全民健康保險醫療費用協定委員會95年度全民健康保險cathy全民健康保險會曾幼筑202015-06-30T08:09:00Z2015-07-06T02:40:00Z2015-07-06T02:40:00Z90776644268DOH3681035193114衛生福利部全民健康保險會第2屆104年第5次委員會議議事錄中華民國104年6月26日PAGE 8PAGE \* MERGEFORMAT3衛生福利部全民健康保險會第2屆104年第5次委員會議紀錄壹、時間：中華民國104年6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 李委員成家 中華民國全國中小企業總會李副理事長育家(代) 李委員蜀平 林委員至美 林委員敏華張委員文龍 中華民國工業協進會楊顧問玉琦(9:50以後代)張委員煥禎 壢新醫院院長室劉特別助理碧珠(10：00~11:17、12:20以後代)張委員賜黃委員啟嘉陳委員幸敏陳委員健民陳委員義聰 中華民國牙醫師公會全國聯合會陳常務理事彥廷(11：15以後代)陳委員聽安莊委員志強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宛芬蔡委員登順潘委員延健滕委員西華謝委員天仁 謝委員武吉 戴委員桂英羅委員紀琼肆、請假委員：侯委員彩鳳伍、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 蔡副署長淑鈴 施組長如亮李副組長純馥本會柯執行秘書桂女范組長裕春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、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4)次委員會議紀錄，請鑒察。決定：討論事項第二案「105年度總額協商通則案」所敘述之討論過程說明中，第二點「在場委員均十分努力反覆討論上述3點通則…」文字，修正為「在場委員均十分努力就正反意見反覆討論上述3點通則」。 餘確定。第二案案由：本會上(第4)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)事項及歷次委員會議未結案件之辦理情形洽悉。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」，依衛生福利部社會保險司之說明，行政院採取尊重主管機關(衛生福利部)之原則辦理，由於處理原則已確定，爰該案解除追蹤；至說明中所述「就健保法第3條文義並未限定計入政府負擔數之範圍，…，應檢討健保法施行細則之相關規定，將中央政府於健保收入面已實質負擔之保險費列入考量」乙節，因後續檢討將涉及保險收入，屬本會法定之監理業務，爰請中央健康保險署適時提報下列事項：(一)檢討全民健康保險法施行細則之相關規定後，對諸如政府負擔健保總經費法定下限(36%)之計入範圍與金額等影響健保財務的部分，均應研析並提報。(二)在法定下限計算方式確定前，中央健康保險署與主計總處因算法不同所產生差額之撥補情形。請幕僚調查委員意見，瞭解有無值得辦理參訪、座談會或其他形式活動之議題後，提報委員會議定奪。第三案案由：104年5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：105年度全民健康保險醫療給付費用總額協商程序(草案)，提請討論。決議：訂定105年度總額協商程序如附件一。第二案提案人：干委員文男代表類別：保險付費者代表案由：建議試辦中醫治療「過敏性鼻炎」案，提請討論。決議：請中華民國中醫師公會全國聯合會及中央健康保險署在以實證醫學為基礎之前提下，依全民健康保險法之相關規定，提至中央健康保險署相關共同擬訂會議討論；其中若涉及總額增減者，再納入總額協商考量。第三案提案人：謝委員武吉代表類別：保險醫事服務提供者代表案由：基於保險業務監理，建請健保署於委員會定期按月提供醫學中心、區域醫院之門、住診初(次)級照護及下轉等數據資料，提請討論。決議：請中央健康保險署按月於全民健康保險業務執行報告提供：各層級醫院之門診初級照護案件數與費用，及急診下轉件數等資料。個別醫學中心之急診下轉情形，請健保署持續關注並採取必要措施及定期提報；各層級醫院之門診初級照護檢驗檢查及藥事服務費與藥費等費用資料，則盡可能提供。餘案內所建議提供之資料，考量涉及資料可信度及可取得性等因素，請中央健康保險署收集國外其他保險單位之相關統計，作為未來進一步分析之參考。第四案提案人：李委員蜀平代表類別：保險醫事服務提供者代表案由：關於現今藥品各醫療院所實際採購價格及藥品健保給付價格，資訊不透明化，導致藥價差之情形日趨惡化，嚴重影響到全民健康保險之藥品費用，應立即公布各層級醫療院所之藥價差金額多少，提請討論。決議：考量本案有深入探討之必要，爰交付由各方之委員代表所組成專案小組討論藥價差公開相關事宜，所獲致之結論，提下次委員會議續議。專案小組成員：(一)提案人：李委員蜀平。(二)醫院代表：潘委員延健、張委員煥禎、謝委員武吉。(三)西醫基層代表：蔡委員明忠。(四)雇主代表：何委員語(會後商請渠擔任召集人)。(五)被保險人代表：謝委員天仁。(六)專家學者及公正人士代表：戴委員桂英。請中央健康保險署共同參與專案小組會議，並提供相關說明與資料。第五案提案人：李委員蜀平代表類別：保險醫事服務提供者代表案由：敬請將健保署已執行第六年之高診次者藥事居家照護計畫改列為一般性常態服務，提請討論。決議：本案涉及已公告總額協定事項之變更，請依循年度總額協商之相關程序辦理。拾壹、專案報告第一案報告單位：中央健康保險署案由：健保代位求償執行情形與成效報告，請鑒察。決定：洽悉。第二案報告單位：中央健康保險署案由：各部門總額需保障或鼓勵服務，採點值保障方式之合宜性探討及改善方案，請鑒察。決定：需保障或鼓勵之醫療服務，以回歸支付標準處理為原則，採點值保障方式尚非長久之計，爰應逐步合理調整支付標準並減少保障項目。請中央健康保險署依前開原則辦理，並適時提會報告。第三案報告單位：中央健康保險署案由：新醫療科技項目對財務之影響評估及替代效應，請鑒察。主席裁定：保留至下次委員會議報告。拾貳、臨時提案第一案提案人：蔡委員明忠(提案資料詳附件二)連署人：黃委員啟嘉、何委員永成、謝委員武吉、潘委員延健、張委員煥禎、楊委員漢湶、羅委員紀琼、陳委員義聰代表類別：保險醫事服務提供者代表、專家學者及公正人士案由：全民健保會應就104年5月22日第2屆104年第4次委員會議討論事項第二案、第三案與專案報告第一案再行置案討論與報告。主席裁定：提案人蔡委員明忠對本案提出撤案動議，並獲8位連署人同意，爰予撤案。第二案提案人：楊委員漢湶、張委員煥禎、謝委員武吉、蔡委員明忠、黃委員啟嘉、潘委員延健(提案資料詳附件三)代表類別：保險醫事服務提供者代表案由：有關「105年協商通則」案，提請討論。主席裁定：本案擬變更經議決通過之內容，爰須依本會會議規範所定復議案之程序辦理。拾參、散會：下午14時15分。PAGE \* MERGEFORMAT7PAGE \* MERGEFORMAT1附件一二105年度總額協商程序第2屆104年第3次及第5次委員會議(104.4.24及6.26)通過一、工作計畫表工作項目及內容預訂時程一、協商前置作業1.討論105年度總額協商架構、通案性原則及協商程序。104年5月22日6月26日2.建立協商參考資料：(1)編具「104年全民健保總額支付制度協商參考指標要覽」。(2)編具「104年全民健保各部門總額執行成果摘要」。104年6~8月3.召開各部門總額執行成果評核會議：檢討、評估各總額部門103年度協定事項執行情形。104年7月30、31日4.請健保署提報104年度各部門總額協定事項重要計畫之執行情形。104年7月24日5.105年度總額案於主管機關交議後，進行各項相關作業：(1)請主管機關派員於委員會議說明行政院對總額範圍核定情形及政策方向。(2)確定各部門總額醫療服務成本及人口因素成長率。104年7月24日(或8月28日)6.由健保署會同各總額部門預擬協商因素/專款項目及其預算規劃草案。(1)規劃草案內容應包含協商減列項目及預估金額。(2)各總額部門與健保署擬訂規劃草案時，對相關之醫療服務項目，如護理、藥事服務、門診透析服務等，得邀集相關團體參與。104年8月7.安排總額協商之相關座談會/會前會。(1)召開105年度總額協商因素項目及計畫草案座談會：①請各總額部門及健保署報告所規劃之105年度總額協商因素項目及計畫草案，並進行綜合討論。(註：除簡報外，並請提供各協商項目或計畫之詳細說明，其須包含目標、醫療服務內容、費用估算基礎、過去執行成果、預期效益等資料)②請幕僚彙整評核會議評核委員之共識建議，及各部門總額之執行成果，供討論參考。104年8月28日(下午) (2)召開健保署和付費者代表、專家學者與公正人士、相關機關代表座談會。104年8~9月(3)另視需要召開座談會。104年8~9月二、各部門總額成長率及分配方式之協商1.協定各部門總額成長率。104年9月18~19日2.協定各部門總額一般服務費用之分配方式(地區預算)。104年10~12月3.年度整體總額協定成長率及其分配之確認，及報請主管機關核定。104年10~12月三、協定事項之執行規劃與辦理1.健保署會同各總額部門，提出各協商或專款項目配套計畫之執行方案。2.各方案/計畫進度之追蹤，並視需要，請健保署或總額部門專案報告。104年10月~105年12月二、協商會議(含共識會議及委員會議)之日程(一)協商會議日期：本(104)年9月18日(星期五)及19日(星期六)上午，共一天半。(二)工作內容：1.協商共識會議(9月18日)：(1)分場次協商牙醫門診、中醫門診、西醫基層、醫院等各部門總額，及健保署管控之「其他預算」。(2)門診透析服務獨立預算，依西醫基層及醫院等二總額部門協商順序，併於先談部門之時段(時間外加)協商。2.委員會議(9月19日上午)：完成協商結論之確認。(三)協商共識會議之與會人員：1.付費方：保險付費者代表之委員。 2.醫界：(1)保險醫事服務提供者代表委員。(2)牙醫、中醫、西醫基層、醫院等總額部門協商時，由該總額部門代表之委員主談，各部門並可推派9名代表協助會談。(以會場可容納為原則，去年為9名) (3)護理及藥師公會全聯會代表委員可參與相關部門總額之會談。(4)門診透析服務：由西醫基層及醫院部門代表協談，並邀請台灣腎臟醫學會推派代表乙名列席說明。3.專家學者及公正人士、國家發展委員會及主管機關代表委員。4.社保司與健保署相關人員及本會幕僚。(四)協商共識會議進行方式與原則：1.各部門協商順序：於7月份委員會議抽籤決定之。2.議程提經委員會議確認後，即應遵照辦理，不可臨時要求變更。3.各部門協商時間，安排如下表： 部門別提問與意見交換部門之預算協商合計（不含各自召集會議時間）付費者委員視需要自行召開會議醫界委員視需要自行召開會議推估最長時間醫院30分鐘(門診透析20分鐘)60分鐘(門診透析20分鐘)130~170分鐘30分鐘30分鐘130~230分鐘西醫基層25分鐘50分鐘115~150分鐘20分鐘20分鐘115~190分鐘牙醫20分鐘40分鐘60~80分鐘20分鐘20分鐘60~120分鐘中醫20分鐘40分鐘60~80分鐘20分鐘20分鐘60~120分鐘其他預算20分鐘35分鐘55~73分鐘20分鐘55~93分鐘 備註：各部門協商時間若確需延長，以不超過該「部門之預算協商」時間之50%為限。4.相關原則(1)所有委員均可入場，惟非協商當時之總額部門委員，僅聽報告、提問與發表意見，但不參與預算協商。(2)各部門與付費者代表委員進行預算協商時，請健保署相關人員在場提供所需說明。(3)付費者及醫界委員視需要自行召開內部會議時，可邀請專家學者與公正人士之委員提供諮詢意見，及本會幕僚與健保署同仁協助試算或說明。5.各方未能達成共識時之處理方式(1)保險付費者代表委員間無法達成共識時：於協商共識會議中，由付費者委員進行內部會議討論，若無法以共識決形成一案時，得以多數決定之。(2)總額部門代表委員間無法達成共識時：於協商共識會議中，由總額部門委員進行內部會議協調之。(3)總額部門與付費者委員無法達成共識時：依全民健康保險會組成及議事辦法第10條規定，分別就保險付費者代表之委員、保險醫事服務提供者代表之委員建議方案當中各提一案，報主管機關決定。個別委員對建議方案有不同意見時，得提出不同意之意見書，由健保會併送主管機關。6.各部門總額年度預算之協商終止點，原則預訂為9月份之委員會議，未能在安排時限內達成共識，除經保險付費者、醫事服務提供者雙方代表同意再行協談，否則依法送請主管機關裁決，不再重啟協商。三、協商結論之確認(一)協商項目之成長率(或金額)：於協商共識會議當場試算並進行確認。除經部門總額代表提議，並獲得付費者委員支持，方可重新協議及再行確認。(二)協定事項：於委員會議中確認；文字若不違原協商事項，可酌修。四、協商共識會議實錄之製作與公開為讓各界瞭解年度總額之協商過程，與會人員發言內容，將以實錄方式上網公開之。PAGE PAGE \* 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MERGEFORMAT13第2屆104年第5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4)次委員會議紀錄」與會人員發言實錄柯執行秘書桂女各位委員、所有與會者，大家早！現在委員出席人數已過半，請鄭主任委員守夏召開今天的委員會議。鄭主任委員守夏一、各位委員，大家早！(與會者回應：早！)今天外面的天氣很熱，希望會場裡面的氣氛不要太熱。請大家參看會議資料第1頁，今天委員會議的議程，安排例行報告3案、討論事項5案，專案報告3案，議案頗多。委員對議程的安排有無不同意見？(未有委員表示意見)若無意見，議程就確認，並依程序進行今天的會議。二、接下來確認上次委員會議紀錄，請同仁宣讀。同仁宣讀鄭主任委員守夏謝謝同仁宣讀，請問委員對會議紀錄內容有無修正意見？請楊委員漢湶。楊委員漢湶一、請參看會議資料第5頁，有關討論事項第二案(105年度總額協商通則案)，所記錄的內容很奇怪！既然有人提出散會動議，有人附議，而且表決結果是多數贊成，則會議資料第6頁第四、五點所記錄的內容就應予修正。因為散會動議依內政部規定應採多數決，既然多數委員贊成，那就應該散會。二、本會會議規範對散會動議部分，並未明訂處理方式，贊成本會針對散會動議訂定處理程序，但在未訂定前，應依第8條規定：「本規範未盡事宜，依內政部所公布會議規範處理」，則須依內政部會議規範處理，當議案有人提議，有人附議，則採多數決，即只要多數人贊成，該動議案就成立。三、所以我認為會議資料第6頁第四、五點，在陳述醫事服務提供者及付費者代表各自的主張後，卻只挑選其中一種主張，這對另一種主張者很不公平。那天我人在國外，但這樣的處理，是不對的。鄭主任委員守夏請何委員語。何委員語一、有關會議資料第5頁討論事項第二案，討論過程之說明第二點「在場委員均十分努力反覆討論上述3點通則」，我認為是「在場委員持正反意見反覆討論上述3點通則」，若要再加上「十分努力」4個字，也是可以。二、至於剛才醫事服務提供者代表提出表決後應散會的意見，因為願意留下來繼續開會的委員超過半數，亦即現場26人，11人贊成散會，9人反對，5人無意見(主席不參與表決)。雖然內政部會議規範為多數決，但當時超過14人願意繼續開會，所以會議決議仍屬有效，不然醫事服務提供者代表可以提請釋憲。鄭主任委員守夏剛才何委員語的建議比較單純，若大家都無意見，建議將討論事項第二案，討論過程之說明第二點的部分文字修改為「在場委員均十分努力就正反意見反覆討論…。張委員煥禎對不起！請主席應依發言順序，先處理第一位發言委員的意見，怎能先處理第二位發言委員的意見？鄭主任委員守夏考慮到實質議題比較複雜，所以先處理文字修正的部分，此與實質的通則內容無關。請張委員煥禎。張委員煥禎一、有關剛剛兩位委員的發言，我的意見是法規問題就應該依法處理，當大家都不是很清楚，而有爭議時，不是我或誰說了就算；若對引用法規有疑慮，則需釐清遊戲規則，宜請衛福部法規會解釋，若大家不接受其解釋，可再討論如何處理，待遊戲規則確定後，就照此規則進行。二、現在不是講情誼的問題，而是討論法規適用的問題，若散會動議通過，醫事服務提供者委員離席當然是符合規定，否則就屬個人風度問題，此兩個情形截然不同。希望紀錄能夠很明確，到底怎麼回事？鄭主任委員守夏我們先確定上次委員會議記載的文字是否符合開會事實，若文字不符合，可以修正；若符合，則會議紀錄就無問題。至於會議紀錄帶來的實際效用，就像立了某個法後，不見得能執行，則可對那個決議究竟合不合理加以檢視，後續可再討論。張委員煥禎上次委員會議紀錄這麼記載，贊成散會人數未超過在場委員之半數，散會動議未通過，及醫事服務提供者代表委員離席等文字，我們都覺得有問題，可以那樣敘述嗎？鄭主任委員守夏其他委員還有無意見？等一下請幫我受罪主持會議的吳委員肖琪發言。相信當時無論誰來當主席都一樣，不會有誰比較厲害。請蔡委員明忠。蔡委員明忠會議資料第6頁，討論過程之說明第四點「醫事服務提供者代表之委員認為，依表決結果應散會；付費者代表之委員則認為，贊成散會人數未超過在場委員之半數，散會動議未通過，應繼續開會」。有關散會動議程序，投票結果是過半或多數決，散會是否成立等疑義，會議紀錄並未記載，我贊成張委員煥禎所提意見，主席應就當時狀況所適用法規做明確裁示，所以我們提出相關的臨時提案。鄭主任委員守夏請潘委員延健。潘委員延健主席，各位委員大家早！有關討論事項第二案，剛剛主席提及現在是確認委員會議紀錄的內容，但我認為不只如此，我們應該注意進行的時間順序，也就是要先確認散會動議表決的合宜性及效果，這是基礎問題，確認後才能決定當時繼續進行的會議是否有效，也才能決定是否要確認上次的會議紀錄內容。鄭主任委員守夏稍後請付費者代表表示意見。請羅委員紀琼。羅委員紀琼一、主席，各位委員早安。當天會議進行時，正反雙方的討論非常熱烈，之所以支持戴委員桂英提出的散會動議，是因為在那種情況下，雙方都已陷入情緒性發言。離開會場後，碰到曾在司法院任職的法律專家，就委員會議所遭遇情況及表決結果(11人贊成、9人反對、5人無意見)向渠請教，他表示散會動議屬多數決。二、上次委員會議，我想就政府代表委員屬性，對是否繼續開會，一定會表示無意見；而若繼續開會則會留到最後。但就法規來看，當散會動議經過表決成立後，則後續所做的決議(定)事項不應成立。鄭主任委員守夏謝謝羅委員紀琼。先請謝委員天仁，再請蔡委員宛芬。謝委員天仁一、主席，各位委員，我想很多事物，不是司法院的人講了就算數，他們的法學造詣不見得比別人高明。二、依據本會組成及議事辦法第8條第3項規定，會議應有二分之一以上委員出席，始得開議；其決議依下列方式為之，跟總額對等協議訂定及分配事項有關者，應以協商方式達成各項協定；跟總額對等協議訂定及分配事項無關者，應經出席委員超過二分之一同意行之。應該沒有第3種處理方式，所以我認為主席的裁量是對的，就上次的委員會議紀錄應予確認。至於有委員提出疑義的部分，則轉請衛福部法規會表示意見，這很容易處理。本會每次確認議事錄都要花費很多時間，真是不可思議！只是核對文字是否正確而已，若有疑問，可對照錄音檔。楊委員漢湶請問一下，是依議事規範第幾條？謝委員天仁第8條。楊委員漢湶本會會議規範第8條應該是：「本規範未盡事宜，依內政部所公布會議規範處理」。柯執行秘書桂女謝委員天仁所提係本會組成及議事辦法的第8條。鄭主任委員守夏請蔡委員宛芬。蔡委員宛芬一、主席，各位委員，大家早！當天開會時，當主席針對此議題做出裁示時，並未看到醫事服務提供者代表提出異議就離席，如果大家剛好有事先離開，主席的裁示就因此沒效嗎？現在爭執當天會議後面的決議無效，是沒有意義的。二、醫事服務提供者代表所述沒有事先論定的會議規則，自應以主席的裁示為主，現場無異議就繼續開會，而不是拿內政部的會議規範出來反對，否則我也可以拿立法院的會議規範來提出見解。委員離席的原因可能都不相同，但此無法否決有意義的決議事項。三、會議紀錄已詳實記載當天會議的情形，包括多數醫事服務提供者代表之委員離席。有委員認為不應該這樣描述，但這是事實，忠實呈現當時狀態，至於這部分文字是否要列入，可再討論，但以此否認後續決議(定)事項，則沒有意義。鄭主任委員守夏謝謝蔡委員宛芬，請何委員語。何委員語一、第一點，我認為應該在會議資料第6頁第四點「散會動議未通過，應繼續開會」，之前加上「主席說明」4個字。即修改為「主席說明散會動議未通過，應繼續開會」。二、第二點，主席說明散會動議未通過後，醫事服務提供者代表均未表示異議，此即代表同意主席的裁決。我最近幫一個社團打了兩次官司，最後都是以「主席宣布決議後，當事人當場沒有表示異議，代表當事人默認，所以當事人不能再提起告訴」為由而被駁回，可以將這些判決書拿給大家看。我贊同刪掉「多數醫事服務提供者代表之委員離席」文字，因為當時離席的不只醫界代表，其中也有一、二位非醫界代表，所以我認為不應該列「OO委員離席」這句話。三、贊成醫界代表針對紀錄的問題申請釋憲或打官司，但我已經說過，可以拿最近協助處理訴訟案件的判決書供參，在開會現場主席裁定後，若沒有提出異議，就表示默認，承認主席的裁示。干委員文男主席！鄭主任委員守夏請干委員文男。干委員文男一、健保會的每位委員都是各取所需，為本身所代表的團體發言，沒有絕對的對或錯。現在最重要的是今天的會議要能繼續進行。至於上次委員會議表決的效力，當時主席在現場已經裁示，經清點人數後表決，還是繼續開會，也沒有委員提出疑義，就代表表決的效力存在。二、希望大家能夠向前看，不要在此問題上一直打轉，本會每次確認會議紀錄，幾乎都要花上一個多鐘頭，使後續的議程無法順利進行。每次講到議事效率，我們都說主席沒有處理好，但如果繼續發生這種情形，則主席的位置不論誰來當都一樣，要整合大家的意見真的很困難，因為我們都不是神仙(台語)。三、建議本案討論到此，並請記取這次的經驗，重點在往後遇到相同情形時要如何處理較佳。例如楊委員漢湶所提建議，將本會會議規範訂得更清楚，這點建議可接受，可針對應多少人出席、多少人贊成才有效等詳加規範。希望會議紀錄的確認到此為止。黃委員啟嘉主席！鄭主任委員守夏請黃委員啟嘉。陳委員聽安(同時舉手)主席！我要提出程序問題，可否優先發言？鄭主任委員守夏好！程序問題優先，請陳委員聽安。陳委員聽安我認為現在進行的程序是確定會議紀錄，如果上次會議紀錄的文字敘述沒有任何錯誤，就應該予以確定。至於醫界代表認為，當時會議有人提出散會動議，所以最後開會所做的決議無效，但我認為他們應當可提出復議案，而不應該在會議紀錄上做任何變動。紀錄文字沒有錯誤，就可以確認，有不同的意見就請提復議案。鄭主任委員守夏謝謝陳委員聽安。請問黃委員啟嘉，也是與本議題相關的意見嗎？黃委員啟嘉我想說明一下。鄭主任委員守夏好！黃委員啟嘉一、現在程序上是確認會議紀錄，但記錄的事實到底是否存在？此問題可分為兩種角度討論，一個是從程序面，另一個是從實質面。就法規來講，程序重於實質，但我們就算略過程序，剛剛醫事服務提供者代表也陳述很多對程序瑕疵的質疑，而且不僅醫界代表，包括其他代表也有人對程序提出質疑。二、拋開程序面的瑕疵，就實質面來講，當時討論案是與總額協商相關的事項。依健保法第5條第1項第3款規定，有關總額協商相關事項必須透過對等協商為之；本會組成及議事辦法第8條第3項第1款也規定，與總額協議訂定及分配之相關事項，必須透過協商的方式達成，即不可採投票表決的方式決定。三、為何不可採投票表決？理由很簡單！因為本會35位委員中，有18位屬付費者代表，如果將所有醫事服務提供者代表的名額全部加起來，夯不啷噹包括各總額部門、藥界及護理界代表，也只有10位，這樣是無法投票表決的(人數不對等)。四、有關總額協商的事項必須透過對等協商，是依健保法的規定辦理。所以上次委員會議與總額協商有關的討論案採投票決定，是否可能違反健保法？希望主席了解是否存在此問題，若有，今天的會議紀錄是否還存在？我覺得需要討論。鄭主任委員守夏一、謝謝黃委員啟嘉，委員表示意見就請到此。我認為會議紀錄是忠實反映當天會議的狀況，所以紀錄本身沒有問題，建議先予確定。二、至於「105年度總額協商通則案」，個人認為「總額協商通則」是為了減少9月份總額協商時發生的紛爭，所以提前將大家的共識先訂下來，屆時就不要再為這些事情爭執，這是訂定協商通則的目的。三、協商通則是否如黃委員啟嘉所提，與總額協商事項有關？聽起來兩者似乎有相關，如果與總額協商議題有關，不論依健保法或本會組成及議事辦法的規定，都不宜採表決方式為之。四、如果大家都同意協商通則案與總額協商議題有關，則沒有達成共識的部分，即使納入通則也沒有用，因為協商時還是會有爭執；醫事服務提供者代表會說，那是付費者代表強勢表決通過的協商通則。說實話，這樣對總額協商是沒有幫助的。五、拜託各位付費者代表，這樣通過的「105年度總額協商通則案」，其實對總額協商沒有太大助益。本案在上次委員會議確實有討論，也獲致決議，這是事實；比起去年通過的「總額協商通則」，當時兩邊都心平氣和的談，所以今年通過的通則，效力大概會差很多。但我還是必須說，本通則案是會議決議通過的。六、協商通則案關係到總額協商，醫事服務提供者代表可能提出討論過程中，因為他們有人退席，所以不屬對等協商。在程序方面也許缺乏正義，但建議不要再討論會議紀錄，因為當天的真實情形就是如此。七、若認為總額協商通則與9月份總額協商有實質相關，因此希望此通則是以對等協商的方式產生，有共識才可稱為通則。因此「105年度總額協商通則」，必須再討論，可以如陳委員聽安所建議，請醫事服務提供者代表提出復議案，再度討論上次的決議。至於散會動議是否符合內政部會議規範，則是另一個議題。八、以上是我站在學者立場的看法，我認為如果本案變成討論案，那對今天已安排的議案太不公平，不應該如此。到9月份協商總額前還有時間，如果任何一方的委員要提出對總額協商有助益的更好提案，我會非常感謝！要不然的話，現在卡在會議紀錄確認問題，真的會無解，也對協商沒有幫助。九、現在討論的是會議紀錄確認，文字有無不實的部分，需要再修正？如果沒有的話，就確認會議紀錄。請楊委員漢湶。楊委員漢湶一、一般會議如果已經提出散會動議，且贊成者多，就不會再有後續的動作，即不可以再繼續開會，這是我要提出的第一點。二、本會會議規範第8點規定，規範中沒有規定的事宜，應該依內政部所公布的會議規範辦理。這屬明文規定。三、第三點要說明的是，有幾位醫事服務提供者代表不是退席，他們的認知是，按照當天表決的結果，散會動議既然以11票比9票通過，就應該散會，理所當然就離開會議現場，所以並非退席，與自己因故退席是完全不一樣的情形。四、第四點，我認為既然上次會議在散會動議表決後仍繼續進行，會議本身存在爭議，所以同意按照主席的意見，就是後續所討論的這些事項，並沒有符合健保法第5條總額對等協商的規定。既然是單方面決定的總額協商通則，醫事服務提供者代表是無法一起遵循的。謝委員天仁主席！鄭主任委員守夏請謝委員天仁。謝委員天仁一、我認為主席沒有權力裁示議案決定內容的效力，這是很清楚的，如果有疑義的話，應該轉請衛福部法規會表示意見，每個單位各司其職，這種事情不能以誰講的話越多，誰就越贏來處理。二、楊委員漢湶所提問題，其實與本案的結論不見得有必然關係。到底本會應如何處理會議進行的動議案，包括散會動議，這是比較重要的。楊委員所提的觀點，我看不出其他法規有相關規定，僅本會組成及議事辦法有規定。至於以後要怎麼做？需要很清楚地釐清後告訴所有委員。三、本會需要決議時，到底採多數決？還是依本會組成及議事辦法規定，以出席委員超過二分之一同意行之，要先弄清楚。如果沒有弄清楚要怎麼做，而大家的想法又都不一樣的話，以後乾脆將總額協商前的相關議案全部廢掉(不討論)，因為有人可以不遵守啊！不要浪費大家時間，全部回歸至9月份總額協商會議時討論。如果衛福部法規會對協商通則案的解釋，是認為屬總額協商事項，不能夠以表決方式進行，那我建議以後通則等議題都不需事先談，這樣浪費大家時間，討論這麼久，最後得到的結論也是枉然，對協商沒有助益。四、我要指出，我們最大的問題就是議事沒有效率。實施二代健保法已經超過一屆(委員屆期為2年)，相同的問題還是存在，會議紀錄確認竟然要花超過半小時以上的時間，講的內容卻與確認紀錄無關，都是實質效果的問題。老實講，我是很氣憤，這種情形不應該一再發生，主席已裁示會議紀錄有效力，至於爭議的問題請衛福部法規會解釋，大家是否不應該再講話了。鄭主任委員守夏一、感謝謝委員天仁！我想請幕僚同仁幫忙，以後如果會議進行當中，真的有碰到不是很確定的表決規則，例如是要超過半數、還是要多數才能通過，能否趕快喊停，提醒主席先確定相關規定。我必須承認，相信當時代理主席吳委員肖琪跟我差不多，我們都不是專業的開會人才。比起那些專業開會的人，他們對會議的眉眉角角(台語)真的懂太多了！二、在健保會的運作，我相信重點還是實質認定，只要過程不是明顯不恰當，應當沒有太大問題。感謝謝委員天仁的指教，我們就確認上次會議紀錄。本案如果任何一方委員有意見的話，後續可以再提案，至於是以何種方式？是提復議案，或另外提案，可再討論。因為「105年度總額協商通則案」在會議紀錄上並沒有問題，所以就予確認。在場委員如果沒有特別的問題，就繼續開會。請潘委員延健。潘委員延健我認為會議紀錄還是有問題！會議資料第6頁第四點所載「散會動議未通過」，其描述情形與開會的狀況有所出入，剛才有委員提到，當時主席有裁示散會(多位委員回答：沒有！沒有！)喔，沒有！我們還在現場時，主席並未裁示散會動議未通過，所以要確定會議紀錄，必須先將當天的事實加以陳述。醫事服務提供者代表委員是在主席未裁示散會動議不通過前，因為誤認當時已經散會，所以才離開會場，因此不應該被視為離席，如果要將「醫事服務提供者代表之委員離席」這件事陳述在會議紀錄，我們希望能夠忠實呈現事實。鄭主任委員守夏。如果會議紀錄還有需要修改之處，請委員清楚建議需要修改的文字。請問當時代理主席的吳委員肖琪，會議資料第6頁第四點「付費者代表之委員則認為，贊成散會人數未超過在場委員之半數，散會動議未通過」，這部分文字是否需要補充說明是針對散會動議所做的裁示？吳委員肖琪一、各位委員大家好！上次委員會議討論的情形十分熱烈，於進行「105年度總額協商通則案」時，我希望盡量做到依本會組成及議事辦法第8條第3項第1款規定，以協商的方式達成共識，避免以投票方式作成決定。另外，我必須說，當天是就散會動議進行表決。由於戴委員桂英提出散會動議，並且獲得其他委員附議，所以散會動議成立；散會動議一旦成立，不能討論，必須表決，這部分非我個人所能決定。二、依本會組成及議事辦法第8條第3項第2款規定，針對健保法第5條第1項第1、2、4、5款及其他健保法所定健保會應辦理事項，應經出席委員超過二分之一同意行之。但要如何定義「出席委員」？剛才有委員提到，如果不確定如何定義「出席委員」，可以請教衛福部法規會。但請大家翻到會議資料第6頁，當天出席委員有33位，表決前清點現場的人數為26位。不論是以出席人數或清點現場的人數來計算，贊成散會動議者僅11位，都沒有超過半數；由於散會動議未獲通過，所以繼續開會。我盡可能還原當天的過程，如果有講錯的地方，請各位委員補充。三、至於會議紀錄是否需要加上當時主席說的話，以杜絕爭議，我認為錄音檔都很清楚，建議可以不需要再加相關文字，謝謝！鄭主任委員守夏好，還有無文字修正？干委員文男沒有！鄭主任委員守夏目前已很清楚，會議紀錄的文字是忠實記載現況，本案進行到此。謝謝大家！現在進入例行報告第二案。劉代理委員碧珠(張委員煥禎代理人)主席，對不起！鄭主任委員守夏請劉代理委員碧珠。劉代理委員碧珠(張委員煥禎代理人)一、就總額協商通則案而言，上次委員會議離席的委員是在主席宣布散會動議未通過之前，因為現場還有11人贊成散會，所以才離開，並非離席。我記得當時會場還有非醫界代表委員提出，如果會議繼續討論總額協商通則案，於醫界代表都不在場的情況下，後續決議(定)之事項是否成立，會被質疑。二、因為大家對「105年度總額協商通則案」之決議是否成立有爭議，可否先請衛福部法規會解釋。雖然前面議案說要通過，但目前醫界代表並不同意。干委員文男一、主席，我也要發言！現在主要的問題如同剛才楊委員漢湶所提，本會組成及議事辦法並未規定散會動議及表決動議，該辦法第8條所指的出席委員，是以33位計算，還是以26位計算，都有爭議。建議將之定義清楚，取得委員認可後，再將認可的文字訂在相關法規中。二、至於當時醫界代表所關切總額協商通則的3點內容，我們還是尊重你們的意見，文字並沒有更動。本案(會議紀錄確認)已經超過很多時間，希望不要一直在同一個話題打轉。我以前不曾提案，再打轉下去，說不定今天討論不到我的提案，希望趕快確認會議紀錄！鄭主任委員守夏剛才滕委員西華有舉手，在滕委員發言後，本案討論就告一段落。請滕委員西華。滕委員西華一、謝謝主席！醫界代表不滿意、有不同意見，我們可以理解。但因為當時離席的委員，並未對主席的裁示表示不同意見，例如請問主席散會動議是否成立？如果當時主席有說散會動議成立，當然所有醫界代表的離開就不會被理解為離席；但當天確實未得到這樣的訊息，我們都有實況錄影、錄音，或許如我之前建議，開放媒體旁聽、全程現場轉播，大家就不會有爭議了！二、今天不是要讓醫事服務提供者代表不開心，您們當天確實沒有再次跟擔任代理主席的吳委員肖琪確認散會動議是否成立，部分委員就離開現場。現在再提出是因認為散會動議成立才離席，我覺得有點牽強。三、有關會議規範部分，如果法律有規定，當然就應該依之辦理。但在民主機制下，假設大家都同意用猜拳作為決議的方式，而不用表決或共識，則若沒有剝奪他人權益的前提下，這樣的決議方式也應該被尊重。既然醫事服務提供者代表已提出臨時提案，對於未來的議事處理，如：表決通過之數額、表決方式的認定，或議案之處理等，是否要依據嚴重程度，而採取不同的決定方式，建議於臨時提案時再討論。四、上次會議的代理主席吳委員肖琪剛才已說明議案進行的情形，當場確實沒有聽到主席裁示「散會動議成立」，若真有argue(爭議)，也只能調會議的錄影帶、錄音檔來確認。醫事服務提供者代表認為，當時他們是確認散會動議成立後才離席，但付費者代表及代理主席的理解並非如此，會議紀錄的記載也不是這樣，所以當時會議才會繼續進行。若真如醫界代表所提，不是只有協商通則案的決議無效，包括後面所有討論的議案也都有決議效力的問題。五、楊委員漢湶當天並未親自出席，可能不清楚情況，建請醫事服務提供者代表再好好思索，今天所言「當時醫界代表委員是確認散會動議成立才離席」的意見並不是很恰當，因為當天真的沒有聽到主席裁示「散會動議成立」。可以理解醫事服務提供者代表委員不滿意議案的處理，至於要如何彌補委員在會議程序上認知不同的問題，建議臨時提案時再來處理。鄭主任委員守夏一、提醒一下，對於剛才醫事服務提供者代表提出的臨時提案，就上次委員會議已經決議的議案，若要於本次再提案，係屬復議案？還是該如何處理？請幕僚幫忙委員將相關法規弄清楚，等一下討論臨時提案時，才不會發生不符規定，而白做工的情形。二、接下來進行下一案「本會上(第4)次委員會議決議(定)事項辦理情形及重要業務報告」，請柯執行秘書說明。貳、例行報告第二案「本會上(第4)次委員會議決議(定)事項辦理情形及重要業務報告」、例行報告第三案「中央健康保險署『104年5月份全民健康保險業務執行報告』」與會人員發言實錄柯執行秘書桂女各位委員及所有與會者，大家早！請委員翻到會議資料第13頁，針對上次委員會議決議(定)事項辦理情形及重要業務報告，共有5點說明：一、說明一，上次委員會議決議(定)之7事項，依議程製作當時相關單位的辦理情形，原建議解除追蹤3項，繼續追蹤4項，惟之後部分事項有更新辦理進度，請委員翻到會議資料第15頁之附表一，說明如下：(一)第1項，「105年度全民健康保險醫療給付費用總額範圍(草案)諮詢案」已依據當天兩位委員的建議，將新增的1項付費者委員意見，及醫事服務提供者委員所提之書面意見，併函轉衛福部參酌。函文內容請參閱會議資料第53、54頁之附錄一，本項建議解除追蹤。(二)第2項，有關委員所提增列各醫學中心病床增減情形及各層級醫院初級門診照護率資料供委員參考之建議，健保署回復自本年6月起，於每月業務執行報告中增列資料。相關資料已列於本次業務執行報告第77頁(表29、全民健康保險醫學中心病床增減情形)、78~79頁(表30、全民健康保險醫院總額各層級醫院門診初級照護)，本項建議解除追蹤。(三)第3項，針對委員關心缺藥情形之處理，決議請健保署在今年總額評核會議或7月委員會議將提報之藥品相關專案報告中一併說明，因還未報告，本項建議繼續追蹤。(四)第4項，有關委員對「全民健康保險居家醫療整合照護試辦計畫」之相關建議，健保署回復，試辦計畫已完成規劃，目前尚在宣導推廣期，委員意見將納入後續之檢討規劃中，本項建議解除追蹤。(五)第5項，有關建請衛福部於本(104)年年底前，召開「醫療服務成本及人口因素計算方式」檢討會議，並檢視計算方式之合理性建議，本會將於本年12月再洽請衛福部社保司提供辦理情形，本項建議繼續追蹤。(六)第6項，有關自付差額特殊材料案，本會決議請健保署先提經藥物共同擬訂會議討論後再提會，該署同意依本會決議辦理，本項建議解除追蹤。(七)第7項，有關「提升住院護理照護品質計畫」之支付方式及護理人力指標監測結果報告，對健保署提出之三種連動方案，本會多數委員係支持護理全聯會之方案，健保署回復，該案已陳報衛福部裁示，本項建議繼續追蹤，於衛福部公告後再解除追蹤。二、說明二，本會歷次委員會議未結案件，依例於每年6月及12月彙報辦理情形。請委員參閱會議資料第18、19頁之附表二，歷次會議未結案件之辦理情形，多數案件(第一屆歷次委員會議之未結案件)已納入本年度工作計畫中，會按照工作期程提報，此外，尚有6項未結案件，說明如下：(一)第1項，有關「全民健康保險業務監理指標」監測結果報告，健保署及本會幕僚已完成報告格式規劃，目前正送請健保署依格式統計相關資料，完成後會盡快送請委員參閱，本項將分別於7月及12月進行專案報告及掣案提會討論。(二)第2項，有關「擬具全民健保藥價政策之問題研析」，健保署將於7月進行藥品相關專案報告時一併提出，並於12月提出短、中、長程改善方案之專案報告。(三)第3項，有關請健保署提供「提升保險人管理效率」經費編列之相關資料，該署回復將納入9月份業務執行報告提供。(四)第4項，請健保署檢視健保醫療服務的利用情形有無改善空間，並研提改善方案，該署表示將於12月份進行專案報告。(五)第5項，有關多數委員關心「政府應負擔全民健康保險總經費法定下限(36%)」健保署與主計總處核算方式見解不同案，行政院已決定採取尊重主管機關之原則辦理。請參閱會議資料第55頁之附錄二，社保司提供詳細的說明，重點如下：「一、政府應負擔健保法法定下限差額之計算方式，尊重全民健保主管機關(本部)對健保之法令解釋權及計算方式…」。本案本會原決議建請衛福部將委員意見轉陳行政院參酌，當時衛福部已將委員建議函轉行政院，但委員希望等到行政院正式回復採哪種計算方式後再結案，現在行政院已回復尊重主管機關之計算方式，爰建議本項先予結案。至於後續之處理過程，若有委員認為需要追蹤事項，再另起追蹤機制，為免議案追蹤複雜化，建議本案解除追蹤。(六)第6項，有關自由經貿區開放對醫療人力及全民健保之衝擊案的辦理進度，醫事司回復意見，請參閱補充資料第1頁：「立法院對自由經濟示範區特別條例審查進度延宕，本會期仍未完成立法，下會期能否排入委員會討論仍是未定之數」。本報告案須待立法院法案確定後再安排才有意義，爰建議本案繼續追蹤。(七)綜上，未結案件尚有8小項，將分別安排於7、9、12月份提報。三、說明三及四，中醫師公會及醫師公會全國聯合會分別於5月及6月舉辦總額相關計畫之訪查活動，本會分別有8位、14位委員參加，謝謝委員關心總額相關計畫之執行狀況。幕僚就實地訪查情形，擬具訪查報告如附錄三、四(會議資料第56~65頁)，請委員參閱。四、說明五，健保署於3~6月間發布並副知本會之相關資訊，如會議資料第66~85頁之附錄5~12，為節省時間，請委員自行參閱。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？請滕委員西華。滕委員西華一、對本報告案有兩點意見，首先謝謝醫師公會、中醫師公會及牙醫師公會全國聯合會，安排西醫基層、中醫及牙醫總額相關計畫之參訪活動，我從每次的活動中都學習到諸多很好的經驗。惟在西醫基層、中醫部門醫療資源不足地區改善方案或相關計畫的參訪過程，發現所轄各分區業務組的主管均未能親自出席座談會，可以理解可能因公務繁忙而無法全程參與，但至少安排能參加綜合座談，因為健保會委員的參訪經驗，是未來總額協商時的重要基礎。在聽取基層醫事人員反映意見時，有時可能因醫事人員對健保署的相關規定不熟悉，或對支付標準的規定有誤解，導致所提出的意見與事實不符，或有需要修正檢討相關健保規定的情形，而分區業務組的重要長官均未能參與，或參與的人對相關規定不熟悉，致無法於現場提出說明，我覺得很可惜！在此拜託黃署長三桂，以前監理會時期的參訪活動，分區業務組都有副組長或科長級以上層級的人員蒞臨指導、分享。未來若有機會安排參訪活動，仍請健保署長官或主管的分區業務組，盡量派員出席，才能與基層醫事人員或委員有進一步的澄清、交流機會。二、我是本會第二屆新任委員，不知第一屆委員有無舉辦參訪活動？至少今年沒有，只有各部門總額舉辦的參訪活動。之前監理會時期，為讓委員能更瞭解健保業務，辦理過非常多實地訪視活動。明年能否辛苦健保會執行秘書、幕僚，建議選擇一、二項健保業務辦理訪查，而不是由各總額部門舉辦。可考量先與健保署溝通，看有哪些業務可透過實地訪查活動，讓委員更瞭解實況，例如從前的沒有健保卡時，採取何種便民措施讓民眾辦理，或有關經濟扶助業務的相關訪視等，確實非常有助於委員瞭解更細緻的業務面。若因經費或工作繁重緣故，無法訪視很多業務，可考量擇一、二項由健保會來辦理，讓委員有深度學習的機會，此有利決策，對健保會是好事。鄭主任委員守夏一、謝謝滕委員西華的建議。會後請同仁調查35位委員的看法，以了解對於健保業務的監理事項，有無特別議題值得辦理參訪或其他形式的活動。至於請健保署長官盡量出席之建議，則請署盡可能配合。二、請問委員還有無詢問？請李委員永振。李委員永振一、首先感謝衛福部社保司，努力了一年，有關「政府應負擔全民健康保險總經費法定下限(36%)之計算方式」總算有結論。二、有關會議資料第55頁附錄二，其中第二點說明「依健保法第3條規定『政府每年度負擔本保險之總經費，不得少於每年度保險經費扣除法定收入後金額之36%』。就其文義並未限定計入政府負擔數之範圍，而實務上，政府除依健保法規定負擔保險費外，尚依其他規定提供保險費補助，應檢討健保法施行細則之相關規定，將中央政府於健保收入面已實質負擔之保險費列入考量」。該內容涉及保險收入，屬於本會職掌，將來健保署檢討健保法施行細則相關規定後，究竟影響多少經費，請提本會報告，以利委員瞭解，全案才算有圓滿的結果。鄭主任委員守夏謝謝李委員永振，政府應負擔全民健康保險總經費法定下限(36%)部分，若於檢討後發現某些項目有「以前算、現在不算」或「以前不算、現在算」的情形，因其計算會直接影響健保收入，請衛福部社保司將相關進度提供本會瞭解。請干委員文男。干委員文男有關政府應負擔全民健康保險總經費法定下限(36%)部分，健保法第3條清楚規定，屬於健保收入。本案經溝通後雖有結果，但不曉得將來修改施行細則之後會如何，對健保收入有何影響？本會還是應該了解其影響的時點及相關經費，此屬本會權責。即使修改保險費補助項目的經費，只要是用在健保，我們也不堅持，但重新計算的結果應該讓本會知道。本案若現在解除追蹤，只圓滿一半，並未真正圓滿。檢討後健保收入會損失多少？是否因政府沒有經費才衍生出此問題，因為健保法其實寫得很清楚，但現在要檢討施行細則的相關規定，將中央政府於健保收入面已實質負擔之保險費列入考量。無論如何，都要有相關配套，希望等報告清楚後本案再解除追蹤。鄭主任委員守夏謝謝干委員文男。原追蹤案(干委員文男等委員所提「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」，本會絕大多數委員認同健保署對「政府應負擔全民健康保險總經費不足36%部分」的計算方式，並建請衛福部轉陳行政院參酌)改為新追蹤案，因行政院已確定採取尊重主管機關之原則辦理，因此原案解除追蹤，改為追蹤後續的辦理情形。請何委員語。何委員語一、有關政府應負擔全民健康保險總經費法定下限(36%)部分，4、5月時，工商團體代表曾兩次到行政院，與毛院長治國開座談會討論，毛院長非常有誠意解決此事，交代國家發展委員會杜主任委員紫軍研議處理。後來6月座談會，杜主任委員紫軍當面向工商團體解釋，依衛福部及健保署計算之金額，送行政院核定，但中央政府年度預算並未編列此部分，往後將依行政院批示逐年撥補。二、非常感謝毛院長很有誠意解決此事，不過，希望健保署提供相關數據讓委員瞭解，包括政府應負擔全民健康保險總經費法定下限(36%)總共多少費用？這2年主計總處與健保署因計算方式不同所產生的差額有多少？行政院決定逐年撥補，需花費幾年時間、以何種方式撥補？我非常支持毛院長的裁決，及國發會的撥補計畫，杜主任委員紫軍與我當面討論過，所以我非常支持朝此方向處理。鄭主任委員守夏謝謝何委員語！感謝各位委員從各個開會場合幫忙爭取健保經費，大家一起努力總會有好結果。至於真正有多少錢撥入？多少錢移出？等較明確後，再請健保署於例行業務執行報告，提供相關數據讓委員瞭解。請楊委員芸蘋。楊委員芸蘋我知道主席剛才已裁示，不過，再次呼應滕委員西華所提意見，今年參加醫師公會及中醫師公會全國聯合會所舉辦的參訪活動，覺得各總額部門都很用心，辦得很好，因此收穫很多。記得監理會時期，由監理會所舉辦的參訪活動，對新、舊委員也都很有幫助，剛才主席裁示得很好，先調查委員意見，讓委員瞭解更多議題是很好的作法。我知道幕僚很辛苦，事情多而且預算又少，舉辦參訪活動的花費不少，不過應可擠出一點經費，因為日後還會陸續有新委員加入，很多議題會繼續討論，而委員大多非屬健保專業人士，無法什麼都懂，因此讓委員多參訪、瞭解業務，相信議事效率會更好，監理與費協兩會合併為健保會後，功能也會更佳。鄭主任委員守夏謝謝楊委員芸蘋。例行報告第二案就進行至此。請蔡委員明忠。蔡委員明忠向滕委員西華及楊委員芸蘋說明，健保署在這方面已經夠努力，基本上舉辦參訪各部門總額計畫之執行情形，主要是讓委員瞭解各總額部門執行面的狀況，健保署大多有相關人員隨行，至於所屬分區業務組組長可否親自參與，亦需視當時狀況，且可能因2天行程，時間較不允許。就個人經驗，參訪過程中，若執行面涉及需健保署回答的問題或協助，健保署的人員也能隨時配合協助。非常贊成滕委員西華所提建議，多溝通、多讓委員瞭解，是絕對有必要的，最好能對醫療整體面進行瞭解。鄭主任委員守夏一、謝謝！例行報告第二案到此結束。二、例行報告第三案為健保署業務執行報告，依本會102年2月22日委員會議決定，本項例行性報告，書面資料須每月份提供，但口頭報告採季(每年1、4、7、10月)報方式辦理。依慣例今天是提供書面資料，請委員參考，若有相關詢問，可利用桌上的發言條提供書面意見。三、接下來進行討論事項，請同仁宣讀討論事項第一案。參、討論事項第一案「105年度全民健康保險醫療給付費用總額協商程序(草案)」與會人員發言實錄同仁宣讀鄭主任委員守夏謝謝宣讀。本案係為9月份召開105年度健保醫療給付費用總額協商會議預為準備，本協商程序草案與過去2年非常相似，已將協商會議時間、與會人員、進行方式與原則、各方未能達成共識之處理方式等列明清楚。請問委員有無意見？若無意見就通過。請干委員文男。干委員文男對總額協商程序案沒有意見，但對協商草案的研提有意見，我參加健保署的醫療服務給付項目及支付標準共同擬訂會議時，發現各總額部門下的各醫學會常常有很多提案，所提議案，事實上屬內部問題，但最後都會講到一句重點，為何協商前、後都未與他們討論，就決定他們未來的命運。因此希望醫界在協商前、後要多與各醫學會溝通，不然以後不知要再透過立法委員提多少案，讓我們傷腦筋，造成不必要的麻煩。我們在會議的發言要讓人心服口服，希望醫界代表能將這件事記在心裡。鄭主任委員守夏一、謝謝干委員文男提醒。請四總額部門(包含門診透析服務)，於研提協商草案前，應與可能受影響的地方分會或相關專科醫學會等先行溝通，讓大家都瞭解情況。二、請問委員還有無意見？(未有委員表示意見)沒有的話，本案就通過。請同仁宣讀討論事項第二案。肆、討論事項第二案「建議試辦中醫治療『過敏性鼻炎』案」與會人員發言實錄同仁宣讀鄭主任委員守夏先請提案人干委員文男補充說明，接著請健保署及中醫師公會全聯會表示意見，之後再開放討論。請干委員文男。干委員文男一、本提案是許多民眾都會遭遇的問題，如果孩童時期沒有將過敏性鼻炎治療好的話，長大後會變成非常煩人、惱人的鼻竇炎，屆時連手術都治不好，即使動過兩次手術還是無法解決，造成精神無法集中、無思考力、鼻涕倒流、晚上睡不著、白天沒精神等情形。我6月22日觀看電視台轉播日本人鼻子過敏的情形，足足播了5分鐘，顯示此情形在日本也相當嚴重，但日本並未有漢醫的治療方法。 二、人家說實證醫學，我有3個兒子的親身體驗，他們依序是48歲、46歲、45歲，命運都不同，最大的孩子照書養，稍微感冒就帶去看醫生，阿嬤再煎些中藥給他喝，所以沒問題。後面兩個兒子就照豬養，感冒只帶去看醫生，但沒流鼻水，不代表完全治癒，2人的鼻子都動過兩次手術，還是無效，常常精神無法集中，一位是消防技師、一位是工業技師，都無法集中做專案，尤其晚上睡覺時鼻涕倒流，實在很痛苦，而且擔心此疾病會延至第三代。三、健保雖然有給付科學中藥，但科學中藥的量，有時無法達到水煎藥劑的治療效果。過敏性鼻炎最佳的治療時段為6~13歲，即小學期間的學童，以水煎藥劑等治療方式，能澈底根除問題。希望健保署網開一面，漢醫有五千年歷史，請大家給予支持，而且長庚大學中醫學系在國際已發表30篇研究報告；至於人體試驗，我有3個兒子的經驗。健保因為科學中藥有製造標準，所以納入給付，對科學中藥無法解決的部分，希望能網開一面，讓小孩的過敏性鼻炎可以水煎藥劑來解決。鄭主任委員守夏謝謝！黃委員啟嘉先舉手，請黃委員啟嘉。黃委員啟嘉感謝干委員文男提案。現在講到學歷問題很敏感，因為我有個教育部不承認，但WHO(World Health Organization，世界衛生組織)承認的學歷。我在南京中醫藥大學獲得中醫博士學位，論文就是以中醫的方法治療小兒過敏及氣喘。大陸所謂「中醫治療」是中西醫合併，而非只用中醫治療；台灣則礙於法令規定，很多時候西醫無法併用中醫、中醫無法併用西醫。因我的論文即是用小兒推拿治療小兒氣喘及過敏，有機會可以提供參考。若想解決民眾問題，可以中西醫合併治療的方式，建議本案考慮與西醫一起合作。干委員文男補充一下，西醫治療過敏、流鼻水的方式，是到兒科或家醫科打針治療，雖然可以不再流鼻水(治標)，但後續還有很多問題須處理，本案想治標又治本。鄭主任委員守夏中西醫合併的議題暫不討論，先聽聽中醫師公會全聯會代表的意見，請何理事長永成。何委員永成一、首先感謝干委員文男重視民眾健康，以自身經驗現身說法。我也有過敏性鼻炎，而且相當嚴重，以前只要回高雄，大概每月都會發作，因為當時發展石化工業，空氣品質很糟糕，後來靠自己運動及中醫治療，現在算已根治，所以以中醫治療是有效果的。從103年申報案件來看，過敏性鼻炎有121萬件，因此干委員文男的提案，我們相當重視，將與健保署討論列為105年度中醫門診總額的協商項目。二、健保給付科學中藥，但中醫治療過敏性鼻炎、鼻竇炎、慢性鼻炎的武器，不只科學中藥，水煎藥劑效果更好，另外還有像三伏貼、鼻薰法等療法，但這些療法並未納入健保給付，因此民眾需自費，若能與健保給付項目配合使用，效果會更佳。希望容許中醫總額有相關經費來執行這項配套治療或專案，例如健保已給付診察費，以往水煎藥劑並未納入健保給付，但可以配套包裹式給付來估算一年所需預算，後續再提出執行成果報告。本案對民眾健康及中醫部門來講，都很有意義，我們願意全力配合！鄭主任委員守夏了解！請楊委員麗珠。楊委員麗珠過敏性鼻炎是很普遍的疾病，從小孩到成人都有，鼻塞、鼻涕不斷是影響生活品質很嚴重的問題。干委員文男參加中醫舉辦的訪查活動參訪了桃園長庚醫院，該院中醫部門所發表4篇有關水煎藥劑治療過敏性鼻炎的研究報告，在國外具有相當高的評價，顯示該療法確實有效。中醫委員代表剛才也提到可造福很多家庭，減輕父母困擾，尤其小孩過敏，晚上都睡不好，造成學習困擾。支持本案列為105年度的試辦專案。鄭主任委員守夏請林委員敏華。林委員敏華請教中醫部門，是否估算過這種治療方式，需多久療程，一年下來大約需多少費用？因為有一百多萬名病患，聽起來有點恐怖。鄭主任委員守夏沒關係！大家今天如有共識，還需經過總額協商及健保署相關共同擬訂會議討論，所以一定要先擬訂計畫，才會有數據。干委員文男提案只是幫民眾爭取將該醫療服務或藥物納入健保給付，若此與預算有關，還需要經過協商；若與預算無關，只要提至健保署相關共同擬訂會議討論即可。目前尚屬提案階段，還未有細部方案。請其他委員表示意見，請滕委員西華。滕委員西華一、剛才黃委員啟嘉提到中西醫合併，難得雙方和樂融融，也是好事。但在本案決議前，有些資料需請健保署提供，因為協商時不能憑感覺「這東西好」就決定編列預算。楊委員麗珠提到此問題很嚴重，就醫人口很多，但現行健保並非未提供相關治療，中、西醫都有給付項目也是事實。上呼吸道問題是否也涉及口腔，不知牙齒疾病與此疾病有多少關聯。請中醫師公會全聯會提供Evidence-based(實證基礎)的資料，例如以三伏貼、鼻薰法方式治療過敏性鼻炎相關疾病與目前治療方式的效果比較，才有相關基礎數據觀其差異。二、另外，請健保署提供相關診斷之就醫人數，在西醫、中醫的分布，占健保多少醫療費用。若由中醫總額中切割一部分經費試辦，應從中醫總額基期扣除，否則會有經費應用不清楚的問題；若不切割，則應說明新試辦方案與現行方案之病人是否有overlapping(重疊)的情形，若範圍不清楚，重複給予經費，病人也流來流去，則會產生問題，因此需要相關資料支持，才能進一步討論有無效益，及訂定監測指標或篩選機制。三、對干委員文男的提案樂觀其成，但希望補充更充分的資料，以利繼續討論。鄭主任委員守夏謝謝滕委員西華。請謝委員天仁。謝天仁委員一、站在健保會立場，支持有效率的治療。以單一藥品或治療方式列為試辦計畫比較特別，從某個角度來看，並不周全。二、中醫部門就專業立場，若認為不只科學中藥有效，水煎藥劑更具治療效果，為何不在健保署藥物給付項目及支付標準共同擬訂會議爭取列為給付項目？民眾有流鼻水、睡不好、精神不集中、書念不好的問題，長期卻只以科學中藥治療，又治不好，這不是很奇怪嗎？此點反而讓我好奇，中醫是傳統醫療，為何一定要用科學中藥，假使水煎藥劑的療效更好，健保署則應該列為支付標準的給付項目。 三、我認為不要以試辦方式，中醫部門應站在專業立場，以實證為基礎，證明何種方式最有效，並提至藥物給付項目及支付標準共同擬訂會議討論，爭取納為給付項目，嘉惠民眾才對，也才能將錢花在刀口上。四、個人親身經歷，到醫院去做復健牽引，4個月後情況還是一樣，牽引後感覺很輕鬆，但回到家卻又不舒服了，請問花這些錢有用嗎？可能只暫時舒緩疼痛或不適，並無真正療效，這部分值得深思，應該檢討。所以，請中醫部門與健保署以此角度密切合作。干委員文男很用心，對民眾是好事，希望能朝好的方向發展。鄭主任委員守夏謝謝！請楊委員芸蘋。楊委員芸蘋一、對於干委員文男的提案，心有戚戚焉，我兒子有很嚴重鼻炎，但沒吃中藥就好了，因為醫生要他多運動，不要常待在潮濕的地方，一定會好。我兒子是足球隊員，一天到晚運動，時間久了，加上自己保養，就痊癒了。二、剛才黃委員啟嘉提到中西醫合併治療，會好得更快，確實是這樣。但我也贊成謝委員天仁所提，中醫部門應自己實驗，十個醫生可能抓十種不同藥方，火候也不一樣，效果一定不同，且藥材價格有高有低，很難掌握應該支付多少費用，所以要有實例，用相當的經驗數據累計，才能估算應支付多少費用。本案的出發點很好，但中醫部門應以實證數據說服健保署，以納入給付項目，對民眾也是一大福音。鄭主任委員守夏謝謝！請何委員語。何委員語一、今天早上本來不能來開會，因為我也是一家股票營業總額70幾億元上市公司的董事，早上要改選董事，我想不去參加也會當選，還是來參加健保會委員會議比較重要。二、干委員文男很熱心，十分令人敬佩，對這些小孩的疾病，他都非常關心。現在因空氣問題，導致鼻子過敏的因素很多，例如地毯，及其他化學製造的物品太多，還有食物的化學添加劑也很多，另外，植物、動物的生長激素，被濫用的情形也很嚴重。現在小孩的體質都受到很大的傷害。三、對中醫專業不是很清楚，本案提出後不知是否有效？可否授權中醫師公會全聯會與健保署共同擬訂可行方案，如果可行，就於下次委員會議報告成果，並且列入總額試辦計畫；如果不可行，則回歸原來的治療方式，這樣比較完善。鄭主任委員守夏謝謝何委員語，意見非常明確，委員還有無意見？請莊委員志強。莊委員志強一、依據干委員文男的意見，水煎藥劑的效果比科學中藥顯著，所以想請中醫師公會全聯會研究看看，如果我們選擇給付水煎藥劑，另一方面是否應考慮不給付科學中藥，因為應該選擇有效的治療方式納入給付，不能又要給付科學中藥，又要給付水煎藥劑。二、剛才楊委員芸蘋提到，中醫師給的藥，她帶回去煎，煎出來再服用的效果可能不一樣。所以如果要給付水煎藥劑，是否應該由中醫師負責煎藥，或由藥師來煎？在西醫方面，是由藥師調劑，中醫目前好像沒有中藥師，所以可能要委託專業幫忙煎煮藥劑，這樣才能控制藥效的穩定性。鄭主任委員守夏謝謝莊委員志強。請蔡委員明忠。蔡委員明忠回應謝委員天仁、莊委員志強的意見。有關是否要限縮健保給付範圍的問題，相信未來會被大家廣泛討論，以目前健保情況而言，整體支付面未來將面臨更嚴峻的考驗，及如何面對限縮給付項目的挑戰，第一次聽到付費者代表有這樣的概念，等於使用某種醫療服務品項時，就必須考慮限縮其他品項，類似這樣的概念，未來在管控給付範圍時，樂見其成。干委員文男主席，我再補充說明。鄭主任委員守夏請干委員文男。干委員文男謝謝各位委員，有關此議題，讓大家傷腦筋了！但這是好事。不是否定科學中藥，而是關於科學中藥的藥量，如果要吃到一碗水煎藥劑的量，相對必須吃好幾包科學中藥，而且科學中藥的賦形劑太多，占約10多%，要吃到有效果，也會吃進不少賦形劑；而水煎藥劑並未添加賦形劑，之所以建議適用對象為6~13歲的兒童，是因為6歲已可喝湯，而且父母都在身邊，可以照顧；到了13歲，早上上學前，喝一次藥劑，晚上放學回到家，可再喝一次。希望可以讓台灣的兒童身體更強壯，一定要將這些病症根治，我們國家才會更有競爭力。二、我兩個孩子都動過手術，結果又復發。也不知道手術一次要花健保多少費用？所以麻煩中醫師公會全聯會與健保署研究看看，不要讓老百姓痛苦，讓我們的下一代有更多機會為國家服務。鄭主任委員守夏本案已經獲致比較明確的共識，依據干委員文男的意見，請中醫師公會全聯會與健保署相關同仁共同研議可行方案，當然要有真正的Evidence-based(實證基礎)，但如果影響到中醫總額，可在協商時討論，如果沒有影響，則可提至健保署相關共同擬訂會議討論，這些都有一定規範可供遵循。再次感謝干委員文男的提案，接下來進行討論事項第三案，請同仁宣讀。伍、討論事項第三案「基於保險業務監理，建請健保署於委員會定期按月提供醫學中心、區域醫院之門、住診初(次)級照護及下轉等數據資料案」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，請提案人謝委員武吉補充說明。謝委員武吉感謝健保署的說明，本案是要求健保署每個月提供醫學中心、區域醫院門診、住院初級照護，以及下轉的相關資料，因為民眾經常一床難求、一號難掛，所以建議也應提供急診的相關資料。很高興健保署自104年6月份起，於業務執行報告增列各層級醫院門診初級照護率的資料，希望以後能按月提報。請健保署說明目前無法提供的數據部分為何？鄭主任委員守夏感謝謝委員武吉的說明，委員有無其他意見？請謝委員天仁。謝委員天仁本提案的範圍可否更為廣義，因為發生急診壅塞的醫院，可能在某幾家醫學中心，或部分區域醫院，因此不能只看整體數據，這樣問題會被稀釋，致無法清楚了解問題核心。所以針對急診壅塞問題，請按季提供個別醫學中心輕症、重症的相關資料、其下轉情形如何？成效如何？才能逐一檢視問題所在。到底是病人不願意下轉？或者支付誘因不夠？或是其他問題？所謂垂直整合才有實際成效，建議健保署針對我提出的意見，提供比較完整的資料，而不是大鍋炒，因為這樣無法看出問題。鄭主任委員守夏感謝謝委員天仁。請滕委員西華。滕委員西華一、謝委員武吉的提案其實很好。但能否更齊全一點。支持剛才謝委員天仁所提急診部分的意見，因為急診壅塞的問題，才是我們要花力氣處理的，其他醫院要做分層轉診也很好，可是在急診部分，針對前十名急診壅塞的醫院，可以找出更有效的改善措施，不論採獎勵或其他方案，要讓民眾有感。所以，在此呼應謝委員天仁的意見。二、針對謝委員武吉的提案，健保署也有回復意見，但有點保守。我也覺得按月提供無法看出趨勢，不太有意義，如果謝委員武吉同意的話，我認為可以按季提供。但在初級照護方面，原本就有提供相關資料，只是建議新增下轉資料，建議不要只提供下轉資料，如果要確實知道問題所在，因為轉診是從西醫基層診所到地區醫院、區域醫院、醫學中心間相互合作的關係，應該要鼓勵基層及地區醫院上轉，鼓勵醫學中心及區域醫院下轉。所以，上轉率及下轉率的變化，都蠻重要，可看出有無實質推動轉診，還是只有特定層級在執行轉診。三、健保署可以考量維持現行提供的初級照護資料，並新增納入各層級醫療院所的上轉、下轉、平轉資料，說不定資料分析的結果是醫學中心之間彼此平行轉診的頻率很高，屆時也可看出問題所在。雖然醫學中心現在的數據有些變化，但如果平行轉診率增加，不就表示各醫學中心有發展其特色嗎？所以，請健保署辛苦一點，我認為值得分析，以瞭解民眾就醫的分布有無因為政策而改變，這點很重要。鄭主任委員守夏謝謝滕委員西華，委員還有無意見？請楊委員芸蘋。楊委員芸蘋這個資料如果能夠每個月呈現是很好，但也要看健保署有無足夠的人力？可以按月呈現，若呈現的趨勢又不是很明顯，能否每2至3個月提供一次，不要花那麼多人力來做這些事。剛剛滕委員西華、謝委員天仁所提意見，健保署如果能接受的話，請健保署辛苦一點，我們也蠻希望能有這樣的資料可供參考。鄭主任委員守夏謝謝楊委員芸蘋，請吳委員玉琴。吳委員玉琴一、謝委員武吉的提案，值得支持，能夠讓我們比較清楚看到各層級醫療院所在初級照護的變化情形，可進行前後比較。健保署表示自104年6月起將各層級醫院門診初級照護資料納入業務執行報告，可是在該報告第78、79頁，好像各層級醫院門診初級照護的變化不大，僅微幅下降，建議區域醫院或醫學中心，不要執行那麼多初級照護服務，應該回歸基層院所執行。可以請一些初級照護下降率表現比較優秀的醫院來分享經驗，讓其他醫院有學習機會。二、剛才提到急診壅塞問題，也應立即處理，真正需要解決的問題，還是在鼓勵如何上轉及下轉，剛才滕委員西華建議，呈現的層級資料要增加地區醫院，既然要做垂直整合，或要提供整體照護，對於上轉及下轉的情形也都要全盤瞭解，因此都需要有相關數據。鄭主任委員守夏謝謝吳委員玉琴。謝委員武吉是否需要補充？謝委員武吉一、非常感謝各位委員的支持，就上轉的部分做說明，一般的基層診所及地區醫院，一旦上轉後，就會一去不回頭，所以，提案並未列入上轉資料，其實我當時的設計，是有包含上轉的報表。非常感謝多位委員對本案的支持，我認為還是要每月提報，然後按季整理，從每月看到每季的統計資料，應該可以有更深入的瞭解。二、感謝謝委員天仁提出的建議，因為我屬醫療體系的成員，不方便寫得這麼清楚，但謝委員天仁幫我將心裡的話說出來。最後，還是希望健保署能針對補充資料第3頁說明二所表達之「門診及住診下轉目前並無明確定義」進一步說明。鄭主任委員守夏謝謝！我想委員意見蠻有共識。請健保署說明實務上會有哪些困難？請蔡副署長淑鈴。蔡副署長淑鈴一、非常謝謝各位委員關切轉診數據，針對本案，我必須說明，如果健保署的資料可以正確提供，我們沒有不提供的理由，按月、按季都可以，但本案確實有其限制。首先，因為現行初級照護是以門診的診斷作為分類，但診斷並不能代表疾病嚴重度，所以健保署缺的是嚴重度的相關資料，本案的需求是希望提供門診及住院資料，但同一個診斷，可能在門診屬輕症，但在住院可能是需要住院(屬重症)。過去本署都是提供門診的資料，如果住院採相同定義，歸為輕症住院，則我們認為所提供的資料反而會造成誤解，因為健保署未有疾病嚴重度的資料，因此對此部分採保留態度。我們可以提供資料，但當大家都不瞭解此資訊時，擔心反而造成誤解或誤用。二、其次，健保的資料庫對於轉診中上轉或下轉的資訊並不完整，我們有什麼資料呢？在現行制度下，透過轉診可以減輕部分負擔，如果醫院有申報減輕部分負擔代碼，才會知道該案件屬上轉，但此數據恐怕嚴重低估；另健保署並未有下轉資料，因為下轉沒有減輕部分負擔的誘因，所以整體來講，如果只靠擷取轉診免部分負擔的資訊，無法完整說明整個體系上轉或下轉的情形，也會造成大家的誤解。三、目前辦理的「急診品質提升方案」，對於急診上轉或下轉有提供支付誘因，但因有些醫院並未申報費用，在此限制下，我們能提供的數據也屬一定程度的低估，且必須醫院申報，健保署才有相關數據。另外，用同一個定義，將初級照護率引用至住院部分，也不恰當，所以才會很保留地提出以上意見。四、另明(105)年起所有疾病編碼要以ICD-10-CM/PCS (國際疾病分類第10版)進行編碼，因此現在運用在門診初級照護率的ICD-9-CM編碼，屆時也會改變。這些編碼都須要重新檢討，才有辦法繼續提供類似概念的門診初級照護率，此點要先跟委員說明清楚。如果大家覺得沒關係，也可提供那些被低估的數據，門診部分，過去一直都有提供，急診轉診部分也可提供，至於低估多少，健保署則完全無法回答，也無法提出實證數據。委員可以要求呈現相關資料，但如果要引用這些資料來做決定，我們擔心會非常不準。鄭主任委員守夏謝謝蔡副署長淑鈴的說明。接下來，請專家學者表示意見。戴委員桂英一、謝謝主席！大家都很肯定資料應該越來越透明，我也很認同這樣的作為。只是一般而言，資料統計需要先定義清楚，如果沒有清楚的定義，等於是拿一堆模糊的資料來解讀。有關初級醫療案件的區分，這一點醫界可能更清楚，請問醫學中心、區域醫院在住診部分，能否區分初級與非初級醫療案件，如果醫院可以區分，健保署只要多加一個code(申報碼)，請醫院申報資料後，就能夠分析；但如果連醫院也無法區分，健保署只憑診斷碼統計，相信到時我們看到的資料會有問題。二、其次，有關上轉、下轉的部分，依健保署的說明，因為現在沒有要求醫院申報下轉資料，所以取得有困難。請問醫院申報此下轉資料是否會有困難？我們要務實地思考，既然要統計分析，就要精準的數據，如果醫院申報下轉資料沒有困難，健保署就可以進一步統計、分析。現階段如果執行有困難，假設僅急診方案有請醫院申報上轉或下轉的資料，雖然屬低估，但至少是醫院申報的數據，可在說明時，加註可能低估的原因。以上是我的看法，不知道其他幾位專家學者的意見。鄭主任委員守夏謝謝戴委員桂英。請吳委員肖琪，健保署之前就是參採您研究計畫所建議的初級照護分類指標。吳委員肖琪一、感謝謝委員武吉的提案，我從提案中看到三~四個重點。第一，我們關心的如果是案由第二行所述的「初級照護」，此議題最早是由呂碧鴻醫師所提出，其認為有些小病不需要到大醫院就診，到小醫院即可。不好意思，這樣說好像有點得罪人；其實涉及的是如何定義初級照護；之後李教授玉春與我一起研究初級照護的定義，健保署後來也參用該研究結果。剛才蔡副署長淑鈴提到，現在運用計算門診初級照護率的ICD-9-CM編碼，因為105年要全面實施ICD-10-CM/PCS，因此需要重新檢討。通常關心初級照護會是在門診部分，所以住院部分就不會有相關定義，因此表一右邊的住院欄位就無法提供，只能提供左邊的門診欄位。二、其次，表二所提占率，分母為何？可能需要請謝委員武吉幫忙補充，是占一家醫院門診費用的占率？還是一家醫院初級照護占門診檢驗檢查的占率？分母一定要定義清楚，否則不曉得這些資料可以做何用？如果我們關心的是醫學中心初級照護占所有門診的比率，則以前其實就有指標，這樣的話，我會更關心門診的診次占率。如果要提供此表格的資料，要先想清楚分母為何？三、如提案說明第一點，假若本案是為解決大醫院病床一床難求、人滿為患、醫師、護理人力沈重負荷的問題，我會覺得應該先關切住院超過30日的案件，這才是最需要管理的部分，這部分管控好後，病患才有可能下轉，現在管不管？實際上，DRG(Diagnosis Related Group，住院診斷關聯群)支付制度實施後，最應該管控的就是住院超過30日部分，之前醫學中心至少增加5,000床，區域醫院增加20,000床，總計增加25,000床，結果還是人滿為患、一床難求，這時我們要思考的是，接下來人口老化的速度這麼快，我們負擔得起嗎？如果真的要幫地區醫院的忙，必須趕快落實DRGs支付制度，而且不可以排除住院超過30日的案件。四、如果我們關心的是醫學中心與區域醫院的初級照護，則我可能會關心這麼多年來，醫學中心與區域醫院的病床占全國的六成，住院病人卻占全國七成，這才是問題所在，所以我們要思考的是，台灣究竟需不需要這麼多急性病床，很可能減床就可以解決此問題了。 鄭主任委員守夏一、謝謝吳委員肖琪，其他委員還有無意見？(未有委員表示意見)二、先提出初步結論，請大家參考。依照剛才吳委員肖琪的講法，謝委員武吉的提案要解決的問題還蠻多，如果重點是大醫院不要看小病，那有兩個數據很重要，一個是初級照護的件數，不應再繼續往上升，而該下降，這是現在已經有的監控指標；另一個是剛才謝委員天仁所提，如果重點是急診塞爆的那十幾家大醫院，就需要持續關注其急診下轉的情況，此點也比較明確。三、住院部分，是否有所謂初級照護住院，真的沒有相關研究可參考，而若要從ICD-9-CM編碼看出是否屬初級照護住院，恐怕也有困難。上轉的資料其實也有困難，因為民眾會自己去醫院就診，所以這部分的資料會明顯低估，雖然有委員提出要新增，但我覺得就如同謝委員武吉所提，一旦上轉就不會再下轉，健保署大概也沒有相關資料可提供，因為真的很困難，所以建議先提供表一的左邊欄位(門診初級照護)，及急診的下轉資料，這兩個數據似乎健保署比較有信心，因為可信度較高。這部分如果沒有困難的話，請健保署列入每月份業務執行報告中提報。四、其餘部分，請健保署去了解國外其他保險單位，是否有相關的統計資料，如果國外有分析，則可以參考其定義，進行上轉、下轉，或小病住大醫院的資料整理及分析。如果統計出來的確實很離譜，或許可以考慮現階段暫時先不要提供，這是我初步的建議。請謝委員武吉。謝委員武吉一、謝謝主席剛才所提，上轉的資料確實取得不易，但下轉的資料，可能只要健保署設計一個欄位，請醫院在下轉時填報，看病人下轉至哪個層級的院所，以後就可以瞭解下轉情形，相信一定可以提供，但健保署會比較麻煩，所以立刻要求健保署做到，也顯得太凹蠻(台語)，對於現在健保署還做不到的部分，健保署可採漸進改進。二、剛才謝委員天仁所提的急診壅塞，的確是不應該發生的事情，因此對謝委員天仁提出的意見，我表示贊同，請健保署依謝委員天仁意見提報有關資料；至於下轉的人數，請健保署思考需要多久時間，用何種方式報告，這方面我並未有強烈建議。三、有關吳委員肖琪所提的資料項目，我現在設計的表格，包括件數及點數占率，全部夯不啷噹列在一起，是一個總括概念。所以，表二的資料可等以後再處理，但不是不處理，我認為健保署能夠做的就先做，目前做不到的，可以漸進的方式來處理，這樣比較好。鄭主任委員守夏請莊委員志強。莊委員志強一、主席，我看謝委員武吉所設計的這些表格，應該是為了解決一位難求、人滿為患，醫師、護理人力沈重負荷的問題。記得上次健保署有個關於急診壅塞的專案報告，印象中是說腳長在病人身上，他想去哪家醫院，我們控制不了。我想請問，如果今天我去台大醫院掛急診，醫師判斷屬輕症，他可以叫我去別的醫院看診嗎？如果我堅持要在台大就診，台大可以拒絕我嗎？(有委員回應不行)那就對啦！上次我頭暈到三總掛急診，醫師要我去附近的醫院就診，我就是不願意去！若醫院拒診，我就告你！我的意思是說，有什麼辦法可以達到解決一位難求、人滿為患的問題，除非醫院告訴我，你屬輕症，堅持來急診就醫可能須自付10,000元，我才會思考沒那麼嚴重的話，也許可以在附近的其他醫院就診。二、呈現此表格資料能否解決一位難求、人滿為患的問題，我的看法是可能健保署多麼努力，都還是無法解決，因為腳長在病患身上，我上次只是頭暈就去三總掛急診，為什麼？因為負擔的費用便宜啊！所以設計這些表格可能無法達到解決上述問題的效果，除非大醫院可以拒絕輕症病人，如果病人仍堅持到大醫院就診，那就必需自行負擔很高額的費用，病人才有可能自行轉診。鄭主任委員守夏一、謝委員武吉的提案列出很多問題，但其實不大可能一次解決，剛才提到不希望小病到大醫院就診，就可藉此數據進行監控，至於莊委員志強所提問題有無辦法處理，病患就是要去醫學中心掛急診，也不能跟他說不行，怎麼辦？相信謝委員武吉的意思是，如果屬門診初級照護，至少有數據可供監控。至於細項占率，如果可以計算，就請健保署協助，如果計算後在解讀上非常不符現實或可能造成誤導，也許可再另外報告，這樣處理可以嗎？(未有委員表示反對)二、本案討論至此，請同仁宣讀討論事項第四案。陸、討論事項第四案「關於現今藥品各醫療院所實際採購價格及藥品健保給付價格，資訊不透明化，導致藥價差之情形日趨惡化，嚴重影響到全民健康保險之藥品費用，應立即公布各層級醫療院所之藥價差金額案」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，先請提案人李委員蜀平說明。李委員蜀平一、主席、各位委員，大家健康、大家好！我日前享受健保的恩澤，去醫院開刀，深感健康的重要。感謝黃署長三桂對健保的付出，真的是以感恩的心感謝有您！因為膝關節半月板損傷去進行修補，雖然算是小手術，但因還未拆線，又不能踩地，現在才知台語講的「上大號也痛、上小號也痛」的感覺。住院時沒事做，每天思考在健保會扮演的角色，為何自己都當海鳥，只會落下糞便惹人嫌，而不當喜鵲每天報喜訊，但榮幸為健保會委員真的需要對健保的永續經營付出，所以特別關心嚴重的藥價差問題。已經提案好幾次的藥價差，希望主席及健保署了解，我要求藥價差的金額公布，是因為藥價差可能對未來的醫療及健保結構有嚴重的副作用。例如去年推動雲端藥歷就省下50多億元，可見重複用藥的可怕，重複用藥不只多支出藥費，也可能用藥不當造成洗腎、住院，及可能RCW(呼吸照護病房)的病人也會因用藥不當造成。藥價差不只占20%，現在各醫院可能還會因藥價差而多開藥，會造成醫療行為的偏差、甚至於造成醫療價值觀改變，這些問題民眾可能不是那麼清楚。二、委員及主席都指示說提案要很明確，所以我再次提案，我也不敢得罪健保署任何一個官員，因為他們實在很認真，但本案不處理，會產生整體醫療結構的偏差、以藥養醫、開藥賺錢等很多看不到的副作用，也會讓我國製藥工業因惡性競爭而無法發展。所以我們絕對要重視藥價差這個問題，而且健保署絕對有此能力了解資料，絕對有數據，懇求主席及所有委員支持本案。因為這不只是你、我之間的問題，而是整體健保及藥品制度的問題。三、健保署的答覆說意見會提到全國藥品政策會議，但全國藥政會議，6年才開一次，藥界九大公協會等團體，大家在會議前，也都有很多想法，但開會那天沒有人敢講話，因為廠商知道只要講話，他的藥就會可能被換掉。今天敢請問黃署長，您知道嗎？有1顆12元的藥，只賣9毛、8毛、或1.5元的離譜情況嗎？希望合理的藥價差並將省下來的藥價差回歸醫師、醫界，創造健保真正高品質的醫療服務，讓未來高齡化的長者、慢性病患者能有更好的照顧也讓醫界有合理的報酬。我今天算是殘障人士，拜託大家支持。鄭主任委員守夏這是李委員蜀平第三次提案，此次提案寫得非常明確。請委員表示意見，先請謝委員天仁，再請潘委員延健。謝委員天仁一、李委員蜀平一直提案，這次又剛好不良於行，拄著柺杖，可看出他真的非常堅持。我的看法是醫療資訊應該公開透明，這沒什麼不好。本案的要求基本上不會影響個別醫療院所，只是希望了解各層級醫療院所藥價差的實際情況，若涉及個別院所的藥品交易價格，才有可能涉及商業機密曝光的問題。二、其實健保署2~3年前有公布類似資料，李委員蜀平提出本案，我認為非常好，以後應該列為常態性報告，不需要每月提報，每季提報各層級醫院的藥價差，作為監理指標。如此李委員也不用一再提案，他似乎不達目的絕不終止，就算為了讓委員會的議案量負擔減輕一點，建議大家支持本案。潘委員延健一、對於李委員蜀平說明的內容，有些部分我要提出澄清。在健保署的監督下，每家醫院的總藥費、每人平均藥費都受到嚴格的監控，在我所知道的醫院中，醫師開藥行為及其所得完全沒有關連，醫師絕對不會因為開藥而增加所得，純粹是基於病人需求，這點必須嚴正澄清。二、藥價差有高有低，有價差較好的藥品，當然也有價差很低的藥品，甚至有些價差為負值，尤其是癌症等重症患者的用藥，幾乎沒有利潤。健保署每年都會進行藥價調查、調降藥價，最後的結果就是全民受益，因為醫界會努力與廠商議價，使得藥價調降，健保也可節省很多支出，省下來的費用，可以開放更多的新藥納入健保給付，有些新藥就是因此納入的。所以這是良性循環。這樣的市場機制，最終的結果對民眾有益，所以不宜就醫院與藥商拼命議價有負面意見，因為若沒有人議價，健保署做再多的藥價調查也沒用，因為藥價仍會居高不下。大家千萬別誤解，以為醫院跟醫師很喜歡開藥，現行因為藥品費用比率受到監控，對醫院來說是很沈重的負擔。鄭主任委員守夏請蔡委員登順，再請楊委員芸蘋、蔡委員宛芬。蔡委員登順李委員蜀平已經多次提案，但我有不同看法。藥價差議題涉及的層面很廣，也很複雜，不知道提案要健保署公布各層級院所藥價差的金額，意義何在？這關係到醫院的採購數量及經營的商業機密，醫院方面是否願意公開？我想大概有困難。若真的公開，其採購資料是否具真實性？有無其他問題？也很難判定。建議依健保署的意見辦理，有關藥價差議題，健保署已依本年2月10日全國藥品政策會議的結論，於5月27日、6月15日持續邀集醫界、藥界就相關議題召開溝通會議，我想這是很好的專業溝通平台，前後已召開過3次會議。對藥品不是很內行的人，可能也搞不太清楚情況，因此於上述平台可能較適合討論，建議健保署在相關會議，應明確清楚表達意見，以消除委員的疑慮。鄭主任委員守夏請楊委員芸蘋。楊委員芸蘋一、祝福李委員蜀平早日康復！不用再拿柺杖。我以消費者的立場，很不願意看到「獲取不當利潤、造成以藥養醫、開藥浮濫，以及藥價黑洞等問題」這些字眼，這些文字在媒體看到的頻率很高，因此一般民眾對藥品的價差有疑慮。到底藥價差在哪？因為李委員蜀平也沒有講得很清楚，到底「差」在哪裡？李委員這麼堅持再三提案，我雖然不懂，但很想弄清楚、更了解一些。每個病人若有需要就會吃藥，我想醫院不至於讓患者吃到不好的藥，醫院開的藥應該對病人有幫助，但為何會有藥價差的名詞出來，請健保署也要釐清，不要讓民眾有這麼深、這麼大的疑慮。二、我注意此問題已經很久，但一直找不到答案，也沒有請教過李委員蜀平，他可能也無法回答我太深入的內容；若請問健保署或現場委員，大概也都講不出來，因為蠻多人問我，自己也講不清楚。提案資料顯示藥價差有300多億元，此金額很大，若將這些費用拿來照顧病患，會造福很多人。三、剛剛蔡委員登順提到，此議題已召開過3次會議，而李委員蜀平提到開這些會議沒用。6年開一次的全國藥品政策會議，難道沒有用嗎？我不清楚。不過健保署的意見提到，5月27日及6月15日曾邀集醫界、藥界就相關議題召開溝通會議，希望也讓委員瞭解溝通結果，能否有助釐清問題。當然這個問題與醫院的關係更為密切，本來大醫院就較具議價能力，因為買的量多，當然價格就較低。藥價差也是維繫醫院生存的方式之一，並無罪過，只是要讓民眾瞭解其作法。不要說以藥養醫，是以藥養大家。在不明瞭內幕的情況下，希望健保署有機會跟大家說明清楚，以免加深民眾對藥價差的疑慮。鄭主任委員守夏謝謝楊委員芸蘋！請蔡委員宛芬。蔡委員宛芬支持李委員蜀平的提案，藥價差問題本會已討論多次，4月份委員會議也曾請健保署專案報告。我認為各層級醫療院所的藥價差金額，對付費者代表是有意義的，將來協商總額時，可以作為參考指標；例如醫院總額800億元，其中藥價差有100億元，就可重新思考這部分的資源配置，所以我認為是有意義的。因此，支持本案，請健保署提供各層級醫療院所的藥價差，有助後續協商。至於多久提供一次，可能與藥品費用分配比率目標制有關，因為這部分後續還有安排專案報告，屆時大家可以再討論。常態性的提供時點是在每年總額協商時，或每季或與藥品費用分配比率目標制併同考量，可再討論。鄭主任委員守夏請滕委員西華。滕委員西華一、我原以為在前兩次會議，主席已裁示藥價與藥價差議題很複雜，須找機會進行專案報告，之後李委員蜀平就不須再提案，沒想到今天又再次提案，顯然上次主席的裁示，並未讓提案人滿意。不過這次的提案，健保署的說明有點文不對題，人家問橘子卻回答柳丁，答案也不是回應藥價差的議題。簡單來說，健保署的回應看來就是不想再討論的意思，我覺得這樣也不太好。二、藥價差議題的「差」字要用引號，現在藥價差有兩個議題，一個是我們講的藥價黑洞，大家不喜歡引用此名詞，但指的就是採購的價差；另一個是指被砍過的藥價很差，越來越多人討論低價藥品占健保給付的比率逐漸增加。前陣子符合PIC/S(國際醫藥品稽查協約組織)標準的藥廠出事，大家知道價格確實影響品質，好的東西不一定貴，但太便宜的東西如藥品，就需要擔心其品質問題，因原料及製程的規範，與礦泉水、餅乾的成本不同。所以不論是藥價很差，或是採購的價差，顯然都與訂價策略及採購價差的管理有關。三、二代健保對這項議題並未處理得很漂亮，雖然訂有藥品依照市場交易價格，授權保險人調整的機制，但畢竟行政裁量空間還是很大，有些問題仍無法解決。第二部分，是藥品定型化契約規定須將折讓、餽贈等一併納入價格中考量，顯然也沒有發揮很好的機制，所以才用原本的藥價調查做為藥價主要的調整機制。我認為健保署的調查很難無中生有，所以，若無劣幣驅逐良幣，以及真的有廠商用很大的價差賣給醫療院所，健保署當然可以理直氣壯地說，市場上確有其事且經查獲，因此須調整藥價。這是結構性問題，並非只有定價問題，所以上次會議，主席才會裁示，應從整體來看，而非單一議題。四、李委員蜀平的提案，提出兩點建議。誠如謝委員天仁及蔡委員宛芬所言，公開藥價差可能對社會有意義，但意義是什麼？怎麼使用這份資料？藥價差是否要合法化？其次是「藥價很差」這件事如何合理化？這兩件事很重要。價差可能無法杜絕，正如無法杜絕自費一樣，但要如何管理價差？我們可以同意在採購過程，為反映行政管理費用，有多少價差是無法杜絕的？如果此點無法討論，則公布後，就會有干委員文男所提如何解讀的關鍵問題。否則社會大眾會誤認為價差很大，還有砍價空間，結果藥價就會更差，但藥價差的問題還是沒解決，所以要先討論藥價差合法化與合理化的問題。五、至於公布各層級醫療院所的藥價差部分，部立醫院的採購標案中，甚至就寫明要提供多少價差，這也是很荒謬的事情，衛福部也要改進，自己帶領爭取價差，自然就形成風潮。健保署每年都公布APG(Ambutory Patient Group，門診病人組群)前幾大用藥品項，某些藥品價差特別偏高或偏低，可能與採購項目或病人分布有關。我們關心的整體金額變化，或某類藥品價差惡化到不得不予以正視，其實是不一樣的議題，相信李委員蜀平也同意。現在所出現要不要退出健保市場或部分藥品缺藥問題，都與此有關，所以在觀察價差金額時，藥品類別也是一項議題。我支持適度考慮公開價差金額的變化，並納入藥品類別，不知李委員的想法如何。在公布價差時，哪類藥品的價差比率最大，對我而言很有意義。決定公布什麼樣的資訊，用何種方式公布及如何解讀，對社會大眾是重要的，就和之前戴委員桂英及主委所提解讀門住診初級照護等資料一樣。鄭主任委員守夏請何委員語。何委員語一、本來要報告的內容，主委有先見之明已經講過。首先我認為藥價合理很重要，若藥價讓藥廠及供應商認為很不合理，而不願意繼續供應，這些藥品就會退出市場，或是國際藥廠不願進入台灣。在此情況下國內能生產的，就是增加許多賦形劑，我過去都說加太白粉，吃多也不傷身體，就多加一點。所以，問題出在這屬自由交易市場，有些股票上市公司為打開藥品市場及年度營業額，可以不賺錢做生意。由於只要營業額提高，股價就能維持穩定上漲，反之就下跌；因此有些股票上市藥廠的某些藥品根本不賺錢，也就低價供應醫界使用，以創造高營業額。至於有無賺錢，是未來股東會的事，這是交易市場很大的應變策略。二、就如剛才滕委員西華所言，藥價差語帶雙關，一是藥價高低差距太大，二是藥品很差，賦形劑、太白粉增加很多。藥價是塊很大的餅，很多人在搶食，為防止藥品供應背離價格，健保署應有能力分析處方藥、專利藥及特殊藥的合理價格，這點很重要；第二點就是品質的穩定性，健保署應定期檢驗，藥品成分有無不足。很多醫師都說以前吃1顆就好，現在要吃到2、3顆，就是因為藥品品質變差。三、最近看到一份資料，在美國包括婦女癌症、心臟病用藥及抗生素等藥品發生短缺。抗生素原有兩家藥廠生產，其中一家受到污染，美國FDA(食品藥物管理局)下令回收，而另一家供應不及，因此，影響很多病患權益；另外皮膚科用藥也非常短缺。不知衛福部及健保署評估結果，國內是否也會發生藥品短缺的現象？我認為對於藥品的管控，健保署要有健全的機制，但也別讓生意人越做越虧損，無法維持生存。四、前天有家最大的科學中藥廠老闆告訴我，他現在關掉藥廠就能賺很多錢，因為庫存的人參價格已經漲8倍以上，全部賣掉比這10年營運所賺的錢還多，可以不必營業了，但基於社會責任，還是要硬撐下去。他說健保支付中醫的每日藥費1天僅30元，現在原料漲價40%~50%以上，根本不敷成本。我詢問是否多加太白粉，渠回答他們是最好的科學中藥，不會這樣做，但現在1天支付30元，要如何經營？他也為醫師抱屈，有良心的醫師都要虧損貼補。很多醫師不願違背良心換藥，否則整體醫療品質一定會受影響。因此，我認為健保署應該從長規劃妥善方案，才是正確之道。鄭主任委員守夏謝謝何委員語！請葉委員宗義。葉委員宗義一、其實藥的問題就是錢的問題，有錢的地方是非就多。這些都是商業問題，我非常同情李委員蜀平及謝委員武吉，他們遇到的都是採購規模的問題。普通藥房開立連續處方箋所需藥品的進價，當然比醫院來得高，因為藥房的進貨量少，而醫院採大批採購。買兩噸藥和兩粒藥，價格當然不同，就如謝委員武吉的地區醫院，採購規模比不上醫學中心。二、我經常建議藥局及藥商，規模較小的診所及藥局，應透過公會聯合採購，以獲取與大醫院相同的價格。要解決藥價差並不容易，因牽涉到生意問題，特別是治療重大傷病的藥品，採購量不多，根本不可能降價。依我觀察，大部分藥局經營上的困難在此，建議李委員蜀平應清楚您訴求的弊端及利益，否則問題永遠無解。鄭主任委員守夏一、本案需要做些處理，否則下次李委員蜀平可能會再提案。考量本案與總額協商無關，可用計名表決方式處理，如果多數委員贊成，就公開各層級院所的藥價差；反之，則不公開。二、上次委員會議，我業以學者的立場向各位說明，藥價差的數據一旦提出，十之八九會成為新聞議題，對事情的幫助不大。但也有部分委員認為，資訊公開透明後，可能引起社會較多的關注，才能盡快改善問題，所以好處、壞處都有，建議大家不要再堅持己見。請本會幕僚準備一下，並清點在場人數後，就進行表決，讓委員為自己的主張負責。三、另外，已請健保署將「全民健保藥價政策之問題研析」併入下個月(7月)的專案報告中，今天委員所提的問題，屆時請健保署盡可能回答，如藥價調整後，藥價低至某種程度時，藥品的品質是否會變差？健保署有無定期監控？以及以後應如何處理？若委員有需要拉票或表達不同意見的再發言，否則就進行表決。請李委員蜀平。李委員蜀平一、向大家報告，今天提出本案，許多前輩及官員告訴我，要小心可能會被調查局及國稅局修理，但我堅持一定要提案，並反對用表決的方式處理。因為身為健保會委員，要知道藥價差有多少，以做為未來健保藥價政策及策略修正的參考，這樣有錯嗎？我已經冒這麼大的風險提案，就是為了對全國民眾負責，所以我重申反對表決。 二、跟蔡委員登順報告，今天之所以會有藥價調查，就是健保署有每項藥品銷售給醫院價格的完整資料，包括實際銷售價格及溢得的價格，即每家藥廠或藥商賣給醫療院所實際的交易金額，例如100元的藥品，不論賣90元或2元，都有非常明確的記載，所以健保署才會以90元及2元，來做比例公式上的藥價調整，這就是以實際價格，及健保價，所產生的藥價差，而變成藥價調整的因素。我們不是反對藥價差，而是要求合理的藥價差，不要「以藥養醫」。建議健保署應將不合理的藥價差，回歸至醫療使用，這樣可以照顧更多的醫師及其他醫事人員，希望在座委員支持本案。三、今年初辦理的全國藥品政策會議是一個不合理的會議，所有的提案都沒有充分討論就草草結束，6年才召開一次，卻連個會議紀錄都沒有給我們，而且再開會議，就不通知我，因為我會放炮。藥業九大公協會雖然有想法想提案，但到現場都不敢提，因為擔心一講出來，他們的藥價就有威脅。四、這是一個很嚴肅的問題。我已經第3次提案，如果今天還是要這麼樣呼攏我，一定不會妥協，會向調查局、監察院等單位投訴，不會這麼簡單就結束，因為我是用命來拚案子的。鄭主任委員守夏我們瞭解，也很擔心李委員蜀平的性命，如果大家不在乎，本案就不會討論這麼久。還有無委員要拉票或表達意見？請莊委員志強。莊委員志強醫院採購藥品的價錢屬自由市場競爭機制，健保署以統一價格支付，大醫院一定會要求低價買進，所以一定會有藥價差。我想請教李委員蜀平，希望健保署提供什麼資料？是各層級醫院整體的藥價差？或每項藥品的藥價差？是要整體數據，還是要每項藥品的數據。如果是個別項目的藥價差，資料量可能會很大。李委員蜀平醫療院所會向健保署申報全部的藥價銷售資料，不過我們要的只是整體藥價差數據，這樣就可以用來檢討及分析藥價政策。莊委員志強健保署說兩者相差不多。李委員蜀平不，兩者相差非常多。莊委員志強提案內容提到，不論每年健保總額有多少，藥費支出大約都占健保總額的25%。記得有次總額協商未達共識，就是因為健保署引進某項藥品，硬要醫界自行吸收，而引起醫界很大的反彈。印象中當時健保署回應，反正每年的藥費就這麼多，而且每年藥價調整後，所調降的費用，健保署並未將錢扣回來，所以醫界就應該自行吸收這筆費用，聽起來好像以喊價的方式來決定藥費。請問藥費每年都是占健保總額的25%嗎？藥費的金額是使用多少就支付多少，還是採總額支付方式，超過申請的部分，就打折，點值每點不到1元？健保署若引進新藥，應考量支付價夠不夠？而不是一昧要求醫界吸收，因為以前的藥價若未調降，就無法引進新藥。所以健保署應該詳細評估，該調降的藥價就調降，而不應該給予固定比例之藥費。鄭主任委員守夏大部分的委員都很清楚藥價、藥價差、點值保障等議題，會後請健保署或本會幕僚向莊委員志強說明。請蔡委員明忠。蔡委員明忠一、各位委員應記得一件事，即國外的罕病及癌症的新藥一直無法引進健保的原因，在於健保規定新藥必須通過「專家諮詢會議」及「藥物給付項目及支付標準共同擬訂會議」才能納入。健保署以10國之藥品中位價訂價。坦白講，我國的藥價比其他國家低，健保署已經盡最大的努力，維持藥價在合理的範圍。二、不希望本會以民粹的方式來處理藥價問題，李委員蜀平看起來好像才經過一項手術，請尊重自己的身體，不要隨便以生命做賭注。本會的發言，全國民眾都看得到，其對民眾是一種教育，用此方式處理，會讓民眾對主管6,000億元總額醫療費用的單位產生誤解，認為委員竟然以生命來威脅。未來民眾會誤以為用這種方式，就能解決問題，這種負面的結果，請大家深思。三、李委員蜀平提及「以藥養醫」以及不當吃藥造成許多腎臟病患者的說法，以醫界的立場，非常反對。過去偏鄉不當的用藥，例如王祿仔仙(台語)街頭賣藥的情形，已逐步改善中，請不要引用過去的氛圍闡述現況。健保署每年調查藥價，砍下來的錢，實質上都已運用於民眾所需的醫療服務上。我絕對不談藥價差，因為醫療院所買進藥品以後，需要庫存、保管、處理等費用，所以，這是藥價合理的管理費用。若要完全取消藥價差，建議以後藥品全部由健保署統一採購，但這是不可能的事情，因為藥品價格是屬自由市場機制。醫界也同意合理的管控藥價差，但可能要求將所有藥物的價差全部都攤開來嗎？不可能的，也做不到。此外，李委員蜀平也提到全國藥品政策會議沒有效，真的嗎？應該考量實際面如何執行的問題，醫界還很羡慕藥界有藥政會議，可是醫界的醫政會議在哪裡？鄭主任委員守夏 請謝委員武吉。謝委員武吉一、提到藥價差，還會發生「藥價逆差」，就是我們醫院買的藥比健保支付的價格還貴，這是實際發生的情形。二、不要說藥價差，應該是說藥價合理化，各層級情況不同，應思考各層級醫療院所存在哪些差異。本會委員明智且智慧高，大家應該以最佳的方式好好講，不要用激烈的語氣，相互刺激。三、藥價的評量應排除罕病及癌症用藥，才能瞭解實際用藥的合理性。四、我反對投票，記得曾經有一次，某位委員提出反對意見，結果他所屬的醫院層級，被某單位修理得很慘，過去曾有這種公報私仇的情形。因此，在此沈重呼籲，大家應以理性的方式，來處理今天所要面對的事情，絕對不能用投票的方式處理。鄭主任委員守夏李委員蜀平建議不要投票，就公開；但有委員說不要投票，也不要公開，本案真的很難處理。再聽聽其他委員的意見，請謝委員天仁。謝委員天仁一、健保會主要的兩項任務，一是總額協商，另一是監理健保業務，有些資訊沒有公開，不知在座的委員如何監理？怎麼去談總額？在暗室裡抓黑貓，不知道應該怎麼抓。我要講的是，這些功夫面的問題，可以透過技術面來處理，相關資訊可以讓大家瞭解，今年度的藥價差有多少？明年度藥價差又有多少？有無超過大家認為不合理的增長狀況，這是我們應該做的，如果健保會委員都無視這些事情，隨便談，怎麼對全民交待？二、在民主法治社會，除非是涉及秘密的事項，否則原則上都應該公開，就如同健保會的發言實錄，都該公開讓外界審閱。我們監理別人，也應該讓別人監理我們，今天我們只是代表付費者看管相關醫療資源，若沒有資料，請問要如何看管？三、各位委員不需要害怕表決，所謂的表決事項，就是大家將各自的想法公布給所有的老百姓知道，看看付費者委員是否盡到責任、醫界委員是否代表醫界看管相關事項。表決通過與否並不是重點，重點是每個人都要對外負責。本案就該訴諸表決，讓資訊公開，讓外界看看每位委員是否都盡到本分。如果不公開，外界都不清楚狀況，也無從瞭解這些代表如何行使權力。我們每個人都要受到監理。支持主席的提議，唱名逐一表決，資訊公開沒什麼大不了，請問公開後，會有國安問題嗎？我們並未要求公開個別醫院的交易金額。關於主席擔心公開資料後，可能有人會提及「藥價黑洞」如何等，我想這種事情講久了就沒人要聽。應該更深入地分析相關資料才對，資料只要合理，每個人都要面對，再次強調，支持主席所提的唱名表決。鄭主任委員守夏請何委員語。何委員語一、深刻了解李委員蜀平承受藥界九大公協會的壓力，甚至晚上都睡不著覺，心理的煎熬勝過身體的疼痛，所以若是壓力大到受不了，請務必打電話給我，由我來陪您，並提供協助。二、我想這種事情太過敏感、激烈，因此提出付委動議，由李委員蜀平出面，邀請醫學中心、區域醫院、地區醫院代表各1名，加上勞工代表1名、資方代表1名、付費者代表(不含勞工)1名，及專家學者與公正人士代表1名，組成專案小組，與健保署討論，研究出合情、合理且被社會大眾接受的公開方案。若專案小組所提方案太超過，對醫界的衝擊太大，社會大眾不見得喜歡，相信委員也不會接受。若公開的內容不痛不癢，李委員蜀平可能會因為背後承擔的壓力，不得不每個月提案。建議成立專案小組研議，並於下次會議提報。鄭主任委員守夏建議先休息5分鐘，請何委員語、謝委員天仁、李委員蜀平及楊委員漢湶4位先溝通，看看我們下一步可以怎麼辦？剛剛幕僚提醒，只要有委員提議表決，主席也同意表決，就可以表決，並非委員不同意表決，我們就不可以表決。李委員蜀平那多數暴力要如何解釋？鄭主任委員守夏這裡是健保會，本案非屬總額協商議題，且也不是付費者與醫界代表的意見不同…。李委員蜀平本案屬健保的監理業務，我只是想要知道一個數據，有必要動用表決嗎？鄭主任委員守夏休息5分鐘。(休息5分鐘)鄭主任委員守夏剛剛幕僚提醒，目前有兩個動議，處理的優先順序不大一樣，何委員語所提的付委動議優於表決動議，所以應該先討論何委員語的動議。請問各位委員，是否同意請各方各推派1位代表，組成專案小組與健保署討論，以決定是否同意公開藥價差；若公開，則適合或不適合的項目各為何。付委動議也需要大家同意，故我們先不進行表決，先處理付委動議。請問何委員語的付委動議，是否有委員附議？(有委員口呼附議)干委員文男提出付委動議之修正建議，我一直在思考，今天如果表決，是否通過是一回事，但知道相關數據會讓我們承受更大的壓力，走到哪裡都會被問藥價黑洞的問題，我們也受不了。若醫院屬正當經營，對醫院經營者也是很大的壓力。我的修正建議是請李委員蜀平自己去健保署看相關資料就好，而不要對外公布數據。若大家同意讓李委員蜀平去看健保署的相關資料，如果可以就不需要動用表決，也不需要勞師動眾成立專案小組，這是我的修正動議。李委員蜀平我們是要解決問題，而且以我的職位，有知道這件事的權利與義務，如果不公開相關數據，如何讓外界瞭解。我們並不是要將這些金額浪費，而是促使藥價差合理，不合理的部分，就回歸醫療，給醫師及其他醫事人員。我要的是解決問題，不要讓惡性循環持續下去，拜託付費者代表，請支持公開相關數據，讓所有不合理的金額全部回歸正常醫療。鄭主任委員守夏剛剛已經有委員提出附議，委員如果對付委動議沒有特別的問題…。蔡委員宛芬我要對付委動議提問，請問付委動議的內容是原則公開藥價差資料，至於公開哪些內容再進一步討論，還是先討論可公開的內容？再決定是否公開藥價差資料？鄭主任委員守夏一、付委動議包括是否對外公開，以及公開的內容，並非本會已經決議要對外公開。二、付委動議是組成專案小組，先討論是否對外公開，及對外公開的內容，等有較明確的共識後，下個月再討論，屆時若還是需要表決，下個月則進行表決，若有共識，就不需要表決。何委員語有建議專案小組名單，但為公平起見，請幕僚以書面詢問委員意願，請願意幫忙的委員簽名，否則不曉得該請哪位委員協助。請問是否同意此動議？何委員語再補充說明，剛剛提到的是請醫學中心、區域醫院、地區醫院代表各1位，勞工代表1位、資方代表1位、專家學者與公正人士代表1位、還有付費者代表(不含勞工)1位，總共7位。這7位…。蔡委員明忠何委員語，請問西醫基層怎麼沒有代表？何委員語我以為地區醫院是基層代表(其他委員回答：不是)，我一直認為西醫基層屬於地區醫院，那就西醫基層代表也1位。鄭主任委員守夏請陳委員聽安。陳委員聽安一、關於何委員語提出籌組專案小組，內部先凝聚共識的建議，我並不贊成，理由很簡單，因為最後還是要提到委員會議討論，問題還是一樣，結果也會一樣，白費力氣。二、我非常欽佩李委員蜀平為了藥界的利益鍥而不捨。李委員蜀平不是藥界的利益，而是全民健康的利益…。陳委員聽安李委員蜀平這麼說，我也同意，假如本案不是由藥界提出要求公開醫學中心、區域醫院、地區醫院、基層診所、藥局等藥價差資料，相信會較為可行，因為有利益衝突的問題。您提案要求公布別人的資料，雖然講得義正辭嚴，我也同意是為了全民健保全體保險對象的利益，但您的立場與提案人的身份恐怕會有牴觸，令人懷疑您提案是否有其他用意存在。在自由市場的競爭機制下，健保署一而再、再而三表示公布資料有困難，在此情況下，我覺得組成專案小組的方式，可能也無法解決問題。我很同情主席不得不動用表決，我也不贊成採用表決，相信對主席而言，也是很為難。因您每次提案，我們都要花很多時間討論，但都沒有結果，主席不得已只好動用表決，可是表決也得不到大家的認同，本案恐怕很難解決。我不贊成組成專案小組的方式，然後再將結論提至委員會議，因為預期結果還是一樣。鄭主任委員守夏請蔡委員宛芬。蔡委員宛芬我覺得本案應該分兩個討論層次，對於是否公開，以及公開資料被外界解讀的問題，應該有兩種處理原則。如同剛剛謝委員天仁所提，應以資訊公開為大原則，若此原則成立，那就應該公開。第二個問題是如何公開，才不會造成傷害或誤解，我們應該先討論。如果李委員蜀平的提案內容會造成外界誤解，則應該考量須增加哪些項目來使資料更完整，以達到資訊既可公開又不會造成外界誤解的目的。所以建議分為兩個層次討論，首先討論公開與否；其次討論是否組成專案小組，以及討論公開哪些內容，既可公開外界期望看到的資料，又不致產生誤解或誤用的情況。鄭主任委員守夏謝謝蔡委員宛芬，現在又回到原來的問題，我們到底要不要公開，李委員蜀平的提案是要公開，但有委員認為不應公開。我贊成蔡委員宛芬所言，先討論要不要公開，再討論如何公開以及公開哪些資料。但何委員語的意見也很有道理，先組成專案小組討論，也許屆時的共識是極大限度的資料公開，所以是否公開也可以由付委的專案小組先談，再回到委員會議議決。多花一個月的時間，請幾位委員思考此問題的好處、壞處，並請健保署提供意見，說明相關數據所代表的意義，而非先同意公開，應也可是個選項。請問大家的意見是先組專案小組討論，還是與陳委員聽安相同，認為組專案小組無濟於事。請滕委員西華。滕委員西華請教一下，剛剛主席的意見與何委員語所提付委動議，及主席針對李委員蜀平之前提案所做的決議：「藥價調整、藥價差、藥品費用支出目標制等，屬『全民健保藥價政策』中環環相扣之議題，無法個別處理，必須在整體且全面性思維下合併考量」，這些議題有何差異？本會前已安排健保署於7月份委員會議進行「『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」專案報告，並請署併同提出「擬具全民健保藥價政策之問題研析」，及於年底前研提短、中、長程之改善方案，包括對策、規劃時程及預期效益等送會。請問這些事項有何差異？何委員語若今天最後仍採表決方式，結果不論是公開或不公開，都沒有必要再成立小組討論。建議委員會議先不決定是否公開，交由專案小組討論是否公開，以及公開到哪個程度，或不公開的理由，提下次委員會議確認。最重要的一點是，李委員蜀平提出的議案內容，付費者代表無法瞭解實際的架構。若能在專案小組呈現實際的內容與架構，並做最後判斷，應較為合理。至於很多委員所提的建議事項，均可供專案小組參考。鄭主任委員守夏謝謝何委員語！請蔡委員明忠。蔡委員明忠贊成滕委員西華的說法，本案先保留，也許等下個月李委員蜀平聽過健保署專案報告後，滿心喜悅接受了！若屆時李委員還不滿意，我們再討論後續如何處理。鄭主任委員守夏請李委員蜀平。李委員蜀平一、請容我再解釋，去年的雲端藥歷就節省50幾億元，民眾只要重複每日看診5家醫院，早、中、晚連續服用1個月五家醫院開的prednisolone(類固醇)就可能會面臨洗腎危機，我不是說吃這種藥品會洗腎，而是有的洗腎患者確實是因吃這個藥品造成的。二、有關藥價差問題，請付費者代表挑選有空的時間，由我向大家說明，並請不同的廠商代表來向各位報告。今天是要解決問題，而不是製造問題，我擔任健保會委員，有監督、瞭解、解決問題的職責，萬一所有的付費者代表發覺數據差異很大時，也可以選擇不公開但要處理此藥價差問題。藥價差是一個非常可怕且具毀滅性的惡性循環，包括製藥工業、醫師都可能受害，民眾也因浪費健保資源，而改變價值觀。健保總額有5,000多億元，藥費就約1,600億元，其中藥價差有多少？占總額多少百分比？健保署絕對有相關資料，實際採購價與健保支付價等資料都有，希望我們能共同解決問題，達到用藥安全的目的。鄭主任委員守夏請莊委員志強。莊委員志強贊成何委員語所提組成專案小組討論後，再決定是否公開。藥價差若確如李委員蜀平所述之300億元，並且公布要把多出來的錢回歸還給醫師，那往後可否以總額的20%做為藥費？另外，後續之藥價調查，若發現藥價差還是300億元時，該如何處理？鄭主任委員守夏本案就延至下次委員會議再討論，並依何委員語建議，組成專案小組，人數不要太多，請同仁先徵詢委員參加意願。我再重複何委員語的建議，醫學中心、區域醫院、地區醫院、西醫基層代表各1位，李委員蜀平是提案委員當然納入，再加上勞工代表1位、資方代表1位、專家學者與公正人士代表1位、還有付費者代表(不含勞工及雇主)1位，總共9位。請幕僚協助開會相關事宜，並請健保署相關同仁一起參與討論，結果再提至下次委員會議。蔡委員明忠容我再講一句話，就醫療專業對用藥一個月就會洗腎的說法，提出抗議，絕不能這樣講，會嚴重誤導民眾。滕委員西華主席，能否告訴我們名單。鄭主任委員守夏目前還在蒐集中，我們盡量在散會之前宣布。現在進行討論事項第五案，請同仁宣讀。 柒、討論事項第五案「敬請將健保署已執行第六年之高診次者藥事居家照護計畫改列為一般性常態服務案」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，請提案人李委員蜀平說明。李委員蜀平主席、各位委員，請原諒我浪費各位這麼多時間，藥事居家照護計畫從99年開始，已經執行6年，我們有一份資料提供大家參考，其呈現試辦成果。本案主要建議因應未來高齡化社會，針對高診次病人做面對面的藥事照護，讓藥師提供最好的專業服務，本案非常有意義，也可避免藥品浪費，又可增加病人、醫師與藥師互相溝通的機會。健保署的補充說明，讓我感覺，對藥師似乎沒有善意，因為所提出的數據有問題。本計畫光藥師公會全聯會人事與訓練就花費千萬元以上，還不包括健保署的費用。藥師照護不論是未來的長照及高齡化社會都是很重要的議題，因為要與醫師、病人做非常好的溝通，讓用藥達到最高效益，且珍惜健保的藥費資源，而且本計畫都有設定指標，並沒有浪費錢，請問主席，能否由譚執行長延輝補充報告？鄭主任委員守夏委員有意見時，再請譚執行長延輝說明，今天的議事已經落後很多，現在已經下午1點半，後面還有2項臨時動議、3項專案報告，不曉得委員願意開會到何時。謝委員天仁提出程序問題，本案涉及總額協商，程序上應該依照協商的流程處理，若當成一般議案，表決通過後就執行，會很奇怪，因衛福部公告的事項，只要健保會決議通過，就全部翻盤，不太合理，應該依照本會的相關規範執行。本案程序不符，請李委員蜀平依照相關規範再行提案，本案無法這樣討論。李委員蜀平尊重！鄭主任委員守夏若是如此，本案最好的提出時點可能是7月份的評核會，若能在該會說服委員…。李委員蜀平我會準備資料。鄭主任委員守夏在此鼓勵委員盡可能參加評核會。李委員蜀平本案只須幾分鐘的時間討論，希望能將功贖罪。何委員語我認為不應該在評核會決定，應該是交由總額協商會議決議才對，屆時要看醫事服務提供者及付費者代表是否同意；要列入專案計畫還是一般服務，應於總額協商時決議才對。鄭主任委員守夏一、我是說在評核會時好好報告，說服付費者代表。另8月份委員會議是召開一整天，當天下午是總額協商座談(預備)會，看總額部門代表與健保署提出何種方案，或修改原來的方案內容，以及需請健保署提供哪些資料等，相關議題都會討論，請委員預留時間與會。本案依協商流程進行。二、接下來還有個臨時提案，醫界代表原來提出的臨時提案取消，再重新掣案。有委員建議先處理臨時提案，之後再進行專案報告。委員是否都已拿到臨時提案的資料，請領銜的提案人楊委員漢湶補充說明。捌、臨時提案「有關『105年度總額協商通則案』」與會人員發言實錄楊委員漢湶主席、各位委員，本臨時提案是針對上次委員會議討論事項第二案「105年度總額協商通則案之決議」而提，提案目的不是討論散會動議是否成立，而是討論實質內容，因協商通則屬總額協商的範疇，依法總額協商必須在雙方對等的情況下進行，不能採表決的方式處理。有關上次委員會議所通過的總額協商通則案，針對會議資料第5頁討論過程說明一之(一)~(三)項有疑義，因此提出修正意見。何委員語主席，程序問題！因為大家收到兩個臨時提案，既然臨時提案交到委員手上，若要撤案，就應正式提出撤案動議，說明要撤銷哪一案，而且會議程序規定，該案連署人只要有一位不同意，就不可以撤案，其中有個臨時提案已取得9位委員連署，應先徵求這9位連署人是否同意撤案，請主席點名確定後，再繼續進行討論。鄭主任委員守夏目前有兩個臨時提案，我不清楚可否由主席決定哪一案先處理，此部分是否有明確規範？先說明這兩個臨時提案都是由醫界代表提出，而現在有委員認為撤案必須要正式提出撤案動議，可是以前並未如此嚴格規範。楊委員漢湶完全尊重其他委員所提的程序問題，現在討論的是有9位委員連署的臨時提案是否要正式提出撤案動議。蔡委員明忠9位委員連署的臨時提案，剛剛與柯執行秘書桂女討論過，已經撤銷該案，若何委員語希望能點名確定，在此將程序補齊。我再唸一遍，本人連同黃委員啟嘉、何委員永成、謝委員武吉、潘委員延健、張委員煥禎、楊委員漢湶、羅委員紀琼及陳委員義聰等9位委員都同意撤銷該案，在此向何委員語報告，也向主席做此陳述。鄭主任委員守夏現在只剩一個臨時提案，剛剛楊委員漢湶已補充說明，對於上次會議所通過的總額協商通則案，醫界代表認為其中3項內容未有共識，所以提出修正意見，如提案之說明三。何委員語 一、臨時提案內容為上次會議已決議無異議通過的議案，雖然上次會議只有33位委員出席，但不必全部到齊才能開會，只要二分之一以上委員出席就能開會，在表決時，有要求清點人數並記名表決，經清點現場委員人數有26位，已超過法定開會人數，所以該次討論的決議是有效力的。二、散會動議的表決結束後，代理主席有口頭說明散會動議未通過應繼續開會，贊成散會委員並未提出異議，表示接受代理主席的裁示。此外，代理主席並未違反內政部公布的會議規範，雖然該會議規範是採多數決為原則，但代理主席可以決定表決是採多數決或過半數決，因此在散會動議進入表決前，我有舉手要求過半數表決，代理主席也接受，所以並未違反議事程序，完全合法、合情、合理，可以調錄音檔來聽。既然代理主席接受我的過半數表決，不同意的人也沒有當場提出異議或反對，表示所有出席的委員同意過半數決，即便到法院，法官也會這樣裁定，所以本案不構成臨時提案，法律專家在場，也可請教謝委員天仁。謝委員天仁主席，程序問題！鄭主任委員守夏請謝委員天仁。謝委員天仁總額協商通則案於上次委員會議已有決議，醫事服務提供者代表又重新提案，依本會會議規範，本提案符合復議動議，請提案人依據復議動議的規定，如未依復議動議的規定提案，就沒有討論空間。滕委員西華我與謝委員天仁的想法一致，再次與提案人確認提案內容，因提案說明一就推翻剛才已確認的上次委員會議紀錄，這是不對的。說明的理由可以表示上次決議事項有所不足或需補充修訂，然後再提出復議動議，而不是討論未達共識，前次會議應散會未散會而做成決議。我們上午花這麼多時間確認上次會議紀錄，沒有應散會而未散會的前提，要提案前應先確認這個前提，其未符會議開始主席所確認的上次委員會議紀錄，所以本臨時提案與上次委員會議紀錄有衝突。鄭主任委員守夏委員有無意見？請潘委員延健。潘委員延健針對本提案提出兩點聲明，第一點，今天早上僅確認對上次委員會議紀錄的文字有無意見，會議紀錄是記載上次會議的過程，所以是尊重上次會議過程的紀錄，至於應散會而未散會所產生的決議，應請衛福部法規會釋疑；第二點，上次會議討論事項第二案總額協商通則的決議，是在表決散會動議後所獲致，協商通則是總額協商的相關事項，依本會會議規範應該採協商方式為之，所以認為該案討論過程說明一之(一)~(三)項，係應散會而未散會所獲致的決議內容，所以值得商榷，建議應該回歸會議規範採協商方式來處理。鄭主任委員守夏委員還有無意見？請蔡委員明忠。蔡委員明忠上次委員會議議事錄第72頁，何委員語曾發言表示：「我認為應該進入表決，表決結果誰輸誰贏還不知道，表決就是採民主機制、公平公正的方式，所以認為應該進行表決。在此徵求委員意見，提議本案全部通過，同意通過的請舉手。」我並未看到表決要過半數的發言。謝委員天仁主席，請先處理程序問題，不應該再做其他發言，若確定為復議動議，請符合相關規定，若不符合規定就不需要再討論，怎會一直開放發言呢？那我提程序問題做什麼！鄭主任委員守夏好，先看臨時提案的案由，是希望改變上次會議討論事項第二案的決議，性質上需要提復議動議。討論相關議題時，我認為委員會議應該以和諧為重，不要用程序問題或依法論法來處理。以主席立場，本提案很明確是要修改、變更、或推翻上次委員會議的決議，所以應該提復議動議，請依復議動議的相關程序規定辦理。提出復議動議的條件是，原來贊成的委員改變其立場，並提出復議動議，也就是原案議決為同意者，發現新事證或當初有誤會，覺得原來的決議有不盡合適之處，因此改變立場為反對，現在無法以臨時動議來進行討論。對這樣的決議委員有無意見，請何委員語。何委員語尊重主席的裁決，最後補充一點，在上次會議中，代理主席並未宣布散會，委員可以離席。所以離開的舉動很明確是表示放棄開會的權利及義務，都未跟代理主席報告就先離開，也沒有委員在徵求代理主席同意後才離開。請問那天有哪位委員去跟代理主席說要先離開？(蔡委員明忠舉手表示有跟代理主席說明)，接下來主席宣布繼續開會，您未留在現場，就是自己放棄開會的責任與義務。我認為過程很明確，只有一位委員徵求主席同意後才離開，但留在現場開會的委員還是超過出席委員的半數。後來沒有再清點人數，所以繼續開會是有效的。鄭主任委員守夏本臨時提案就不再討論。 蔡委員明忠最後只講一句，我們絕對尊重主席剛剛所提關於總額協商，雙方以對等原則協議訂定，這等於是國家的憲法一樣，尊重這樣的機制。至於單次會議的討論過程，只是枝微細節，這些都不可以違背上述憲法。鄭主任委員守夏我想醫界代表的立場非常明確，本臨時提案就這樣處理。接下來還有3個專案報告，請時間許可的委員盡量留下來。請健保署進行專案報告第一案。玖、專案報告第一案「健保代位求償執行情形與成效報告」與會人員發言實錄健保署李視察瑞蘭報告鄭主任委員守夏謝謝健保署的報告，請問委員有無請教？請謝委員武吉。謝委員武吉我國文程度不好，請問公害及公共安全定義為何？先讓我們清楚定義。鄭主任委員守夏等一下請健保署同仁一併回答，委員還有無詢問或請教？請吳委員肖琪。吳委員肖琪建議投影片寫清楚，依本報告，法令依據是健保法第95條，請問第94條職災是否也屬於代位求償。如果健保法第94條也屬於代位求償，則今天只報告第95條代位求償部分，並未包括所有的代位求償。鄭主任委員守夏委員還有無請教？若沒有，請健保署洪組長清榮說明。洪組長清榮一、公害係指因人為因素，破壞生存環境，致對國民健康所造成之危害。其範圍包括水污染、空氣污染、土壤污染、噪音、振動、惡臭、廢棄物、毒性物質污染、地盤下陷、輻射公害及其他經中央主管機關指定公告為公害者。二、公共安全事故係指依法規應強制投保責任保險之場所或行業發生之該責任保險事故，如捷運車站、電影院等公共使用的場所。三、目前職災是由勞保局請健保署代辦職災之醫療給付服務，該醫療費用由勞保局給付，所以未列入代位求償。鄭主任委員守夏謝謝健保署同仁的說明，委員還有無請教？謝委員武吉請問如果是屬於CDC(衛福部疾管署)應該負責任的公害，是否算在公害案件中？鄭主任委員守夏待會請健保署同仁一併說明。請滕委員西華。滕委員西華有關簡報第5頁，公共安全事故中代位求償未獲償案件的台北捷運江子翠傷害案件，建議健保署再思考，哪有刑案在做代位求償的。出發點很好，當事人殺、傷那麼多人，讓健保花這麼多錢。但代位求償的概念應該不是這樣，這種刑案或意外災害應該不符合代位求償的概念。記得以前監理會時期，謝委員武吉所提大胃王比賽案，還更符合代位求償要件，因為這種事可事先知道可能的後果及預先投保。我認為氣爆事件還有道理符合公共安全，但刑案要代位求償是否過於牽強，還是我有所誤會，請健保署說明為何刑案會納入代位求償。鄭主任委員守夏謝謝滕委員西華，委員還有無詢問？(未有委員提出)請洪組長清榮說明。洪組長清榮一、有關謝委員武吉詢問的部分，現在健保署處理的代位求償案件，一定是經過主管機關認定的公害案件，健保署才會進行代位求償。二、有關台北捷運江子翠傷害案件，依照規定，捷運公司需要投保公共意外責任保險，所以我們認為其屬公共安全事故，目前本案正在訴訟中。滕委員西華是因為台北捷運局投保公共意外責任保險嗎？洪組長清榮對！鄭主任委員守夏請謝委員天仁。謝委員天仁請問如果發生在國外呢？比如旅行團在國外搭乘飛機或船，發生事故，有代位求償的問題嗎？鄭主任委員守夏可以回答嗎？洪組長清榮目前發生在國內，比如復興航空空難事件，我們都有代位求償。國外則比較困難，之前遠東航空公司在韓國濟州島失事案件，因為屬本國籍航空公司，本署進行代位求償並已獲償。若為外國籍航空公司，目前還沒有這樣的案例。謝委員天仁不論是本國籍或外國籍航空公司的飛機，法規都要求須有強制保險。若一樣飛到日本名古屋，華航空難可以代位求償，全日空空難則無法代位求償，這邏輯不通。若都送到台灣的醫療體系治療，地位上應該一樣，代位求償應該要有一致的標準，不能遇到外國籍航空公司就不管。鄭主任委員守夏這部分請健保署研議可行性。請干委員文男。干委員文男會議資料第43頁，104年2月16日衛生福利部與健保署拜會金管會交換意見後，雙方已達成「持續檢討現行作業模式」之初步共識，所達成共識為何？請詳細說明，將來強制汽車責任保險的部分，能否完全恢復以前模式？洪組長清榮現在有關強制汽車責任保險部分，後續是由金管會、產險公會、衛福部與本署共同討論。由於以往強制汽車責任保險法的精神著重於需有因果關係，因此去年與前年才被質疑，一個車禍受害者，連傷風感冒的醫療費用都要代位求償，所以現在被要求限於汽車事故造成的疾病才可求償，目前的共識就是與車禍具相當因果關係之3184項疾病代碼才行，也就是車禍患者不是所有的疾病都可代位求償。鄭主任委員守夏本案就進行到此。徵求各位委員的意見，目前已經超過下午2點，會議已經開了4個半小時，是否還要再進行下一個報告案，或可以延至下一次會議？干委員文男繼續開會啦！鄭主任委員守夏我們就再進行報告事項第二案，請健保署報告。拾、專案報告第二案「各部門總額需保障或鼓勵服務，採點值保障方式之合宜性探討及改善方案報告」與會人員發言實錄健保署李副組長純馥報告鄭主任委員守夏謝謝李副組長純馥的報告，請問委員有無詢問？請蔡委員登順。蔡委員登順中醫藥品調劑費這部分是採浮動點值計算，請問目前藥費是採固定點值或浮動點值計算？李副組長純馥藥費都是採固定點值計算。蔡委員登順本案資料並未呈現藥費部分。李副組長純馥因為藥費是法定保障點值的項目，所以未在此呈現。謝委員天仁因為藥費是法律規定保障點值每點1元，會議資料第48頁呈現的是採保障點值。蔡委員登順目前中醫藥品調劑費要採浮動點值計算，請問中醫有無聘中藥師及支付調劑費？何委員永成有支付調劑費。藥師每次調劑23點，醫師調劑13點。鄭主任委員守夏委員還有無請教？吳委員肖琪醫師的診察費並未保障每點1元，為何要保障醫院的藥事服務費每點1元？ 李副組長純馥討論點值保障項目當時，大家在法律解讀上，認為藥費與藥事服務費有關聯，因而有保障藥事服務費點值的共識。謝委員天仁所提沒錯，法律並未明訂保障藥事服務費點值，目前僅剩醫院總額部門仍採保障點值的方式，其餘總額部門，包含西醫基層等部門，皆已改採浮動點值。謝委員天仁一、現行各總額部門點值保障的項目，已寫滿1頁(會議資料第48頁)，再繼續發展下去，恐怕1頁也寫不完。我想表達的重點是，有些點值保障項目應回歸支付標準處理，即從基本結構面調整，不要有那麼多違章建築，像現在那麼多保障項目，大家忽然驚覺為何藥事服務費也要被保障，我想這在回應上也會很吃力。二、建議支付標準應盡量朝合理化修正，該調整就調整，保障項目不要多到寫滿1頁，最好只有兩三行，即必需保障點值的項目，只有少數幾項，不要例外的項目那麼多，例外都快變成原則了，這不符合正常架構。三、建議逐步探討支付標準的合理性，該調高就調高，逐漸將點值保障的項目取消。目前的做法是便宜行事，到最後會越來越奇怪，例如連地區醫院也提出要保障點值。希望日後有機會能逐步將支付標準的結構導正。鄭主任委員守夏一、謝委員天仁所提回歸制度面(支付標準)處理是很明確的建議，特例的點值保障項目應減少，是正確的方向；如果因支付標準不合理而採點值保障，則應調整支付標準。請健保署檢討現行的點值保障項目，有那些項目可以不要再保障，就回歸支付標準處理。記得謝委員武吉曾提出地區醫院保障項目的費用點數占率，較其他層級低，表示這是不公平的現象。請同仁追蹤何時可以安排相關報告案。本案進行到此。二、補充說明討論事項第四案，何委員語所提「付委」動議，因我們不是立法院，並不適用，而是成立專案小組討論。向委員宣布剛剛徵詢委員意見的結果，西醫基層代表為蔡委員明忠，必要時黃委員啟嘉陪同；醫院部門為謝委員武吉、張委員煥禎、潘委員延健；藥界為李委員蜀平；付費者代表，提議組專案小組的雇主代表何委員語是當然人選。因大家都很客氣，付費者代表公推謝委員天仁，若謝委員天仁不反對，就拜託他擔任代表。謝委員天仁沒有公推，並未有任何書面文字。鄭主任委員守夏好，是口頭上推薦謝委員天仁。滕委員西華我們沒有公推，尊重謝委員天仁個人的意願，我們自己不做，也不能勉強他人。鄭主任委員守夏由主席拜託謝委員天仁代表付費者委員；專家學者的部分也沒有公推，他們希望戴委員桂英能代表參加。以主席的立場，拜託戴委員桂英參加。至於後續…。干委員文男付費者代表，建議再增加蔡委員登順。鄭主任委員守夏如果蔡委員登順願意，我們很歡迎。後續請幕僚同仁徵詢上述幾位委員的時間，再做安排。有人已開始在收東西了，建議專案報告第三案延到下次委員會議。何委員語主席，建議付費者代表再增加滕委員西華。鄭主任委員守夏因之前有請委員表達意願…。干委員文男剩下最後一個報告案，建議會議繼續進行，讓今天所有的議案都可以討論完成。鄭主任委員守夏我們非常不希望開會時間超過4個小時，之前的默契是開會到下午1點30分已經夠長了。後續應討論，會議最晚的結束時間，例如不要超過2點或2點30分，以利委員安排下午的行程。剛剛已先提醒委員預留時間，8月份的委員會議是全天，9月份的協商會議則需過夜。今天已經討論夠久了，下一個專案報告並無急迫性，延至下次委員會議報告。謝謝大家！今天會議到此結束，散會！PAGE 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