失能者並無該手冊，本項究要包含那些人，是否涵蓋短期失能又無法外出就醫者？39歲的失能者與79歲的失能者，影響程度並不同。79歲失能者的孩子已長大成人，而39歲失能者則非如此。若目標是往提供在宅醫療服務的方向邁進，則只要重症、無法外出就醫且未領有身心障礙手冊者，就應包含在內。鄭主任委員守夏請吳委員玉琴。吳委員玉琴落款會有什麼問題嗎？鄭主任委員守夏若有不好的結果，我們必須負責。因並未增編預算，健保署擔心原「牙醫特殊醫療服務試辦計畫」照護對象的牙醫醫療服務是否會受到影響。李副組長純馥104年已在一般服務項目新增「牙周顧本計畫」，並給予成長率，建議不要在「牙醫特殊醫療服務試辦計畫」中，新增「老人」兩字。鄭主任委員守夏一、我了解吳委員玉琴在幫老人族群爭取權益，惟考量本項未增編預算，個人建議先不要列「老人」文字。二、若我是牙醫師，在同一預算項下，應該會選擇較容易的內容執行。我們認為最重要且該執行的項目，其實在去年、前年都已編列預算，健保署擔心新增此項服務，恐排擠原計畫項目之推動；剛才李副組長純馥也提到，104年已於一般服務新增「牙周顧本計畫」，對老人族群已有特別考量。請問委員是否同意不增列文字，以確保「牙醫特殊醫療服務試辦計畫」能維持4.43億元預算，而且專款專用。未有委員表示反對，就不新增文字。三、另一項為「牙周病統合照護計畫」，第3階段服務人數原列95,000人，牙醫部門建議修正為90,000人。委員有無不同意見？未有委員表示反對，第3階段服務人數修正為9萬人。陳代理委員彥廷(陳委員義聰代理人)再次確認，是不推動至老人照護機構提供服務的部分嗎？鄭主任委員守夏就是比照西醫部門，以一般服務預算支應。請健保署補充說明。李副組長純馥一、目前醫院、西醫基層部門至機構提供服務，都是以一般服務預算支應，歷年也沒有另外給予成長率。因院所不至機構提供服務，機構住民也會到院所就醫，現在只是提供更好的服務，提高就醫可近性。為考量各部門總額間的公平性，建議應以一般服務預算支應。二、再次聲明，本署不反對牙醫部門至機構內提供服務，惟無論西醫基層、醫院部門至機構提供復健或早期療育服務，皆支用一般服務預算，並未額外給予經費。鄭主任委員守夏若屬執行細節，請牙醫部門再與健保署討論，協商僅框列預算額度及大方向、大原則；執行、管理面細節等與總額協商未有直接相關事項，不需在此討論。牙醫部門可否就此確認？請謝委員天仁。謝委員天仁現已完成協定，表2之標題「…醫療給付費用成長率項目表」應改為「…醫療給付費用協定項目表」，且表頭之「預估增加金額」應改為「增加金額」。鄭主任委員守夏一、謝委員天仁認為目前已完成協定，項目金額都確定了，所以應配合修正，請同仁依謝委員天仁意見修正。二、請問委員對牙醫部門是否還有修正意見？請吳委員肖琪。吳委員肖琪請修正表2「品質保證保留款」協定事項第2點之排版。柯執行秘書桂女第2點為「金額應全數用於鼓勵提升醫療品質…」。鄭主任委員守夏如果沒有其他意見，牙醫部門就此確認。下一個是醫院部門。謝委員武吉下一個應是中醫，中醫部門確認會較快，醫院部門則較慢。鄭主任委員守夏比較耗時的先來，醫院部門如果完成，「頭過身就過(台語)」，請同仁宣讀。同仁宣讀104年度醫院醫療給付費用總額及其分配一、總額設定公式：104年度醫院醫療給付費用總額＝校正後103年度醫院一般服務醫療給付費用×(1＋104年度一般服務成長率)＋104年度專款項目經費＋104年度醫院門診透析服務費用104年度醫院門診透析服務費用＝103年度醫院門診透析服務費用×(1+成長率)註：校正後103年度醫院一般服務醫療給付費用，係依全民健康保險會103年第5次委員會議決議，校正投保人口數成長率差值。二、總額協商結論：(一)一般服務成長率為4.346%。其中，醫療服務成本及人口因素成長率2.128%，協商因素成長率2.218 %(二)專款項目全年經費為13,828.3百萬元。(三)門診透析服務成長率2.341%。(四)前述三項額度經換算，104年度醫院醫療給付費用總額，較103年度所核定總額成長3.659%；而於校正投保人口數後，成長率估計值為3.453%。各細項成長率及金額如表3。三、總額分配相關事項：(一)一般服務(上限制)：1.品質保證保留款(0.1%)：(1)依醫院總額品質保證保留款實施方案支付，並以品質相關指標作為獎勵依據，該方案請於103年11月底前完成相關程序，並於104年6月底前提送前一年度執行成果。(2)金額應全數用於鼓勵提升醫療品質，並以最近2年(103、104年)該保留款成長率之累計額度為限，其餘額度回歸一般服務預算。2.新醫療科技(包括新增診療項目、新藥及新特材等)(0.649 %)：(1)請中央健康保險署於103年12月委員會議說明擬調整之相關項目(包含罕病特材12.5百萬元)與作業時程，及於104年6月底前提送執行結果(含新增項目及申報費用/點數)。若未於時程內導入，則扣減該額度。(2)考量資源有限，對給付項目之新增或適應症之調整，請中央健康保險署於額度內，依全民健康保險法第42條精神，善用醫療科技評估工具，並考量人體健康、醫療倫理、醫療成本效益及保險財務，排定納入健保給付之優先順序。3.強化醫療資源支付合理性(0.100%)：請中央健康保險署於103年12月委員會議說明擬調整支付標準項目與作業時程，依時程導入，並於104年6月底前提送執行情形。4.103年導入第2階段DRGs所需費用之調整(0.110%)：103年導入第2階段，相關專款預算已併入103年醫院總額一般服務費用結算，爰104年於一般服務計列成長率。5.配合安全針具推動政策之費用(0.057%)：(1)配合安全針具推動政策，5年內按比例逐步完成全面提供安全針具。本項自102年起分5年編列，104年為第3年。(2)請於104年6月底前提送執行情形。6.提升住院護理照護品質(0.568%)：本項自專款項目移列至一般服務，經費並用於調增住院護理之支付標準，除支付方式必須與護病比連動，並應訂定護理人力相關監測指標，於104年4月前提經全民健康保險會同意，否則經費不得動支，及於104年6月底前提送執行情形。7.其他醫療服務利用及密集度之改變(0.624%)。8.配合結核病防治政策改變之費用(0.010%)：用於「抗結核病藥物副作用個案住院≦30天」住院醫療費用，並於104年6月底前提送執行情形。9.違反全民健康保險醫事服務機構特約及管理辦法之扣款(-0.0003%)。(二)專款項目全年經費為13,828.3百萬元：具體實施方案(含預定達成目標及評估指標)由中央健康保險署會同醫院總額相關團體訂定後，依相關程序辦理，並送全民健康保險會備查。前述方案之作業時程，延續型計畫應於103年11月底前完成，新增計畫原則於103年12月底前完成，並於104年6月底前提報執行成果及成效評估報告(新增計畫僅需提供初步執行結果)；實施成效並納入下年度總額協商考量。1.鼓勵器官移植並確保術後追蹤照護品質：全年經費3,972百萬元，不足部分由其他預算支應。2.罕見疾病、血友病藥費：(1)全年經費7,815百萬元，不足部分由其他預算支應。(2)為檢視本項費用成長之合理性，請中央健康保險署於104年6月底前，提出專案報告。3.醫療給付改善方案：(1)全年經費741.3百萬元。(2)辦理原有之糖尿病、氣喘、乳癌、思覺失調症、B型肝炎帶原者及C型肝炎感染者個案追蹤、早期療育等6項方案，並新增孕產婦方案。(3)宜提升涵蓋率，照護更多相同疾病的患者；屬成效明確的方案，應將該類病患全部納入，以避免選擇性偏差的問題。整合各方案，朝以病人為中心的整合性服務發展，以提升醫療資源的使用效益。4.急診品質提升方案：(1)全年經費160百萬元。(2)請中央健康保險署檢討方案執行內容，以提升急診照護品質。5.鼓勵繼續推動住院診斷關聯群(DRGs)：(1)全年經費280百萬元，導入第3階段DRGs項目。(2)本項經費應依實際導入施行之項目與季別，併醫院總額一般服務費用結算。6.醫院支援西醫基層總額醫療資源不足地區改善方案：(1)全年經費60百萬元。(2)配合支援西醫基層醫療資源不足地區所需，提供專科巡迴醫療等服務。本項經費得與西醫基層總額同項專款相互流用。7.全民健康保險醫療資源不足地區醫療服務提升計畫：全年經費800百萬元。 (三)門診透析服務：1.合併西醫基層及醫院兩總額部門所協定之年度門診透析服務費用，並統為運用。2.門診透析服務費用於醫院及西醫基層總額之計算方式：先協定新年度門診透析服務費用成長率，再依協商當年第1季醫院及西醫基層之門診透析費用點數占率分配預算，而得新年度醫院及西醫基層門診透析費用及其成長率。3.門診透析服務總費用成長率為3.7%，含偏遠地區門診透析服務保障每點1元支付。依上述分攤基礎，醫院部門本項服務費用成長率為2.341%。4.請中央健康保險署研議門診透析院所相關檢驗資料上傳至該署健保資訊網服務系統(VPN)之可行性，並將院所上傳情形納入「慢性腎衰竭病人門診透析服務品質提升獎勵計畫」之指標。鄭主任委員守夏謝謝同仁宣讀。先請醫院部門楊委員漢湶表示意見。楊委員漢湶主席、各位委員，針對醫院部門協商文字，建議修正如下：一、新醫療科技：(一)對本項昨天其實已提意見，但主席請我今天再提。建議刪除「(包含罕病特材12.5百萬元)」之文字及預算，將之移列至專款項目項下之「罕見疾病、血友病藥費」，則原「罕見疾病、血友病藥費」所編列7,815百萬元經費，修正為7,827.5百萬元。(二)為何醫院部門要提出此建議，在此跟各位報告。本人十分重視及關心罕見疾病患者之需求，但過去6年，罕見疾病病人數僅增加27%(原5,300人，增加為6,700人)，藥費之增加卻超過2倍；97年罕見疾病患者的藥費僅13億元，但102年藥費卻高達30億元。(三)目前醫院部門於104年專款項目「罕見疾病、血友病藥費」編列78.15億元，惟一般服務新醫療科技項下之「(包含罕病特材12.5百萬元)」文字說明，讓我擔憂未來對醫院部門可能產生巨大的預算衝擊。(四)本人支持罕見疾病患者應由政府照顧，但應由何部門照顧及其方式應有規範。醫院部門沒有辦法以有限的經費負擔無限的責任，雖然經費列計在一般服務項下，預算可滾入基期，但此項支出可能會暴衝，對醫院部門不合理亦不公平。文字內容若不修正，則罕見疾病患者所需之特材費用皆由此12.5百萬元負擔，當預算超支該如何處理？可以想見醫院部門未來還是要被迫接受。(五)罕見疾病的定義為盛行率在萬分之一以下，即每1萬人口中少於1人，該類患者屬於弱勢者中的弱勢。依我的瞭解，很多類罕見疾病患者都不超過100人，因此其特材、藥品及食品等都相當昂貴，我國訂有「罕見疾病防治及藥物法」來保障罕病患者，因此，若健保預算有限，政府應另編列預算補助才是。(六)若配合經費移列，則原專款項目之「罕見疾病、血友病藥費」名稱，建議配合修正為「罕見疾病、血友病藥費及罕見疾病特材」，且該項總經費修正為7,827.5百萬元。二、提升住院護理照護品質：(一)感謝昨天付費者委員同意將本項由專款移列至一般服務項下，完全贊成此費用應考慮與護病比之關聯性，但「連動」2字過於抽象，建議將「除支付方式必須與護病比連動」修正為「除支付方式應考慮護病比」。(二)日本雖實施護病比連動制度，但其國內亦有國會議員表示此制度已產生相當的副作用，且對非都會區醫院非常不利。(三)雖然建議將「連動」兩字刪除，但在此承諾，未來使用護理經費時，一定會要求與護病比有關連性，但在此恐不適合將「連動」列入。鄭主任委員守夏謝謝楊委員漢湶說明。請干委員文男。干委員文男一、針對一般服務項下之「其他醫療服務利用及密集度之改變」，建議增列「含藥物給付放寬適應症所增之費用」文字，否則現在新藥都無法納入給付，這件事讓葉委員宗義很生氣。二、另針對門診透析服務第4點再說明，現行健保署雖有要求院所上傳資料，惟項目比之前上傳至腎臟醫學會的少很多，請健保署比照腎臟醫學會原要求的項目，請院所全數上傳。鄭主任委員守夏請謝委員武吉。謝委員武吉一、針對一般服務項下之「配合安全針具推動政策之費用」，很感謝昨天付費者委員支持本項預算，惟目前無法得知醫院與西醫基層使用數量的多寡，請健保署提供採購數量的數據(含不可申報的安全針具)，僅提供、分析可申報數據是不合理的。二、昨天付費者委員於協商時非常和藹可親，雙方氣氛融洽。干委員文男所提修正一般服務項下「其他醫療服務利用及密集度之改變」之意見，實務上常出現放寬給付規定後，經費增加超出預期的情形，請問該如何處理？請主席裁示。鄭主任委員守夏委員還有無意見？請楊委員麗珠。楊委員麗珠一、回應楊委員漢湶的意見，日本現行制度是要求同一醫院內的單一護病比，與我國將研擬的制度不同。二、一般服務項下之「提升住院護理照護品質」，文字若修改為「除支付方式應考慮護病比」，因「考慮」感覺上可有可無，我昨天已提出報告，目前104年醫院評鑑已將護病比列為重點項目，建議文字修正為「支付方式以護病比架構方式支付」。三、健保會已訂有護理人力之監理指標，為避免重複監控，建議後段文字修改為「並應訂定護理人力相關監理指標」，並列為健保會例行的監理項目。鄭主任委員守夏請葉委員宗義。葉委員宗義一、剛才干委員文男提到我很生氣，其實老人家的說法是憤怒。二、楊委員漢湶提到支出可能會暴衝，擔心昨天同意編列之「其他醫療服務利用及密集度之改變」項目，預算不夠支應，這也是另一個問題。另謝委員武吉提及給付規定放寬後預算不足該如何處理？可以等真的發生了，大家再來討論。鄭主任委員守夏其他委員有無修正意見？請李委員蜀平。李委員蜀平一、謝委員武吉及葉委員宗義都是「全民健康保險藥物給付項目及支付標準共同擬訂會議(藥品部分)」之委員，因此對藥品部分較為關注。二、有關一般服務項下之「其他醫療服務利用及密集度之改變」，是否包含藥物給付規定放寬之費用，應明確說明。鄭主任委員守夏請謝委員天仁。謝委員天仁一般服務項下之「強化醫療資源支付合理性」，昨天協商時有特別提出，本項經費僅用於調整安寧療護與語言治療部分，我們並未同意編列調整RBRVS之預算，所以請新增「另RBRVS支付標準調整不另增預算，應在104年完成調整」文字。楊委員漢湶主席，是否逐項修正文字？鄭主任委員守夏目前委員所提建議都先以括弧呈現，等一下再逐項檢視、確認。委員還有無修正意見？請蔡委員登順。蔡委員登順一、一般服務項下之「配合安全針具推動政策之費用」，依健保署規劃，自102年起分5年編列，1年編列1億元，5年共編5億元。二、104年醫院部門編列2億元預算，昨天協商時，原僅同意1億元，經再次協商，才同意編列2億元，所以應增列「累積5億元即不再編列預算」文字。三、剛剛楊委員漢湶所提「應考慮護病比」文字，我認為應該還是要有「護病比連動」文字會較明確，「應考慮」用詞有疑慮，也可不予考慮，並沒有明確定義，建議保留原來文字。另，建議增列「並應訂定護理人力相關監理指標」，此點與楊委員麗珠的意見相同。鄭主任委員守夏一、請問委員還有無意見？沒有的話，開始逐項對建議修正文字進行確認。二、有關「新醫療科技(包括新增診療項目、新藥及新特材等)」，楊委員漢湶建議將「包含罕病特材12.5百萬元」移至「罕見疾病、血友病藥費」專款項下，健保署覺得執行會有困難。請健保署提出說明。李副組長純馥一、「罕見疾病、血友病藥費」專款項目原僅預估藥費，目前罕病及血友病病人也有使用特材或其他費用，如在未估計預算的情況下就壓入文字，我們擔心會侵蝕原來的專款項目。二、「罕病特材」基本上有其特殊性，針對仿單上有寫「罕病特材」的項目，若均移列「罕見疾病、血友病藥費(含特材)」專款項目，我們擔心會包含仿單非屬罕病的特材，甚至連一般特材也包含，如此未來在執行專款預算時，會產生很多爭議，建請再三思。鄭主任委員守夏請楊委員漢湶。楊委員漢湶這個講法很奇怪，我建議將「包含罕病特材12.5百萬元」全部移至專款，由於原專款名稱只包含藥費，所以建議要加上「特材」文字。若覺得不夠明確，建議列明包含「藥費及特材」。另外，經費要一併移列，該專款項目之經費改為7,827.5百萬元。目前並不清楚未來會有多少罕病特材被納入，所以沒有能力承擔這種無限責任。鄭主任委員守夏我們之前曾討論過罕病特材之相關議案。目前罕病特材並未包含在「罕見疾病、血友病藥費」項下，其性質特殊且費用昂貴，若列在一般服務項下之「新醫療科技(包括新增診療項目、新藥及新特材等)」，醫界擔心凡屬新增的給付項目，一經納入後會吃到醫院總額一般服務的預算。而如果列在「罕見疾病、血友病藥費」專款項目，則比較容易管控。雙方說法都有道理，如何在執行上顧及民眾權益、健保署也可執行，真的是難題，今天如果有辦法決定當然最好，如果無法決定，建議先予保留。請郭代理委員正全。郭代理委員正全(翁委員文能代理人)健保署提出因為仿單寫法會產生爭議，所以建議將罕病特材列在一般服務項下，我則認為，若將罕病特材列在一般服務，雖然預算會滾入基期，但所支出經費不可預期，對醫界而言仍有很大的執行風險。健保署若認為不適合寫「罕病、血友病藥費及特材」，建議改為「罕病特材及罕病、血友病藥費」。鄭主任委員守夏請問健保署的看法。請陳委員川青。陳委員川青今天上午請教健保署同仁，剛剛兩位委員的顧慮是對的，罕病特材是給付予特定對象，國健署會專案核准，與協商的通案不一樣，故建議列在一般服務項下之「新醫療科技(包括新增診療項目、新藥及新特材等)」，以免產生執行上的疑慮。若依照行政作業的方便性，建議依健保署意見，來年如有類似狀況，再重新檢討。郭代理委員正全(翁委員文能代理人)一、有很多委員認為，提出政策的單位就應負擔經費，罕病政策是由國健署提出，該署就應編列預算，不應佔健保署便宜，國健署編列預算後，將經費列於此項共同運用也可以。但若將罕病特材的經費列在醫院總額的一般服務預算，就會用到醫院的額度，並不公平。二、若將之列在專款項目，較可以監控其支用情形，假設1,200萬元不夠，以後可能會變成5,000萬元，甚至更多，但至少可以看到其成長趨勢。若列在一般服務項下，則無法監控。短期來看，是醫院佔便宜，但長期而言就很難說。建議將之區分清楚，如此也可照顧到罕病病人。以後支出金額若太高，建議健保署也可要求國健署編列預算。鄭主任委員守夏請謝委員天仁。謝委員天仁一、如果醫院部門有顧慮，建議將項目分列：罕見疾病、血友病藥費全年經費7,815百萬元，不足部分由其他預算支應；罕病特材全年經費12.5百萬元。二、請問這樣可否執行？李副組長純馥主席，能否加上「新增」文字，以後較不會有認定的問題。目前已有罕病及血友病病人使用特材，建議加上「104年新增」等文字會較清楚。謝委員天仁那就改成「104年新增罕病特材，全年經費12.5百萬元」，最主要是解決雙方疑慮，現在是框列經費，既然怕兩項混在一起會產生困擾，那就分列，各自都有預算，也不會吃到醫院的一般服務預算。鄭主任委員守夏請莊委員志強。莊委員志強有關「不足部分由其他預算支應」文字，從其他預算的說明，似乎僅支應罕見疾病、血友病藥費的不足部分，並未提到罕病特材。鄭主任委員守夏有關罕病的部分，過去無論是醫院總額專款或其他預算均只支應藥費。楊委員漢湶一、「罕見疾病防治及藥物法」規定，中央主管機關應編列預算，補助罕見疾病預防、篩檢、研究之相關經費，及依全民健康保險法未能給付之罕見疾病診斷、治療、藥物與維持生命所需之特殊營養品、居家醫療照護器材費用等，均應由政府編列預算支應。罕病特材如果列在醫院總額之一般服務，擺明了就是這12.5百萬元會滾入基期，也會吃到醫院的預算。二、建議橋歸橋、路歸路，應該由國健署編列預算支應才對。各位放心，國健署應該可以負擔這部分費用。罕病病人不僅需支用藥費及特材，還包括檢驗費用，目前有些檢驗台灣還沒有能力執行；另外，食品、牛奶等，這部分國健署都有編列預算；只是不清楚從哪一年開始，健保也分擔一部分費用。鄭主任委員守夏感謝楊委員漢湶的說明，請何委員語。何委員語贊成將「新醫療科技(包括新增診療項目、新藥及新特材等)」之「包含罕病特材12.5百萬元」文字刪除，並依謝委員天仁的建議移至專款第2項「罕見疾病、血友病藥費」之下。也尊重健保署的意見，限104年新增的罕病特材。謝委員天仁「新醫療科技(包括新增診療項目、新藥及新特材等)」的12.5百萬元應相對扣減。鄭主任委員守夏一、數據沒有問題，請同仁將經費移至專款項目。接著繼續討論下一個項目，我們的進展有點慢。二、第2頁「強化醫療資源支付合理性」，有委員建議加入「另RBRVS支付標準調整不另增預算，並於104年執行完成」文字，請問委員有無意見？請健保署說明。張專門委員溫溫我們無法執行。謝委員天仁請健保署敘明能執行的項目，不然每次要錢的時候都說可以執行，給了錢後又說現在無法執行或有問題，請執行104年規劃爭取經費的項目。張專門委員溫溫因本來預估以RBRVS調整的項目約需20億元預算，若要調整20億點，卻沒有相對增加預算，執行面會有困難。李副組長純馥我們從100年開始推動RBRVS，預估預算約需四百多億元，如果要壓縮總額去完成，相信沒有任何部門總額可以承受一次調整四百多億元的衝擊。建議只列「另RBRVS支付標準調整不另增預算」，至於何時完成，請容我們有協商的空間。鄭主任委員守夏請謝委員天仁。謝委員天仁剛剛牙醫門診總額也同意在不增加預算的前提下調整診察費20點，所以健保署該做的事就要去做，若點值降低，明年再來協商，不要一直要求增加預算。你們以前該調的不調，現在才要增加預算，沒道理。鄭主任委員守夏健保署這次調整RBRVS的項目需要預算20億元。謝委員天仁主席，我講得很清楚，健保署同仁的水準很高，並未要求一次調完，是健保署預期要調的項目應在104年完成，我們對牙醫部門也有同樣的要求。鄭主任委員守夏這樣合理，所以是「另RBRVS支付標準調整不另增預算，預期調整項目應於104年完成」，至於「預期項目」請健保署自行協調，五百多項中有哪些應於104年完成，這樣可以嗎？確定要執行，但可能還需與醫界溝通。李副組長純馥一、很感謝委員於協商102年度總額時，同意編列50億元用以調整支付標準，但為了執行該項預算，健保署與醫界協商了一整年。今年沒有預算，卻要求調整20億點，我們不曉得該如何運作。二、委員要求不增加預算，我們同意，但如何執行或要不要啟動，請不要列文字，因為執行面真的非常困難。謝委員天仁給了預算，健保署也說執行有困難，所以問題與錢無關，問題在於醫界會吵要調整哪些項目。鄭主任委員守夏請吳委員肖琪。吳委員肖琪關於這部分的經費，昨天協商的方案列有3項，其中有關監察院所提的安寧療護，經上網查詢，推動安寧療護目的是要減少無效醫療，甚至有某學會提到，只要做好安寧療護，一個個案就可節省20萬元，推動一萬個安寧療護個案，就可節省20億元。若大家重視監察院對安寧療護的看法，建議努力推動社區或居家安寧療護，而不是增加醫學中心或區域醫院的安寧費用，而是鼓勵朝社區化發展安寧療護，節省健保住院費用。鄭主任委員守夏原則上執行此項有其困難度，但總額協商總要有進步，個人贊成謝委員天仁的落款文字，既然是預期調整項目，請健保署勉力為之。請謝委員武吉。謝委員武吉我感受到謝委員天仁對醫界的愛護，也贊成「預期調整項目」文字，但「應於104年完成」，我敢保證絕對不可能做到，請不要叫健保署背這個黑鍋，我們良心會過意不去。鄭主任委員守夏請陳委員宗獻。陳委員宗獻大家可能要思考RBRVS是什麼？相對值表是一項制度性工程，並不是一個疾病或一種藥品，與我們剛才討論的事項完全不同，不是有錢就能做到哪裡，要總額來支付這項工程的費用，沒有道理。李副組長純馥還有一點要解釋，RBRVS涉及支付標準調整，有些項目是醫院與西醫基層共用，如果醫院總額要壓文字，西醫基層可能也會受影響，因為相對會吃到西醫基層總額。這次協商時，委員要求支付標準調整項目都不另增預算，這部分我們也認可，但中間牽動非常大。上次50億元調整支付標準的協商之所以會討論那麼久，是因為有部分會吃到西醫基層總額，可是只在醫院部門編列預算，實際上執行時也對西醫基層總額造成困擾。若RBRVS沒有編列預算，希望能給我們執行的空間，請不要壓文字。鄭主任委員守夏協商草案，醫界提出25億元，健保署提出23.5億元，規劃用於調整支付標準，我們以健保署版本刪去其中20億元。既已刪掉20億元，就不要強迫健保署104年一定要完成。請問付費者委員可否同意將「應於104年完成」文字刪除？謝委員天仁剛剛陳委員宗獻說RBRVS是個工程，醫療密集度沒有任何改變，只是讓它更合理而已，怎會還要花錢，只是拿我們的錢去堵他們的嘴巴而已。我可以委屈求全，同意刪除「預期調整項目應於104年完成」等文字，但要告訴健保署，這只是項工程，應趕快從公平性上調整其相對值。鄭主任委員守夏請何委員語。何委員語我們很喜歡104年總額，因為104年時我們可能已不再擔任委員。謝委員天仁同意刪除「預期調整項目應於104年完成」，惟若沒有落款，好像就不做了，個人建議改為「應於104年持續推動」。鄭主任委員守夏一、謝謝何委員語，這是對的方向，我們期許健保署繼續努力推動，文字改為「應於104年持續推動」。二、再來是「配合安全針具推動政策之費用」項目，請楊委員漢湶。楊委員漢湶一、我昨天有針對安全針具提出說明，現在市場上的價格上漲很多。醫療法規定分5年完成，第1年時，預算是編列1億元，結果安全針具價格全盤上漲，所以我們在編列第2年預算時，覺得經費不夠，建議調整為2億元，但未被接受。今年是第3年，2億元的經費，以現在的價格根本不可能買到2年的安全針具。過去因為法律沒有規定，所以沒有執行，現在法律規定醫院一定要分5年逐步導入。醫院是分部門執行，如加護病房、急診部門先執行，至執行情形的監測，是醫院評鑑時到每個部門去計算。建議編列2億元預算，是因法律規定醫院一定要購買，導致市場價格調漲之故。二、不清楚法律這樣規定是否合理、公平，但這是立法院訂定的，安全針具有其安全效果，但使用上非常不方便。尊重蔡委員登順的意見，但我們確實在購買安全針具上發生困難，買不到並非今年才有的問題，去年就已買不到，問題吵得沸沸揚揚，連衛福部都同意於5年內逐步全面提供，之後不再編列預算。今年是第3年，明、後年是第4、5年。鄭主任委員守夏感謝楊委員漢湶，請蔡委員明忠。蔡委員明忠謝謝蔡委員登順對經費管控如此用心，我們予以肯定。醫界強調該用就要用，該拿的預算就要拿，不該拿的我們也不願意要。所以把錢框在這裡，萬一超過的時候，又是另外一回事。建議不要列入這些文字，而是逐步實行。鄭主任委員守夏請問蔡委員登順接受這些說明？蔡委員登順這要請健保署回答，當時規定5年，1年編列1億元的原因為何？鄭主任委員守夏請健保署說明。蔡專門委員文全當初在立法後要編列102年預算時，以101年資料估算，若全面改用安全針具，估需5億元。為配合法令所規定之5年內完成，並考量預算衝擊問題，所以每年編列1億元。因此是以當時的使用量及5年為期，全部替代為安全針具前提下，每年編列1億元。謝委員武吉請教健保署，當初編列預算時，健保署有無考量市場缺貨時，安全針具的售價將調高5~6倍。而且，健保署自己於全民健康保險藥物給付項目及支付標準共同擬訂會議，也決定調升內含空針之檢驗、檢查支付多1倍的價格。當時的1億元是粗估，並非準確數值，所以並不正確，建議不要增列「累積5億元即不再編列預算」文字。鄭主任委員守夏一、先暫停一下，有委員舉錶提醒時間不早了。現在是12點25分，為避免太晚去餐廳，廚師下班，建議縮短討論時間。二、向蔡委員登順說明，重要的是醫療院所採購安全針具的數量與價格，若數量乘以價格遠超過1億元，就沒有話講，因為1億元是健保署的預估。落款可否改為「請健保署提供醫療院所的使用量(或購買量)及價格」，發票上都有記載，無法做假，這樣就知道是否合理。可以嗎？(蔡委員登順表示同意)謝謝蔡委員登順。後面要討論的項目還很多，可能要加快速度。謝委員武吉在「配合安全針具推動政策之費用」項目中，應有「請於104年6月底前提送執行情形」文字。剛剛我有提到，不得另行申報之安全針具，則應由健保署提供資料，讓各位委員大家都知道。鄭主任委員守夏不太清楚不得另行申報之安全針具部分。謝委員武吉對於不得另行申報之安全針具，也都是我們的確也在使用的東西。鄭主任委員守夏若可提供數量資料，就可以進一步討論。謝委員武吉各次會議已經提過多次了！鄭主任委員守夏建議列入「請於104年6月底前提送執行情形」文字。楊委員漢湶一、為了幫主席加快腳步，「配合安全針具推動政策之費用」項目就定案。二、有關「提升住院護理照護品質」項目，接受各方所提意見，我幫忙整理後，建議修正文字如下：「除支付方式應依護病比架構辦理，並應訂定護理人力相關監測指標」。已將各方意見通通納入。干委員文男少了「連動」兩字。楊委員漢湶就不用「連動」。蔡委員登順應是「監理指標」，而非「監測指標」。監理指標是用於監督與管理，詞意很清楚，需要監理分析數據，也要報告。楊委員漢湶什麼叫做「監理指標」？柯執行秘書桂女健保會訂有「全民健康保險業務監理架構與指標」，健保署會依該架構指標定期做報告。蔡委員登順「監測指標」不用報告，但「監理指標」要報告。楊委員漢湶可以加「報告」兩字，但醫界習慣用「監測指標」。鄭主任委員守夏之前已經將護理人力納入「監理指標」，所以並不影響。楊委員漢湶既然已經納入，文字建議修改為「並應訂定護理人力相關監理指標」。吳委員肖琪是否改用「品質公開指標」？鄭主任委員守夏謝委員天仁當時很堅持應列護理人力指標，所以監理指標已有放進去。楊委員漢湶醫院總額部分就此結束。鄭主任委員守夏對提升住院護理照護品質計畫，是否就此定案？吳委員玉琴剛剛醫界一直反對「連動」，但我們對於「架構」不清楚，什麼是「醫護比架構」？柯執行秘書桂女係指「護病比」。吳委員玉琴「護病比架構」是新創名詞。謝委員武吉應請財團法人醫院評鑑暨醫療品質策進會來報告。楊委員漢湶其實「架構」兩字可以不要，只要保留「護病比」即可。吳委員肖琪建議用「調整」。楊委員漢湶可以。干委員文男如果沒有連動，後面…。楊委員漢湶如果一個人照護一張病床，是否給付就要更高一點點，沒有這樣連動的。一定是訂一個標準，例如1個護士最多照顧7張病床，重點在護病比，不是前面或後面加文字。鄭主任委員守夏建議將「辦理」改為「訂定」。楊委員漢湶主委更會修改文字，可以。鄭主任委員守夏文字修改為「除支付方式應依護病比訂定，並應訂定護理人力相關監理指標」，至於監理指標要幾個，則請健保署擬訂。李副組長純馥主席，相關護病比應該要跟隨衛福部政策，目前尚在醫院評鑑中研訂護病比之標準中。本段文字列出「於104年4月前提經全民健康保險會同意」，我比較擔心醫事司在10月以後才要啟動討論，恐時間來不及，所以建議提經健保會同意就好，不要列明時間，因為我們尚需依循衛福部政策。鄭主任委員守夏因為要依衛福部政策，若部處理較慢，我們也沒辦法。干委員文男建議「104年4月」的文字還是保留，給衛福部一點壓力。若都沒有時間壓力也不行。楊委員漢湶可否將「否則經費不得動支」文字刪除，那句話太嚴重了，改為「另於104年6月底前提送執行報告」。鄭主任委員守夏務實一點，文字改為「於104年6月前提經全民健康保險會同意後動支預算」。楊委員漢湶這樣就不能動支預算了！鄭主任委員守夏一、刪除「否則經費不得動支」文字，若104年4月或6月真的來不及，就要等通過後才能動支預算，這屬正向表列，而非負面表列。希望衛福部的動作快一點，今天曲司長同光也在，不要到104年底才通過。提升住院護理照護品質計畫的部分，就這樣確定。二、其他醫療服務利用及密集度之改變，增加「含藥物給付放寬適應症所增之費用」文字，請問醫界代表有無意見。郭代理委員正全(翁委員文能代理人)干委員文男的用意我們大概清楚，當初放寬Lucentis適應症，我們有提列預算之爭取。若依據現在落款之文字，以後所有適應症放寬都要包括在內，那還得了。不曉得以後還有什麼新藥要修改適應症。希望大家對這段能有共識，我們之所以爭取預算是認為對102年放寬Statins、Lucentis適應症所增加的金額做個彌補而已。干委員文男還是堅持我們的看法，預算都已編列，看醫界如何執行。現在連政策內的新藥也無法納入，醫界在全民健康保險藥物給付項目及支付標準共同擬訂會議中，不讓新藥納入給付，民眾需要的新藥被阻擋在共同擬訂會議內而出不來，這是不對的。這樣訂定，是希望能看到成果。葉委員宗義主席，這屬預算的執行依據。剛剛罕見疾病特材我們已經勉強同意了，現在這項不要讓我憤怒。蔡委員明忠104年「其他醫療服務利用及密集度之改變」項目，醫院編列22億元，西醫基層7億元，但因為放寬Statins、Lucentis適應症所增加的數量非常龐大，光此項就可讓預算爆掉了，完全無法再支應其他項目費用。醫界一直建議應該編列款項支應新藥，及舊藥新用也應該要額外編列預算支應，才能避免總額財務受到衝擊。否則坦白講，若今年「全民健康保險藥物給付項目及支付標準共同擬訂會議」開放幾個新增項目或放寬適應症，而健保署的估算出了問題，所衍生的醫療利用量暴增的結果，醫界無法承受。基於確保民眾就醫權益及維護醫療品質，我們都同意病患使用新藥及放寬適應症的舊藥，但要思考財源從何而來，像Statins、Lucentis一開放下去真的嚴重衝擊總額，重點在此。干委員文男若未落款文字，到時醫界在全民健康保險藥物給付項目及支付標準共同擬訂會議擋掉新藥或舊藥放寬適應症時，健保會就沒有立場講話。鄭主任委員守夏一、付費者委員在乎的是，全民健康保險藥物給付項目及支付標準共同擬訂會議過去兩年，只要是多花錢的項目，就會被踩剎車，應該是放寬Statins、Lucentis兩項藥品適應症的事件，把醫界嚇到了。二、重點是今天談的新藥本來就有編列預算，之後就不用再講上開兩種藥品放寬適應症所造成的影響，因為在這邊已經有所彌補。現在討論的是藥物給付規定放寬所增加的費用，104年已有編列新藥預算，就不能再說藥品給付規定放寬未編列預算。三、也許可以增列「在合理預期增加的費用之內」等類似文字，期待健保署與醫界互相尊重，並能為民爭利。放寬藥品給付規定所產生費用衝擊的部分已納入計算，在此一定要落款，不然付費者委員也擔心全民健康保險藥物給付項目及支付標準共同擬訂會議什麼都不通過，建議增列「在合理預期支出範圍內，應含藥物給付放寬適應症所增之費用」文字。請蔡委員登順。蔡委員登順昨天在協商時，金額一直往上加。昨天就講得很清楚，應包括藥物給付規定放寬所增加的費用，不能金額往上加，今天卻要推翻已經協議的條件。主席剛剛有講，醫界最近在全民健康保險藥物給付項目及支付標準共同擬訂會議擋掉了許多新藥引進，所以一定要寫「應含藥物給付放寬適應症所增之費用」文字，昨天協商已講明了，今天醫界若不同意，就沒有道理。為讓104年醫院點值能更好，此部分付費者委員已盡最大誠意，增加10幾億元預算，當然藥物給付放寬適應症所增加費用，亦應含括在內。鄭主任委員守夏以上的處理，大家同意嗎？陳委員宗獻對於文字沒有修正意見，兩個月前健保署有個專案報告，說明新藥、新科技、改變適應症的費用計算公式，當初只有兩張投影片，請健保署未來再詳細說明，讓醫界沒有疑慮，不用擔憂超支，可以放心在全民健康保險藥物給付項目及支付標準共同擬訂會議上通過新藥，不要成為新藥、新科技、放寬適應症納入健保的障礙。鄭主任委員守夏全民健康保險藥物給付項目及支付標準共同擬訂會議依法就是要討論新藥、新科技、放寬適應症等事項，若真的爆量，在共同擬訂會議中，應該就不會通過。蔡委員登順昨天協商已經談妥，現在沒有道理反對。陳委員宗獻所以昨天協商時就已經不講Statins、Lucentis開放適應症的事情，那已經是過去式。蔡委員登順昨天協商已列有「包括藥物給付放寬所增加的費用」文字，是我拜託付費者委員同意的，不要現在說要翻案，這樣誠信會出問題。楊委員漢湶昨天寫的文字並不清楚，現在用藥物的角度來看，改變適應症、包裝，都算新藥，都必須重新申請。至於全民健康保險藥物給付項目及支付標準共同擬訂會議審查新藥、新科技時，審查不通過則無法納入健保給付。所以「在合理預期支出範圍內，應含藥物給付放寬適應症所增之費用」到底是什麼意思？若係指放寬Statins、Lucentis適應症，現在寫了一張空白支票，請問我們要如何接受？鄭主任委員守夏文字可以修正，請提出建議。楊委員漢湶若僅指放寬Statins、Lucentis適應症，可以列在此，若屬開放新的適應症，應該列在新藥項目。鄭主任委員守夏若是新藥就應該列到新醫療科技(包括新增診療項目、新藥及新特材等)項目。楊委員漢湶對，是否明列「新藥除外」。鄭主任委員守夏可以，文字加上「新藥除外」。陳委員宗獻本來就有新醫療科技(包括新增診療項目、新藥及新特材等)項目。楊委員漢湶新醫療科技、新藥項目本來就不應列屬於「其他醫療服務利用及密集度之改變」中。謝委員天仁特別框新藥除外，不合理，這是全民健康保險藥物給付項目及支付標準共同擬訂會議的問題，該會的重點應該是財務失去平衡時，要如何處理。可否在後面落款「若有健保法第26條所定情形不在此限」，健保法第 26 條的意思是當健保財務平衡發生問題時，大家要去調整範圍，醫界真正擔心的是發生健保法第26條情形。陳委員宗獻健保法第 26 條是指總額協商時嗎？謝委員天仁不是總額協商，係指給付範圍變動致影響財務平衡時，此時要提到健保會進行相關的審議，屆時我們再來處理此問題，這樣可以嗎？鄭主任委員守夏也就是當影響真的很大時，就應該送到健保會討論。楊委員漢湶可否不要寫包含放寬適應症，因為適應症放寬就是屬於新藥。鄭主任委員守夏如果大家都有這種共識，就會納入新醫療科技項目。楊委員漢湶若這樣寫，會變成申請新醫療科技(包括新增診療項目、新藥及新特材等)項目未獲通過時，就會支用到「其他醫療服務利用及密集度之改變」項目，建議文字落為「經衛福部核定之費用」。謝委員天仁楊委員漢湶擔心的問題已經在健保法第26條解決，若有健保法第26條之情事，如給付範圍變更、放寬適應症，或新增給付項目時，當然就依第26條規定解決；若對財務平衡沒有影響，就屬合理預期的支出範圍，好不好？謝委員武吉現在討論的事項，感覺有些說的有道理，有些則沒道理。我們究竟是幫忙本國廠商爭取，還是幫忙外國廠商爭取，令人感到非常矛盾；現在甚至有外國的廠商帶著他們的人，說要在健保署藥品共同擬訂會議中增加幾個人，就可以增加幾個人！為什麼國內的廠商不敢這麼做呢？而且我們醫界也說應該要平等對待，但是都沒有啊！現在我在說的是別單位的事情，竟然連這種事都發生了，我們在這邊…。鄭主任委員守夏抱歉，許多委員都聽不懂，到底是指哪件事？謝委員武吉可以請健保署陳專門委員尚斌說明。鄭主任委員守夏相信楊委員漢湶的擔心是有道理，但我們在這邊處理的是財務，包括各種原因所造成的財務影響。剛剛謝委員天仁已經說明，當發生健保法第26條情事時，就會在全民健康保險藥物給付項目及支付標準共同擬訂會議上阻擋，並送到本會討論，已經考慮到醫界擔心的財務風險問題。楊委員漢湶如果這樣，就不要寫另送健保會，就寫「若有健保法第26條之情事，則不適用」。謝委員天仁這樣可以。鄭主任委員守夏好，就這樣。陳委員宗獻但總額財務也是屬於全民健康保險法第 26 條所提保險財務。鄭主任委員守夏一、我們現在討論的是「其他醫療服務利用及密集度之改變」項目，其中「應含藥物給付放寬適應症所增之費用，若有健保法第26條之情事，則不適用」，就這樣決定。二、另外，剛剛已將新增罕病特材移至「罕見疾病、血友病藥費」專款項目，本項已討論。李副組長純馥標題是否一併改為「罕見疾病、血友病藥費及新增罕病特材」，這樣較符合剛才的討論結果。鄭主任委員守夏好，就這樣修改。再來，「急診品質提升方案」應該沒有問題。最後就是門診透析服務。張專門委員溫溫這部分說明一下，之前院所傳送給腎臟醫學會的項目非常多，例如社經地位等。有些是為了學術研究而上傳，健保署則建議與品質相關的項目才上傳至健保資訊網服務系統(VPN)，但非所有項目均上傳，如果要上傳所有資料，恐會造成院所端很大的負擔，因為項目真的非常多。干委員文男我認為還是需要請腎臟醫學會將我昨天所提到的項目，以及相關的10幾個表上傳給健保署，以前外界都無法索取到這些資料，現在有機會可以取得，健保署反而不要。資料所需要的大資料庫空間、上傳頻寬的問題等都解決了，院所端願意上傳給健保署，健保署反而不要，不是很奇怪。謝委員武吉說大陸很多學者都在進行相關研究，先進國家也來看台灣透析品質有多好；我們透析品質號稱全世界第一，希望不要拒絕資料上傳。謝委員武吉一、不反對資料上傳給健保署，但不要增加院所負擔。我們已經被外界認定是血汗醫院、血汗護理人員及血汗老闆，在這裡的各位不要變成血汗委員。二、建議院所有向腎臟醫學會提報的資料，也可以比照醫策會。台灣目前的品質指標分為，TCPI(台灣臨床成效指標系統)、TCHA(地區醫院品質指標系統)及THIS(醫務管理學會照護品質指標)等三套。醫策會現在已經改變方式，如果院所有參加這三個指標系統，可以寫一個委託書，在不洩漏個資的前提下，由腎臟醫學會直接轉給健保署就可以了，不用再增加院所的負擔。不反對資料上傳，但建議由腎臟醫學會直接轉給健保署即可。鄭主任委員守夏一、我相信健保署在資訊系統上不會有困難，之前醫療院所可以上傳給腎臟醫學會，現在為何不能上傳給健保署？我不知道為什麼。沒有什麼理由，以後專家學者要做研究，只能找腎臟醫學會提供資料，這是不進步的原因。二、如果真的讓醫療院所很麻煩，或是健保署的資訊系統很差，我會同意謝委員武吉所提，不要去虐待醫療院所。資料是同一套，只要按一個鍵就上傳了，過去也是這樣，看不出有什麼道理不可行。個人支持干委員文男的看法，有資料也沒壞處，為什麼健保署不要接收，除非健保署有困難。謝委員武吉我的意思是門診透析院所上傳的資料包括兩種，一種是學者研究用，一種是健保署需要的，可以在醫療院所上傳腎臟醫學會後，由該會整理，再直接傳送給健保署。鄭主任委員守夏腎臟醫學會與健保署沒有直接隸屬關係。謝委員武吉在不違反個資法規範的前提下，寫一個委託書就可以。干委員文男我參加透析總額研商議事會議已經2年，當時就是怪錯對象，例如健保署委託腎臟醫學會研究，研究結果的資料竟然拿不到，好像資料是否提供都把持在幾個人手上。健保署預訂7月請醫療院所上傳資料，最後送的資料項目也還是不足，真不明白只要指令一下，項目就可以通通上傳，也沒有增加任何一家院所的麻煩，但健保署為什麼不要？每次開會健保署都在現場，也清楚我所有的努力，最後我還得向別人道歉。我們要的資料，腎臟醫學會都不提供健保署，給的項目也只有一點點，難道用一個醫院看天下嗎？現在幫健保署要，你們反而不全部要，這樣對嗎？健保署這樣會進步嗎？我也是很憤怒。謝委員天仁有道理！鄭主任委員守夏健保署可以說明嗎？李副組長純馥我們不希望落款全數上傳的文字，是因為醫療院所上傳給腎臟醫學會的部分資料，在我們的申報檔本來就有，如果要全數上傳，其實作業會重疊；同時也擔心資料精準度的問題，會使資料庫的使用者困擾，所以才建議可否容我們有協商空間，就是資料要盡量完整，但不要寫全數上傳，因為有些資料我們已經有了。干委員文男(要求繼續發言)鄭主任委員守夏一、完全瞭解，我是支持您的。二、如果醫療院所沒有太大問題，就全部上傳，之後再由健保署挑選，對於申報檔已有的項目，就跟醫療院所說明並請其以後不用再上傳；同時也可向健保會委員說明，醫療院所的資料我們已經都有了，這樣不是很好嗎？三、干委員文男要求的只是以後不論要看什麼資料，請健保署分析都沒問題，相關資料不會僅腎臟醫學會有，若每次都得找腎臟醫學會索取，感覺很奇怪。已經有的資料當然可以不用再去要，也不要增加醫療院所的負擔，這樣處理，可以嗎？蔡委員登順好。謝委員武吉剛才謝委員天仁建議將「成長率項目表」文字，改為「協定項目表」，修改了沒？柯執行秘書桂女已經修改了。鄭主任委員守夏委員有無其他意見？吳委員玉琴一、請將各總額部門協定事項表的標題，依謝委員天仁的建議修改。二、書面資料上的成長率、金額與昨天通過的金額有落差，例如醫院總額的「強化醫療資源支付合理性」金額應該是351.0百萬元、「第2階段DRGs所需費用之調整」金額應該是387.0百萬元、以及其他預期之法令或政策改變項下的「配合結核病防治政策之改變」，金額應該是36.0百萬元等。因為是用成長率百分比換算金額，以致書面資料上的總金額加起來反而比昨天增加一百多萬元，所以我認為應該要用金額換算成長率，而不是用成長率換算金額。鄭主任委員守夏好，這部分請同仁會後處理。但我必須說，現在的公式是用成長率換算金額，百分比要到小數點後8位才能相同，因此金額才會稍有落差，會後請同仁修改，該25億元的就25億元，該2,000萬元的就2,000萬元，大家互不相欠，這個合理。但若真的沒辦法，就用手動方式調整成協商金額。柯執行秘書桂女這部分會後再請幕僚依委員意見修正，並於下次委員會議確認。鄭主任委員守夏一、好，謝謝！醫院總額確認通過，後面還有兩部門總額，我們加油！(部分委員建議講重點)二、好，就講重點，不必唸文字，直接看協定項目表，上面列有金額及主要協定事項。同時也請付費者委員留意，協定事項有無特別需要增列的落款文字。現在請委員從中醫門診協定項目表最上方開始。三、中醫門診部分：非協商因素成長率0.978%，增加金額是210.6百萬元；協商因素成長率0.684%，增加金額是147.3百萬元。(一)一般服務成長率1.662%，合計357.8百萬元：1.品質保證保留款(0%)2.調整藥事服務費(0.135%)，增加29.1百萬元。3.其他醫療服務及密集度之改變(0.557%)，增加120.0百萬元。請同仁會後更正金額。4.違反全民健康保險醫事服務機構特約及管理辦法之扣款 (-0.008%)，扣減金額1.7百萬元。(二)專款合計241.5百萬元。1.醫療資源不足地區改善方案，經費96.5百萬元，增加22.1百萬元。2.西醫住院病患中醫特定疾病輔助醫療試辦計畫，經費113.0百萬元。3.提升孕產期照護品質計畫，經費32.0萬元。(三)校正人口差值後104年度總成長率1.897%；相較103年度核定總額成長率2.124%，總金額為22,129.3百萬元。四、請委員檢視協定事項文字是否需要修正。謝委員天仁「其他醫療服務及密集度之改變」的協定事項第2點，人口占率R值應往前進，表示中醫部門對此有承諾，既然有保證，若最後沒達成，也應有處理機制。建議協定事項文字修改為「人口占率R值應往前進，否則本項預算收回」。鄭主任委員守夏好，請同仁將上述修正文字列入協定事項，這樣應該很明確。委員還有無意見？李代理委員豐裕(何委員永成代理人)請將螢幕拉到最後一頁，請問411.9百萬元是「協商」總金額嗎？柯執行秘書桂女不是，411.9百萬元是增加金額，中醫門診的總金額是22,129.3百萬元。李代理委員豐裕(何委員永成代理人)好，沒有問題了！鄭主任委員守夏一、好，中醫門診總額確認通過。接下來，請委員參看西醫基層總額的協定項目表。二、非協商因素成長率1.154%，增加金額1,132.7百萬元；協商因素成長率1.293%，包含品質保證保留款0.1%，新醫療科技0.122%，新增1億1,980萬。陳委員宗獻是1億2千萬。鄭主任委員守夏一、抱歉，是1億2千萬，請同仁修正數據。二、調整藥事服務費及語言治療診察項目0.399%，配合安全針具推動政策之費用0.004%，增加3.9百萬元。 吳委員玉琴調整藥事服務費及語言治療診察項目之增加金額應為391.6百萬元，非391.7百萬元。鄭主任委員守夏一、調整藥事服務費及語言治療診察項目之增加金額，請同仁修改為391.6百萬元。二、其他醫療服務利用及密集度之改變，原呈現之699.9百萬元修正為700百萬元。三、其他議定項目，違反全民健康保險醫事服務機構特約及管理辦法之扣款，成長率為-0.045%。一般服務成長率為2.447%。四、專款項目：醫療資源不足地區改善方案，經費1億5,000萬元，慢性B型及C型肝炎治療計畫，經費4億元，醫療給付改善方案，經費2億5,440萬元，家庭醫師整合性照護計畫，經費1,180百萬元。專款總金額1,984.4百萬。五、門診透析服務成長率5.557%。六、相較103年度核定總額成長率3.191%；含校正投保人口數成長率差值後，總成長率為2.991%，總金額為117,254百萬元。七、請各位委員檢視協定事項文字是否需要修正。請干委員文男。干委員文男剛才醫院總額一般服務有關「含藥物給付放寬適應症所增之費用」的文字，及對門診透析服務的附帶條件，應都要納入西醫基層總額的協定事項。鄭主任委員守夏就是與醫院總額共通的項目，西醫基層總額的協定事項文字比照修正。請問陳委員宗獻，這樣處理可以嗎？干委員文男對。陳委員宗獻一、沒有意見。二、請大家看到「新醫療科技」的協定事項第1點，最後有一段文字「若未於時程內導入，則扣減該額度」，在103年總額執行沒問題，但104年總額則不行，因為健保署為與全民健康保險藥物給付項目及支付標準共同擬訂會議連動，目前估計新醫療科技的預算，是計算5年費用，也就是新藥是以前5年的平衡來計算，多退少補的意義在此，建議將這段文字刪除，因為沒辦法處理。新監控機制的時程是5年，今年跟往年不一樣。鄭主任委員守夏請健保署幫忙說明。陳專門委員尚斌新醫療科技的預算，主要包括新增診療項目、新藥及新特材等，在新藥、新特材這部分，健保署從規劃總額預算制度開始，一直都是用5年去計算導入新藥、新特材在新醫療科技項下所需增列的費用。鄭主任委員守夏這邊文字要怎麼寫較好？陳委員宗獻若是放著沒有窒礙難行的問題，我沒有意見。先前不是有個簡報，最後要有個總計，不就解決了問題。李副組長純馥其實這個文字過去幾年都有出現，用意是協商時，如果總額部門都不同意新增項目，就要扣除相關預算，但那是整體概念，並沒有精算個別項目。意思是，如果總額部門在協談時，都不通過，那就要將整筆額度扣掉，但每年12月底前，只要在共同擬訂會議有通過新增項目，基本上這筆預算就不會被扣除。陳委員宗獻好，那我同意。鄭主任委員守夏一、西醫基層總額也確認通過，接下來是其他預算，屬健保署控管的計畫，文字部分不用再唸。二、針對昨天委員有意見部分已配合修正，例如「推動促進醫療體系整合計畫」項下已增列謝委員武吉所建議的「跨層級醫院合作計畫」子計畫；22億元的「鼓勵醫療院所即時查詢病患就醫資訊措施」，原則上也同意，文字說明非常清楚，明年6月底前提送執行成果及成效評估報告；2.85億元的「提升保險人管理效率」，委員已經善意、盡責提醒，是否有法律上的疑義，原則上只要衛福部同意，那麼責任就在衛福部，本會已善盡告知責任。最主要是這幾項，委員有無其他意見？楊委員漢湶「提升保險人管理效率」協定事項的第2點，用詞看起來有些奇怪，昨天我們是說，本項計畫就送衛福部核定，「原則同意」四字應刪除。鄭主任委員守夏可否將「本項經費原則同意」文字刪除，修正為「本計畫須報經衛生福利部法制單位通過後始得動支」，大家有無其他意見？(委員回應：好！)。吳委員玉琴昨天大家關心的「提升急性後期照護品質試辦計畫」，看起來執行成效不是很好，有無可能請健保署在試辦計畫修正後提報健保會，因為這屬延續型計畫，應該104年初就可以送過來。鄭主任委員守夏協定事項中已要求各計畫於104年6月底前提送執行成果及成效評估報告。吳委員玉琴好。另外昨天也提到可否在協定事項中，落款「幾年後將居家護理、照護機構納入」等文字。鄭主任委員守夏這部分，應該在討論細部方案時處理，而非列在協定事項。李委員蜀平昨天有提到要將「全民健保高診次民眾就醫行為改善方案-藥師居家照護」單獨列項，是否有列？鄭主任委員守夏「全民健保高診次民眾就醫行為改善方案-藥師居家照護」已經單獨列項，但因單獨列項，所以要設定計畫目標，並且於104年6月底前提送執行成果及成效評估報告。謝委員武吉吳委員玉琴我要提醒您。吳委員玉琴是。謝委員武吉去年協商時就有要求「提升急性後期照護品質試辦計畫」要在實施6個月後提出檢討報告，當初就有提出，但到現在已8月都還未提出，所以應該下個月就要檢討。不只您很關心這個計畫，我也盯得很緊。鄭主任委員守夏我們可以盯緊這個計畫，並排入專案報告，可是我們也排了許多專案報告，時間卻常不夠。干委員文男昨天謝委員武吉所提有關醫院垂直整合方案，有無增列？名稱是什麼？現在是否用跨層級整合?鄭主任委員守夏一、已增列，計畫名稱是「跨層級醫院合作計畫」。二、本案討論完畢。請問委員有無其他補充？(未有委員表示意見)參、臨時提案「有關中央健康保險署與主計總處核算全民健康保險法規定政府法定負擔36%比率見解不同案」之與會人員發言實錄鄭主任委員守夏早上干委員文男提出臨時提案，並已獲得二十幾位委員連署，打破歷來臨時提案的連署人數，先請干委員文男說明。干委員文男本案經過昨天的發飆，大家才知道，最後受益的會是醫界，當然付費者也多少有些好處，但最困難的部分要請衛福部社保司提出說明。我們後續已經準備很多問題，若沒有個令人滿意的答案，也會像謝委員天仁一樣，透過記者會聲討公道，不然也可以到總統府或行政院前發動抗議。謝委員天仁本人認為關鍵並不在採取什麼樣的行動或作為，決議內容才是重點。建議請權責機關(即有權解釋法規的機關)解說，所以應該是衛福部(社保司)，意即請曲委員同光說明。鄭主任委員守夏請曲委員同光。曲委員同光一、衛福部社保司對本議題的立場與各位委員一致，認為健保法的計算有其基本精神，但關鍵點還是在援引的法條與觀點。事實上，在健保會本(103)年8月份委員會議，曾對此進行討論，會後衛福部也已將該次委員會議的意見彙整，陳報行政院。二、今天再次慎重地提出本建議案，我們也會轉請行政院考量。鄭主任委員守夏請教謝委員天仁有關決議文字的部分，「如果在體制內溝通無效，健保會的委員就會…(停頓)」，我實在不知道要如何接下去。請大家幫忙。謝委員天仁本人建議決議文字如下：一、健保法應由衛福部(社保司)依法解釋，行政院主計總處無權置喙。(吳委員玉琴同時表示，當適用法規有疑義時，本應由主管機關函示)二、依健保署的核算方式訂定政府負擔，並請衛福部轉行政院參辦。鄭主任委員守夏如果其他委員都沒有意見，請同仁按照謝委員天仁所唸的文字列入紀錄。請李委員永振。李委員永振一、本人贊同謝委員天仁的意見，但有兩點補充。二、依全民健保法第5條第1項第4款規定，健保會的職責包括：保險政策、法規之研究及諮詢。照理講，健保會也不能置身事外。三、另外，依商業保險所適用的保險法第54條規定略以：保險契約之解釋，應探求契約當事人之真意，不得拘泥於所用之文字；如有疑義時，以作有利於被保險人之解釋為原則。保險法對商業保險有此規範，但不確定此立法精神社會保險是否也適用。鄭主任委員守夏一、依照剛剛謝委員天仁及李委員永振的建議，可歸納成3點結論。二、第1點，依照健保法相關規定，健保會職責包含對法規的研究與諮詢；第2點，健保法應由衛福部解釋；第3點，衛福部應依健保署的計算方法，循行政程序將健保會意見陳報行政院。謝委員天仁健保會不是解釋機構，我們是被諮詢單位，所以剛才李委員永振所提，當法規適用有疑義時，可以諮詢健保會，本會可以表達意見，但有權解釋法規的機關，應該是衛福部(社保司)。曲委員同光法規解釋是衛福部的權責，不是社保司。鄭主任委員守夏請問委員還有無其他臨時動議？何委員語中醫門診的總金額還未確認。鄭主任委員守夏書面資料沒有列，但剛才螢幕有顯示，104年度中醫門診總額的總金額為22,129.3百萬元。何委員語請再投影一次，讓我們確認。謝委員武吉剛剛突然發現議程資料第118頁的討論案第二案還未討論，很奇怪，為何會先討論臨時提案，難道是醫事服務提供者的提案比較不重要嗎？所以能跳過就跳過。鄭主任委員守夏一、絕對不是這樣，每位委員都一樣重要，只是因為剛才的氣氛太好，就先討論了。請問是否同意將討論案第二案移至下次委員會議討論？(多位委員表示同意) 二、今天會議到此，感謝大家！PAGE PAGE PAGE \* MERGEFORMAT35PAGE \* MERGEFORMAT34PAGE \* MERGEFORMAT87PAGE \* MERGEFORMAT90PAGE \* MERGEFORMAT33PAGE 18PAGE \* MERGEFORMAT1PAGE 8iVBORw0KGgoAAAANSUhEUgAABHgAAAZSCAIAAADDOMFtAAAAAXNSR0IArs4c6QAAAAlwSFlzAAAV
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