衛生福利部全民健康保險會第1屆103年第12次委員會議議事錄中華民國103年12月26日衛生福利部全民健康保險會第1屆103年第12次委員會議紀錄壹、時間：中華民國103年12月26日上午9時30分貳、地點：本部301會議室(台北市忠孝東路6段488號3樓)參、出席委員：干委員文男曲委員同光何委員永成 何委員語 吳委員玉琴吳委員肖琪李委員永振 國泰人壽陳稽核襄理炳宏(代)李委員成家 李委員蜀平 林委員至美 林委員錫維侯委員彩鳳柴委員松林翁委員文能新光醫院管理部保險課廖襄理秋鐲(10：50~13:15代) 台灣大學附設醫院醫療事務室黃組長雪玲(13：15以後代)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中華民國醫師公會全聯會黃副秘書長啟嘉(11：00以後代)陳委員錦煌陳委員義聰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 中華民國醫師公會全聯會李理事紹誠(11：00以後代)蔡委員登順蔡委員圖晉 中華民國工業協進會張秘書長文龍(代)謝委員天仁 謝委員武吉 台灣社區醫院協會朱監事長益宏(11：00~11:50代)肆、請假委員：周委員麗芳林委員啟滄伍、列席人員：本部社會保險司楊副司長慧芬中央健康保險署黃署長三桂 蔡副署長魯林組長阿明施組長如亮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：陳燕鈴、林淑華柒、主席致詞各位委員、黃署長及所有與會人員，大家早！今天是本(第一)屆最後一次召開委員會議，衛生福利部蔣部長特別蒞臨本會向各位委員致意，歡迎蔣部長！捌、蔣部長丙煌致詞鄭主任委員、各位委員及所有與會同仁，大家早！就我所知在過去2年來，各位全民健康保險會的第一屆委員非常辛苦，所以今天特地前來致上十二萬分的謝意與敬意！聽說總額協商時，各位甚至挑燈夜戰至晚上近11點，對大家盡心盡力為健保事務奉獻的精神，本人極為感佩！全民健保業務涉及層面很廣，而健保會在處理法定任務時，須考量與兼顧醫界、病人、社會大眾及保險財務等多面向因素，以凝聚最具智慧的共識，真的相當不容易！全民健保因各位委員奉獻諸多心力與智慧，而得以穩健地往前邁進，在此由衷感謝！另外，也要特別感謝鄭主任委員守夏，渠任勞任怨地主持會議，真的很不容易。昨天再度透過電話，懇切拜託鄭教授，只有像他這麼深具威望與睿智的學者，才足以擔負主任委員的重責大任，所以懇請各位委員務必繼續給予支持！委員桌上都有一份本部致贈的感謝狀，雖然禮輕，但情義重！希望藉此聊表心意，爾後還希望大家多多指教！謝謝！玖、議程確認決定：確定。拾、例行報告第一案案由：確認本會上(第11)次委員會議紀錄，請 鑒察。決定：確定。第二案案由：本會上(第11)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：上次委員會議決議(定)事項辦理情形洽悉。本屆歷次委員會議之未結案件，將移請下屆委員繼續關心。日後若有相關法規經修正或擬修正，而致原非由全民健保給付(如依其他法令須由政府負擔)之費用，可能轉由全民健保總額預算支應時，請中央健康保險署即時、主動於每月例行之業務執行報告中提報。第三案案由：中央健康保險署提報「104年度各部門總額協定事項中需向本會說明或經本會同意後方可施行之項目」案，請 鑒察。決定：洽悉，請中央健康保險署盡速依法定程序辦理後續事宜。第四案案由：中央健康保險署函送本會同意之「104年度各部門總額一般服務保障項目」案，請 鑒察。決定：洽悉。附帶決議：需保障或鼓勵之醫療服務以支付標準處理才是正途，現行之點值等保障方式，久而久之恐將使結構失衡，請中央健康保險署於6個月內研提相關改善方案送會。第五案案由：中央健康保險署「103年11月份全民健康保險業務執行報告」，請 鑒察。決定：請中央健康保險署參酌委員所提建議，調整報告內容，餘洽悉。拾壹、討論事項第一案提案單位：中央健康保險署案由：103年731高雄石化氣爆之醫療費用由103年總額其他預算之「其他預期政策改變及調節非預期風險所需經費」項目支應案，提請 討論。決議：同意103、104年度其他預算之「其他預期政策改變及調節非預期風險所需經費」之款項，可用以支應103年731高雄石化氣爆事件自發生後起算，共 6個月各分區該事件之醫療費用。第二案提案單位：中央健康保險署案由：有關醫院總額103年新增診療項目未於年度內支應之額度准予於104年支應案，提請 討論。決議：鑑於103年度全民健保總額及其分配案，業經衛生福利部核定公告，爰應遵循相關核定事項辦理。103年度醫院總額原擬新增之診療項目，若未於當年底前導入，則應扣減該相關預算額度。第三案提案單位：中央健康保險署案由：「可調式腦積水引流系統--『英特佳』內植用腦積水引流管組OSVⅡ」自付差額特殊材料案，提請 討論。決議：委員所提下列意見，請中央健康保險署參酌：本案未提醫療科技評估資料供參，而就所提供之資料，其相較於現行健保已全額給付之品項，價格差距達8倍以上，但效益似不明確。考量開放自付差額特材攸關民眾權益，且特材品項推陳出新，療效與成本效益不確定性高，建議日後提案時，應檢附嚴謹之醫療科技評估報告及輔助性客觀資料，以利討論。第四案提案單位：本會第二組案由：全民健康保險年度總額對給付項目調整之處理機制案，提請 討論。決議：為使本案處理機制更周延，以利運用，請幕僚再徵詢委員意見並予彙整後，提下次委員會議討論。第五案提案單位：中央健康保險署 案由：檢討「全民健康保險保險對象應自行負擔費用之合理性」案，提請 討論。決議：本會委員經參酌中央健康保險署前召開會議所彙集之各界代表意見，及本次委員會議之討論，對於是否調整保險對象自行負擔費用，尚未有可供決策參考之一致看法。基於本案屬保險政策諮詢事項，本會為溝通平台，爰綜整保險付費者、醫事服務提供者代表委員之意見(如附件一)，供衛生福利部及中央健康保險署參酌。拾貳、專案報告報告單位：中央健康保險署案由：保險對象自付差額特材之實施情形，請 鑒察。主席裁定：保留至下次委員會議報告。拾參、臨時提案(如附件二)提案人：謝委員天仁連署人：干委員文男、吳委員玉琴、林委員錫維、連委員瑞猛、蔡委員登順、何委員語、葉委員宗義、楊委員芸蘋、陳委員川青、柴委員松林、侯委員彩鳳、吳委員肖琪、楊委員漢湶、陳代理委員炳宏(李委員永振代理人)、李委員蜀平、莊委員志強、陳委員錦煌、蔡委員明忠、翁委員文能、劉代理委員碧珠(張委員煥禎代理人)、謝委員武吉、陳委員宗獻、陳委員義聰、何委員永成、楊委員麗珠、林代理委員敏華(張委員永成代理人)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：有關汽車肇事，擬刪除保險人健保署對保險公司之代位權，或修改強制汽車險傷害不賠，涉及肇事者相關責任轉由全民負擔，嚴重影響健保財務及公平正義，提請 討論。決議：基於「強制汽車責任保險法」若刪除「傷害醫療費用給付」之給付項目，將使中央健康保險署喪失向強制汽車責任保險之保險人行使代位求償權，而將相關費用轉嫁由全民負擔的健保費支付，嚴重影響健保財務且違反公平正義，爰本會27位委員共同連署反對，並將透過公開聲明向權責機關表達渠等之立場。拾肆、散會：下午2時12分。附件一檢討「保險對象應自行負擔費用之合理性案」之委員意見彙整表代表類別表 達 意 見 保 險 付 費 者 代 表傾向不調整1.調整自行負擔應顧及民眾觀感及社會氛圍，且目前健保財務尚佳，建議維持現況。2.調高自行負擔費用，等同調漲費率，目前健保尚有盈餘，在不調降費率的情況下，調整自行負擔費用，沒有正當性。3.目前已有約72%的保險對象穩定地在基層診所就醫，至於分級醫療及轉診比率應多少才合理，並無定論。4.過去曾多次調整自行負擔費用，但似乎未顯現落實分級醫療及轉診制度之效果，若要調整，應提出更多佐證數據支持。5.在自由競爭的市場下，調高自行負擔費用，並不影響經濟富裕者前往大醫院看病，反而造成經濟弱勢者的就醫障礙，形同懲罰弱勢民眾。6.單靠調整自行負擔無法落實分級醫療，也無法解決地區醫院面臨的困境，健保署應該從長計議，整體考量相關配套措施，如透過垂直整合方案、急診品質提升方案等，引導輕症病患轉至地區醫院，及解決急診壅塞等問題。 保 險 醫 事 服 務 提 供 者 代 表傾向調整1.衛福部應依法行政，依健保法第43條規定，收取保險對象應自行負擔費用，及落實該條文之分級醫療、轉診制度。2.目前自行負擔費用比率(11.8%)與法定比率(最低20%)差距甚大，並已多年未調整，致產生許多問題(如檢傷分類第4、5級病人，為求方便，湧至急診就醫)。3.若無法一次調整到位，可先調整部分項目(如急診)。並要有相關配套措施，如推動急性後期照護計畫，促使落實分級醫療。4.贊成門診依健保法第43條第3項，必要時得以定額方式收取，但需依照各級醫院前一年平均門診費用及第1項所定的比率計算。5.對經濟弱勢者，可採行配套措施，如設定自行負擔費用上限，或予以減免。附件二第1屆103年第12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11)次委員會議紀錄」、例行報告第二案「本會上(第11)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、謝謝部長蒞臨致贈委員感謝狀及致詞！二、等一下請各位委員到1樓大廳拍大合照時，再邀請部長一起合影留念。謝謝部長(與會者鼓掌)。三、今天的會議，計有5項例行報告，5項討論事項及1項專案報告。對於今天的議程安排，各位委員有無意見？(未有委員表示意見) 。四、等拍照場地準備好，我們就去合照。現在先進行例行報告，大家同意嗎？(委員表示可以)，請同仁宣讀上(第11)次委員會議紀錄。同仁宣讀鄭主任委員守夏謝謝同仁宣讀！請問各位委員對會議紀錄內容有無修正意見？請李委員蜀平。李委員蜀平尊敬的主席，各位委員大家早！上次委員會議討論事項第9案，我是提案人，我不認同該案的決議內容，我們的健保制度是世界第一，目前健保收入也很充裕，但藥價差卻一直沒有明確的數字，我不了解到底為何健保署不願意告知委員藥品之健保給付價格與實際銷售價格，之間差距到底是多少金額？這樣金額究竟屬於健保費用或是獎勵金？我想藥價差應有佔健保總費用約10%，這藥價差一直是許多專家及公協會所質疑，希望不要因為藥價差讓醫界蒙羞，以為醫界多好賺。鄭主任委員守夏李委員蜀平的用意，大家應該都了解，上次委員會議討論事項第9案決議，是大家討論後的共識。我知道李委員要的，不只是這樣。李委員蜀平這不是我要的決議！鄭主任委員守夏但紀錄上的決議是大家的共識！李委員蜀平我的意思是，沒有把我的意見放入決議裡。鄭主任委員守夏那部分應該已在實錄裡面，可以寫一條…。李委員蜀平很簡單，告知藥價差總金額多少？佔健保費比率多少？是健保費還是給額外的獎勵金？要求這樣有困難嗎？決議內容不是我所講的，也和提案的內容方向不一致。鄭主任委員守夏請問決議文字內容有無需要修正？李委員的意見，若大家都同意，就據以修正決議內容。李委員蜀平我的意思不是這樣，只是想了解藥價差佔健保費比率是多少？就這麼簡單而已！ 鄭主任委員守夏李委員說，討論事項第9案的決議「文字」不是他要的，但該「文字」是幕僚依據錄音內容所撰寫，而且是大家的共識，所以請李委員確切說出如何修正。李委員蜀平我堅持這一點，不要讓藥價差成為醫院經營追求利潤的方向，應該給醫院或醫師專業的好待遇，讓其發揮專業。我建議決議要敘述：請健保署統計藥價差總額多少？占健保比例多少？藥價差屬於健保費或是其他獎勵金？鄭主任委員守夏我們在討論會議紀錄「文字」可如何修正，照李委員的意見，修正「文字」很長，不知還是不是我們的決議？現在的決議是，請健保署來報告，內容包括藥價調整後藥價差百分比，這就是李委員所要的數字。李委員蜀平對！但決議內容敘明健保藥品費用分配比率目標制相關事宜，並不是我所提的。鄭主任委員守夏藥品費用分配比率目標制相關事宜，是我們付費者代表委員想要的！(吳委員玉琴點頭)討論後決議就是現在這樣。李委員蜀平我提案的用意，並不是這樣子！鄭主任委員守夏本案是經大家討論後，部分委員認為不能只談藥價差，還要看「健保藥品費用分配比率目標制」執行結果，所以是在獲致共識後形成決議。李委員蜀平尊重所有委員的意見，但我的提案內容被漏掉的部分，請幫忙加上去，可以嗎？藥品健保給付價格與醫療院所實際售價的差距，健保署都有資料，到底佔健保比率多少？究竟屬於健保費用或是屬其他獎勵金，請健保署告知。鄭主任委員守夏這一段加到討論事項第9案的案由，李委員今天的發言內容，也請健保署於專案報告時，說明可以辦理的部分。李委員蜀平健保署一定做得到！若做不到，電腦就有問題。謝委員武吉主席，我覺得這種決議內容，都是主席講出來的，屬於司空見慣的決議方式，我支持李委員蜀平的意見，應該修改就得修改。案由沒有健保藥品費用分配比率目標制，決議內容卻有，健保會2年來，都是這樣打唬弄。鄭主任委員守夏現在處理的是，決議文字究竟有無錯誤？若只是決議沒有出現李委員蜀平所要的「文字」，則在後面再加上想要的「文字」，並經大家同意就可以了。李委員蜀平遵照鄭主任委員所講的，原則上這個決議的內容，有漏掉我所講的部分，拜託再加上「請健保署運用電腦，統計藥品健保給付價格與醫療院所實際售價的多少？佔健保比率多少？屬於健保費用或其他獎勵金？」這樣可以嗎？我們委員應該了解這些！今天是本(第1)屆委員最後一次委員會議，說不定下一屆我就被撤換掉，所以，我一定要講。鄭主任委員守夏就剛才李委員蜀平想要增加的文字部分，若大家都同意，其係上次有討論到卻未寫進去，就直接修改決議文字，也就是健保藥品費用分配比率目標制試辦方案之評估與檢討、藥價調整結果藥價差百分比後面，加上「(健保給付價與實際售價的差距金額，及佔健保的比率)」；但若委員有意見，表示上次並沒有講這些，今天想加的文字只是李委員蜀平的意思，沒有人支持，當然就不是決議。李委員蜀平因為所有的藥價實際銷售，健保署都有資料。鄭主任委員守夏我剛才所唸的括號內文字，在場委員如有不同意見，請提出來。因為李委員蜀平是提案人，他認為加上此些文字，這才是他要的。李委員蜀平目前健保藥品的費用約1,500億元，與實際醫療院所的售價差距總金額。鄭主任委員守夏請蔡副署長魯。蔡副署長魯主席、各位委員大家早！剛剛李委員蜀平所提的內容，係屬理想，似乎覺得健保署掌握了臺灣所有的藥品市場。有關健保給付價與醫療院所實際售價的差距總金額，據我了解，健保署並無法掌握此部分的數據，要健保署提供，可能有點困難。李委員蜀平全國每二年都進行藥價調查，每一筆銷售資料都要誠實申報，都非常明確，健保署絕對有辦法統計，電腦操作一下就知道了！拜託大家一起來改善醫療環境好嗎？鄭主任委員守夏對於上次委員會議的紀錄，委員沒有意見，而李委員蜀平認為，第9案的決議內容尚缺某段文字，渠欲加入的部分，大家都同意嗎？請蔡委員明忠。蔡委員明忠依李委員蜀平的邏輯推論，則對於大賣場的東西都可調查其獲利價差情況。我們很清楚健保署的藥價調查，主要目的，是希望藥品的健保給付價格，趨近醫療院所實際的購入價格，這個機制若遭打破，則整個自由經濟市場將全部癱掉。藥價差並不是醫界的秘密，我認為要尊重整體自由經濟市場的機制，健保署的努力，大家都看到了！每年從藥價調查節流很多錢，若要一次到位，則請大家深思，這樣的做法好與不好？謝謝！鄭主任委員守夏請陳委員宗獻。陳委員宗獻所有產品都有其價格系統，價格系統是沒有限度的，也沒有道德觀念，藥價太高或太低，這是一種市場機制，不應要求健保署去做不合市場機制的事。謝謝！李委員蜀平主席、各位委員，我們都是健保會的委員，不是所有賣場商品的委員，要了解健保藥品差額的價格資料有錯嗎？蔡委員明忠、陳委員宗獻，你們在怕什麼？大家共同來面對，讓藥品價格申報之每筆帳都很清楚，如虛報被查到會健保價歸零，健保署與大賣場有什麼關係？藥費是健保資源的一環，我希望這部分可以透明清楚。謝委員天仁主席。鄭主任委員守夏請謝委員天仁。謝委員天仁拜託一下！今天是我們這一屆要結業的時間，這樣下去，恐怕下午1點都無法結束。現在是確定會議紀錄中有哪些文字要修改，剛才李委員蜀平所提的部分，可以在其他段落敘述，也可以提案，請照議事程序進行，會議紀錄之確認竟要那麼久，會被人家笑！本屆為期2年，已經唸了20多次「確認上次會議紀錄」，這次會議仍要耗費諸多時間確認紀錄？請大家注意相關的議事規則。鄭主任委員守夏感謝謝委員天仁！請何委員語。何委員語一、主席、各位委員，照道理講，現在是確認會議紀錄，不應該進入討論。二、剛剛我們尊重提案人李委員蜀平的意見，可是他所說的，大家還是聽不懂，因為講了一句內容，後面又解釋很多，這樣斷斷續續……，所以，建議李委員提供明確的書面修正文字，影印給大家。現在暫停這個程序，等會議進行到某個時段，再來確認是否放入，或者修改後再放入，這是我的淺見。鄭主任委員守夏謝謝何委員語！現在確實不該進入實質討論，必須向李委員說聲抱歉！討論事項第9案的案由文字，是李委員所提供的，至於不要請健保署提供個別藥品價格資料，則是大家的共識，因為本會歷來不干預個別醫療院所的個別藥品價格內容。接著因為在討論過程中，個別委員有不同的意見，付費者代表之委員表示，健保藥品費用分配比率目標制是否繼續推行為更重要議題，因為大家有共識，所以才有此決議。我同意何委員語的建議，請李委員蜀平提供明確的書面修改資料，等一下找時間請大家表示意見，看是否同意。會議紀錄還有無須文字修正？(未有委員表示意見)確定上次會議紀錄。接著進行下一案，例行報告第2案本會上次委員會議決議(定)事項辦理情形及重要業務報告，請柯執行秘書桂女。柯執行秘書桂女請委員翻到議程第13頁，上次委員會議決議(定)事項辦理情形及重要業務報告共4項：一、說明一，上次委員會議決議(定)之8事項，原依辦理情形建議解除追蹤2項，繼續追蹤6項，現在恐怕要改為解除追蹤3項，繼續追蹤5項。請委員翻到議程第15~18頁附表一：(一)第1項，應於本年12月底前完成之104年度各部門總額協定事項辦理情形案，依辦理時程另於104年7月份委員會議進行追蹤；並請健保署於104年4、7月份提報總額重要計畫之執行情形，故繼續追蹤。(二)第2項，104年度全民健康保險抑制資源不當耗用改善方案，於衛福部核定後才能解除追蹤，故本項繼續追蹤。(三)第3項，104年度全民健康保險費率方案，於衛福部公告後再解除追蹤，故繼續追蹤。(四)第4項，健保第1類第1目至第3目被保險人所屬之投保單位或政府負擔之眷屬人數案，健保署依據健保法施行細則第68條第3款，業於本年12月23日公告上述眷屬人數為0.62人，故建議解除追蹤。(五)第5項，有關法定傳染病之醫療服務費用，請依法編列公務預算支應，不應由總額各部門費用支付案，健保署已回復：符合「其他預期政策改變及調節非預期風險之適用範圍與動支程序」之相關議案，將依本會決議辦理，故建議解除追蹤。二、說明二，本會第一屆(期間：102年1月1日至103年12月31日)歷次委員會議未結案件，截至11月底共計8件，如議程第27頁至29頁附表二，將併說明一之未結案件，移請下屆委員繼續關心。三、說明三，依據全民健康保險法第5條規定，本會的會議實錄，應於會議後10日內公開，所以本次會議實錄必須於明(104)年1月5日前上網。因為明年1月1日至2日適逢國定假日連續假期，為作業之需，本次實錄預定於本(12)月29日送請各發言者確認，懇請委員於次(30)日中午前回復修正內容，以及時完成上網公開作業。四、說明四，為衛福部及健保署本年9月至12月份發布及副知本會的相關資訊，在議程第101頁至126頁之附錄一至附錄九，請大家參閱。鄭主任委員守夏謝謝柯執行秘書的報告！請問委員有無詢問？請楊委員漢湶。楊委員漢湶剛才柯執行秘書所提的時間，因值過年，我認為10天應放寬扣除例假日，否則是在折磨發言較多的委員，大概都只有一個晚上的時間可以修改實錄。建議改以工作天而非日曆天計算，沒必要讓委員帶著電腦到處跑。 柯執行秘書桂女向楊委員漢湶報告，因立法院將日數規定於健保法，經確認為日曆天而非工作天，其實本會幕僚作業時間，也很緊迫。楊委員漢湶此事應與立法院無關，而是委員確認紀錄即可。鄭主任委員守夏因健保法規定的「十日內」，係指日曆天而非工作天，本會幕僚是依照規定辦理，但楊委員漢湶建議，若執行有困難且經委員同意，實際執行面應可採工作天。楊委員漢湶這10天，幕僚作業即占去8天，委員僅剩1、2天。我認為也不要折磨同仁，放假日還要趕夜工整理紀錄，事情沒有那麼嚴重啦！剛好過年，就讓大家放假嘛！也不要逼著委員趕夜工。鄭主任委員守夏謝謝楊委員漢湶體貼大家！健保法這樣的規定若真造成委員困擾，那就當作原則。委員都了解，依法於會議後10日內要公開會議實錄，若少數委員尚未確認，也不宜直接逕行公開。我們儘量遵守規定，拜託各位委員辛苦一下，盡快確認實錄，儘可能在會後10日內公開。楊副司長慧芬議程第15頁第2項「104年度全民健康保險抑制資源不當耗用改善方案」，經健保署報部，衛福部業於本(103)年12月17日核定，因此，本項建議應可解除追蹤。鄭主任委員守夏謝謝楊副司長慧芬的說明！請謝委員武吉。謝委員武吉議程第16頁第5項「有關法定傳染病之醫療服務費用，請依法編列公務預算支應，不應由總額各部門費用支付案」建議解除追蹤，本人表示反對！應改為繼續追蹤。這是不定時會發生的狀況，據說2年後，愛滋病費用就將列入醫院總額範圍。鄭主任委員守夏無論追蹤與否，若有法定傳染病醫療費用要納入健保給付，我們一定會知道！但是否須經過本會的同意或通過，則須視法令之規定情形而定。如果不須經本會，要繼續追蹤亦無不可，意即有類似的事情發生時，請衛生福利部或健保署務必即時通知所有委員；若依法須經本會決議才可納入，則當然不會發生這種情況。因此，是否追蹤並非重點，若為讓委員放心，每月追蹤有無發生類似情形，也無不可，但這比較像例行報告，而非追蹤。因未來此種情況有持續發生的可能，要求健保署遇有類似事件發生，應立即通知本會即可。謝委員武吉問題是委員會議每月才開一次，委員也未必全員到齊，因此，列入繼續追蹤較為合理。鄭主任委員守夏那就列為例行報告(有多位委員表示同意)。有無其他意見？請陳委員川青。陳委員川青贊成主席意見，先解除追蹤，發生法定傳染病例由健保給付時，再作專案報告。否則一直列入追蹤，徒增案件累積，故建議解除追蹤。謝委員武吉我建議繼續追蹤！目前台灣法定傳染病的發生情況，可說非常地嚴重，對此，本會有無追蹤、善盡責任呢？鄭主任委員守夏請蔡副署長魯。蔡副署長魯特別在此向各位委員報告，確如謝委員武吉所提，昨天在立法院衛環委員會審查「人類免疫缺乏病毒傳染防治及感染者權益保障條例」(即AIDS)修法案，上午委員出席人數雖足夠，但是下午委員的出席人數卻不足，所以，修法案並未審查。謝委員所擔心的CDC(疾病管制署)的愛滋相關法案，目前仍在立法院衛環委員會，尚未開始逐條討論，修正(草案)重點，是當CDC防疫AIDS之個案確診2年後病情穩定時，醫療費用全數由健保支付。確實有這樣的修法事件，所以特別在此報告。蔡委員明忠回應蔡副署長所提，請各位委員深思，目前政府對於很多疾病所提出的解決方法，全是爭取納入健保。這樣的做法，未來將對健保造成很大的困擾。愛滋病40億元、罕見疾病60~80億元，還有其他疾病持續加入，很擔心哪天會讓健保財務崩潰。在健保經營困難時，這是很大的問題，要請大家思考！鄭主任委員守夏建議追蹤表中之第5項解除追蹤，但列入健保署每月例行報告觀察。目前健保處境很為難，好不容易財務由短絀轉為結餘，各方都想透過修法來瓜分。誠如蔡委員明忠提醒，在這種氛圍之下，應思考保護健保體制的運作，適度表達反對立場，避免類似情形發生。蔡委員明忠政府照顧弱勢民眾，應另行編列預算，不該用全民健保的經費來照顧弱勢者。政府確需照顧弱勢者，但應以福利政策來處理，而非由全體被保險人繳納的保費來照顧。鄭主任委員守夏請楊委員漢湶。楊委員漢湶該案原由我提出，對於最後的決定沒有特別意見。同意主席的建議，將其解除追蹤，因如要繼續列管等於永遠列管；但往後若有該等情況，健保署有責任適時在健保會委員會議中報告，因委員不可能每天查閱法案通過情形，委員至少要了解狀況，才能表達意見。何委員語針對立委所提法案，請健保署就其中有影響本會委員權責或健保資源者，務必每月以書面通知我們，我們是「荏荏馬也有一步踢」(荏荏馬：不好的馬，也就是羸弱的馬。指的是人各有秉賦，雖然有高下之別，但用在不同的地方，一樣各有成就；就是再笨再差的人，一樣有可取之處)，希望大家共同努力！鄭主任委員守夏這個建議似乎不錯！請健保署回應。蔡副署長魯委員的意見我們當然會尊重。補充報告昨天立法院的動態，針對汽車責任險代位求償…。何委員語謝委員天仁已臨時提案，我們都連署了！蔡副署長魯但請還是容我報告，因我們的出席代表到了立法院，無法上台陳述意見。目前健保所規定的代位求償，係本署代付醫療費用後，針對強制汽車責任險進行代位求償，每年金額約30億元。若依目前修法方向，日後代位求償將轉為個別投保的第三人責任險，每年約有11萬9千件，假設50%的案件須經過法院審理，就有將近6萬件需要個別訴訟，可能增加本署的人事成本及訴訟律師費用約20億元。這是目前立法院的另一動向，是有立法委員想修有關健保法規定的代位求償。陳委員川青立法委員可以審查官方行政機關的公務預算，要如何審查，我沒有意見，但全民健保醫療費用並不是官方的公務預算；很多立法委員對於本委員會權責，或影響被保險人權責的分配，以及健保醫療給付的項目，常有越權的部分，健保會及健保署應積極作為，提出復議或採行政抵抗權，並向媒體表達窒礙難行之處。鄭主任委員守夏建議先不再討論，若本會35位委員一起連署表達意見，相信立法委員會有反應，知道有群體在關心該案，並對該案有意見。建議本部或健保署負責國會公關較有經驗的同仁，能提供意見。個別委員或團體發言似乎比較沒有力量，若本會35位委員可以一起連署，相信影響力就會不同，是否有此機制，有機會再予討論。目前各位委員的意見還滿多的，建議先休息十分鐘，請各位委員到一樓大廳拍團體合照。一邊走路，仍可以彼此腦力激盪，思考看看有無好的方法，若有則正式提案，或可供下屆委員參考。現在休息10分鐘，請大家移駕至一樓大廳拍團體照。謝謝！柯執行秘書桂女補充報告，桌上的巧克力是何委員語請各位委員的；另，吳委員玉琴送老人福利推動聯盟的「台灣與日本經濟交流論壇成果報告-醫療保險與長期保險的連結與整合的可能性」及「老人福利推動聯盟二十週年紀念特刊-打造老人福利國」資料，請各委員參考。(休息10分鐘)貳、例行報告第三案「中央健康保險署提報『104年度各部門總額協定事項中需向本會說明或經本會同意後方可施行之項目』案」與會人員發言實錄鄭主任委員守夏請各位委員回座，今天案件很多，繼續開會。請同仁宣讀報告事項第三案。同仁宣讀鄭主任委員守夏謝謝宣讀！本案是依照總額協商時所作的附帶決議，需要在年底前由健保署及相關總額部門確認計畫，並經本委員會議同意後再由健保署施行。請本會幕僚說明。張組長友珊請委員參閱議程資料第31頁的附表，幕僚彙整健保署依據104年總額協定事項中，需向本會說明或經本會同意後方可施行之項目，總共有6小項，分別屬於西醫基層、醫院總額部門及其他預算。各項的執行結果，呈現在議程資料第32頁至35頁，如有需要，可以請健保署再加以說明。鄭主任委員守夏議程資料第31頁至32頁，請委員看一下有無需補充的地方。這6項包括新醫療科技(含新增診療項目、新藥及新特材等)、調整藥事服務費及語言治療診療項目等，這都是協商時委員所同意的。有關要如何分配及執行，以前的作法，是請健保署與各總額部門研擬，現已擬出來，需要由本委員會同意。請問委員有無詢問？請吳委員玉琴。吳委員玉琴一、對於議程資料第31頁第6項「其他預算」，項目中只提到居家安寧療護及居家護理，對於在宅醫療計畫的進度，請健保署說明。二、對不起！現在雖已進入第3項報告案，仍想再詢問第2項報告案。議程資料第17頁，「全民健康保險藥品費用分配比率目標制」試辦計畫之辦理情形，預計明年4月份完成試辦兩年之藥價調整時進行相關報告，但議程資料第28頁第6項，健保署辦理情形說明，要在明年年底才報告，這兩個報告不一樣嗎？因為時間點不一致，請健保署說明。三、報告案第二案，追蹤表附件三提到自由經濟示範區開放，對健保不會造成衝擊，其論述很難說服醫界，也很難說服我，這樣的寫法很奇怪！醫事人員的異動，是上(11)月委員會議時，幾位醫界委員都會擔心的議題，卻寫不會影響，這樣的評估太過粗糙！是否有機會再做相關的報告及討論？鄭主任委員守夏一、謝謝吳委員玉琴！自由經濟示範區國際健康產業之規劃，將對國內產生什麼影響，請健保署適時邀請衛生福利部醫事司或國際合作組，至本會說明。二、剛剛吳委員玉琴所問，有關健保署對「全民健康保險藥品費用分配比率目標制」試辦方案之評估與檢討的報告時間，在議程資料第18頁與28頁呈現的，分別為明年4月與明年年底，報告時間不一致，請本會幕僚說明。張組長友珊一、在此向委員說明，確實如吳委員玉琴所提，該二案是不同案由的追蹤事項。議程資料第28頁是針對「全民健康保險藥品費用分配比率目標制」試辦方案，之前委員關心該試辦方案的執行結果，健保署回復將於104年年底相關研究計畫完成後，再將方案的評估與檢討結果提會報告，這部分是有關試辦方案的檢討。二、至於議程資料第17、18頁的追蹤情形，是有關李委員蜀平的提案，決議事項不僅包括「全民健康保險藥品費用分配比率目標制」試辦方案之評估結果，還包括委員關心藥價調整後是否發生換藥情形，以及是否損及病患權益等檢討，這個部分，健保署回復預計於104年4月完成試辦滿兩年之藥價調整後，再提會報告。確實因為議案的內涵不同，所以，提會報告的時間也有所不同。鄭主任委員守夏謝謝張組長友珊！議程資料第31頁，104年度各部門總額協定事項中需向本會說明或經本會同意後方可施行之項目表之項次6「其他預算」，有關在宅醫療的部分是否也列在裡面？請健保署說明。林組長阿明一、吳委員玉琴特別關心在宅醫療，在104年總額的協定事項中，已列入牙醫與一般西醫的在宅醫療部分。牙醫的部分，是在牙醫特殊醫療服務試辦計畫列入失能老人在宅醫療，該部門甚至可到安養機構與病人家裡提供在宅牙醫服務，這些已在103年第4次全民健康保險醫療服務給付項目及支付標準共同擬訂會議報告通過，並於本(12)月24日報部核定，後續會公告實施。二、西醫的部分，在上(11)月上旬請台灣醫院協會、醫師公會全聯會、牙醫師公會全聯會提出意見，將參考相關團體的意見，再進行後續研擬。目前希望能在台灣的北、中、南地區先行試辦，原則上，初步限定在出院後，需要醫師至家裡看病以提供在宅醫療的重症病患、行動不便的重病病人。本署將積極盡速推動西醫在宅醫療服務。鄭主任委員守夏請林委員錫維。林委員錫維一、大家好！提出以下幾點建議，如同剛才幾位委員談到，在相關業務報告多向立法院的委員溝通健保相關問題，或是向立法委員說明其對健保制度與精神有所不了解之處。二、健保會有其職權，我們在這裡開會，辛苦地針對健保各方面議題進行探討所做出的決議(定)，但有些立法委員是應某些單位要求，而肇致反向結果，其中甚至立法院衛環委員會的委員，也不一定了解我們的整個過程，要像本會何委員語這麼了解健保的其實並不多。在這情形下，健保會透過討論後的決議(定)，立法委員若做修改，對於我們的職責與職權而言，可說非常地不合情，也不合理。三、在適當的時間，健保署把遇到的問題於業務相關報告時提出，透過健保會討論後，反映形成具體明確的意見，必要時，可以請主任委員或相關代表，舉行記者會說明，而不是立法委員想怎麼改就改，否決健保會經過多次會議所做成的決議。因為攸關保險對象的權益，所以有必要召開記者會公開說明。這些立法委員就有理由對選民交代，不然只有為反對而反對，我認為非常不應該，不但不合法、不合情，也不合理，健保會也沒有存在的必要。四、在第一屆健保會委員的團體畢業照拍過後，在此要感謝各位委員這兩年對我的愛護與相挺。雖然知道任何辦法都有其不公平的地方，但仍要說「全民健康保險會組成及議事辦法」不公平之處，會讓人認為健保會組成有黑箱作業的嫌疑。在第一屆健保會委員抽籤(註：健保會12位被保險人代表中，有3位是以公開徵求方式遴選推薦團體，由於推薦進來後，符合條件的團體不少，最後在律師及政風人員見證下，以公開抽籤方式抽出三個團體)的時候，我就一直反映，第二屆也反映，若再沒有改進，我也會考慮舉行記者招待會，將該辦法的不合宜之處，訴諸大眾。五、我不是在戀眷有無擔任委員，而是針對公平性探討，更不是要針對哪位委員作人身攻擊。舉例來說，付費者代表中有3個代表是直接洽請工會團體推薦，其他工會若想進來則要抽籤，事實上，整個勞動部登記的是十大工會，哪個工會比較大或比較小？我個人所代表的「全國勞工聯合總工會」不會比其他團體小，但因為有很多人是重疊性加入工會，不易釐清，結果，代表的工會卻要抽籤，並不公平。先說明我對於其他3位工會代表，也非常尊重，並肯定他們的用心，沒有個別意見。六、另外，並不是每個委員要經常發言，有表達意見才算支持健保，有些提案合情合理，應該讓其順利通過，所以，不一定要發言講話，才算表示意見。我認為好的健保政策，若與自己代表的單位有關，要多向保險對象說明，有誤解的地方，也應說明清楚。以我在台北市及各縣市的作法，一年當中，對於有關二代健保、健保費率等，在相關的勞工教育訓練，每一場約50人，一年至少宣導35場，二年即宣導了70幾場，在座的委員有誰這樣做？我不是標榜要怎樣，只是覺得有些不公平！七、委員的遴聘考核制度在哪裡？有些委員整年出席次數不到一半，且非常不願意參加，卻保留他們當代表，這算公平正義嗎？為他們保留席位，也不甘願來，但這些有發言、要做事，為健保好的委員，卻要抽籤。抽籤的標準在哪？一樣性質的團體，有的要抽籤、有的不用抽籤，我認為一定要取消抽籤制度，否則很沒道理。例如被保險人代表12位，可請符合資格的團體，全部都來抽籤，大家都來關心，才不會形成不用抽籤的團體，好像是來應付一下；或者不需要抽籤的團體代表，才是委員。哪有這樣的制度？這是什麼政策？代表不願意來參與，還保留席次做什麼？建議要訂出1年應出席的次數，包括本人親自出席或代理出席之次數。八、因為下(第2)屆的委員會議，我不會參加，基於好心好意，希望建立考核制度，不能像尾牙抽獎，抽到大獎、抽到小獎或沒抽到，開什麼玩笑！這麼大的委員會，有的團體抽籤決定；有的團體不用抽籤。應採相同方式，符合標準的都要抽籤，不然就都不抽籤，這樣才對！制度不一定百分之百完美，不好的地方，一定要修改。千萬不要有馬總統的想法，常自我感覺良好，自己認為感覺良好就好，這樣不對！我代表最基層的民意，希望大家能瞭解，整個制度有必要修改！九、若我講話不禮貌或得罪個人，請各位委員見諒！我絕對沒針對個人作人身攻擊，而是認為整個制度有必要修改。希望下次討論健保會組成35位人選之推薦團體時，有些部分一定要修改。我剛才一直強調，之前已反映過2次，但一點用都沒有，若再不修改，我一定會找相關立法委員公布整個過程。我堅持以下意見：(一)有些制度一定要改，不能對於不講話的人，就不給糖吃；而有的委員講一大堆與議案無關的話，重複了5、6次，主席人太好了！還讓他們一直講，有時聽到快睡著。應針對議案發言，因為健保會不是口才訓練中心。(二)應嚴格限定每個人的發言時間，或以書面呈現意見，才能繼續開會。常開會超過中午12點，沒道理！開會6、7個小時，其實浪費掉一半以上的時間，根本未針對議案主題發言。並非有發言才表示有用心，不一定！十、我今天都是肺腑之言，再次強調沒有針對哪位委員或單位，只認為制度不好要改，應建立考核標準，既然有心參與，就要用心！用好的政策向民眾說明有誤解的地方，這樣才有意義。對不起！我已經拍畢業照，應可先回家了。謝謝各位！鄭主任委員守夏一、從我有印象以來，不管是以前的監理會或現在的健保會，勞工團體非常多，所以如何決定取捨，一直都讓以前的衛生署或現在的衛生福利部頭痛。個別委員的意見，尤其剛才林委員錫維所提意見很好，請社保司曲司長同光與本會幕僚一起檢討委員聘任相關作業，提出改善方案，陳請部長參考。相信每次委員聘任時，部長都很頭痛。二、健保會很重要，我這個主席，對會議若主持得不好，則必須深切檢討！林委員錫維沒有！您誤會我的意思，我是說因為您人太好…。鄭主任委員守夏一、因為委員人數有35位之多，各自代表不同團體，有時不得不表示意見，回去才不會被罵，所以難免重複發言。二、會議剛開始時，我就先向各位「健保會第1屆」委員表達謝意，感謝大家共同完成2次總額協商，一路走來，沒有太離譜的狀況，而且健保業務監理的部分，也慢慢上軌道。至於下一屆，有些委員應會繼續留任，但難免也有委員像林委員錫維一樣，參加公開抽籤沒抽中，因為健保會組成及議事辦法就是如此規定。再次感謝所有委員，尤其這次拍完「畢業照」，下次會議不會再出現的委員。部長常說，不一定會做多久，現在換部長的速度比換所長還快很多。三、抱歉！時間已超過11點，才進行到報告事項第3案，應該加快腳步…。謝委員武吉一、我們要尊重林委員錫維，因為他現在仍是健保會的委員。二、有人打電話給我，依其說法，遴聘委員時有所謂的「御用委員」，即比較會替某單位講話，就聘任；而比較不會與醫界吵架的委員、或沒有講話的委員，叫做「中間牌委員」，也會聘任；而為社會正義講公道話、說實話的委員，是不乖的委員，就不聘任。這些是聽某人士說的，是否為真，應再釐清，如果是真的就應該送請檢調、廉政署調查。鄭主任委員守夏謝謝！衛生福利部的同仁都是公務員，不能違法亂紀，真的有問題，請監察院、調查局調查都沒問題。以我的立場，健保會的同仁、幕僚出問題，當然不可能護短，但若是非常「藝術性」的問題，例如「你覺得圓形漂亮；我覺得方形漂亮」，則無可厚非。我想，若謝委員武吉現在是部長，可能也會頭痛。謝委員武吉你別講我！因為我在初中2年級時，就發誓不當公務人員。鄭主任委員守夏一、您比較好命！當公務員應也可以做得不錯，但現在當公務員很不容易。二、謝謝同仁提醒，趕快回到報告案，不然會來不及。報告事項第3案洽悉。陳代理委員炳宏(李委員永振代理人)一、在拍合照前跳過報告事項第2案部分議題，所以請再回到該議題。請大家看議程第29頁，健保會第1屆委員移請下屆委員繼續關心之相關事項，第8項「政府應負擔36%健保經費議題」攸關健保經營之財務穩健，建請衛生福利部依健保法第4條規定負起健保法解釋權責，很多委員甚至親上媒體，主張為健保爭取權益；回顧今年9月份委員會議的臨時提案已經決議，法律之解釋權責屬於衛生福利部，應回歸立法意旨，妥為解釋及處理；但對照本頁「相關單位辦理情形」欄，衛生福利部(社保司)卻回復：業於本(103)年10月16日將本會委員建議函轉行政院參酌！…？前述之回復、頗令人不解！二、另向大家報告，煩請翻閱「103年11月份全民健康保險業務執行報告」第7頁表5-1「全民健保財務收支分析表(權責基礎)」，其數據係皆引用行政院主計總處的計算方式，顯示安全準備規模為1,200億元，而依健保署原來遵循「健保法第76條規定」計算方式，其實際規模應不只1,200億元，等到議程進行到報告事項第5案有關業務執行報告時，我再接續補充說明。三、本案已歷經3個月，仍持續以「不利全民健保利益」方式，依主計總處的算法提列安全準備；至今遲未改善，卻要移請下一屆委員會繼續追蹤，頗不合理！建議健保署應堅持健保法第4條之主張，伸張合法、合理的全民利益。鄭主任委員守夏一、今日有臨時動議，有關強制汽車責任保險的提案。這是健保會第一次對外發聲，採用何種方式，連署、召開記者會或其他方式應都可考慮。由大家一起代表健保會，至少有三分之二或五分之四委員同意，即可聯合作業。屆時可順便處理政府負擔健保總經費36%，機關間見解不同的問題。本會委員均同意，應採健保署或衛生福利部的解釋辦理。二、公開聲明連署或召開記者會，都是可行方式。若召開記者會，由誰去比較好？因為並無前例，對我們也是新嘗試。所以，拜託有經驗的委員先商量，思考用什麼方式最好。三、本案建議等臨時提案再行處理，否則今日議案真的來不及討論。趕快進行下一個報告案，請同仁宣讀。何委員語一、依健保法第4條，主管機關為行政院衛生署，現改制為衛生福利部，故應由衛生福利部計算政府應負擔多少費用後，再向行政院主計總處收取才對！而不是行政院主計總處計算應給多少費用，否則，以後也可由投保單位計算須繳交的費用。若大家都這樣算，就會亂掉！衛生福利部應計算行政院主計總處須負擔之健保費用，由行政院主計總處支付，依法、依理、依情才對，現在變成主客易位，這是不對的。二、建議應依健保法第76條第1項至第5項規定，計算年度健保總收入，以此為基期，來換算行政院主計總處應繳多少費用。三、健保法第78條規定安全準備，以1至3個月之保險給付支出為原則，衛生福利部應明確說明採1個月、2個月或3個月為基準。若以3個月為基準，則應就此基準，向行政院主計總處要錢，也向投保單位要錢，這樣才對。不能說行政院主計總處採1個月為基準，對投保單位採3個月為基準來計算，這樣就不公平、不合理，也不合法。鄭主任委員守夏謝謝何委員語！報告事項第3案洽悉，請同仁宣讀第4案。參、例行報告第四案「中央健康保險署函送本會同意之『104年度各部門總額一般服務保障項目』案」與會人員發言實錄同仁宣讀鄭主任委員守夏謝謝同仁的宣讀！本案為總額協商之後續事宜，附表一為中醫門診、西醫基層、醫院及門診透析服務需保障點值的個別項目，同仁建議為同意後執行。至附表二若有不清楚的地方，再補充說明。請問委員有無垂詢？請朱代理委員益宏。朱代理委員益宏(謝委員武吉代理人)一、代表台灣社區醫院發言，針對醫院總額保障項目，個人有意見。依健保署相關資料，從平均點值及浮動點值來看，社區醫院平均點值最差，歸究原因，主要為保障項目的關係。因為所謂門診手術、急救責任醫院之急診服務、手術、麻醉、輸血，大部分在大型醫院執行。這件事情，我們也向健保署反映過，建議應有平衡方案，針對社區醫院執行的項目，予以保障，至少在平均點值部分，不要相差太多。二、現在健保署所提104年保障項目，並未針對社區醫院應保障項目給予適度保障，使其平均點值能趨近醫學中心及區域醫院，故本案有瑕疵，應退回健保署，請其針對社區醫院之社區型醫療服務部分項目，給予適度保障，讓其平均點值能均衡處理。鄭主任委員守夏等一下再請健保署說明，其他委員有無意見？(未有委員表示意見)請健保署先針對社區醫院代表的意見回應。林組長阿明醫院部門保障項目係比照去年，在會議上有討論，結論也有共識。至地區醫院所提意見，付費者也有相關意見，大家記得的話，社區醫院協會在健保會針對保障項目已討論過，惟未獲同意。朱代理委員益宏(謝委員武吉代理人)一、依健保署資料，社區醫院平均點值較其他醫院為低，健保會委員應考慮公平原則，總額須依據醫療機構不同的特性，對於必要項目進行特別的保障。社區醫院本來就與醫學中心之目的和存在目標不同。這裡僅保障大醫院，導致社區醫院只採浮動點值來執行醫療服務，特別是婦產科醫院或復健科醫院，又沒有開藥，其平均點值大概不到0.9，對於社區醫院很不公平，這也是導致現在醫療體系社區醫院一直崩盤的重要原因。二、現在醫院總額的保障項目，看起來是大型醫院，保障每點1元的項目比較多，對社區型醫院某些必要診療項目，則未給予保障。在此呼籲健保會委員支持我們的想法，能否做成決議，請健保署在醫院總額內部，針對社區醫院必須的保障項目，給予保障，以達到平均點值較為合理的狀況。否則，依現在健保署的資料看起來，假設醫院的平均點值為0.92，則醫學中心的平均點值約0.93~0.94、區域醫院約0.92、社區醫院約為0.9，這是數字呈現的現況與事實，對社區醫院的發展非常不利，希望健保署能重新考慮。鄭主任委員守夏 在場委員有無表示支持或有其他意見？請謝委員天仁。謝委員天仁一、用保障二字會失去其正當性，此應屬分級醫療有無落實，而非保障的問題。社區醫院可能以為獲得點值保障以後，就可以從總額的大餅咬回一口，但就實際面的了解，會有落差。整體應為落實分級醫療的問題，包括今天提出的部分負擔問題，若切割掉就不完整。二、為何急診會壅塞？因檢傷分類四、五級應到門診就診的病人進到急診；而檢傷分類一至三級的病人，因為沒病床可住，塞在急診，故應檢討病床。像現在實施急性後期照護，但就只有急性後期照護問題，而沒有輕症後期的問題嗎？假若能推動，那些病人即可轉到區域醫院、地區醫院，分級醫療的效果就會出現，有機會解決社區醫院或地區醫院的問題。老是用「保障」兩字，要付費者代表支持，我認為只能解決少部分問題，沒有用！這是整體分級醫療落實的問題，而要落實分級醫療，並不是只有轉診部分，其他部分也要整個考慮。三、我所提已包括後面議案的內容，希望這部分能從長計議，不能每次都頭痛醫頭、腳痛醫腳，最後問題受到扭曲，越來越嚴重。鄭主任委員守夏其他委員有無意見？請吳委員肖琪。吳委員肖琪一、我特別提醒朱代理委員益宏，假若偏鄉次區域只有一家社區醫院，沒有其他醫院，政府確實應負起責任。近年來，健保署針對偏鄉設有內、外、婦、兒科與急診任二科以上的醫院，已有每年1,500萬元的補助。另醫發基金針對偏遠地區，也有補助，偏鄉地區甚至還有加成，兒科從3歲加成變為6歲以前都加成。經過試算之後，偏鄉小孩的加成費用高，急診加成高，高到必須思考公平性的問題。朱代理委員益宏提到的社區醫院，希望是針對偏鄉的社區醫院。今年某次健保會有報告，補助社區醫院費用也不少。二、建議下屆委員可以請健保署計算清楚，對於偏鄉是支持過度或是不足？這樣會比較好。對於全面補助社區醫院或內、外、婦、兒科的作法，我並不支持。例如對於婦產科，我們害怕出生率低，其實更要擔心的是偏鄉的婦產科無法茁壯。所以，針對這項議題，我建議下屆委員可以探討偏鄉地區的補助情形，並對於次區域唯一的社區醫院如何提供協助，進行整體檢討。鄭主任委員守夏請問其他委員有無意見？請朱代理委員益宏。朱代理委員益宏(謝委員武吉代理人)一、誠如謝委員天仁及吳委員肖琪所說，社區醫院到底何去何從，是很大的議題，也須從長計議配套措施。其實本案僅觸及議程資料第37頁附表一的保障項目，並沒有討論到那麼遠。謝委員天仁表示反對使用保障的文字，但因幕僚使用，我就沿用。針對每個總額部門需要保障的項目，以醫院為例，主要保障大型醫院的手術、麻醉、急診及供血等，我認為也應針對社區型醫院某些診療項目，或如吳委員肖琪所說某些區域內的某些醫療項目，提供保障，而非全部的診療費。二、我認為針對社區型有特別需要的醫院，並且對於民眾之健康促進有幫助的某些診療項目，或是某個區域的某些診療項目，應給予每點1元的保障。這樣就能回歸到大醫院對於手術、麻醉與急診給予保障，同時對於社區型醫院保障民眾健康的必要項目，也給予保障，這樣才可達到均衡狀況。否則目前總額支付所謂每點1元的保障，都是針對大型醫院，在這種狀況下，若委員認為社區醫院的保障項目不應在此提出，應該從長計議，那麼我認為對於醫院保障項目的第一大項，也應予以剔除。大家都不需要保障，回歸浮動點值。三、其實不管是每點1元或浮動點值，對總額並沒有增減影響。若保障每點1元的項目較多，浮動點值就會變得較低，醫療服務未列入保障項目的，實際給付金額就少。若大家認為不應保障每點1元，我要建議將醫院部門第一大項所有保障每點1元的項目全部剔除，回歸總額，讓點值浮動，這樣也可以。至於垂直整合及轉診措施，可再從長計議，於下屆健保會好好討論可行方案。我反對只保障大型醫院，用門診手術、麻醉、供血與急診等項目處理，卻對社區醫院必要項目不予保障，這樣我無法接受。鄭主任委員守夏一、本案歷來是需要健保署與醫界協議的，但每次談到這個問題，從來沒有共識過。除非本會非常有共識，否則，大家若無支持朱代理委員益宏意見的共識，本會並不會推翻原來議定的項目。二、本會歷來不是在保障供給者，而是保障病人。為何要保障偏鄉？是因為被保險人繳交健保費，就應享有相同的就醫權益。因此，所謂的保障，沒有大醫院或小醫院之別。我同意朱代理委員益宏的意見，長久下來，對社區醫院產生某些不公平的結果，但必須有更好的方案才能取而代之。本案程序上須經本會同意，才能執行。要讓每個部門或每個人都滿意，幾乎是不可能，除非本會有共識，能提出更好的內容，請健保署執行。請謝委員天仁。 謝委員天仁 當初保障住診相關項目每點1元，是因其支付標準長久未作處理，日後若其支付標準已處理反映，則保障每點1元就需要檢討，這是大家要面對的。否則那邊提高，這邊又每點1元，那鼓勵的機制何在？討論本案，必須瞭解相關的背景。朱代理委員益宏(謝委員武吉代理人)事實上，內、外、婦、兒科與急診的支付標準，已經調整過，所以，才會在此提出意見。支付標準調整已增加點數，在這裡又保障每點1元，對地區醫院將更不利。據我了解，本案在醫院總額內部並未詳細討論，係沿用前一年資料，因此，我認為依主席所言，既無共識就應退回醫院總額，形成共識後再送本會。台灣社區醫院協會有意見，就代表醫院內部並沒有共識，依照本會過去慣例，就應退回醫院協會討論，俟有共識後再提送本會。鄭主任委員守夏有無委員支持退回？請教代表台灣醫院協會的楊委員漢湶，台灣社區醫院協會代表表示，因醫界沒有共識，要求委員會議退回，請表示意見。楊委員漢湶因本人未參加健保署所召開的醫院總額研商議事會議，不清楚討論過程，但這些保障項目，確實有些奇怪！例如：醫院藥事服務費保障每點1元，為何醫師診察費沒有？我尊重該項會議討論的結果，但若重新思考，其決定的保障項目，確實有些奇怪。理解朱代理委員益宏代表社區醫院協會，須為地區醫院發聲，但我認為，應從項目、科別或地區別的角度來討論保障的必要性；這個問題確實很複雜，但若退回不實施，也不見得比較好。鄭主任委員守夏謝謝楊委員漢湶！請干委員文男。干委員文男我認為本案不用再討論，因這是報告案，總額協商已完成，醫界內部也已討論決定。這些都是個別科系保障的問題，若醫院部門再提出其他科系的問題送本會討論，本會將不堪其擾。本案應照案通過，醫院內部再繼續去研究這些問題，不要自己內部問題不解決，丟給我們傷腦筋。我認為本案就照案通過，不要再討論了！鄭主任委員守夏請蔡委員登順。蔡委員登順當然社區醫院經營有其特殊環境，過去已討論過很多要求列入保障的項目，但都沒有通過。我建議保障項目應儘量減少，回歸到正常的浮動點值，這樣各層級醫院都能公平競爭，也較為合理。這是結構性的問題，長久以來都是如此，今天要討論出結果，是很不容易的。不論如何變動，都會有人獲利，也有人吃虧。我認為本案是報告案，不須再作討論。今天是本屆委員最後一次開會，應尊重之前委員會議的決議，不要再變動。鄭主任委員守夏請吳委員肖琪。吳委員肖琪我呼應謝委員天仁的發言，若支付標準能合理調高，就不要保障每點1元。因保障每點1元，相對地，其他項目點值的浮動會受影響。很認同楊委員漢湶提到，藥事服務費保障每點1元，為何醫師診察費沒有保障每點一元？若保障項目持續增加，即使近年來RBRVS(resource-based relative value scale，醫療資源耗用相對值表)強調點數中平原則，部分項目調高，其他項目就要調低，但結果都只調高不調低，造成點數持續增加。所以，我呼應保障每點1元的項目，越少越好。鄭主任委員守夏請黃代理委員啟嘉。黃代理委員啟嘉(陳委員宗獻代理人)我認為應先考慮保障項目對非保障項目造成排擠的影響。考量醫院部門對此尚無共識，是否本案其他總額部門的先通過。醫院部分保留再議，俟有共識後再提本會討論較妥？本案對付費者而言，關聯性並不大，主要是涉及醫院內部資源的分配問題。鄭主任委員守夏先請教健保署，本案是否確實依照程序，召集相關團體開會討論？(健保署表示確定)今天本案很難討論出更好的結果，若無更好的辦法，本案就通過。朱代理委員益宏(謝委員武吉代理人)一、剛才楊委員漢湶也說，不清楚保障項目的過程。連續幾年沿用這種方式，都未改變，不代表今年也不能改。呼應吳委員肖琪及謝委員天仁，這樣的點值保障在結構上是有問題的，若不趁此機會加以修正，等明年討論時，新任委員又繼續沿用，永遠無法更改。二、健保法第51條明定，除非因緊急傷病經醫師診斷認為必要之輸血外，否則血液項目，是不列入給付的，但保障項目中仍有促進供血機制合理方案，以每點1元支付。包括藥事服務費等已有50億元調整支付標準點數的項目，結果都還有保障。或許在2、3年前認為應該保障，但目前時空環境已不同，應重新檢討。懇請委員支持，其他3個總額部門若無意見，先讓其通過，但醫院部門，多位委員也認為保障項目有不妥之處，建議退回醫院總額支付委員會，另行協商後再提本會。鄭主任委員守夏個人認為，不會有更好的結果，建議可作成附帶決議，要求健保署研議減少保障點值項目或範圍，並合理提高支付標準。大家都有共識應啟動此項機制，例如半年後請健保署報告，取消那些保障項目，這樣也可回應社區醫院所擔心的問題。退回本案只是將麻煩問題延後處理。謝委員天仁也認為，保障只是取巧，因此，要求健保署研擬減少保障項目，作為附帶決議。(謝委員天仁表示贊成)謝委員天仁原則上同意，但請再講清楚一點，因為在102年度醫院總額協商項目，支付標準調整50.554億元，對於支付標準已經調升的項目，建議這部分要取消點值保障的相關機制，這樣比較公平。鄭主任委員守夏這部分，請健保署再行討論。何委員語我的意見是，第一，建議本案先行通過；第二，醫界現在才在會上提出很多意見，讓我們傷腦筋。我們擔任兩年委員，已老了三歲。你們應該在接到開會通知後，就研擬出好的構想，若所提意見比健保署好，當然會同意你們的方案。現在不清楚到底要修改哪一條？要如何修正？建議本案先行通過，你們的意見以後再提出研議。鄭主任委員守夏請李委員蜀平。李委員蜀平一、感謝何委員語及謝委員天仁之意見，但要特別向所有委員報告，實際上，藥事服務費在結構上與醫療給付是不一樣，因為藥師進行調劑是沒有掛號費，但診所醫院有掛號費，社區藥局也是沒有掛號費，這很不公平。二、我們的藥事服務費比其他國家低很多，基本上，一個社區藥局光靠藥事服務費，是無法養家活口的，因整個收入不公平，若要讓藥事服務費變成浮動點值，我沒有意見，但要調整給付結構。如果沒有掛號費，而藥事服務費又那麼少，巧婦難為無米之炊，請問收入都不能養家，藥師的專業要如何發揮？朱代理委員益宏(謝委員武吉代理人)一、不是特別針對藥事服務費，但其中仍有很多不合理之處。如果今天通過本案，就是違反健保法第51條，該條文特別提及除了醫師認為必要輸血以外，其他血液是不給付的項目，但是在這裡未做說明。促進供血機制合理方案，就是保障每點1元，已違健保法第51條，我認為很多項目需再從長計議。二、不認為回到醫院總額研商議事會議討論，會沒有結論，或許在以前是沒有結論，但以現在的狀況，最近台灣醫院協會改選，楊委員漢湶是新任理事長，我認為可以有一個重新討論的機制。三、懇請各位委員能夠給醫院總額一個重新討論的機會，若在下次委員會，仍沒有結論或共識，就依照本案內容，但希望能透過在會中討論，形成但書，亦即大家有共識，同意某些項目不要再保障。蔡委員登順針對朱代理委員益宏的發言，我有不同意見，健保法第51條是規範不列入健保給付範圍之項目，其第6款規定：「血液。但因緊急傷病經醫師診斷認為必要之輸血，不在此限。」表示健保可以給付。朱代理委員益宏(謝委員武吉代理人)我的意思是保障項目要有所限制，這裡只有寫促進供血機制合理方案。李副組長純馥其實在協商97年度醫院總額時，即在一般服務預算中，針對「促進供血機制合理運作」方案編列約2.59億元，保障每點1元，另血液的確是無償的，健保是給付處理血品的成本(如檢驗及保存管理)。鄭主任委員守夏如果是非常早就已經決定，很多委員可能也不清楚，需花時間去重新了解。本案通過，附帶決議：請健保署於6個月內提出改善方案，如何減少保障點值項目及範圍，讓支付標準回歸該有的同等價值，不要再用保障點值的方式處理。繼續進行下一案。肆、例行報告第五案「中央健康保險署『103年11月份全民健康保險業務執行報告』」與會人員發言實錄鄭主任委員守夏本案是健保署的例行報告，照以前協議，本月份不進行口頭報告，請各位委員參考健保署的書面資料。陳代理委員炳宏(李委員永振代理人)可以就健保業務執行報告提問嗎？鄭主任委員守夏可以，請陳代理委員炳宏。陳代理委員炳宏(李委員永振代理人)一、請各位委員翻閱到業務執行報告第7頁，有關健保財務穩健議題，表5-1「全民健保財務收支分析表(權責基礎)」右下角，全民健保自開辦以來迄今(84年3月至103年11月)，累積安全準備有1,203.84億元，這是依照行政院主計總處核算健保法規定政府應負擔健保總經費36%所得的金額。請問各位委員，是否記憶猶新？102年及103年上半年因健保署與行政院主計總處核算健保法規定政府負擔36%健保經費見解不同，而被減列多少億元…大家漸漸回想起…該項已被減列數百億元的顯著規模；若健保署依照健保法第76條規定核算，保守估計這項金額至少是1,500億元，這攸關全民健保財務穩健持續經營，以及全民的利益，請各位委員持續關注！ 二、我建議在下個月(103年12月份)的業務執行報告，因為委員已經換屆，為利經驗傳承，健保署計算累積安全準備時，敬請改以健保署原依健保法第76條有關應提列安全準備規定，列示本表(表5-1)相關數據；而行政院主計總處所主張核算的安全準備，煩請改列在備註的說明中。我主張本項的目的，是希望讓下屆委員可以立即掌握全民健保安全準備實際權責金額有多少？以及曾經被行政院主計總處依不同見解而逕行減列金額有多少？這個歷史軌跡，應該留下來，由新進委員持續追蹤，讓政府落實負擔36%健保經費的職責，以確保未來健保持續經營、長期費率適足及財務穩健。以上補充。謝謝！鄭主任委員守夏謝謝陳代理委員炳宏！請干委員文男。干委員文男一、我贊成陳代理委員炳宏所提的意見，在表5-1「全民健保財務收支分析表(權責基礎)」，將行政院主計總處與健保署核算健保法規定政府負擔36%比率，因見解不同，分別所算出來的安全準備，可在備註中說明與比較。二、本(103年11)月份的業務執行報告，我要特別提出來，這(第1)屆委員應該可以非常地驕傲！我前曾擔任健保監理會委員，當時有好幾年都提案，籲請增強健保IC卡的功能。在本(12)月15日健保署舉辦健保雲端藥歷系統成果檢視會，我很高興健保IC卡所需擁有全面的功能，大多具備，運用健保雲端藥歷系統，今年最末一季有13億元的結餘，以此類推，一年就可以省下52億元。另外，附加價值病人少吃藥，洗腎患者會減少，洗腎點數與點值也會提高；藥物對於環境的污染可以減輕，其他藥物副作用也會少一點，也減少健保資源的浪費。感謝健保署對這個重大政策的執行，也感謝健保會同仁的努力盯著建議政策執行，值得嘉許！三、在健保雲端藥歷系統內，可以看到每次調整藥價，被換藥是否有後遺症，所以身為這一屆委員，可以說覺得很光榮，因能將健保雲端藥歷系統建立起來，也可以看到個人健康存摺，這是健保的驕傲，可以降低不必要的醫療利用。四、在健保雲端藥歷系統成果檢視會，發現大家在討論個人資料保護法議題，例如要不要簽名，如果不識字如何簽名？這也是一個問題，若能改用多元方式，簽名、蓋章或按捺指紋，就比較方便、容易執行，所以不一定要簽名，就可以解決這個問題。然而大家在該成果檢視會，都集中於討論個人資料保護議題，似乎討論不出結果。該會有幾個報告案，對於重複用藥等重點，是否可以統一標註相同顏色，以提醒注意，否則將來再發展下去，就會很麻煩！每個單位個人做個人的標示、符號、顏色，如果這樣發展下去，再來統一，就很麻煩！希望健保署在這方面多用一點心。五、健保署在這兩年編了40幾億元預算，一年就能回收，醫療費用沒有多花，環境污染卻減少了，在後端能節省，這是突破事項，非常感謝健保署及健保會的同仁。為此案努力了很久。謝謝！鄭主任委員守夏謝謝干委員文男！現在已將近中午12點，例行報告尚未結束，拜託大家，把握時間。請何委員語。何委員語一、主席、各位委員，業務執行報告第7頁，表5-1全民健保財務收支分析表(權責基礎)，目前累積安全準備為1,203.84億元，但是我認為，不應該因為行政院主計總處與健保署核算健保法規定政府負擔36%比率見解不同，而在102年減列158億元及103年減列266億元，兩年來共被減列424億元，推算5年會被減列約855億元。我剛才有講到，應該要向行政院主計總處收錢，希望能夠正視這個問題。二、業務執行報告第13頁，本(103)年度截至11月底保險收支淨結餘458.02億元，如果不被減列，應該超過680億元。三、業務執行報告第31頁，103年第2季各部門總額點值結算情形顯示，西醫基層平均點值為0.9147元，他們一直反映點值非常低；門診透析平均點值為0.8290元。四、業務執行報告第73頁，表28「全民健康保險重大傷病證明有效領證統計表(103年11月)」顯示，需積極或長期治療之癌症很多，102年底有效領證數為482,949件，比過去的40萬件多了20%，不知衛生福利部可否將頂新黑心油等食安問題造成的影響，追蹤統計出來？為什麼最近這兩年，癌症患者增加8萬多人，若能夠代位求償，則建議也要代位求償。有關職業病部分，為4,454件，是否能向勞動部追討此部分代位求償經費，因為資方有支付職業災害保險金。鄭主任委員守夏謝謝何委員語！其他委員有無要請教？請干委員文男。干委員文男我再補充一下，由健保雲端藥歷系統成果報告，發現還有很多家西醫基層診所沒有參與，希望健保署在最近幾個月內，趕快執行，若西醫基層診所還沒有裝置加入雲端藥歷系統所需機器，請趕快去裝起來，一定要全面執行。鄭主任委員守夏謝謝干委員文男！請謝委員武吉。謝委員武吉echo(呼應)剛才何委員語所提表28「全民健康保險重大傷病證明有效領證統計表(103年11月)」部分，我很懷疑現在癌症患者增加那麼多，是否與去年4月份食安風暴地溝油等有關。目前所有食品可能都存在問題，是不是該使用代位求償方式要回因而產生的醫療費用，健保費是老百姓辛苦謀生所交出來的錢，卻支應為非做歹者製造問題所產生的醫療費用，這是不對的！健保署要有辦法處理。鄭主任委員守夏一、感謝謝委員武吉！這個意見之前本會委員就有建議。還有沒有委員要請教健保署？如果沒有，本案洽悉，委員的相關建議，請健保署參考。二、現在進行討論案。請謝委員天仁。伍、臨時提案「有關汽車肇事，擬刪除保險人健保署對保險公司之代位權，或修改強制汽車險傷害不賠，涉及肇事者相關責任轉由全民負擔，嚴重影響健保財務及公平正義案」與會人員發言實錄謝委員天仁一、在會議程序上，目前要進行5個討論案，但是我提一個臨時提案(有關汽車肇事，擬刪除保險人健保署對保險公司之代位權，修改強制汽車險傷害不賠，涉及肇事者相關責任轉由全民負擔，嚴重影響健保財務及公平正義)，因為這個臨時提案是昨(25)日發生立法院的財政委員會修改強制汽車責任保險法，把保險之給付項目有關「傷害醫療費用給付」予以刪除，也就是民眾被車撞到，強制汽車責任保險不予涵括；若沒在裡面，病人去醫院治療，將會使用健保的經費，而健保卻不能行使代位求償。二、由健保署的資料顯示，健保代位求償金額，一年約在25億元至30億元之間，這對健保財務影響很大！不知委員是否同意變更議程，先討論臨時提案？原排定第一個討論的高雄氣爆案，醫療費用才幾千萬元，若大家可以接受變更議程，我們一定會將高雄氣爆案討論及處理完畢。鄭主任委員守夏現在有委員提議變更議程，因為臨時提案內容是針對目前最新的消息，委員是否同意要將臨時提案提到討論事項第1案之前討論？(委員表示同意)這是第一次幾乎所有委員都簽名連署。請提案委員謝委員天仁簡單說明。謝委員天仁一、各位委員如有看到媒體報導就了解，強制汽車責任保險推動者柯媽媽認為，健保行使代位權，讓強制汽車責任險的準備金日益減少，原想建議修正健保法第95條，把汽車交通事故代位權刪除。立法院社會福利及衛生環境委員會的立法委員當然是內行人，並未接受，所以鎩羽而歸。然後到立法院財政委員會，一不做二不休，將強制責任險的範圍縮小為，只有殘廢給付及死亡給付，才由強制責任險支付，傷害醫療部分不予給付，如此則等同廢掉健保代位權。二、健保法第95條第1項第1款及第3款規定，非常清楚，只對強制汽車責任保險或其他重大之交通事故、公害或食品中毒事件，例如餿油等，才能行使代位權。針對個別案件，在效益及整體行政考量，並不在代位權之範圍內，雖以保險法一般觀念財產保險人有代位權法律基礎來講，是有的，但在健保法中卻沒有，因為這是特別規定。假使汽車肇事，車主沒有強制汽車險，則使用任意險，若沒有任意險，會變成健保沒有代位求償的權利，結果是由2千3百萬的國民，共同承擔開車肇事者的責任。三、基本上，開車者是屬於強勢地位，有人說強制險不只汽車，也有機車，沒錯！但統計資料中，機車大多都屬於被害人，肇事者有90%以上都是汽車。汽車擁有人是強勢者，若撞到人，健保無法行使代位權，變成所產生的傷害醫療費用由健保支出，形成劫貧濟富，這是不公不義，健保會應提出意見，讓立法院財政委員會的委員瞭解，若決定這樣做，健保法必須有配套措施修法，否則，以現行健保法之規定，消費者要分散風險，只好買任意險，但又不在健保代位求償的範圍，誰會得利？當然是保險公司得利啊！四、某個角度看，強制汽車責任保險推動者柯媽媽提出那樣的修法建議案，很不可思議！因為不是對消費者有利，反而是偏向業者。個人曾經審議過強制汽車責任保險費率，我認為應強烈反映本會的意見，讓立法委員瞭解，沒配套機制，最後會由全民買單，車子頂多1千7百萬輛，全民2千3百多萬人，能要求每台車都買保險嗎？若沒保險，被撞到受傷，所有消費者幫忙付錢，這是不應該的事。請各位委員表達意見，並做出相關決議，讓立法院及社會大眾瞭解。陳委員宗獻我十分贊成謝委員天仁的意見，非常正確且大公無私的角度。從技術面建議，委員連署後會發聲明書，若以健保會委員個人名義提出，外界可能覺得，這些委員是衛生福利部的打手，所以，建議除了連署的委員姓名，並將各委員所代表的單位名稱，即委員的推薦團體，各工商團體、醫事服務團體之工(公)協會等名稱都列出來，比較具有民意基礎及說服力，更讓大家注重及聚焦，而非僅隸屬在衛生福利部之下。鄭主任委員守夏先請問委員們是否都同意本案？再看形式上如何連署。(委員們表示：大家都同意啦！)謝委員天仁請健保署把事情講得更清楚，且要務實地觀察情勢演變，若強制汽車責任險範圍真的縮小，健保署如何因應？若改成任意險，健保署有無可能對所有保險公司行使代位求償權？是否需透過修法？修法後實際執行層面有無困難等，都要考量，例如，修法後是否會因案件量暴增為幾萬件？連法院都會當機，以及法院如何面對及處理等問題。鄭主任委員守夏請李委員蜀平。李委員蜀平謝委員天仁人緣很好，大家都連署簽名了。若本會所有委員都共同提出意見並簽名，那同意柯媽媽提案的立法委員可能會改變想法？如以公平正義的立場，肇事者當然要自己負責，如果大家都簽名，那麼贊成由全民負擔的立法委員一定會收手，這法案將可間接影響到全國的交通安全，重罰幾個人之後，大家開車會更注意，有明確的教育附加的價值。我完全贊成大家一起連署，好讓那些立法委員知道反對的力量。干委員文男剛剛算了一下，大約28位委員簽名，只少了先離席及未出席的委員，雖然未達全體委員連署，不過我們想到可採兩種方式處理。第一，用媒體公布所有委員及其代表之團體名稱，表達完全支持本案之意見，藉此途徑，表達對立法院財政委員會通過此案的不滿及抗議。第二，直接將30多位委員的連署書拜訪送給立法院王院長金平，請侯委員彩鳳聯繫，表達立法院財政委員會通過強制汽車責任保險法部分條文修正草案，已跨越健保法及各種領域的強烈意見。開車肇事者沒責任，反而全民幫忙負擔肇事責任，這樣是不公義的。希望試試上開兩種方法，或者還有其他更有效、更快速的方式，現在一讀通過而已，要盡快處理，否則若經立法院院會三讀通過，屆時就欲哭無淚。鄭主任委員守夏大家的意見滿一致。請何委員語。何委員語一、昨天謝委員天仁來電表示要提出本臨時提案，我立刻說：一定連署。二、在此正式提出對本案之建議：(一)第一，請中華民國消費者文教基金會謝委員天仁擔任召集人，處理本案後續事宜。(二)第二，由謝委員天仁召開記者會，通知本會所有委員出席。(三)第三，記者會後，請謝委員天仁將所有委員連署的建議函，寄給立法院，包括財政委員會、社會福利及衛生環境委員會、及王院長金平在內的全體立法委員，每個委員的信箱都投寄。三、請謝委員天仁幫忙將全民健康保險法及強制汽車責任保險法相關條文列出，並對照整理本會的主張，例如第幾條可改或是不能改，這樣才能說明清楚，讓立法委員比較容易瞭解我們的訴求。像侯委員彩鳳也曾經是立法委員，他們實在是太忙，不可能有時間細讀所有資料，多半是由辦公室主任幫忙，因此，我提出後續執行的建議方式。不要麻煩主任委員或健保署出面，因為會太明顯，打擊面太大，之後希望由謝委員天仁擔任召集人。鄭主任委員守夏一、各位委員現在簽署的是臨時動議，並不是聲明稿，需再簽一份聲明稿，立即送到衛生福利部公關室。若時間趕得及，也許晚報會刊登，則日報也會跟進報導。二、今天出席的委員對於這個臨時提案，已有百分百的共識，那麼連署的這一份文件，可以先給公關室。後續就請謝委員天仁幫忙召集，要召開記者會或是馬上到衛生福利部記者室直接講，都可以，同時也拜託干委員文男、侯委員彩鳳等幾位比較有經驗的委員，能一起幫忙。(現場委員鼓掌通過)謝委員天仁我再補充說明一下，這個案子之所以會提修法，主要是因為保險公司怕準備金不夠會破產，但各位可知道強制汽車責任保險降過幾次費率？他們10年總共降了9次！反觀我們的健保費費率，也只有上次二代健保要啟動時，因已另徵補充保險，才從5.17% 降到4.91%，其餘都是調漲的。所以，他們若是覺得費用不足，就應該調升費率，並想辦法減少意外的發生，而不是縮減理賠範圍，或乾脆不賠。老實講如果要這樣，柯媽媽根本不用推動強制汽車責任保險，因為最大宗的受傷事件都不賠，殘廢或是死亡案件有幾件？強制汽車責任保險還有何意義可言？金管會其實有意見，但沒辦法，因為這是立法委員所提出，硬要強渡關山。林委員至美從個人角度，本人與行政院主計總處的代表，都認同這是關乎公平與正義的提案，但因為今天並未被所屬機關授權，未便參與連署，覺得很抱歉！也請謝委員天仁理解。鄭主任委員守夏合理！此案政府官員代表不在連署之內，所以，拜託謝委員天仁對外說明時，強調這是本會保險付費者代表與醫事服務提供者代表的共識。鄭主任委員守夏本會通過支持本提案。請同仁宣讀下一案。陸、討論事項第一案「103年731高雄石化氣爆之醫療費用由103年度總額其他預算之『其他預期政策改變及調節非預期風險所需經費』項目支應案」與會人員發言實錄同仁宣讀鄭主任委員守夏謝謝同仁宣讀！請問各位委員有無意見？謝委員天仁此案的啟動機制，在上個月委員會已決議，予以尊重，但我還是要對新增「不可預期因素屬非天災所致之大型事件」的評估指標，僅以「該事件發生後，前2個月之預估醫療費用達該地區當年季平均總額預算之0.3%以上」做為門檻，表達看法。這個評估標準是否設的太低？將來會不會因為門檻設太低，以至於常常要啟動這個機制，而多到不勝其擾？所以，我認為日後還是要注意這些情況，並好好檢討這個標準。但既然本案上次委員會議已經通過，原則上，我還是同意。鄭主任委員守夏一、本案在前幾個月已經深入討論，之前因為「『其他預期政策改變及調節非預期風險所需經費』項目」之適用範圍與動支程序設定的評估標準，門檻太高，以往未曾啟動過，也沒有試算基礎，所以不知道設什麼樣的門檻才算合理。既然上次會議大家已經有共識，就先通過，累積若干案例後再檢討門檻是否過低？但應該不至於三天兩頭就須啟動。二、請問其他委員有無意見？請黃代理委員啟嘉。黃代理委員啟嘉(陳委員宗獻代理人)本案大家應該是有共識，建議通過。有關「前2個月之預估醫療費用達該地區當年季平均總額預算之0.3%以上」之標準，會不會太低？從過去的幾年經驗來看，這款項沒有啟動過，未來若真有頻繁啟動的現象，再來檢討。鄭主任委員守夏因為原訂指標，從沒有符合標準而適用過的案例，即使這次高雄氣爆事件災情嚴重，卻也未達到啟動門檻，所以，上次會議才修訂指標。本案尊重委員意見先通過，未來若有需要，再行檢討指標。陳委員幸敏針對本案尊重討論結果。但想請問，本案不是天然災害，而似為人為疏失所致，健保後續是否會對肇事者提出求償？鄭主任委員守夏上次會議討論「其他預期政策改變及調節非預期風險所需經費之適用範圍與動支程序案」時，已經請健保署釐清是否符合健保法代位求償規定。蔡副署長魯有關代位求償，只要檢察官確定肇事責任在哪一個事業體或機關，本署即會依健保法代位求償規定，啟動相關機制，爭取代位求償。謝委員武吉一、此案原先是由我提出，本次氣爆事件發生在我們高雄地區，感謝委員同意通過。二、回應陳委員幸敏的關心，高雄氣爆案是天然災害，不是人為故意造成的事件。三、代位求償方面，據我所知，高雄地方法院已經起訴好幾個單位，原先我也是主張爭取代位求償，現在決定用「調節非預期風險經費」來支應，也是非常好的做法，不過若有機會還是希望健保署能爭取代位求償。鄭主任委員守夏一、請問各位委員是否還有其他意見？(未有委員表示意見)。二、本案照案通過。請同仁宣讀下一案。柒、討論事項第二案「有關醫院總額103年新增診療項目未於年度內支應之額度准予於104年支應案」與會人員發言實錄同仁宣讀鄭主任委員守夏謝謝同仁宣讀！請健保署說明。林組長阿明原103年尚未執行預算額度約4.34億元，但昨天共同擬訂會議針對過程面所使用特材，通過1.54億元的預算，因此，實際剩餘金額約2.8億元，希望能於104年繼續支用。吳委員肖琪以前費協會時代，不希望預算逐年遞延使用，且過去是議案成熟才會提出預算要求，現在卻變成經費先通過，才談如何分配，本會第1屆運作下來，發現這不是一個很好的方式。誠如剛才所討論的支付標準合理性，或李委員蜀平所抱怨藥師沒有掛號費(但其實醫院醫師及居家護理師也都沒有，因為掛號費由醫院收取)，這些問題都須事前整體規劃。現在反過來，是先決定預算，再決定如何給付，這樣好嗎？前天我和李玉春教授因參加長期照護保險會議，無法參加共同擬訂會議的臨時會以表達意見。請大家思考，是將這次視為特例，以後不能再發生，或是未來都可延後一年執行？鄭主任委員守夏付費者代表之委員尚未回到會場，但相信吳委員肖琪應可代表多數付費者委員意見，亦即希望專款能在期限內使用完畢。請教健保署這次是否有任何特別理由，可當作特例處理？否則，若形成慣例，就違反以前費協會的共識。林組長阿明 在協商103年度總額時，考慮很多手術處置過程，原使用之一般特材，已可由不斷引進的新醫療科技及特材來取代，但健保未給付，幾乎都由病人自費。為改善讓民眾自費購買的情況，因此在總額中爭取預算。但目前面臨的困難是，新特材可能適用多個診療項目，每項都要請台灣醫院協會核對，之後還要詢價，再召開專家諮詢會議及共同擬訂會議，程序非常冗長，因此，確實無法在既定的時間內完成。為維護民眾的就醫權益及減少民眾自費項目，希望能保留預算。鄭主任委員守夏相信醫界委員不會反對。請楊委員芸蘋。楊委員芸蘋付費者代表委員幾乎都不在場，剩下我們幾位應該表示意見。當年度預算應於當年度使用完畢，這是基本的道理。健保署表示確有執行上的困難，無法於當年度使用完畢，可作為特例。我贊成吳委員肖琪的意見，不應該延宕至次年度使用，如果沒有計畫，就不該編列預算。我認為應建立機制，好的制度要執行，不好的就取消。希望下年度不要再有特例，若無計畫就不要編列預算，編列了就要執行。鄭主任委員守夏謝謝楊委員芸蘋！請林代理委員敏華。林代理委員敏華(張委員永成代理人)我持保留意見，因為特例有一就有二，剛才吳委員肖琪也在提醒這個問題。特例一開，以後什麼都能叫特例，所以，對本案我持保留態度。鄭主任委員守夏因為付費者代表委員大多不在，不知道還需多久才能回來。本案若依健保署意見，先通過預算，再談計畫，恐緩不濟急，理想的做法，應該是逐年預先排定計畫。本案適不適合當特例，請委員討論。楊委員漢湶就制度而言，年度預算要在當年度使用，這是原則。但實務上，政府部門很難在年初就核定預算，開始執行；總額預算也常會遇到這種情形。因此，我基本上支持健保署的提案，否則延續性的業務沒有經費。將年度未使用的經費收回，對整體機制運作並無好處，尤其是病人，雖然超越一般預算原則，但在政府部門保留經費、延長使用的情形，只要符合程序，其實相當多。鄭主任委員守夏請侯委員彩鳳。侯委員彩鳳本案僅賸餘2.8億元，剛才發言的楊委員漢湶也曾任前行政院衛生署的官員，很了解預算執行的程序，不一定能100%執行完畢。但醫療日新月異，可能隔年就有很大的變化，建議健保署清楚交代2.8億元的用途，就同意本案繼續執行。鄭主任委員守夏請謝委員武吉。謝委員武吉感謝楊委員漢湶及侯委員彩鳳對本案的支持。新醫療科技的費用，第1年最少，第5年至第7年最多，但都未考量其預算額度與實際成本的差距，明年可能相差幾十億元，全都由醫界犧牲而吸收。所以，我認為這筆預算不應再扣減收回，應照案通過，醫界願意含淚接受。鄭主任委員守夏醫界傾向同意本案，但目前付費者代表委員大多不在場。這次是本屆委員最後一次開會，因此，我建議健保署與醫界討論，延長期限由半年縮短為一季。這次是特例，以後不應再發生。難得健保署支持醫界意見，或許有新醫療科技或新藥材，對於民眾有很大的幫助。誠如侯委員彩鳳所言，應讓付費者代表委員了解，這筆經費不是為了補貼醫界。是否有委員建議暫緩討論，等付費者代表委員回來再討論，徵求大家意見。請林代理委員敏華。林代理委員敏華(張委員永成代理人)我還是有意見！政府執行預算的規定，有其道理。因行政有其一貫性，我認為不應該破例，因特例一開，以後任何事情就可當特例，特例一多就變成慣例。我不支持通過本案，若認為需要經費，就在下年度預算編列，不要破壞體制。鄭主任委員守夏請蔡副署長魯。蔡副署長魯協商103年度醫院總額「新醫療科技」項目時，核定由本署訂定相關項目之額度與開放時程，於102年12月委員會議說明訂定原則及作業時程，若未於預定時程內導入，則扣減該額度。因此，本案可依此核定事項執行。至於與政府預算留用，是否一體適用，本署無從解釋。楊委員芸蘋既然是本會協商103年度總額的核定事項，就應遵照辦理。尊重林代理委員敏華的意見，但建議可再考慮，因金額不大，也不會特例變慣例。鄭主任委員守夏依照協商的核定事項，其文字非常明確，若未在預計時程內導入 ，則扣減該額度。當初編列20億元，若依照協商的共識，新醫療科技未用完的額度，就應扣減收回。所以，我才請教健保署有無特別理由，可說服大家當作特例處理；若沒有，就應按照原來決議。剛才健保署的說法是…。侯委員彩鳳本會幕僚補充說明第一點就寫得很清楚，健保署希望本案通過，就應解釋清楚，不要誤導委員，大家忙了半天，又回到原點。直接針對第一點說明清楚，就不會誤導委員，剛才2位付費者代表委員 離席前，對其他都沒意見，只針對討論事項第5案，希望等他們回來再行討論。吳委員肖琪如果這樣，就是不能保留，昨天通過的1.5億元可於103年支應，但剩餘的2.8億元，就請明年重提。劉代理委員碧珠(張委員煥禎代理人)一、醫界在協商新醫療科技時，曾提出希望先將其列入其他預算中，觀察1~2年的使用情形後，隔年再導入部門總額的一般服務。目前新醫療科技的經費，都是健保署依據歷史資料進行預估，但未來使用量必定會增加，若觀察實際的使用量及金額，相信遠高於所編預算。醫界一再提出，但本會從未追蹤過。二、今年導入過程中，很多項目在過程面採包裹給付方式，剛才林組長阿明也提到，在和醫界討論過程中，也發現很多新的特材項目，可能在其他處置或檢查使用，但過程面並未另外給付，難道要醫界自行吸收嗎？諸如此類，2.8億元預算尚未執行，我認為真的要看看實際執行是多少。懇請付費者代表委員同意保留預算至明年繼續執行，並追蹤每年實際使用金額與編列預算是否相符。(付費者代表委員回到會場)鄭主任委員守夏付費者代表委員剛回到會場。目前進行討論事項第2案，103年新增醫療科技，健保署與醫界尚在商討中，目前預算有2.8億元尚未執行。若依之前本會協商共識，至年底未使用完畢，即予以扣減，但健保署表示，因尚在討論中，並非無進度。請大家討論。莊委員志強請教本會幕僚補充說明第一點，若醫院總額一般服務預算尚未執行，會滾入基期嗎？(蔡委員登順回答，會滾入基期)因此，尚未執行的4.34億元(侯委員彩鳳更正是2.8億元)，也會滾入基期。鄭主任委員守夏請謝委員天仁。謝委員天仁我們為何要有年度預算？當然是為落實預算之執行。除非有特殊理由，否則共擬會議尚未完成擬定，就不能作為支付項目。年度內無法作為支付項目，如何延至104年執行？與其如此，等104年大家再來討論要追加的項目，我認為這樣較有道理，以預算遞延的方式處理，並不適當。鄭主任委員守夏委員還有無不同意見？若按照當初協商的共識，是希望盡快導入，若來不及導入，就用104年度的總額支應。剛剛林組長阿明提及，現在是有好幾項新的醫療科技在排隊，但有些導入確實較慢，如果回到原來總額協定共識，其實不太有討論空間，但這次難得健保署與醫界有共識且快要談成，我們是否要同意？ 謝委員天仁這有適法性問題，不要忘了總額協商本身，是經過衛生福利部對外公告而產生法律的效力，怎麼可能這樣說一說，就會發生法律效力。這個部分的適法性要特別注意！會有問題。鄭主任委員守夏健保署仍要堅持所提意見？蔡副署長魯尊重各位委員的意見。謝委員天仁若經費不足，可於往後年度再編。鄭主任委員守夏現在是因為有些新進的醫療科技較慢導入，導致會無法用到103年度的預算，這部分的金額要保留到104年。黃代理委員啟嘉(陳委員宗獻代理人)部分付費者代表持反對意見，本案需考慮對消費者權益是否會有影響？本案是要解決民眾自費的問題，若不通過，仍無法解決民眾自費的問題。剛剛謝委員天仁提出適法性問題，健保署有法務單位，應已對適法性有所思考過及提出解答。我認為第一，適法性應優先考慮；第二，應考慮是否會影響付費者權益。鄭主任委員守夏付費者代表之委員，就是代表付費者權益。林代理委員敏華(張委員永成代理人)一、除了考慮付費者權益外，國家會立法，就是不管健保法、預算、決算等，大家都須依法遵循。今天若要破壞這個規則，須有充分的理由，惡法亦法，因這是已經立法的東西。二、剛剛謝委員天仁提到總額公告涉及法律問題，還有，目前討論的賸餘預算也不是很多，今天有需要去破壞原則嗎？若如此強調這些理由，當初在共擬會議討論時就應有共識，現都牽扯在一起。提案說明也寫得很清楚，若未於預定時程導入，則扣減該額度辦理，建議依照原來的核定事項辦理，不贊成本案通過。鄭主任委員守夏一、各位委員的意見都已經充分表達，為了不讓下屆委員頭痛，也不想破壞協商所建立的共識，本案就依照原來共識，到年底前，未於預定時程導入，則扣減該額度。二、現在進行下一案，請同仁宣讀討論事項第三案。捌、討論事項第三案「可調式腦積水引流系統--『英特佳』內植用腦積水引流管組OSVⅡ自付差額特殊材料案」與會人員發言實錄同仁宣讀鄭主任委員守夏謝謝同仁宣讀！本案滿專業的，委員關心的是民眾需負擔的價錢，但這些又是獨門獨行。請問委員有無意見？請蔡委員登順。蔡委員登順一、可調式腦積水引流特材健保支付價格為7,127點，若納入自付差額項目，民眾仍然需自付55,873元差額，是健保的8倍。以民眾立場來看，會關心錢花得是否有價值，這項新特材是否有比健保給付的特材好上8倍？二、從議程資料第59頁至60頁資料來看，相對療效似乎沒有差很多，建議健保署應比照之前討論牛心、豬心瓣膜的案子，提供醫療科技評估資料讓我們參考。三、議程資料第57頁，三、(四)專家意見：「考量開放自付差額特材攸關民眾權益，且因特材推陳出新，療效與成本效益不確定性高，建議提案時，應檢附嚴謹之醫療科技評估報告，輔助提供中立、客觀之資料，以利討論。」今天本會委員要幫全國民眾做決定時，若無醫療科技評估資料，會很為難。建議要有醫療科技評估資料，提供相關療效、成本效益的評估，否則今天很難表達是否支持該案。鄭主任委員守夏請吳委員肖琪。吳委員肖琪議程資料第57頁第2行，本會幕僚補充說明第二點，案經幕僚依本會前訂定之「討論自付差額特材案之作業流程」，檢視提案內容後，洽請本會專家學者委員提供建議。我知道健保會的公務預算並不多，請問大概多少？柯執行秘書桂女請委員猜猜看。吳委員肖琪我不太清楚真正金額是多少？但我知道今天委員畢業，並未舉行餐會，在總額協商時很辛苦，也只是吃便當。柯執行秘書桂女健保會104年度的預算約5百多萬元，而且立法院審查預算時，又被減列50萬元，所以只有5百多萬元，但本會所有的支出都要從公務預算支應，審預算時，我還要代表本會至立法院提供必要說明。有些單位的補助款就好幾億元，而本會只有5百多萬元的預算，讓委員這麼辛苦，向委員致敬。吳委員肖琪一、5百多萬元的預算，要包括委員的出席費、交通費、影印所有資料的費用，以及7月份的總額評核會、9月份的總額協商等。我原本以為有1千萬元，若只有5百多萬元的預算，還要請專家學者來建議，而健保署原先提供6篇論文，後來發現有3篇不能用，之後又換了3篇。我認為健保會及健保署，有機會還是要爭取多一點的公務預算，讓健保署有足夠的經費辦理醫療科技評估。建議在健保署的階段就要做好醫療科技評估，若健保署沒做，到本會才要處理，我覺得不妥。二、議程資料第57頁，影響超過3千萬點的才做醫療科技評估，而本案為1,900多萬點，所以，未做醫療科技評估，但真能確定影響只有1,900多萬點嗎？建議兩點：第一，是否可以拜託立法委員增加健保署的公務預算，健保署現在的預算不到1%的健保費。第二，請健保署處理醫療科技評估，而非由本會去請專家學者來做醫療科技評估，才能有客觀的資料供委員參考，這樣比較符合權責。吳委員玉琴一、原來預期本次會討論較多的自付差額特殊材料案，因為本會曾決議一年審2次自付差額特材案，但本次只討論一件，有點訝異！應該不會只有一件，到底是什麼原因？請健保署說明。二、對付費者代表而言，看這些資料是有困難度，之前希望有醫療科技評估報告，能幫我們做專業評估。議程資料第60頁，新的特材併發症似乎比傳統降低很多，但又看到不同的專家有不同的意見，我們無法判斷新的特材是否有具體療效，建議專業判斷應該要回歸醫療科技評估，我們不做太多的專業判斷，因為看不懂。三、本項特材費用，上市的售價是5.8萬元，現在廠商申請的售價是6.3萬元，等於是將健保給付的七千多點再墊上去，變成新的售價，應該是要用5.8萬元去減七千多點，現在卻允許用6.3萬元當售價，這就是健保白給付一筆錢，墊高售價，不甚合理，應要求廠商售價回到5.8萬元。四、看到健保自費醫材比價網的收費標準，有些院所收費還高達7.5萬元，這個現象，健保本身幫不上民眾端的忙，廠商還是收原來的錢。本案需要審慎評估，雖然看不太懂該特材的療效，但還看得懂財務，現在似乎沒幫民眾把關，還有圖利廠商之嫌。干委員文男贊同吳委員肖琪的意見，新特材是否具有效益，應該要做醫療科技評估，並應由健保署來做。剛剛柯執行秘書桂女提及健保會很窮，公務預算才5百多萬元，還要提供委員便當、茶水、出席費等，建議醫療科技評估應由健保署做，以及健保會公務預算的編列要增加。鄭主任委員守夏請何委員語。何委員語一、議程資料第63頁，係3位醫師提供的專家意見，依該資料，本案特材若納入健保，使用量可能相當大，將增加健保的支出，且預估增加的財務衝擊，將大於其所減少阻塞、感染及重置的效益。二、如果這個特材上市價格為5.8萬元，為何其他醫院可以超過這價格？難道不同醫院對於相同特材，會有不同訂價嗎？是否應統一價格，應該要以5.8萬元向病患收費才對。三、由醫師的意見看來，不能確認新特材是否為較好，建議健保署向廠商要求更明確的資料，並提供醫療科技評估報告。現在雖然附了很多的英文資料，但委員無法在短時間內理解這麼多，希望健保署能提供更明確的醫療科技評估報告，供委員參考。鄭主任委員守夏一、依照全民健康保險法規定，健保署同意之自付差額特材品項需提健保會討論，並未規定要審議通過。目前大部分的委員，認為增加療效所帶來的效益，並沒有那麼明確到值得8倍以上的收費。二、委員建議能有公正客觀的醫療科技評估報告，無論報告是由健保署或申請的業者提供，則沒有意見。若有醫療科技評估報告，可以讓委員比較容易解讀，無論是要支持或反對，會比較有依據。委員若沒有其他意見，請同仁將意見臚列，供健保署參考。三、現在進行下一案，請同仁宣讀討論事項第四案。玖、討論事項第四案「全民健康保險年度總額對給付項目調整之處理機制案」與會人員發言實錄同仁宣讀鄭主任委員守夏一、謝謝同仁宣讀！本案是本會於本年7月份委員會議討論「保險給付範圍調整於年度總額作業中之運作機制案」，對放寬保險給付範圍是否會影響到年度總額，針對這點，當次委員會議決議，請本會幕僚與健保署研擬細部操作方案後，再提會討論。二、議程資料第74頁「全民健康保險年度總額對給付項目調整之作業原則與流程」，是健保會與健保署幕僚共同討論後的流程，還需要再請同仁宣讀或說明一下？(未有委員表示意見)三、議程資料第72頁所提的大原則，已經本年7月份委員會議同意，意即須先了解要做甚麼，才能知道要多少錢。不知各位委員是否同意先試行一年？謝委員天仁先試行看看。鄭主任委員守夏這是健保署與本會幕僚共同討論出來的原則與流程，先試行一年，若試行後，發現仍有窒礙難行之處，再作修改。請問委員有無其他意見？謝委員武吉好像付費者代表說一聲就好，又沒有尊重我們的意見。楊委員漢湶這個作業原則與流程很長，看得似懂非懂的，其中引用很多健保法條文，為何沒有引用健保法第26條？該條文涉及若要增加保險給付項目，應該要做一個財務評估。不是說只關心錢，基本上，在總額制度下，經費不是那麼多，點值又那麼低，不得不關心對財務的衝擊。現在醫院經營困難重重，若要試辦沒關係，試辦後才會知道會造成什麼影響。現在不是單價多少的問題，而是總費用的影響會有多少？有的項目雖然單價低，但量很大，影響還是會很大的，建議增加對財務衝擊影響之項目。柯執行秘書桂女向大家報告，上次(103年第7次)會議之提案「保險給付範圍調整於年度總額作業中之運作機制案」涵蓋範圍較大，委員認為內容太空泛，恐難以執行，所以，請健保會幕僚及健保署同仁討論細部操作方案。經過雙方討論研擬，本次提案已把範圍縮小，歷來在談年度總額時，都會將一些給付項目調整納入，爰提案建立此部分的作業原則與流程，同時也將過去醫界所建議的意見納入，因此，與健保法第26條較無關聯。鄭主任委員守夏基本上，訂定此流程的目的是，對給付項目調整或適應症放寬，避免先公告後，再要求總額補足財源，造成大家意見不一致的問題。本案希望建立規則，在給付項目調整前，應先訂定政策目標，估列經費，再談總額所需預算。楊委員漢湶一、之前所發生的事情，都是因為先斬後奏才有爭議。比如Statins(降血脂藥品)及Lucentis(黃斑部新生血管病變藥品)不知道哪個會議先通過，健保署就公告，談年度總額時又不編列預算，硬是叫醫界吞下去，不合法也不合理。二、議程第73頁引用許多健保法條文，不清楚這些條文內容，因沒有逐項核對。但我認為，如果太專業的範疇，不應在本會討論。老實講，前一案可能在座沒有多少人看得懂。我覺得對健保財務有衝擊的議題，不論是影響被保險人、消費者或醫療體系，都是本會需關心事項，我們看的是政策，而不是技術面。鄭主任委員守夏此案比較不緊急，如果委員還沒仔細研讀草案內容，則建議移到下個月，即第二屆的第1次委員會議再討論，趁此機會請所有委員回去審視作業原則與流程，看是否還有可改進的地方。請幕僚徵詢所有委員修正意見，下次一併討論，此案先緩議。進行下一案，請同仁宣讀。拾、討論事項第五案「檢討『全民健康保險保險對象應自行負擔費用之合理性』案」與會人員發言實錄同仁宣讀鄭主任委員守夏謝謝同仁宣讀！請委員表示意見。楊委員漢湶一、目前部分負擔費用與法定標準差距甚遠，102年整體部分負擔費用比率只占11.8%，連法定最低20%都沒達到。上次會議討論平均眷屬人數時，大家都認為健保署應依法行政，公告平均眷屬人數0.62人。印象中，目前部分負擔費用，已施行將近10年(94年7月15日實施)，產生很多怪現象，卻不調整。例如，急診檢傷分類第4、第5級的病人，為求方便，都湧到急診。二、健保財務雖然現在看起來好像還不錯，但這樣榮景、好現象，相信不會維持太久！因為老年人口越來越多，慢性病也越來越多，而健保保費收入不可能永遠成長。我覺得必須檢討部分負擔費用，因為現行制度，距離法所定標準太遠，若無法一次全部調整，可先施行某部分，例如急診先實施，或門診也做調整。至於經濟弱勢者，依健保法規定，本來就可設定上限，或予以減免。否則每次都在討論這件事，永遠都是一個議題。鄭主任委員守夏請謝委員武吉。謝委員武吉一、其實是本案案由寫得不對，當時我們所討論的是，落實健保法第43條分級醫療轉診制度案，不是今天歪七扭八的案子，這是欺騙百姓、欺騙與玩弄我們這群人的提案，在此提出嚴正抗議！二、楊委員漢湶剛才提到，本案是公部門應做的事，本會幕僚卻補充說明：本案屬保險政策諮詢事項，討論結果送供主管機關及健保署參酌。這種寫法，根本是不負責任的寫法，貴會要負百分之一千萬的責任，當然要自殺、切腹自殺也可以，但現在都切魚腹。本案應是落實健保法第43條分級醫療轉診制度，要採用什麼方式來做。三、各界代表都有其想法及看法，若我是勞工代表，也會認為盡量不要動；若我是屬於像何委員語的雇主代表團體，就要調降平均眷口數，平均眷口數也已成功調降了。每個人都有不同想法，但剛才楊委員漢湶講得非常好，這是依法有據的事，已經20年沒動過。我手上拿兩版健保法，一本是101年出版，另一本是95年出版，分別規定在第43條、第33條。四、今天有保險付費者委員偷偷告訴我，這不用提，大家絕對反對！我覺得大家要拿出良心，剛才討論事項第2案，醫院總額103年新增診療項目未於年度內支應之額度2.8億元，要保留至104年支應，你們不同意，就「依法行政」，難道本案不用「依法行政」嗎？20年違法、瀆職，還可以繼續幹下去嗎？大家都辭職算了！五、今日補充資料有民眾投書給行政院毛治國院長及衛生福利部蔣丙煌部長之2封電子郵件，我和謝董事長文輝看了，覺得可能都是同一人所寫，因為一位姓「張」，另一位姓「章」，而且文筆很相似。我出過書，看得出來，所以我覺得很奇怪！另外，西醫基層的人聽好，寫給蔣部長的信第2點提到，「目前各診所、區域級醫院幾乎都沒『轉診單』或根本沒看過」，要如何解釋？最後，我要說的是，你們要怎麼做都沒關係，我一定要落實健保法第條43條，一定要求依法行政。沒依法行政，就看著辦！鄭主任委員守夏我們都瞭解，付費者代表都同意依法行政(委員：當然！都同意)。干委員文男感謝謝委員武吉提醒，補充資料有2位民眾投書，可看出部分負擔的高低，確實影響民眾對健保的觀感。健保有些制度確實與社會的氛圍有些差距，大家應多聽聽外界的聲音，以免與民眾的距離愈來愈遠。為了這個問題，我也走訪過基層許多地方，其經媒體報導，很多民眾會質疑，到底分級醫療是誰的責任？是醫師、醫院還是民眾的責任？在第一線檢傷分類把關的，應該是醫師及醫事人員，並不是消費者，如果僅以調整部分負擔來解決分級醫療的問題，變成只是懲罰一般民眾而已。謝委員武吉沒有懲罰，未落實健保法，才是違法。干委員文男一、怎會沒懲罰？沒落實健保法是當初社會氛圍，在83年勞保時代，說要訂健保法，卻都沒有消費者參與。健保法完全是一面倒的法令，當時大家就想到會出問題，可惜消費者並沒有參與。其實從勞保時代，大家就已知道分級醫療及轉診制度是誰的職責，有位官員也因而下台。所以，真正解決的方法，應該是修改健保法。二、分級醫療其實已經在做了，前些日我到醫院探視病人時，確實有人使用轉診單，目前約有72%的保險對象穩定地在基層診所就醫，請問轉診比率應達到多少才算合理？在自由競爭的市場下，對於有錢人而言，並沒有什麼差別，自行負擔的費用即便調到1,000元，照樣有人會去大醫院看病，只會懲罰到少數的經濟弱勢病人。三、目前的共識，好像是朝向調高急診之自行負擔費用，急診的病人如果較為輕症還好；若是重症的病人，轉來轉去，可能導致病人死亡。四、感謝謝委員武吉提到這兩篇文章！讓我們看到民眾的投書。謝委員武吉你早就已經看過了。干委員文男我是今天較早來才看到補充資料，謝謝提醒我！健保法第43條的規定，並不合時宜，站在付費者立場，對於本案建議，我表達反對！這個時候只要有一點改變，必然引起社會譁然。剛剛付費者下去一樓召開記者會時，記者就詢問我們對於本案的意見。開會議程只要一上網，外界就非常關注各項議案的討論結果，我的發言若是不對，回去馬上就會被釘得滿頭包！我要面對的勞工很多，從基層到中央都有，這樣的調整，民眾觀感並不好。況且目前健保還有盈餘，又不是沒有錢了，建議應該維持現狀，沒有必要在這個時候調整民眾應自行負擔的費用，這樣大家會傷感情的！鄭主任委員守夏請謝委員武吉。謝委員武吉一、謝謝干委員文男剛才所講的一番話，其實干委員已經看過民眾陳情案的報導，還說是我指導的，其實我不敢指導干委員。二、本會委員一再強調，所有的事項都應該依法辦理，楊委員漢湶剛才也重申這一點，我們只是要求健保應該依法行政。健保實施20年，健保法第43條已經考慮那麼久了，誠如何委員語所說，健保若有違法事項，可從過去監理會委員、費協會委員、衛生署署長、健保局局長，到現在的健保署署長及衛生福利部部長，全部一起或選擇特定人員告發。難道本會委員就可以違法嗎？20年從勞保時代，我就已參與健保業務，所以非常清楚這個過程，如果大家有辦法，就馬上叫立法委員修改健保法啊！鄭主任委員守夏請吳委員玉琴。吳委員玉琴一、聽起來好像調整部分負擔是為落實分級醫療與轉診制度，這兩件事其實很難達到！過去健保署也多次調整民眾自行負擔的費用，請問真有達到轉診的效果嗎？會不會對高齡者或是弱勢團體產生很大衝擊？二、這是兩個不同的命題，剛才賴委員武吉(委員同聲說：是謝委員武吉)，抱歉！開會時間太久，有些錯亂了！是謝武吉委員。講到本案的適法性，謝委員強調的是健保法第43條的第1項，各層級醫院未經轉診，應訂定不同的自行負擔費用比率；而我們若著重的是同條第3項，主管機關必要時，可以採用定額方式收取自行負擔的費用，所以，並沒有違法的問題。三、若要落實轉診制度，我們就應該好好去討論。目前已有72%的民眾在基層院所就醫，報告中顯示，轉診制度某種程度也有些成效，健保署應提供更多的數據來印證。這個時間點一直討論增加民眾部分負擔，加上媒體也很關注，在目前大環境的氣氛下，是非常不利的！所以，我們從被保險人立場，反對這個時候調整民眾自行負擔的費用，因為醫界意見也很分歧，真的能改善急診壅塞和轉診的問題嗎？看起來似乎是無法達到，這是我們反對的原因，應該要有很清楚的數據，我們才可能支持。鄭主任委員守夏請謝委員天仁。謝委員天仁一、這個案子老實講是炒冷飯，已炒了很多年，還是在炒！付費者代表的意見很清楚，就是要落實所謂的分級醫療，單單靠調整自行負擔這個辦法，是無法達成的，而且其也無法解決地區醫院所面臨的困境。所以，我們認為健保署應該從長計議。從我的角度來看，急診檢傷分類屬於第4級、5級者，到急診不到半個小時就可以看完診，當然，大家會把它看做快速門診。快速門診只多收費2、3百元，民眾會改變他們的就醫習慣嗎？在鄉下地區，有可能啦！但在都會地區，是不可能的嘛！民眾就是要快速，2、3百元，小錢啦！就付了，反而造成更多的急診壅塞，沒有意義！最後結果，只是弱勢民眾應該得到健保相同服務的機會受到阻礙。二、我認為提高部分負擔只觸及單純的一端，並不夠周整。我剛才提過，急診為什麼分檢傷1、2、3級，還是壅塞？因為醫院沒有病床，轉不上去。如何解決讓病床可以空出來呢？之前一直說的急性後期診療，已經在做了，輕症病患沒有必要在醫學中心住院，可以下轉到地區醫院住院，然後用垂直整合方案處理。這個部分有給1億元的經費，為什麼不去考慮相關的配套事項？三、大家都喜歡便宜行事，像我們剛剛一直吵的，地區醫院提的保障點值，其實在醫院研商會議已經提過幾次了，每次都吵到要打架，只要講到保障點值，付費者就沒辦法接受。應該有其他的方式可以做，連我這個外行人都可以想到這些部分，難道專業的人沒辦法想到更多嗎？把這些病床空出來，讓急診不會壅塞，再配合相關機制釐清真正目的，地區醫院到底想要賺什麼錢，賺這些門診的小錢嗎？把急診那些人轉到醫院病房住院，老實講地區醫院門診也不缺急診這些人，比較缺的是病房的住房率偏低，就跟飯店一樣，要想辦法去衝業績，輕症住院轉過去不是很好嗎？為什麼不要就此部分持續設法解決？拿出一個比較完整的議案，效果會比較好。最後我的結論是，我們這一屆都快結束了，留給下一屆討論吧！鄭主任委員守夏請吳委員肖琪。吳委員肖琪一、本來以為要留給下一屆討論，東西都收起來要回家了。提供一些平均每年每人門診次數資料，澳洲6.7次、加拿大7.4次、丹麥4.6次、法國6.8次，大概都是介於6次或7次左右。台灣則是15次，日本13次，為什麼我們會這麼多次？與就醫太方便有關，這是實話。二、理論上健保法第43條，應該是用定率。其實定率比較好，但現在的定率也有問題，我也建議要修法；還好有備案，就是用定額。之前在計算急診應自行負擔的金額時，其實是以定率換算出來的。只是很可惜，這個定額很多年都沒有動，所以，以前定額是以20%去計算，而現在只剩下大約12%，所以，我們都在做違法的事。我們第1屆健保委員都希望依法行政，有些案子對健保署不好意思、有些案子對醫界不好意思、也有些案子對於消費者不好意思，但是我們宜儘量落實到依二代健保法行政。三、以前用定率的20%訂出定額費用，這麼多年來，很多費用都漲了，但是應自行負擔的費用，卻沒有調整，所以已從20%下降到12%，現在我們應該用前一年平均費用的20%去計算出定額。干委員提到，現在大環境不好，就不要去動門診，我們就先從急診開始。為什麼要從急診調整呢？因為低收入戶並沒有那麼悲慘，如果是晚上急診，延到第二天早上門診就可以處理；如果是星期六、星期天，下個星期一就可以處理。但如果是急性心肌梗塞，當然要緊急送醫院了！由急診轉住院的話，低收入戶應負擔部分的費用，政府都有保障。所以，我支持先從急診開始落實二代健保法，就是每一年根據前一年平均門診費用的20%公告，可是目前僅達12%，不符法令。鄭主任委員守夏請二位楊委員，先請右手邊的楊委員漢湶。楊委員漢湶我要先禮讓楊委員芸蘋。鄭主任委員守夏好！請楊委員芸蘋。楊委員芸蘋一、其實，剛才吳委員肖琪所言，就是上次開會所提的。我贊成這個時候不宜全面調整，也贊成急診這部分需要用定率來調整定額。不過，幾乎我們這些消費者、弱勢單位都不願意、也不贊成全面的調整。而且這幾年物價幾乎上漲5%，勞保費也調整，其他的物價指數也都上漲，真的也都調整到我們每個人的身上去了！所以，以20%的比率而言，我們幾乎等同於負擔20%了。二、沒有錯！真正的費用應按醫療費用支出比率來計算，是不到20%，可是也不希望違法，第1屆的健保委員就做違法的事，不是我們所樂見的。既然是20多年來都沒辦法解決的事，不可能在這1屆就能解決。其實我也滿支持醫界的想法，但反對要消費者負擔更多的費用，這是兩難！吳委員肖琪說得也對，就是有些案子會得罪醫界，有些案子會得罪某個單位，沒有辦法都平等。三、應該做一個長遠的考慮，要全面調漲、全面調高部分負擔，是有點難度。如果必須調整的話，在急診這方面，我個人認為是可以討論的。鄭主任委員守夏請楊委員漢湶。楊委員漢湶一、剛剛委員們在講健保法第43條這個法條，內容即83年健保法通過時的第33條而作修正，20年來這個比率其實都一樣，部分負擔為20%，沒有經過轉診，當然要負擔較高的費用，但現在的比率卻離20%甚遠。二、至於健保法第43條第3項規定，必要時，得以定額方式收取應自行負擔之費用，基本上我贊成門診用定額。但是這個定額不可以亂定，而需按照前一年各層級醫院平均門診費用來定，我們醫學中心每一次門診3,140元，區域醫院2,220元，地區醫院1,400元。所以，如果按照這個算下來，依法應該是620元、440元或是280元。我知道如果現在調部分負擔的費用，會被說沒有考慮民眾的感受，但是也不能永遠都不調整，現在這個比率確實是偏低很多。三、目前各層級醫院部分負擔是120元、240元、360元，而19家醫學中心，在99年時，只有4家的門診收入高於住院，現在卻有一半以上的醫學中心，即10家的門診收入高於住院。門診收入增加，有些則是因為技術的進步，比如說，本來要住院開刀，現在用門診顯微手術就可以了。醫學中心的門診病人，真的增加太多了！醫學中心的目的，不是看小病。可以先從急診開始調整，但是不能十幾年來都不調整。鄭主任委員守夏請何委員語。何委員語主席、各位委員，請把健保法第43條的條文拿出來看。該條第3項規定：「第一項應自行負擔之費用，主管機關於必要時…」，請聽清楚這一句「必要時，得依診所及各級醫院前一年平均門診費用及第一項所定的比率，以定額方式收取」，也就是說前面第1項「應自行負擔門診或急診費用之百分之二十」、「居家照護醫療費用百分之五」，或者「不經轉診於地區醫院、區域醫院、醫學中心，應分別負擔百分之三十、百分之四十及百分之五十」的部分負擔比率，主管機關於必要時，得以定額方式收取，並且每年都要公告其金額。基本上，定額方式收取是不違法的，因為前面均有一個「得」字，即主管機關得參照，也不必得參照，「得」字可用也可不用的意含，希望醫界的朋友弄清楚。楊委員漢湶條文規定的定額，是要按照前面的比率，也就是要按診所及各級醫院前一年平均門診費用及第1項所定的比率，以定額方式收取。何委員語一、是可以這樣子，但是前提是「必要時」，才可以定額方式收取，定額金額的多少，是由主管機關決定，否則，就不用立法來定額收取。我認為以定額的方式，由主管機關來決定，是於法有據。只是這個文字在立法時，並沒有徵詢過付費者的意見，如果我與謝委員天仁有去開會，不會出現這樣子的文字。二、依目前的狀況，我比較贊成急診的部分可以微幅修正，至於門診與其他部分，則不贊成修改。三、請大家依據健保法第5條的精神，了解這個提案只是諮詢建議案，委員並沒有權利來決定，僅諮詢健保會的委員。請各位把健保法第5條的條文內容看清楚一點，這是諮詢的建議案，請讓主管機關去做裁決。鄭主任委員守夏請謝委員天仁。謝委員天仁一、之前也提過，此與給付範圍的變動本身，事實上是一樣的。當醫界爭取給付範圍變動的時候，就認為付費者在整他們。以剛才的討論事項第4案來說，是希望有一個流程去處理；這個案子其實也一樣，付費者本身的自付額增加了，等同調漲費率。如果相關的流程變成在決定104年的總額，則部分負擔的調整應該在前面的討論事項第4案中，一併討論才合理！二、現在費率不調降了，卻另提「自付額要增加」案，我認為是不合理的。從財務的角度上來看，不但不合理，也不是很妥適的。你們的Statins(降血脂藥品)及Lucentis(黃斑部新生血管病變藥品)的給付範圍調整，都希望整體去考量了，對部分負擔難道我們不能作相同要求嗎？三、現在提此案沒有什麼正當性，應將其併到剛才的第4項討論事項一起討論，整體考量在這種情形下，費率需不需要調降？看看這時候健保署因為自付額增加，會減少支付的金額多少？結餘會增加多少？以及要不要調降費率？這樣才合理。四、不能以此種方式處理，這對付費者來說不公平，應該要完整的、妥適的考量分級醫療的目標如何去達成，這比較重要。所以，醫界已經要求給付範圍變動的時候希望按照編訂的方式去改變，我們也要求相同的方式對待。楊委員漢湶這個案子不是醫界提出來的。謝委員天仁一樣的道理，在此案，我們支持你們！那麼，你們不是也該支持我們嗎？楊委員漢湶此案不是醫界提出來的，我們只是表達意見。鄭主任委員守夏一、針對此案，兩邊的意見很明確不是很一致。依據說明一，本案其實是在今年第8次委員會議時委員以臨時提案提出，並決議要求健保署去廣徵所有權利義務相關團體的意見，所以，健保署才邀集消費者代表、付費者代表、學者專家代表，舉辦諮詢會議。這個提案已彙整該會議的意見；健保署是依第8次委員會議的決議辦理，原始提案人是醫界代表。二、今天是健保署依照委員會議的決議，整理了大家的意見。但是，我們都知道不會有共識的，果然，這些意見看起來還是沒有共識。如果沒記錯的話，平均眷口數的公告，是保險人的權限；調漲部分負擔的金額或比率，則是主管機關的權限。健保會委員會議只是一個溝通平台。三、我非常瞭解醫界為了這麼多年沒有調整部分負擔的費用，覺得不合法，也不合理。但是付費者代表今天所講的內容，與之前諮詢會議所講的類似，我只能說兩邊的意見，都各有立場，也都合理，只能把我們的意見送給主管機關參考，因為那是主管機關的權限。主管機關考量的不就是政治問題嗎？各位也都認識很多政治人物，可以用政治的方式來解決。主管機關要不要公告？是否違法？如果有違法的話，不要說委員，一般民眾就會去告他們了。四、健保會委員會議只是溝通平台，健保署已經照決議去蒐集意見，而現在的意見就是沒有共識。今天開會也一樣，還是兩邊沒有共識。一方面是說考量有沒有違法，且演變成對於健保法法條解讀的不同。但是20年來都沒有調整，是應該予以慎重考量。另一方面是部分或自行負擔費用的調漲，其實只是手段之一，真正會受影響的人，不是重病或輕症的人，而是付得起或付不起的人。這是以前費協會都討論過的議題。五、到底是要切成什麼樣子？切這一邊，同時又會傷到另一邊，無可奈何的時候，也只好這樣了。衛福部或健保署都很清楚，法律解讀起來，似乎就是沒有依法行政，可能有民眾要去告衛福部，或者消費者代表則認為依現在的時機，拜託不要再談這個議題。干委員文男一、主席，實在是很冤枉，醫界說20年沒有調整，健保醫療費用在20年前多少錢？現在又有多少？好幾倍了！剛開始是2千多億元，現在則是5千9百多億元。二、本來健保法第43條是在講分級醫療、檢傷分類，要由醫師來決定？或是由醫院決定？消費者當然要配合醫師，但是醫師都接手了，之後才來懲罰這些急診的病人，這樣合理嗎？換我要召開記者招待會，怎麼會這樣不合理！鄭主任委員守夏好！我們了解。現在請還沒有發言的委員先發言。李代理委員紹誠(蔡委員明忠代理人)一、主席，李紹誠第一次發言。其實這個問題談了很久，真正要落實可能要在制度上著手，如謝委員天仁所講的推動急性後期照護計畫，醫學中心就做醫學中心該做的事情，急性期已處理完了，但後期照護計畫怎麼會把醫學中心還納入在計畫案裡面？二、另外，以糞便篩檢為例，怎麼醫學中心拼命在做這個事情，這些事情應回歸到基層社區醫療院所執行。主席曾參加北區監察委員的座談會，有人提到由基層做糞便的篩檢，如果發現有問題，自然會轉診到醫學中心去處理。所以在某些疾病的處理上，是否將來有新的試辦計畫時，可以思考到底應該是由醫學中心扮演這樣的角色，或是由社區醫院、基層來做這件事情。否則醫學中心拼命在廣告，鼓勵病人要做糞便篩檢(註：此係國民健康署委託業務)，這有需要到醫學中心去做嗎？這就是一個很簡單的制度設計上的問題。所以，這些事情將來在急性照護後期階段，要落實給社區醫院，讓其更能夠發揮在Sub-acute(亞急性照護)這方面的功能上。鄭主任委員守夏謝謝！黃代理委員啟嘉(陳委員宗獻代理人)一、首先，要澄清一件事。其實現在的健保財務狀態並不是很好，因為服務量超過預算的標準；如果健保財務狀態很好的話，點值應該都是1元左右。總額雖增加這麼多，但錢都花在民眾身上，當然要考慮民眾是不是真的有必要花那個錢。我認為部分負擔本身的精神，是要避免醫療資源的濫用，而分級醫療就是要避免醫療資源濫用的機制，只是在這個時間點提出來，要有配套措施，例如低收入戶負擔不起的部分，是不是要有一些補救措施，這個需要加以考慮。二、如果我們直接從健保法第43條來看，定率負擔是原則，然後主管機關改採定額是例外，而且這個定額還有條件，是按照前一年費用平均值20%作為定額。所以，到底有沒有違法，我想懂法的人會自由心證，不予置評；付費者代表不敢主張要提高部分負擔，這是很合理的，因為會被罵死！但這是短多跟長多的問題，短多就是說，我今天付多少錢，健保付多少錢；部分負擔如果降到3%，一定可以得到付費者的支持，但是健保財務維持不了兩年就垮台。如有適當的部分負擔，能夠讓健保維持下去，那就是長多的問題。三、謝委員天仁是我很尊敬的委員，他剛才提到部分負擔提高，等於費率的提高。我要向謝委員說明，部分負擔提高跟費率提高是兩回事。因為對醫界來講，部分負擔提高，健保署支付醫界的錢就會變少，比如說原來是醫療費用300元的時候，本來部分負擔50元，我們替健保署代收50元，但健保署要支付我們250元；但當部分負擔調到150元，我們要背黑鍋跟民眾收150元，然後健保署只給我們150元。所以，對健保署而言，實際支出也許會減少，但對醫界而言，總額是不變的。四、這個議題，其實是見仁見智。在這個時間點提出，當然需要有很多配套措施。首先是適法性的問題，大家認為條文有問題或無法實施，需要考慮修法，這是第一點。第二，是民眾端不能接受，所有的消費都越來越高，但醫療費用並沒有變高。我認為站在宏觀面來講，這不是一件壞事，因為對民眾來說，醫療並沒有漲價。我們國家幾年來薪水停滯與物價上漲的狀態下，因為醫療沒有上漲，所以，還可以維持社會安定。雖然說醫界犧牲了，但是基本上對國家社會並不是壞事。但要考慮是不是能長久維持下去，它的合理性在哪裡？公平正義在哪裡？有沒有將資源留給真正需要的人，這是應該考慮。鄭主任委員守夏請謝委員武吉。謝委員武吉一、現在時間已經到下午2點9分了，也準備要結束了。剛才有講一些時機點的問題，等哪天需要暴露出來的時候，我會把它暴露出來。二、要討論這個議題的時候，有人講付費者會反對。沒關係！你們儘量反對，等到台灣健保倒的時候，已經倒過一次，不會倒我才輸你！ 三、我要求的是，落實健保法第43條分級醫療的轉診制度。四、我慎重地向各位委員說明，因為大家都是第1屆健保會委員，就怕大家沒有講到健保法第43條以後會被告，最後我提醒各位，我們應該還是要依法行政－守法。鄭主任委員守夏建議本案就溝通到這裡，將委員相關意見整理送請主管機關參考。後面的專案報告，就延到下一次會議。我們還有一件事情要處理，就是李委員蜀平要求修改會議紀錄。各位手上有書面，他希望「文字」這樣修改，如果大家不同意的話，李委員可以下次再提討論案。我們是把他上午的提議延到現在處理，所以，還是要請大家看一下。李委員蜀平這1屆問題若不解決，以後也是要解決！只是我擔任健保會委員，想知道所有的藥價差是多少？是算健保費？還是算其他的獎勵金？因為這樣會造成許多的連動，拜託大家看一看！我想了解這個數字對各位委員都有意義，我不會騙大家，謝謝！蔡委員登順針對李委員蜀平的意見，我覺得太理想化了！自由商場上藥價有其機制，我們有能力去建構市場的機制嗎？如果是藥價調查，健保署可以做得到，但是市場的機制我們並沒有能力去管控。李委員蜀平的立場和蔡委員明忠所表達的意見，是南轅北轍。所以，我支持主席所做的決議，原來的決議我認為是可行，市場機制我們沒有能力去管控，就不要去管市場機制。有的藥一顆賣10元，也有一顆賣20元，你說哪一個賣的比較合理？由消費者選擇，市場上以量定價亦是常態，所以沒有標準價格。李委員蜀平沒關係啦！主要是到底是多少金額？主要現在連多少金額都不知道！健保藥品是健保付的費用，而且健保署有這個機制，健保支付價與實際售價間的藥價差有多少？我想了解一下，這樣不行嗎？鄭主任委員守夏我們現在是在確認上次會議紀錄，所以，除非會議紀錄有明顯不對，大家同意就增加文字，或不同意就不要改，如此而已，我們不進行討論。蔡委員登順好！不要討論，我支持不要修正，因為沒有共識，決議不作修改了。吳委員玉琴沒有共識！不要修改。鄭主任委員守夏我們是在確認上次會議紀錄，所以，上次會議紀錄既然沒有明顯錯誤，這是共識決，不是多數決。如果對現在的決議，李委員覺得不滿意，以委員的身分還可以再提案，這次的會議紀錄就不修正了。非常抱歉！我們今天會議開得太晚了，謝謝大家！散會。PAGE PAGE \* MERGEFORMAT1PAGE \* MERGEFORMAT12PAGE \* MERGEFORMAT10PAGE \* 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