衛生福利部全民健康保險會第2屆104年第9次委員會議議事錄中華民國104年10月23日衛生福利部全民健康保險會第2屆104年第9次委員會議紀錄壹、時間：中華民國104年10月23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 國家發展委員會謝專門委員佳宜(代)林委員敏華侯委員彩鳳 中華民國勞工聯盟總會陳副理事長美靜(代)張委員文龍 張委員煥禎 壢新醫院院長室劉特別助理碧珠(代)張委員 賜黃委員啟嘉中華民國醫師公會全國聯合會張常務理事嘉訓(代)陳委員幸敏陳委員健民陳委員義聰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 中華民國醫師公會全國聯合會李理事紹誠(10：50以後代) 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、列席人員：本部社會保險司陳專門委員淑華中央健康保險署黃署長三桂(蔡副署長淑鈴代) 龐組長一鳴 王組長沬玉 陳研究員尚斌本會柯執行秘書桂女張組長友珊范組長裕春魏組長璽倫伍、主席：鄭主任委員守夏(13點55分後由吳委員肖琪代理) 紀錄：陳燕鈴、劉于鳳陸、主席致詞(略)柒、議程確認決定：考量臨時報告案「利息、股利、租金及執行業務收入補充保險費扣費標準提高到2萬元」、臨時提案第一案「健保會雇主代表委員聯合各工商團體要求衛生福利部依法將105年度健保費率調降為4.41%」、臨時提案第二案「為維持全民健康保險財務穩定與永續發展，支持全民健康保險105年度費率維持現行4.91%」，為當前社會各界關注且對全民健保財務影響甚鉅之議案，爰依委員建議，在例行報告第四案之後併案討論該三案，餘照議程之安排進行。捌、例行報告第一案案由：確認本會上(第8)次委員會議紀錄，請鑒察。決定：確定。第二案案由：本會上(第8)次委員會議決議(定)事項辦理情形及重要業務報告，請鑒察。決定：洽悉。第三案案由：105年度全民健康保險醫療給付費用總額成長率報告案，請鑒察。決定：本會所協議訂定之「105年度全民健康保險醫療給付費用總額及其分配方式」案，於衛生福利部核定與決定後，辦理公告事宜。第四案案由：中央健康保險署「104年9月份全民健康保險業務執行報告」，請鑒察。決定：委員所提相關建議，請中央健康保險署參酌，餘洽悉。玖、討論事項第一案提案單位：本會第三組案由：105年度牙醫門診總額一般服務之地區預算分配案，提請討論。決議：一、一般服務(不含品質保證保留款)地區預算分配方式：(一)地區範圍：以中央健康保險署六分區業務組所轄範圍區分為六個地區。(二)分配方式：預算100%依各地區校正人口風險後保險對象人數分配。(三)所涉執行面及計算等相關細節，授權中央健康保險署會同牙醫門診總額相關團體議定之。二、需保障或鼓勵之醫療服務，以回歸支付標準處理為原則，如仍有部分服務需採點值保障，由中央健康保險署會同牙醫門診總額相關團體議定之，並於104年12月底前送經本會同意後執行。三、同意牙醫門診總額自一般服務費用移撥4.253億元用於下列項目，經費若有剩餘，則回歸一般服務費用。(一)「醫療資源缺乏地區改善方案之論量計酬費用」、「全民健康保險牙醫門診總額醫療資源不足且點值低地區獎勵方案」與「投保人口就醫率全國最高二區之保障款」等3項，因涉及執行面及計算等相關細節，授權中央健康保險署會同牙醫門診總額相關團體議定之。(二)「牙周病統合性治療第三階段給付費用」、「七所口腔醫學院或牙醫學系之附設教學醫院點值保障」等2項，因涉及點值保障項目，請中央健康保險署會同牙醫門診總額相關團體議定後，於104年12月底前送本會同意後執行。第二案提案單位：本會第三組案由：105年度中醫門診總額一般服務之地區預算分配案，提請討論。決議：為促進各地區醫療資源均衡發展及有利討論，請中央健康保險署協助試算提高人口占率(R值)百分比及其對各分區點值之影響，本案保留至下次委員會議續議。第三案提案單位：本會第三組案由：105年度西醫基層總額一般服務之地區預算分配案，提請討論。決議：考量西醫基層部門尚須召開內部會議以取得共識，本案保留至下次委員會議續議。第四案提案單位：本會第三組案由：105年度醫院總額一般服務之地區預算分配案，提請討論。決議：一、一般服務(不含品質保證保留款)地區預算分配方式：(一)地區範圍：以中央健康保險署六分區業務組所轄範圍區分為六個地區。(二)分配方式：用於「計算」地區預算所採之門住診費用比為45：55，該門診費用(45%)包含門診透析服務。1.門診服務(不含門診透析服務、品質保證保留款)之預算分配參數：人口占率為46%。2.住診服務(不含品質保證保留款)之預算分配參數：人口占率為41%。3.各地區門住診服務，經依1、2計算後，合併預算，按季結算各區浮動點值以核付費用。(三)所涉執行面及計算等相關細節，授權中央健康保險署會同醫院總額相關團體議定之。二、需保障或鼓勵之醫療服務，以回歸支付標準處理為原則。如仍有部分服務需採點值保障，由中央健康保險署會同醫院總額相關團體議定之，並於104年12月底前送經本會同意後執行。三、委員所關心全面導入DRGs將對各層級醫院住院醫療服務及醫療費用產生重大影響，請中央健康保險署會同醫院總額相關團體，於討論106年度醫院總額一般服務之地區預算分配方式前，研提相關資料供參。第五案提案單位：中央健康保險署案由：105年度全民健康保險抑制資源不當耗用改善方案，提請討論。主席裁定：保留至下次委員會議討論。拾、專案報告報告單位：中央健康保險署案由：為「全民健康保險醫療辦法」第11、12、18條修正草案，依預告期間各界所提意見，研提本署研議意見乙案，謹向貴會報告，請鑒察。決定：本修正草案擬規定保險對象已無續留急診治療必要卻仍滯留急診或可出院但拒不出院，須自行負擔該相關醫療費用，恐涉及全民健康保險法第51條第12款之不給付範圍認定，請中央健康保險署釐清其適法性之疑慮後，依法定程序辦理後續事宜。拾壹、臨時報告報告單位：中央健康保險署案由：利息、股利、租金及執行業務收入補充保險費扣費標準提高到2萬元案，請鑒察。決定：併臨時提案第一案處理。拾貳、臨時提案第一案提案人：何委員 語、謝委員天仁、干委員文男、吳委員玉琴、楊委員芸蘋、蔡委員登順、莊委員志強、葉委員宗義、李委員永振、張委員文龍、李委員成家、林委員敏華、陳委員健民、張委員 賜、李委員蜀平、侯委員彩鳳、蔡委員宛芬、滕委員西華 (提案資料詳附件一)代表類別：保險付費者代表、保險醫事服務提供者代表案由：健保會雇主代表委員聯合各工商團體要求衛生福利部依據健保法第24條條文規定，於105年元月1日起調降健保費率0.5%，以4.41%來徵收健保費，以還全民公平、公正、合理、公道收費責任案，提請討論。決議：一、臨時報告案及臨時提案第一、二案等三案併案處理。二、本會委員主張保險費率之調整，應併同費基進行整體性規劃與考量，爰對臨時報告案所提「衛生福利部宣布放寬利息、股利、租金及執行業務收入等之補充保險費，單筆扣費下限一律由5千元提高到2萬元」乙項片面式調整，認為有違公平性、合理性，爰表達一致反對之立場。三、何委員語等18位代表所提「自105年1月1日起調降健保費率0.5%，以4.41%徵收健保費」，及楊委員漢湶等6位代表所提「支持全民健康保險105年度費率維持現行4.91%」等兩項臨時提案，經熱烈討論，委員均認同應遵循二代健保法所揭示財務收支連動精神，建立以科學數據為基礎且不受外力干擾之可長可久費率調整機制，爰請中央健康保險署依下列方向研提「財務平衡及收支連動之機制與標準」及105年度健保費率方案(草案)，供下次(11月份)委員會議審議：(一)「財務平衡及收支連動之機制與標準」中，機制包含啟動時機、相關作業程序等；標準則係指安全準備須設為幾個月之保險給付支出、採現金基礎或權責基礎預估較合宜等。(二)試算「不同費率(含一般保費與補充保費)」之財務預估方案。第二案提案人：楊委員漢湶、蔡委員明忠、潘委員延健、張委員煥禎、謝委員武吉、黃委員啟嘉(提案資料詳附件二)代表類別：保險醫事服務提供者代表案由：為維持全民健康保險財務穩定與永續發展，支持全民健康保險105年度費率維持現行4.91%案，提請討論。決議：併臨時提案第一案處理。拾參、散會：下午2時30分。附件一附件二第2屆104年第9次委員會議與會人員發言實錄壹、「議程確認」、例行報告第一案「確認本會上(第8)次委員會議紀錄」、例行報告第二案「本會上(第8)次委員會議決議(定)事項辦理情形及重要業務報告」與會人員發言實錄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達法定開會人數，請鄭主任委員守夏召開今天的委員會議。鄭主任委員守夏各位委員、與會者、健保署蔡副署長及各位同仁，大家早安！(大家道早安！)。如果委員對議程安排有意見，等一下再討論。首先須確認上次委員會議紀錄，紀錄的篇幅很長，要花點時間。請同仁宣讀。同仁宣讀鄭主任委員守夏一、謝謝同仁的宣讀，請問委員對會議紀錄內容有無修正意見？(委員回應：沒有)如果沒有修正，上次委員會議紀錄確認。二、今天委員會議的議程，安排例行報告4案、討論事項5案；前4個討論案為4部門總額的地區預算分配，非常重要。照本會年度工作計畫，9月份完成部門總額協定後，10月份須討論6分區的預算分配，這是本會職責，今天一定要進行討論。三、至於平衡費率之審議，本會昨天已召開「105年度全民健康保險費率審議前意見諮詢會議」，會後健保署尚需一段時間試算與準備相關資料，下個月才會正式提案到本會進行保險費率審議。我知道今天有個相關的臨時提案，但基於權責，建議討論事項第1至第4案一定要先論定。至於媒體非常感興趣的保險費率，是否一定非得提前到今天討論不可？個人建議，仍按照原安排的議程進行，至於臨時提案的順序是否往前提，尊重各位委員的意見，但還是希望前4個討論案先議定。請干委員文男。干委員文男我們都知道今天的議程很重要，如果可以，希望程序能變更一下，因為昨天的「105年度健保費率審議前意見諮詢會議」，有多位委員出席並建立了一些共識，所以若今天能接續討論費率議題，則討論的結果可一併提供健保署進行分析、試算，相信下個月再依照程序正式提案討論，過程一定更順利。鄭主任委員守夏請謝委員天仁。謝委員天仁一、贊成調整議案進行程序，主要原因是，近日健保署與衛福部逕向社會發表健保費率調整的意見，此作法，已對費率調整的整個法定流程造成扭曲與社會誤解。在此情況下，我們應該要提早討論費率調整。二、我認為讓社會及早瞭解費率調整的流程很重要。哪有未經相關流程決定前，衛福部就對外表示健保費率不動，開玩笑！簡直是對我們上下其手嘛！在費率審議前諮詢會議之專家意見還沒整理出來、健保會尚未審議做出決定前，衛福部就對外宣稱不調整。請問，部長對費率那麼內行嗎？健保署的意見就那麼妥當嗎？因此，我認為有必要調整議案順序。三、建議將我們的臨時提案排入今天的議程，大家好好討論，讓委員能夠完整表達對費率調整的意見，也讓社會瞭解費率審議及調整的真意。唯有如此，在座所有來自各界的委員代表，對所屬團體才能有所交待。這個議題宜盡早討論不宜拖！鄭主任委員守夏好，瞭解。請蔡委員宛芬。蔡委員宛芬我也贊成今天討論費率調降的臨時提案，主要原因在於，當健保會還在討論如何處理健保財務負擔時，政府已經丟出多項利多消息，包括補充保費扣費下限提高，且要進行預告了！該案就是今天補充資料所列的臨時報告，大家可參閱。補充保費及保險費率調整必須一起檢視，否則今天若只決議補充保費的扣費下限不應該調高，結果政府最後還是公告調高，請問下個月我們討論費率調整有用嗎？政府都已經公告施行了，我們還要處理什麼東西呀？所以，這兩個議題一定要併同處理，因為「補充保費扣費下限的調整」和保險費率是否調降及保險財務規劃，有非常大的關聯性，因此，建議兩者今天一起處理。鄭主任委員守夏請問有無委員反對？(楊委員漢湶表示：反對)請楊委員漢湶。楊委員漢湶我們昨天才剛召開「105年度健保費率審議前意見諮詢會議」，有相當多的資料需要再準備，會上專家也提出很多建議。費率調整是一個很重大的議題，在大家沒有很充足的資訊及心理準備下，不適合以臨時提案方式討論。昨天的諮詢會議才開完不到24小時，今天大家就用臨時動議的方式來變更議程，這樣是否周延？值得好好考慮。鄭主任委員守夏一、建議先暫停討論，為了節省時間，請幕僚分送18位委員連署的臨時提案，請大家可先看其內容，現在則一邊進行報告事項，報告請儘量精簡，在各案報告完畢及進行討論案之前，再回來討論臨時動議是否要往前挪。委員本來就可提出臨時動議或臨時討論案，問題只是要不要挪前討論而已。大家若不反對，則議程確定(委員表示贊成)。二、接著進行「本會上(第8)次委員會議決議(定)事項辦理情形及重要業務報告」，請柯執行秘書桂女報告。柯執行秘書桂女請委員參閱議程資料第40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2點說明：一、說明一，上次委員會議決議(定)之5事項，依辦理情形建議解除追蹤1項，繼續追蹤4項，但最後仍依委員議定結果辦理。請委員翻到會議資料第40頁之附表：(一)第1項，有關「研修全民健康保險法施行細則重點報告」案，社保司已進行過1次口頭報告(本年第7次委員會議)，第2次提報(本年第8次委員會議)則囿於會議時間有限，故請委員參閱書面資料，並提供修法意見，本案已按要求辦理，建議解除追蹤。(二)第2項，委員希望健保署對新藥、新科技於累積不同項目之案例後，擇期提出完整資訊之報告，本案將俟健保署提出相關報告後，再解除追蹤，本項建議繼續追蹤。(三)第3項，有關「建請健保署持續關注個別醫學中心之急診下轉情形，並採取必要措施及定期提報」案，相關資料已呈現在本次全民健康保險業務執行報告第80至81頁，按表訂時程，健保署本(10)月份需進行口頭報告，若報告後委員對於本案沒有其他意見，則建議解除追蹤。(四)第4項，有關「105年度牙醫門診、西醫基層、醫院、中醫門診醫療給付費用總額及其他預算案」，決議內容詳如會議資料第4至24頁，許多決議事項需在今年年底，或者是明(105)年3、6、7月提報辦理情形，爰本項建議繼續追蹤。(五)第5項，有關「全民健康保險法施行細則第45條再研修案」，已整理委員意見並呈現在會議資料第135至143頁附錄一，並建請主管機關於修法時卓參，本項建議繼續追蹤，俟衛福部公告後再解除追蹤。綜上，建議1項解除追蹤，3項繼續追蹤，1項於報告後，若委員沒有其他意見就解除追蹤。二、說明二，衛福部及健保署於9至10月份發布及副知本會之相關資訊：(一)衛福部於10月7日修正發布「全民健康保險會組成及議事辦法」(如附錄二)，計修正4條條文，重點如下：1.第2條：配合組織改制，修正機關名稱，將原行政院經濟建設委員會名稱改為國家發展委員會。2.第4條：原規定各團體於推薦委員時，採以複數方式為之，很多團體反映語意不清，所以修訂為以二倍方式為之，使之更為明確。3.第7條：應立法委員之要求，對於委員親自出席之次數從嚴規定，將委員親自出席會議次數需達任期內之三分之二，列為續聘之必要條件。4.第9條：明訂委員已出席且在會場時，不得指派他人代理。(二)有關健保署9月9日公告新增之「全民健康保險燒燙傷急性後期整合照護計畫」，及同月11日公告修正「全民健康保險提供保險對象收容於矯正機關者醫療服務計畫」，詳附錄三及附錄四，請委員參閱。鄭主任委員守夏謝謝柯執行秘書桂女的報告，請問委員有無詢問？(未有委員詢問)若無詢問，例行報告第二案洽悉。接著進行例行報告第三案「105年度全民健康保險醫療給付費用總額成長率報告」。貳、例行報告第三案「105年度全民健康保險醫療給付費用總額成長 率報告」與會人員發言實錄鄭主任委員守夏一、本項相對單純，建議不宣讀。105年度總額成長率及金額已列在會議資料第44頁之表格，其實就是臚列上次委員會議總額協定結果及兩案併陳之資料，數字須在今天的會議確定後，才能進行下階段的行政作業。二、請大家直接參閱表列資料，與104年度核定總額相較，105年度總額成長率為：牙醫門診總額3.463%、西醫基層總額4.274%、中醫門診總額3.927%、其他預算103.6億元，醫院總額有兩個方案(付費者代表方案5.672%、醫院代表方案5.790%)，若醫院總額採付費者代表方案，則年度總額成長率為4.912%，若採醫院代表方案，則為4.992%。至於上面一欄，則是基期有校正人口差值的成長率，請柯執行秘書桂女補充說明。柯執行秘書桂女一、上面一欄是基期校正人口差值後計算之成長率，105年度總額，三個部門及其他預算有達成共識，而醫院部門沒有共識，所以必須兩案併陳衛福部決定，因此，醫院總額若採付費者代表方案，則105年度總額成長率為4.582%，若採醫院代表方案，則為4.663%。二、下面一欄則是基期未校正人口差值計算之成長率，也就是與104年度核定總額相較的成長率，剛剛鄭主委已向大家說明。三、因以基期有無校正人口差值兩種計算方式呈現成長率，所以數值不同，但兩種算法的年度總額預估值都相同，若醫院總額採付費者代表方案，則105年度年度總額預估值為6,195.5億元，若採醫院代表方案，則為6,200.3億元。鄭主任委員守夏謝謝柯執行秘書桂女的補充說明，請問委員有無意見？(未有委員表示意見)若無意見，本案洽悉。接著進行例行報告第四案。參、例行報告第四案「中央健康保險署『104年9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例行報告第四案是請健保署做業務執行報告。依時程安排，1、4、7、10月需進行口頭報告。今天是10月份委員會議，請蔡副署長淑鈴把握時間，進行重點說明。蔡副署長淑鈴報告鄭主任委員守夏謝謝蔡副署長的報告，請問委員有無詢問？請滕委員西華。滕委員西華先就業務執行報告內容之外，最近媒體報導的兩件事請教：一、首先是有關財政部的報導，最近財政部動健保IC卡的腦筋，想把健保IC卡作為報稅的憑證，顯然是想將IC卡做為個人識別的管道之一。但是健保法第16條對健保卡存放內容已經有所規範。據媒體消息，好像是衛福部及健保署要配合財政部修改全民健康保險憑證使用辦法的相關子法規。請問可以這樣做嗎？不知道的人還以為財政部才是健保業務的主管機關。想當初財政部不配合二代健保，現在又對補充保費指指點點，想搞垮二代健保。5、6年來財政部推動自然人憑證報稅的效益很差，現在把腦筋動到健保IC卡上面，衛福部卻絲毫沒有表示憂慮，想知道健保署的態度是甚麼，是不是每次財政部的吩咐衛福都照辦，若是這樣，不如把健保的主管機關改成財政部好了，要怎麼收錢，怎麼用健保卡隨便他們！二、其次是有關內政部的報導，立法院內政委員會的委員認為，財政部都已經規劃用健保IC卡作為報稅平台了，內政部到底有沒有跟衛福部商討啊？因此內政部想要推動身分證跟健保IC卡合一，以及國民健康憑證多卡合一。三、這些作為都會涉及健保IC卡的使用問題，IC卡原本目的是供醫療使用，目前醫師要將資料寫入IC卡都須輸入密碼，以嚴格管控。有否評估跟這些憑證結合之後，如何確保個人隱私？雖然前期只做個人識別用途，但將來有無可能做為資料傳輸用途？特別與政府的大數據整合，這是很重要的議題。記得我跟干委員文男擔任健保監理會委員時，我們一再疾呼，二代健保IC卡的記憶體應該要擴充，讓醫療費用以及病人利用能夠做更好的管控，當初都一直說沒辦法，因為需花費40億元預算，費用昂貴。現在政府竟然願意花100億元以利用健保IC卡作為報稅憑證或是身分證用途，卻不想花錢擴充健保IC卡以進行醫療利用的管理改革。對於財政部及內政部的作為，應該向委員說明衛福部或健保署究竟抱持甚麼態度。鄭主任委員守夏謝謝，請陳委員聽安。陳委員聽安對於蔡副署長的報告，有兩點提醒：一、有關安全準備，有兩個數字非常、非常重要，若以權責發生制來看，本年度截至9月底止，安全準備累計餘額為2,100多億元，約當4.83個月保險給付費用，到年底可能會超過5個月保險給付費用[業務執行報告第15頁，表9全民健康保險安全準備提列情形表(權責基礎)]；但如果以現金收付制來看，本年度截至9月底止，事實上安全準備累計餘額只有1,300多億元，還不到3個月保險給付費用(業務執行報告第16頁，表10全民健康保險安全準備金運用概況表)，並未超過健保法第78條的規定(安全準備總額，以1至3個月之保險給付支出為原則)。二、安全準備的累積來自保險收支結餘的提撥，另外，很大一部分來自菸品健康福利捐分配收入以及公益彩券的挹注。建議報告安全準備餘額時，除了說明依權責發生制計算結果約當4.83個月保險給付，已超過3個月保險給付費用外，也應明白指出，依據現金收付制計算，安全準備金還不到3個月保險給付費用，並未逾越健保法第78條規定，這點在報告上需特別強調。鄭主任委員守夏請問委員還有問題請教？先請李委員蜀平，再請干委員文男。李委員蜀平剛才蔡副署長業務報告，有提到慢性病連續處方箋有成長，請副署長明確提出，由社區藥局自行調劑或醫院調劑的比率是多少。當初設立慢性病連續處方箋釋出的目的，是讓高齡長者及慢性病患者，不須舟車勞頓及等待時間，常往中、大型醫院領藥；也希望這些病患能在社區藥局，接受藥師最專業的藥物諮詢及照護。但現在各醫院在總額支付制度下，經營困難，無奈，必須運用很多策略及方式，讓病人必須回到原醫院領慢性病連續處方箋之藥。這已違背了當初設立的精神，如果只是做表面，結論還是讓這些年長者及慢性病患者再回原醫院領藥，當初的政策及獎勵方法應該檢討，如只做表面的慢箋釋出率的數據，不如就將此制度取消。在此，懇請健保署應立即讓慢箋必須在社區藥局由藥師親自調劑，這樣才能達到當初照顧高齡長者及慢性病患者的目的。干委員文男幾個問題請教健保署：一、業務執行報告第1頁，請問基本工資今年有無調漲？基本工資成長好像不到1%？二、有關人口成長，若扣除外籍人士，人口好像是負成長，請問台灣1年有多少新生兒？去年及今年同期數據是多少？三、依健保法第28條，各級政府應負擔之保險費補助款若仍有欠費，須依還款計畫分年攤還，而還款期限雖有不得逾8年之規定，但有些直轄市政府，例如台北市財務狀況並不拮据，也比其他縣市好，能否請其快一點還款，而不必拖8年。李委員永振一、昨天(105年度健保費率審議前意見諮詢會議)跟今天都談到權責基礎，記得之前委員會議也曾討論過「表5-1全民健保財務收支分析表(權責基礎)」，但從今天資料看來，好像不是以權責基礎計算；該表104年其他收入包含102年及103年政府應負擔健保總經費法定下限36%不足數，亦即依行政院協商結論之核算原則所補列差額489.94億元。其實當中的197億元及293億元應分別算回102年及103年，而不應算在104年。這樣會造成混淆，未來需要回顧資料時會亂掉。依照權責基礎，費用應該回到費用發生的時間才對。很抱歉可能有些跨越了健保署專業，但會計學有其原則，請健保署考量，另行編製可以看出當年、當月實際財務狀況的報表。二、昨天也有提到菸品健康福利捐是安全準備主要財源之一，貢獻很大。既然這筆金額進到保險收入，自然有其用意。照蔡副署長所言，歷年來有2,344億元挹注安全準備(依報告第15頁表9備註2，84年3月至104年9月菸品健康福利捐分配收入2,343.79億元)，好像民眾繳的保費都沒貢獻，這種觀念怪怪的。我的看法是，照健保法第76條，菸品健康福利捐是安全準備的重要來源，既然這筆收入已經進到保險收入這個pool(池)中，健保的收支就應該整體而論，不該再區分是來自政府的、雇主的、還是被保險人的。所以我昨天在做分析時才會說，近6年的安全準備增加了2,901億元，而菸捐挹注於安全準備只有2,300多億元，保費收入也是有貢獻的。健保署應解釋清楚，以免大家誤解。三、近日健保署公告明年調降平均眷口數，媒體報導中雖然也有健保署的聲明稿，但以手邊某時報的報導為例，雖引用健保署的數據，但報導內容令人霧煞煞(台語，模糊不清)，在座的委員可能還勉強看得懂，但其他社會大眾，會不會被誤導？因為媒體的標題是：選舉期釋利多。健保署想必又要抱著肚子喊痛，本署明明是依法行政、依法公告。所以建議健保署與媒體好好溝通，讓其報導不要誤導民眾。媒體報導大眾關心的健保費率問題，若僅3成內容是健保署資料，而其他7成是媒體自己的臆測，則令人擔憂，因為我們在這裡辛辛苦苦的討論半天，媒體的報導卻不甚正確，後果將難以預料。鄭主任委員守夏謝謝李委員，請劉代理委員碧珠。劉代理委員碧珠(張委員煥禎代理人)一、感謝健保署這次的報告，已呼應張委員煥禎之前所提，在健保門住診費用核減統計表中，呈現分區、分層級之核減率資料。二、請教健保署，報告第96頁[表33-3-2醫院總額各層級一般服務部門及專款(不含交付)核定點數、收入及點值統計-北區分區]，北區分區的區域醫院，103年門住診核定點數全年是184.71億點，但報告第119頁(表35-3全民健保門、住診醫療費用核減統計表-區域醫院)，北區業務組(即北區分局)區域醫院的門住診核定點數(C欄)是卻是208.68億點(門診111.24億點+住診97.44億點)，請問兩者為何有此差距？鄭主任委員守夏請健保署簡要回答，無法馬上回答的問題，請於會後再補提供資料或私下向委員說明。請謝委員武吉。謝委員武吉幾點問題請教健保署：一、報告第30頁，有關八仙樂園粉塵暴燃事件之醫療費用執行情形，104年6月至8月份申報的醫療費用約5.92億點，感謝健保署持續函請新北市政府返還健保署代墊之費用，也努力向肇事者博瑞國際整合行銷公司及玩色創意公司投保之泰安及蘇黎世產險公司，爭取代位求償。目前新北市政府才歸墊7,707萬元，但有些傷患還繼續住院治療中，所需之醫療費用若有不足，該如何處理？二、報告第53頁呈現藥費點數統計資料。據我所知，目前已經有許多藥品的原開發廠商退出台灣市場，也有廠商不參加公立醫院的投標，原因為何？這些原因我當然清楚，但還是請健保署深思，給我們一個明確的答覆。三、台灣許多已取得藥品許可證的廠商，不願意製造藥品，例如氧化鎂ＭgO(軟便劑)1千顆賣118元，1顆藥價才0.118元，根本不敷成本。到底該如何補救？以前1種藥可能有10、20家藥廠生產，現在不然，1種藥可能只剩2、3家藥廠生產。據我的瞭解，很多藥廠努力開發癌症藥品，有些新藥只比健保目前收載的藥品，多延長病人7天的生命，健保也是通過收載。這現象請健保署多加注意。四、剛才蔡副署長報告也提到，醫學中心及區域醫院初級照護的占率有一點下降，但整體看來，這兩個層級的初級照護占率還是偏高，對此現象，我認為還是應該有所作為。此問題我已經第2次提出來了，拜託健保署多加關心。鄭主任委員守夏請問委員還有請教？請蔡委員登順。蔡委員登順一、同意李委員永振所提意見，健保收入不管來自那裡，無論是補充保費或健康捐，都算健保的財務收入。蔡副署長淑鈴報告雖指出健保財務有遠憂，但也提到最近安全準備約有2,157億元(104年截至9月底止)，差不多是4.83個月的保險給付，已超出健保法規定安全準備總額3個月保險給付支出之原則，社會氛圍也不太能接受這麼高的安全準備，所以調降保險費率之議，大家也都承受到很大壓力。二、蔡副署長的報告有幾點我支持。調降平均眷口數一年減少收入約14億元；菸品健康福利捐分配健保安全準備之比例，由原來的70%調降為50%，每年可能會減少收入66億元；二代健保補充保費扣費下限由5千元調升至2萬元，年收入可能減少27億元，加起來健保財務自然會有遠憂。這部分的金額不確定性高，隨時都有變動，尤其是菸品健康福利捐，現在政府一直鼓勵大家少抽菸，反菸政策也得到很大的成效，抽菸人口已逐漸減少，再加上立法院一直推動調漲健康捐，基於健康和經濟考量，將來吸菸人口會急遽下降，探討健保財務時，當然應將這些不穩定的財源納入考量。但安全準備既然已經那麼高，付費者也有共識，費率該降就要降，經費不足時該升就要升，建立收支連動，形成浮動機制，社會觀感較佳。鄭主任委員守夏請委員把握時間，請潘委員延健發言。潘委員延健一、蔡副署長提到安全準備餘額時，特別提到菸品健康福利捐，我想最大的用意，當然不是在區分健保費用來自那個名目，但健保所有財源中，還是有穩定性和不穩定性財源之分，而菸品健康福利捐是屬於比較不穩定的財源。就國人健康角度，希望菸品健康福利捐愈少愈好，而不是一直成長來挹注健保，其與整體健康概念是矛盾的。要提醒的是，雖然安全準備餘額已達4.83個月保險給付，但未來也僅能支撐一段時間而已。二、蔡副署長提到雲端藥歷的成效，但雲端藥歷實際上只是提供一個查詢平台，真正的作用來自醫院後端所進行的節制措施，經由系統上的比對，讓醫師即時找出重複用藥。很多醫院和醫師反映，部分病人住院時隨身所攜帶的藥品，有些居然在雲端藥歷查不到，表示雲端藥歷的資料和實際發藥情形有落差。因此，須請健保署確認雲端藥歷資料上傳的即時率，尤其過去健保特約藥局並未強制插卡(健保卡)上傳資料，在此情況下，資料在24小時之內即時上傳的比例，一定會受到影響，若要全面推動雲端藥歷，則必須進行該強制措施。鄭主任委員守夏請何委員語。何委員語一、我昨天於健保費率審議前意見諮詢會議提到，平衡費率是每年進行調升或調降，而非蔡委員明忠昨天說的1個月、2個月、3個月就調升或調降，昨天本來要答覆，但他已先行離開，沒聽到我們的意見。二、印象中99年元月份之前，健保財務虧損約6百多億元，若99年1月份之前是虧損的，則菸捐收入應從99年2月份以後才開始計算，只有1千4百多億元(依業務執行報告第15頁表9，99年1月至104年9月「公益彩券、運動彩券及菸品健康福利捐分配收入」之累計金額)沒有健保署報告的2千多億元(註：此數據是從84年3月起算)。建議健保署應該要提供長官確實的數據，不然衛福部部長和行政院院院長會被誤導。菸捐是工商界和抽菸人口貢獻的，不能將菸捐收入視為健保署另外開闢的財源，而認為因為菸捐多，安全準備才有結餘。健保財務好像大水庫原理，不論是從基隆河或淡水河進來，同樣都是水，不宜做區分。三、雇主自102年至104年7月支出的補充保費共572.44億元，約占整體補充保費的52%(參考105年度健保費率審議前意見諮詢會議健保署第15張簡報)。除一般保費外，補充保費的一半也是雇主支付的，好像是一隻牛被剝二層皮，不但剝掉外層，也剝去裡層。既然健保財務是大水庫的概念，就不能區分這些水是給台北市喝的，那些水來自別條河是給新北市喝的。不管財源從那裡來，都不能這樣區分。四、請教健保署，業務執行報告第9頁的保險費收繳執行情形中，有關欠費部分，為何沒將105、106年中央應補繳的費用列出？既然此節是保險費收繳執行情形，而且也列了投保單位及保險對象欠費收回情形，若不能出現中央欠費文字，就寫中央105及106年應各補繳多少費用。五、依法每年總額成長率由行政院核定，可是錢來自全民。為何政府核定年度總額成長率上下限時，沒有諮詢付費者的意見；付費者沒有表示意見的機會，主管機關就自行決定(註：已向何委員說明，主管機關每年都依健保法第60條，諮詢健保會對總額範圍之意見)。當然政府依法有權決定總額成長率範圍，而我們也依法可以討論平衡費率。六、日本為了醫療和長照體系，將營業稅從6%提升至8%。我們立法院則是規定營業稅可以達8%，也就是說未來長照、老人照護等各方面所需經費不足時，立法院已預備有3%營業稅的空間，讓政府可以動用增加1%或2%營業稅，做為國家財源之需，屆時大家再來討論。調整費率是一件事，提高1%營業稅做為長照、老人照護財源也是可考量的方向，建議健保署不要一直提菸捐有多少錢，菸捐是雇主和抽菸人口付的，希望不要再誤導長官。鄭主任委員守夏現在已經11時5分，依本會的慣例，希望上午11時之前能完成報告案，如果還有委員要發言，拜託請簡短。請謝委員武吉。謝委員武吉健保業務執行報告第1頁，104年8月保險對象人數較同期增加155,688人，我們出生人口和死亡人數，似乎不應該相差15萬多人，希望能提供資料讓委員了解，這15萬人到底是怎麼來的？是外籍人士還是其他管道增加而來，主要分布在那幾類投保人口？那一類為最大宗？請健保署於下次會議提供資料與報告。 鄭主任委員守夏委員如果沒有進一步詢問，請健保署簡短回答，所需要之數據或現在無法回答的部分，則請會後補充資料，再請本會幕僚協助處理。蔡副署長淑鈴謝謝各位委員對本署提出非常多的意見，有幾項在此先向大家說明：一、有關滕委員西華詢問的部分：(一)最近媒體報導明年也許可以用健保IC卡報稅，特此說明，健保IC卡確實是供健保業務使用，相關機制都明訂在健保法施行細則及「全民健康保險保險憑證製發及存取資料管理辦法」中。IC卡本來是就醫憑證，但隨著醫療科技、網路服務的興起，本署為民服務端也需要隨著資訊的腳步進展。在健保提供的服務中，包含在健保會較少提及的櫃台服務，各分區業務組都設有非常好的為民服務櫃台，處理包括承保、繳費、醫療費用核退、重大傷病申請等民眾服務，此外還設有聯絡辦公室提供前開服務。但隨著現在網路服務的興起，我們也需要提供網路服務，用網路取代馬路，以節省社會成本，這是我們一直努力的目標。(二)健保署的為民服務，幾乎是行政院為民服務的標竿。為提供便民的網路服務，網路就需具有識別當事人身分的機制，因為本人已經不用到現場。因此，健保卡若要能提供承保、財務、醫療等網路服務，則必須upgrade(升級)成為網路的識別憑證，以強化健保網路服務業務的推展。提供這些服務所需設備和健保憑證一直在renew(更新)，包括需要網路識別伺服器，加、解密的主機等，讓健保IC卡透過網路註冊及密碼設計，成為網路憑證，規格等同金融卡。能提供這樣的服務，我們才有信心用網路取代馬路，提供民眾更便利的服務。(三)提供網路服務取代櫃台服務，已經是趨勢。因此，本署才設計健保IC卡的身份認證等機制，讓IC卡除就醫憑證外，也成為網路服務的憑證，健保端相關法制作業已全部完備。今天財政部希望這張卡片也成為報稅的憑證，該部需要配合修改他們的法規，這部分已超越了健保可以處理的範圍。我要說明的是，健保IC卡升級成為具網路身份識別功能憑證的初衷，純粹是為了提供民眾健保網路服務。若財政部接受健保IC卡也可做為網路報稅的憑證，基於政府一體我們樂觀其成，但相關的法制部分，還是要由財政部修改他們的辦法。至於內政部希望身份證可以改成晶片卡，並結合自然人憑證及健保卡，因為健保卡有很多獨特的功能，很難完全搭配，這部分還在研議當中。(四)委員都很關心健保業務，現行的健保卡已經使用超過10年，有非常多的機制需要upgrade(升級)，所以我們正在研議規劃二代健保IC卡，希望配合現在的網路和雲端服務，以及未來可能承接的長照保險等諸多任務。請各位委員了解，櫃台是本署服務民眾非常重要的部門，服務效能提升一直是本署為民服務努力目標。二、謝謝陳委員聽安的提醒，剛才報告的安全準備餘額有2,157億元，約當4.38個月保險給付的存量，但這是將所有應收保費都算進來的權責基礎，但真正的現金並沒有這麼多。若安全準備採權責基礎計算平衡費率，可能因費率下降而使保費收入減少，當實際現金流量不足時，就需要向銀行借錢支應保險支出。現金基礎之所以和權責基礎有落差，是因為權責基礎包含政府應負擔健保經費36%不足數之預算編列不足，目前採分年攤還而非一次編足；另外，政府單位過去的保險費欠款尚未還清。本署會持續努力，拉近權責基礎和現金基礎的差距。三、李委員蜀平提到慢性病連續處方箋的成長，且關心社區藥局接收慢箋的比率。從民眾觀點，推廣慢箋的第一個目的，是希望病情穩定的慢性病人，可以減少反覆回到醫院就醫的比率；至於民眾拿到慢箋後的調劑地點，現在是由民眾自由選擇。此外，李委員關心是否只有社區藥局提供藥師諮詢服務？理論上，所有調劑藥品的地方，不管是醫院、診所或社區藥局，都要提供等同品質的用藥諮詢服務才合理。若只有社區藥局提供用藥諮詢服務，醫院或診所之藥局不提供，這就成為需要重視和討論的議題，若有此現象，也請李委員主動告知。四、干委員文男提到基本工資的調整，確實基本工資在今年7月有微幅調整。至於新生兒過去一年有40萬人，最近幾年已降至19萬人，2年前適逢龍年略為提高到21萬人，但現在又減少到19萬人。大家關心保險對象人數成長15萬人(104年8月較103年同期增加155,688人)，其實台灣自然人口扣除死亡人數的淨增加不到15萬人。外籍人士的增加，包括外籍配偶和合格加保的外籍人士，是這幾年保險對象成長的主因。五、許多委員關心我在報告中，將保險費和菸捐等健保財源做比較，其主要用意是提醒大家，整體健保業務的主要財源是保險費，雖然有菸捐和公益彩券等補充性財源，長期以來健保法和相關法令也賦予健保有這樣的補充性財源，但這些補充性財源都不是絶對數額，而是一個比率。計算比率的母數如果改變，同等比例的補助金額也會跟著改變，遑論連比率也被迫在改變。例如，菸捐分配健保比率從本來的90%降至70%，現在又降到50%，這就是比率的調整；另外也存在母數可能因為政策改變而改變的變動。所以，我才會提醒委員，健保需要永續經營，因此，屬主要財源的健保費就需要穩健，至於補充性財源存在非常多的不確定性，未來仍要審慎面對，才有辦法討論健保財務永續的問題。至於近日本署公告明年要調降平均眷口數，記得前次討論平均眷口數調整議題時，委員就要求以後都要實際反映，不可再有延後反映的情形，所以這次的調降是反映實際狀況，以符合大家的期待。六、謝委員武吉提到八仙樂園粉塵暴燃事件的後續處理，說明如下：(一)本署會完全依照健保法與相關規定，以及健保會的決議執行。有關醫療費用部分，已通過可用總額其他預算項下之「其他預期政策改變及調節非預期風險所需經費」剩餘款8.2億元支應，目前預估費用為6點多億元接近7億元，仍在預算額度內，因為須支用到年底，所以尚待持續監控，八仙塵爆病患主要醫療支出集中在前三個月，接下來這段復健期的費用就沒有那麼昂貴。至於民眾自費部分，很清楚健保不能支付，所以本署純粹是代墊，新北市政府成立之捐款委員會已通過由捐款支應，這部分代墊還款作業將非常順利。(二)健保支應的8億元醫療費用中，第1個月的費用依健保法可以代位求償，而且是向公共意外險的保險人代位求償，相關法定程序仍在進行當中，之所以尚未完全啟動，是因為有很多申報費用，需等初審、複審、爭議審議等程序結束，才有實際數據來據以啟動相關法定程序。因為八仙樂園粉塵暴燃事件也有一些刑事裁判上的程序在進行，我們和法律顧問也在研究，除依法公共意外險的代位求償外，還有無其他可能代位求償的方式，本署會很盡責的持續進行。七、贊成何委員語提到的大水庫理論。我剛才要提醒的是補充性財源的穩定性問題。一直以來我們都接受，健保財源分成「主要的保險費」以及「補充性財源」兩部分，加起來就是保險收入。過去在財務的呈現上，也一直將補充性財源納為收入。贊成在健保法允許的範圍內，將這些補充性財源都列為保費收入，只不過長期估計財務時，要充分關心財務的穩定性。健保費的穩定，來自於薪資的穩定、費率的穩定、經濟的穩定；但補充性財源，受到來自母數的大小，以及比例調整的變動因素影響，這部分請大家討論相關議題時，能列入考慮。至於潘委員延健提到雲端藥歷資料即時上傳的落差問題，謝委員武吉提到的原廠藥退出健保問題，或有關安全準備、營業稅等意見，我們都會納入參考。八、當大家看到安全準備這麼高時，有很多意見，且認為二代健保的核心精神，就是要建立收支連動機制。因此，最後建議，希望藉此機會好好研究健保的收與支究竟要如何連動？收支連動這句話講起來很簡單，但執行上還有很多假設、前提、程序與細節有待討論，希望大家共同努力一起研議。鄭主任委員守夏謝謝蔡副署長淑鈴的說明，報告案到此結束。各位委員若還有不清楚或需要詢問的地方，可利用桌上所備的發言條，請幕僚收集並於必要時請健保署提供資料，以節約開會時間。接下來請李委員蜀平。李委員蜀平我的問題很明確，希望看到的是慢箋於社區藥局由藥師自行調劑和醫院調劑的百分比比例。因為醫院設計許多無奈的策略，讓慢性病老人必須回醫院領慢箋之藥，可能是藥價差或其他原因。請不要再告訴大家，民眾有自由選擇調劑處所的權利，不是這樣解釋，如果用不合理手段，可以嗎？而且我也沒資格及辦法提供資料給健保署。拜託蔡副署長淑鈴，下次提供相關資料；以便達到全民健康之目的。鄭主任委員守夏本會歷來的習慣是，對於委員詢問的資料，只要是健保署可以提供，又沒有個別醫院或個人隱私問題，原則上都盡可能提供。所以健保署若有辦法分析資料，下次會議請提供。蔡副署長淑鈴沒問題。鄭主任委員守夏好，謝謝。干委員文男剛才我詢問依健保法第28條，各欠費直轄市政府依還款計畫攤還保險費補助款欠費部分，是否能夠盡快歸還。就是擔心像過去地方政府欠費問題，一再拖延，最後從地方補助變成中央補助。今天有國發會和主計總處代表委員與會，希望讓他們知道，現在政府欠了多少錢，要分幾年償還，應有很清楚的還款計畫，對健保財務才有幫助。雖然我的問題是能否提早還款，但主要用意是希望提醒，不要像過去一樣，把問題推給過去的政府，或換個政府還是一樣的做法，這是我的擔憂。鄭主任委員守夏一、就我所知，中央和地方政府都沒錢，既有還款計畫，當然就是照年限慢慢還，但也了解干委員文男的擔憂。二、接下來請各位委員參閱今天的補充資料，有一個臨時報告案，是健保署要向各位委員說明利息、股利、租金及執行業務收入四項補充保費扣費下限提高到2萬元案，請同仁宣讀。肆、臨時報告案「利息、股利、租金及執行業務收入補充保險費扣費標準提高到2萬元」、臨時提案第一案「健保會雇主代表委員聯合各工商團體要求衛生福利部依法將105年度健保費率調降為4.41%」、臨時提案第二案「為維持全民健康保險財務穩定與永續發展，支持全民健康保險105年度費率維持現行4.91%」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。因為條文都在這邊…。謝委員天仁主席，程序問題。鄭主任委員守夏是，請謝委員天仁。謝委員天仁我們拿到的議程，好像沒有臨時報告案，為什麼臨時報告要插進來就這樣插進來？議程的調整有經過大家同意嗎？我覺得應比照臨時提案一併處理。鄭主任委員守夏如果這是主席的責任或權限，則將其歸成報告案，我的想法是報告案都完成後，再開始進入討論案。現在有2個臨時提案，都是討論案，所以會併到討論案部分。我是將本案當做臨時報告案，至於臨時報告案是不是要放在討論案前面，若大家很有共識，就尊重大家的意見，本報告案要放在那裡？在討論案之後嗎？謝委員天仁放在討論案之後。健保署從來都沒有尊重我們，丟到最後面去。我要很清楚的講，法規的修改本來就要諮詢健保會，都沒有諮詢本會，就都對外公開說了，其實已形同定案，現在才來本會報告，是脫褲子放屁，沒有意義，如果要這樣的話，我們連聽都不要聽。這和健保實質收入有關，沒有理由這麼簡單處理，我們付費者是極度憤怒，怎麼會這樣做呢？鄭主任委員守夏了解。請戴委員桂英。戴委員桂英這是諮詢案沒錯，但的確會影響財務，不知道健保署有沒有那麼急，如果可能的話，建議併11月份討論費率的時候再報告。滕委員西華本案與臨時提案一樣，都和費率有關，建議與臨時提案併案處理。鄭主任委員守夏一、這是諮詢案，主管機關以這樣處理於法有據。但健保會委員覺得非常不受尊重，因事實上不合情也不合理，但卻是合法的。二、依本會議事規則，是先報告案，然後再進行討論案。本案是臨時報告案，若大家有共識要將其併臨時提案處理，我個人沒有意見。本案並非由本會決定而只是徵詢委員意見，若沒有委員反對，就併進去臨時提案處理(委員表示同意)。報告案到此結束。三、有幾位醫事服務提供者代表，由楊委員漢湶領軍，也提出和一般保險費率4.91%要不要調整有關的臨時提案，請各位委員看一下提案內容。現有兩個臨時提案，議題一樣但意見不同，所以要併案討論。請問各位委員，此案是放在原已排定的5個討論案之後，還是要提前？須大家有共識才先討論，否則就照原安排的議程。但提前討論要有理由，須說明為什麼要提前，請干委員文男。干委員文男我剛才已提出程序問題，應該要提前。兩個臨時提案和臨時報告案，都是同一件事，大家同意併案。大家若沒有意見，就應併案先討論。各部門總額的地區預算分配若非完成不可，則今天的會議須所有議案都論定後才可結束，請大家都不要先離開，議案討論完再結束。鄭主任委員守夏如果有共識，請委員都到會議結束才離開，但要先有心理準備，因不知須開到幾點。干委員文男都已經來開會，還擔心開到幾點嗎？鄭主任委員守夏干委員文男的意見是兩個臨時提案及臨時報告案併案，有無委員反對？請楊委員漢湶。楊委員漢湶昨天健保費率審議前意見諮詢會議中，受邀專家及委員所提許多問題及意見，健保署是否都已備妥資料？因為討論費率就是討論精算，必須依據充分的數據來討論，而非憑個人好惡。部分媒體希望我們最好在會上打一架，能提供很勁爆的內容，但這基本上不是穩定健保的作法。若大家能接受，我認為將這些意見提供健保署，讓該署有準備的時間，下個月再來討論。費率可選擇經常調整或數年調整一次，若按照健保法，原則上應有一段時間才作調整，並不適合經常調整，因為在作業上相當困難，民眾也不易接受。鄭主任委員守夏目前除列入議程的5項討論案外，尚有2項臨時討論案及1項臨時報告案，這3項可併案討論，但是否提到例行討論案之前，需看其急迫性及合理性，原訂議程就是10月討論地區預算分配，11月討論平衡費率，真不知有何特殊理由需要提前。若大家有先討論的共識，我一定尊重；若無共識，則建議照原訂議程。請大家表示意見，請吳委員肖琪。吳委員肖琪近年來，我非常關心地區預算分配的R值(各地區校正人口風險後保險對象人數)及S值(總額開辦前一年各地區保險對象實際發生醫療費用)，該議案是本次既定議程，希望能有時間討論。就醫院部分而言，目前各地方政府都在拼命蓋醫院增病床，以減少民眾病床不足的問題。R值往前進，民眾不使用過多醫療資源，才能抑制各區拼命蓋醫院增病床的情形，擴床結果都是全民買單；偏鄉地區反而缺少病床，因錢都被都會區拿走。所以，R值必須要往前進，這是10月份很重要的議題，我希望先討論地區預算分配。鄭主任委員守夏請滕委員西華。滕委員西華一、根據健保法第24條規定，是在總額協商1個月後討論費率，不過此事有急迫性須先討論，因為行政院早就自行決定提高補充保費扣費標準，輿論也沸沸揚揚，若行政院沒有那麼粗魯，能尊重健保機制，先諮詢本會，等11月再討論費率並無問題，因調整是從105年開始。大家都知道今天開會，尤其又有臨時提案，沒道理不做討論。保費收入沒談好，怎麼知道105年度總額該如何分配？地區預算分配大多是技術性問題，大部分費用早已框定，我們承諾會全數討論完畢。所以，地區預算分配一定會討論，只是臨時提案是否要提前處理。我支持先討論臨時提案，將攸關總額的保險費率與補充保費調整原則加以確定。二、剛才楊委員漢湶提到健保署準備工作，我認為已經準備好了；昨天的諮詢會議上，該署資料已呈現包括5年費率及補充保費的相關數據，怎會還沒準備好？只差我們有無共識而已。我認為醫界提出對案也很好，大家可以對結果有不同意見，但都支持要討論。所以，今天先予討論就是共識。鄭主任委員守夏 大家都同意下午一定留下來將包括地區預算分配的議案都討論完竣，所以先講好喔，不能先走人！這也是干委員文男及滕委員西華所言且多數人不反對的意見。既然委員們認為這項議題重要應提前討論，我們就先予討論。請陳委員聽安。陳委員聽安在程序上，臨時提案是否有迫切性須提前討論而將原訂討論案延後？兩臨時提案各有多位委員連署勢必要併案討論，經初步觀察，意見南轅北轍，我擔心今天的討論不會有結果，反而耽誤正常議案的時間。希望大家忍耐一下，差不了1、2個小時，急著討論而導致得不到共識，恐會擔擱正常議案而誤事，請大家再多考慮。鄭主任委員守夏 請羅委員紀琼。羅委員紀琼一、基本上這是一個重要的問題，值得深入討論。但我並不認同健保署已經準備好了的看法。昨天諮詢會議結束後，我詢問社保司與健保署同仁，怎麼會將問題簡化為僅剩調整費率或分擔比率二個選項？事實上健保制度內有很多結構性問題尚待解決。例如，一代健保主要是依工作所得計費，而補充保費的費基也有工作所得；第六類被保險人是無工作所得者，他們所繳交的保險費，其來源可能是利息所得，此部分的利息所得又再被徵收一次補充保險費等。這些結構性問題完全沒討論，就被化約為是否調降費率，並不妥當。二、衛福部及健保署應該最明瞭，不是只有費率問題，結構才更需要關心。第一類至第三類被保險人所負擔之眷屬保險費，是否應由三口變兩口？以往審議健保法時，各界質疑多眷口家庭負擔沈重，此時是絕佳的檢討時機。按照議程，下個月才審議保險費率，不差這1個月。若將費率調降，日後要再調漲又是問題。昨天因主席一開始就設定只談技術性問題，所以這些意見我都沒有機會講。三、在場諸位都很為國家著想，以致能忍耐至今，令人佩服。但我認為主管機關在這last-mile(最後一哩路)要走得更加穩健、負責。看看台灣的未來，大家都知道今年的經濟成長率保1有困難、明年也不會很好；再加上人口老化問題越來越嚴重、且實質薪資倒退10多年，因此財經部會都在研究產業未來的走向。請健保署將所有問題都想清楚，然後研擬多個方案供大家討論。鄭主任委員守夏謝謝羅委員！對不起，請各位暫停發言。因提案雙方都很有興趣，所以就先討論臨時案，但請各位授權，若討論後實在沒有共識，我會喊停，那時就拜託各位等下月再繼續討論，否則後面4個討論案真會討論不完，各部門總額勢必受影響。現在就先討論費率案，補充保費調整部分請健保署說明，兩份臨時提案請同仁宣讀，之後就進入討論。因雙方立場懸殊，我希望利用1個小時溝通意見。請宣讀。同仁宣讀鄭主任委員守夏臨時報告案部分中，放寬補充保險費扣費標準的修法草案，尚在預告時限內，與費率可併同考量。請兩項臨時提案領銜的提案人先表示意見，請何委員語。何委員語一、依衛福部的函示：「目前本部健保署正依105年度醫療費用總額協商結果擬訂保險費率方案，將於今年10月底前，提請健保會審議」。今天提出調降費率審議案不僅合法，而且合乎其函示。二、全民皆知行政院已宣布調高補充保費扣繳下限，民眾及九大工商團體更要求應調降一般保險費率，因安全準備至今年9月底已有2,157.59億元，年底則會超過2,300億元。若依昨天諮詢會議資料，105年至少還會結餘300多億元，這樣安全準備就將超過2,600億元。因此，在全民的要求下，沒理由不調降一般保險費率。三、政府預算是每年編列，送立法院審議通過後執行。健保以3年平衡費率推估就很合理、健全，若健保倒了，國家也就滅亡了，所以，我認為用5年推估是不合理的。四、台灣的醫療費用自付額佔整體醫療費用50%以上，醫院所收取的自付額相當高，醫療費用並非全由健保總額支付，所以，不要將所有缺失都掛在健保總額頭上。我們很傷腦筋也不想訴諸媒體，早上工業總會蔡副秘書長來電，要我到衛福部樓下，接受兩家電視台採訪。我表明以工業總會及九大工商團體代表，而非健保會委員身分接受採訪，所以不讓記者進入辦公大樓內，是冒著綿綿細雨在馬路上接受採訪。為不讓記者淋雨，與警衛協調，後來才在屋簷下受訪。若我代表健保會委員，就進來大樓內受訪了。五、我認為委員們很困擾，大家壓力都很大，因全民都在追蹤本案。安全準備累積這麼多不合理，而且讓整個經濟及消費停滯，所以沒有理由不降。若不調降費率，明年是否退還1千億元，使在社會上流通，以創造消費經濟。楊志良前署長在報上發表評論，若不調降就退還，退還很麻煩，所以希望明年就調降，我們建議採3年的平衡費率。在目前這種情況下，政府沒理由不調降健保費率，至於要調降0.5%或多少，我認為可將菸捐及補充保費所減少的66億元及27億元收入加以換算。因與九大工商團體討論本案時，尚不知補充保費扣取標準要調整，本月28日工業總會理監事會上，還是會有這項提案，若有決議，工總(中華民國全國工業總會)就會依照程序聯合九大工商團體共同推動，屆時就看院長、部長如何回應。六、請大家理性看待本案，我從不希望健保倒，只要健保安全準備低於1個月，工商團體都會同意支持調升費率，一切回歸正常機制。如我昨天所言，以前汽油價格每次調整，都被罵得要死，但現在每週調整，大家也都習慣了。健保以後每3年調整費率，也應該不會有人罵。讓民眾回歸理性，這點很重要，政府的政策不能都是對民眾收錢，而從不還錢。鄭主任委員守夏請另一案的主要提案人楊委員漢湶發言。楊委員漢湶一、我認為保險費率需要冷靜、心平氣和的討論。昨天健保署已提出很多資料，資料顯示，保險收支到106年就會產生明顯短絀。全世界實施社會保險的國家沒人採彈性費率，因為財務必須維持一定期間的穩定，前期雖有結餘，但後期可能短絀，費率不宜每天變動，這是全世界辦理社會保險的基本原則，希望大家都能遵守，保險費率不能每年變動。現在不是工商團體贊成或反對的問題，因為費率調整會涉及所有民眾。二、今天產生這樣的問題，其實也令人相當高興，因為健保開辦至今，難得有這麼多的安全準備；昨天有委員表示，以後大概都沒這種機會了，這可能也是事實。因為從昨天的推估來看，再加上老年人口及醫療費用的成長，這筆安全準備並無法支撐多久。現在要立即調整費率，時機是否恰當？所以，我們贊成暫時維持現行費率，但並非永遠不變，也不可能永遠維持。三、今天所產生的問題，其實是因短期內補充保費收繳超出預期。若沒有補充保費或菸捐等其他補充性收入，結餘不會這麼多，但這些收入的基礎較不穩定。一般保費是基本收入，現要調整基本收入的費率，要從4.91%調降至4.41%，恐怕令很多人擔心。若改從補充保費費率上思考，或許造成的傷害較少，今天要從一般費率動手，我期期以為不可。社會保險保費收取的公平性很重要，若從這點來看，補充保費遠比一般保費更不公平，交補充保費的人不見得有經濟優勢，也可能是弱勢，應該加以思考。四、平衡費率應採3年或5年？這可以討論，但必須有財務推估結果作為討論基礎。所以應交由健保署仔細推估，因為完全沒有數據基礎的討論，是很危險的。在場大多數委員都是團體代表，我們醫界面臨的問題是，整個醫療體系受制於總額制度，預算被總額框住，因而產生很多問題，這些問題該如何處理也需要一併考量。五、我相當贊成羅委員紀琼所述，二代健保保費收繳的制度設計，有很多結構性問題，應思考如何促進公平性。為避免流於空談，就必須有數據支持，以進行使制度更為公平的調整。健保法第78條雖規定，應有相當於1至3個月保險給付支出之安全準備，但這是原則，並未強制超過3個月就須立即調降費率，亦即安全準備是以「1到3個月保險給付支出為原則」，保有彈性。老實說，目前安全準備達3個月，未來甚至可能達到5個月，但這並無法長久，充其量大概只能維持1年。是否要在1年內調降費率，1年後大家再討論是否調升？這會相當辛苦。六、從84年實施全民健保至今，費率僅調升過兩次，卻導致兩位衛生署長下台，可以想像費率調升相當困難。我是李前署長明亮任內的副署長，親身體驗費率調升何其不容易，因為必須說服相當多人同意調升。建議在目前健保財務狀況良好時，保留安全準備，未來財務狀況不佳時，就不須立即調升費率。鄭主任委員守夏接下來，請其他委員發言。請謝委員天仁。謝委員天仁一、這件事今天之所以如此演變，是因為健保署與衛福部進退失據產生的問題。醫界若這麼在意健保財務的穩健，在補充保費扣費標準調高或菸捐分配比率減少時怎不表示意見，卻獨獨對費率調降意見一大堆，冷靜得太異常。二、若依財務專家的建議運作，永遠都不用降費率。既然菸捐或補充保費等來源都不穩定，意思是變少或變多都有可能，但為何這麼悲觀，總認為會減少呢？101年時，我要求衛福部遵守承諾，將費率從5.17%降下來，當時官方也說106年安全準備就會不足。三、我昨天也表示，不應倚賴這種不穩定的基礎來做考量，那是極度危險的。我們要建立制度，亦即年度期末安全準備超過3個月或不足1個月時，費率準備如何處理？這個處理機制需要建立，設計上需要思考調幅多少？依據為何？(一)首先須思考「安全準備超過多少」就要考慮調降費率。假設機制設計是保留3個月安全準備，或稍微寬估保留3個半月安全準備，超過這3個半月的金額就用以調降費率。(二)其次，上開「安全準備計算時點」為何？例如可以第2年期末，或更加穩健採第3年期末的安全準備金額為基準，亦即107年12月31日的安全準備餘額，若超過3個月或3.5個月，超出的金額就用以調降費率。假設超出3個月或3個半月安全準備金額是3百億元，就用3百億元來換算費率調降的幅度。四、費率調整本應公平，怎會先調降補充保費？衛福部被財政部、金管會牽著鼻子走，實在很糟糕，這應是部長主管的事務。今天健保能累積這麼多安全準備，不論原因為何，都是部長的政績，部長不知政績要澤被全民，竟然獨厚坐領利息、股利及租金的菜籃族！請教健保署的年輕同仁，你有這些收入嗎？若沒有，為何不調降你的費率呢？理由何在？這項政策失去平衡，完全沒有合理性。若要調降，就應公平調整才合理，怎會獨厚300多萬的菜籃族？那500多萬年輕的弱勢族群誰來照顧？怎麼講都不合理。五、建立良好的機制最重要！我昨天也講，這是歷史性的一刻，這次若未能調降，依財務專家的看法，永無可能調降。健保的收支連動機制，一定要搞成只漲不降嗎？大家努力的成果，為何不能共享？若未來財務不佳，大家面對調漲的結果，也是應該的。我要講的是，大家難得有機會調降費率，至於降幅多少，我沒有任何堅持的想法，但要告訴健保署，應建立良好的機制，才能擺脫政治因素的干擾，也應具有獨立性而不完全倚賴財務專家。5年的變化實在太大，健保有哪些措施是5年的計畫？預算也都是以年度作為考量。用5年財務平衡做推估，不知他們的想法為何？我認為台灣現在能看3年就不錯了。假使有人心臟夠強，就看1年也沒關係，2年我也認為可以。六、全民將健保的責任託付健保會，所有委員應思考的不是如何對自己有利，而是如何建立良好制度，留給下一代，讓健保能夠永續，這才是重要的。健保署不敢做，我們要給他力量。我認為今天只要做出調降費率的決議，至於如何調整，請健保署就細節進行思考，予以臚列。將來費率應否調整，就如同何委員語所言，就像油價帶入公式計算即可，不必勞駕委員這麼辛苦，也不必讓衛福部部長承受巨大壓力。七、希望委員把握歷史上的今天，大家要對下一代負責，而非總以健保財務穩健為由。一旦財務不穩時就調升費率，大家配合多繳錢，有何大不了？全體民眾要共同面對。在此懇求大家，希望今天能做出調降費率的決議。雖然何委員語主張調降0.5%，但我認為站在穩健角度，或許難讓各界接受，但健保署可以精算，例如採2年財務平衡，安全準備在3個月範圍內，有多少金額可用以調降費率。我認為形成機制最重要，如此將來議事才能更順暢。鄭主任委員守夏請李委員蜀平。李委員蜀平一、大家有無注意到主委一直在揉頭？因為很頭痛。我也是連署支持何委員語的提案，但現在解釋最好不調降費率之原因，請大家就健保潛藏的問題透明的討論，不要當我是精神病或表裡不一。二、健保從民國84年開辦至今，成果非凡可說非常成功名揚世界，包括美國總統歐巴馬都稱讚我國健保。為何台灣健保這麼好？因為我們有guts(膽量)，而且每位健保會委員都非常認真為健保費用把關，所以目前安全準備破紀錄高達2,157億元之多，應該有機會面對許多表面上看不到的問題，提出研究，並設法解決。台灣健保雖可稱世界第一，但是背後的隱憂，包括洗腎、RCW(呼吸照護病房)、葉克膜、達文西手術、膝關節置換、MRI(核磁共振攝影)、CT(電腦斷層攝影)、醫界五大皆空、急診待床及醫美等…問題，也是各列前茅。三、醫界代表都說醫院經營困難，但看到的仍是大醫院持續增加，而且大醫院還收購及增開了許多中小型醫院診所，以分擔整體的健保總額，這是很奇怪的問題。醫學中心及區域醫院利潤最主要來源大概是藥價差，其次是停車場、商店街及殯葬業務，但殯葬業好像在106年後即禁止，最後才是門診及住院醫療與開刀，這是本末倒置。我要講個秘密，因為自己開過5次刀，開刀期間有機會去其他病房四處聊天，探討住院開刀的病患的苦衷，後才發覺許多病患都必須除健保外另外需付自付額，非常可怕，所以合理的判斷，病患自付額可能超過健保總額的6千多億元。懇請付費者代表要幫忙多了解此問題，幫病患解決問題，若健保總額未能建立合理給付的制度，最後受害的還是病患。我們應該以全世界GDP(國內生產毛額)與本國類似的國家，與我國做醫療支付額之比較，台灣的外科醫師為何缺，是不是刀開得多，支付卻太少？為什麼我國有醫師五大皆空、為何沒有人要走進小兒科、婦產科？為什麼會有很多民意代表政府官員會破壞制度，促使醫學中心那麼多，而醫學中心門診數也特別多？可能未來又要設立準醫學中心，現在又設置重症醫院？這些目的其實都是為了能從健保費用中，獲得更高的給付，台灣真的需要那麼多大醫院嗎？四、我們應該重新檢討，請民眾與醫師一起共同珍惜健保資源。例如藥品方面，103年開始實施雲端藥歷查詢，就節省了58億元；藥師曾進行廢棄藥品的總檢查，發現一年就丟棄了近上百噸的藥，這還不是仔細的檢查，講這些話對健保署非常抱歉，當然這些廢藥中不是只有處方藥品，也有很多是民眾自行購買的成藥，或保健食品。如何讓民眾與醫師共同珍惜健保資源是很重要的議題。五、在南部一位很有名的院長，是治療手臂神經叢移植的權威，在國外一個病人手術費用約200萬元，但在台灣健保僅拿到約5萬多點，如果移植時間太長，根本就是賠錢；據悉胸腔外科的手術，健保僅給付約4萬多點，但國外則是美金4萬多元。建議健保署可參考全世界GDP與我國類似的國家，它的醫療支付價為多少，如可能再打7折或6折都可比較，未來可做為我國訂定合理支付價格的參考，希望對醫療方面問題也應該認真檢討。六、健保署應該要尊重及相信醫師的專業，對藥師及其他醫事人員，也應等同尊重其專業，並提升護理人員的薪資。因此重新訂定合理支付原則現在就是機會，讓大家可以合理使用健保、珍惜健保資源。若有發現不合理或違法，健保署就該給予重罰，此外，無效醫療也應認真探討。講了這麼多，是要呼籲大家冷靜看待這些問題，改善醫療結構，讓我國健保制度真正成為世界第一。希望未來在總額的制度下是合理與滿足，不要再有那麼多的自付額，讓病人負擔，這才是實至名歸、世界第一的健保，所以建議，先將2,157億元的安全準備，立即討論，長期無法解決的健保問題，如何解決五大皆空，護理人員、醫事人員的問題，才是根本之道。潘委員延健一、剛才謝委員天仁提到，面對健保財源受到擠壓時，醫界少有反應，其實對於健保法施行細則第45條的修正案，醫界也是反對刪除該條文，並非沒有聲音。平時醫界聲音比較少，並不代表醫界沒意見，有時是因為不夠靈敏，例如就像我經驗少反應不夠快，這一點還請諒解。二、針對健保署擬將補充保費扣費標準提高到2萬元之臨時報告案，提出3個反對理由：(一)行政院及衛福部就等於是健保的主管機關，怎麼可以不考慮健保未來的發展性，直接就因為上級或民意代表的壓力而屈服了。(二)此種調整對民眾並不公平，因僅減輕特定族群負擔，對所有民眾沒有公平一致的對待。(三)程序不符，剛剛已有很多委員提出相同看法。三、至於費率是否需調降，如同謝委員天仁所言，這是歷史性的一刻，尤其這次的調降會影響到健保未來的財務，所以不能只從目前這個時間點或今年的角度看問題，應該要有要更長遠的眼光。我非常贊成討論調整保費議題時，應有明確的制度及公式。法規中只有寫3個月的安全準備(註：健保法第78條，本保險安全準備總額，以相當於最近精算一個月至三個月之保險給付支出為原則)，只有一個數字、沒有時間，這有缺陷，使大家在只看到安全準備達到3個月的保險給付支出時，就出現各種立即反應，相對卻缺乏長期觀點的財務規劃，應有長期財務規劃之後才能談調降費率。四、剛剛很多委員提到，建立制度以後，保險費率就可類比油價調整模式般對油價進行調降或調升，但健保保費不像油價，用3點說明兩者絕對不一樣的地方：(一)醫療行為跟一般消費行為，絕對不一樣。若醫療行為可以控制，就不叫做醫療行為，人生病需要看病是沒辦法擋的，因此醫療費用一定會持續成長。尤其高齡及超高齡時代就快來臨，這會導致兩個結果，一是保費會逐漸減少，二是醫療費用會逐漸提高。根據健保署過去的統計資料，65歲以上人口每年醫療費用，是65歲以下人口年平均費用的3倍，另外，未來65歲以上人口每年至少會增加10萬人，這將使醫療費用更加速成長。必須再次強調的是，消費行為跟醫療行為完全不同。(二)整體健保的發展中，有時會有無法掌握的因素，例如臨時報告案之補充保費扣費標準即將調整；此外，已經公告的菸捐分配健保比率減少等等，這些都是無法預估的。(三)保費調整或整體健保制度改變，效應是遞延的，不會像油價那麼快產生改變。雖然目前安全準備累積這麼多金額，但當106年開始有收支虧損時，才做調整，已經太慢，因為沒有考慮到遞延的效應。五、綜上，若要調整保費，希望大家至少以3年平衡來看。照健保署的預估，收支到106年就會不平衡而開始虧損，這是大家必須要面對的事實。我們用現在有的一點小確幸，來滿足外面的要求，但2、3年後，大家就要開始嚐到苦果，這樣做對嗎？若本會現在驟然決定要調降費率，跟行政院直接宣布調整補充保費的扣費標準有何不同？這兩者其實都未深刻考量到對於健保財務的影響，懇切的請委員慎思。蔡委員宛芬一、我覺得我們被迫做了很多決定。記得在本會今年第7次委員會議，為因應「預告修正『菸品健康福利捐分配及運作辦法(草案)』」案而提出臨時報告，其主要是國健署打算將菸捐分配給健保安全準備的比率由70%降為50%，當時委員一致反對，理由很簡單，因為認為健保財務應穩健，不應該有大幅的變動。結果前幾天看到公文，國健署已經公告修訂前開辦法，菸捐分配給健保的比率還是從70%降到50%，這是衛福部的決定；另外，前幾天也看到衛福部要將補充保費的扣費標準，由原來的5千元放寬為2萬元，也就是將減少對民眾收取補充保費。二、本來在健保財務較為穩健時，可以做很多的健保改革，包括支付制度的改革等，但看起來政府不認為那是重要的，所以不讓我們有這個選擇機會。政府只想單從財務面思考，等於是逼我們僅從「是否調降費率」這件事作思考，才會促使18位委員聯名提出調降費率案，本案其來有自。三、為了避免外界老是對健保會的職權上下其手，我們勢必要有個比較完整的調整費率機制，否則類似事件會不斷發生，今天主管機關認為降低補充保費是其權限，我想這會跟菸捐的案子一樣，雖然健保會委員都反對，但最後主管機關還是照樣公告。如果衛福部是這樣的態度，為何我們不能討論費率調整？是政府在逼我們做選擇。大家應該好好討論費率調整的機制，不要再讓其他單位對健保會的職權上下其手。鄭主任委員守夏先請吳委員玉琴，再請滕委員西華。吳委員玉琴一、去年11月審議104年度費率案時，我們付費者都支持維持現行費率，因為希望健保的財務永續及穩定。但這陣子整個衛福部對健保一直上下其手，包括國健署修正菸捐分配及運作辦法等等，都是在挖牆角，使得健保財務受到影響，這點我要譴責衛福部。二、當外界看到健保的安全準備，超過了4個多月的保險給付支出時，衛福部在立法院也擋不住外力，包括金管會對特定族群做小回饋，也就是所謂的利多。若只針對擁有利息、股利、租金等這些特定族群釋放利多，為何不是向全民釋放利多？三、就某個程度來說，我們真的是被政府逼的要來討論調降費率。昨天在「105年度健保費率審議前意見諮詢會議」，健保署提供105年度保險費率審議方案資料時，一直在試圖警告，106年健保就會開始收支不平衡，但這也不是我們希望看到的。健保會負有審議保險費率的法定任務，所以我們需要很審慎的做評估，但立法院在決定時，並沒有這樣的理性討論，衛福部也沒能守住原則。四、就如同謝委員天仁所提，對費率的調整若能建立一定的公式或基準，就不會輕易發生為對部分群體施予小惠，而隨意調整的問題，這議題應該回歸以全民角度思考。健保經費充足的成果不論是來自健保費用的管控措施或總額協商的結果，應該回歸全民，費率該降的時候降，該升的時候升。這個部分若在此能有共識，我想委員們都會願意回去跟工商、勞工、社福等各自所屬團體來說明，該降就降、該升就升。不然每次在立法院，衛福部的健保財務有結餘時就令人眼紅，造成這次補充保費針對特定族群釋出利多，這是不公平的，該回歸全民時就應回歸。鄭主任委員守夏謝謝吳委員玉琴，請滕委員西華。滕委員西華一、費率是否適足很重要，其也牽涉到各項保險收入穩不穩定，補充性財源在整個保險收入的占比有多大等問題。剛才有委員提到，有兩位衛生署長因為調漲保費而下台，嚴格說來，楊前署長志良並不是因為調漲保費而下台，他是唯一漲了保費而沒有下台的署長，但他是因為不滿二代健保而求去。當年費率由4.55%調到5.17%，5.17%算是略有偏高的費率，當時我們支持的理由只有一個，就是應該做費基的改革，既然楊前署長這麼有擔當的做調漲，我們就給予支持，也希望調漲後能進行一連串的改革。二、從整體來看，無論有無補充保費等補充性財源，健保的財務收入主要還是仰賴一般費率，也就是說，一般保費才是最重要的因素，否則，一整年的補充保費也才450億元左右，約當1個月的保險給付支出。令人不解的是，若保險費率對健保這麼重要，當目前安全準備累計已超過3個月的保險給付支出，且年底將達2,200億元以上，甚至依照健保署黃署長三桂對外的說法，到明年3、4月安全準備會到達顛峰，約2,500億元，為何沒有考慮作整個健保體系的改革。三、政府也不該隨隨便便就做出降低補充保費收入的政策，部長在立法院衛環委員會明明說留給健保會討論，怎麼才隔一週，行政院長在立法院總質詢時就馬上答應調降？剛剛謝委員天仁也有提到衛福部進退失據，但似乎不僅如此，每次衛福部被霸凌，都是我們比衛福部還要生氣，好像皇帝不急，急死太監，我們旁人都還比衛福部著急啊！四、我覺得政府在健保財務充足的時候、有錢的時候，有幾件事沒有做到：沒回饋被保險人、沒提高給付涵蓋率、沒改善急重症的支付標準、沒降低民眾負擔。當健保財務困窘的時候，沒辦法做這些事，現在財務寬裕了可以做啊！例如急重症的支付標準，可以嘗試一步步改善，使達到合理支付標準；甚至引進新藥、新醫療科技或開放新適應症等，也都可以做。以前在協商總額時，因為財務考量，一直都很謹慎，如果政府能有一些規劃及宣示，是可以好好將這些事情做好，但實際上卻沒有。反而之前衛福部所規劃的政策，包括推動藥品差額負擔等，都只是增加民眾負擔，沒有回饋被保險人。五、除了沒有看到改善民眾負擔外，更沒有看到政府在財務面推動改革。例如，與其放寬補充保費扣費標準，不如直接廢除補充保費(一年影響400多億元)，直接改革一般保費的費基。雖然有人認為補充保費的設計，是為了課徵資本利得，立意多麼良好，那為何不在一般保費中，直接納入資本利得呢？一般保費才是關鍵啊！一般保費占整體保費收入的9成，保費的結構幾乎都仰賴薪資所得是不對的。姑且不論少子女化的影響，我們的所得結構也在改變，許多人就算賺不到薪資，也可靠其他收入來增加生活品質，維持生活所需。若政府打算完全用薪資所得來課徵保費，現在就可以宣布民國120年健保一定會倒，不如現在乾脆就直接宣布費率漲到10%算了。六、政府不應該說106年健保收支不平衡而會有虧損，因為保險是隨收隨付制，有結餘時又不回饋全民、改善支付標準、提高給付涵蓋，也不去做費基改革，我們當然只能被迫回應費率調整。且依據健保法第24條，本來就規定在協議訂定醫療給付費用總額後1個月提請審議費率，我們上(9)月協商總額，本月審費率也沒什麼不對，這個機制本來就存在。現在我們僅能選擇還利於民，如果醫界不贊成費率調整，那請問用甚麼還利於民？不能就把人民的錢收著、放在那裡啊！七、昨天「105年度費率審議前意見諮詢會議」，依健保署提供的105年度保險費率審議方案(草案)資料：(一)健保署平衡費率的推估(投影片第25頁)，是假設在「安全準備餘額不變」的情況，進行維持收支平衡的試算。也就是在安全準備約2,100億元的條件下，算出的平衡費率當然很高；即使如此，依據健保署的計算，就算是105年度總額支出採成長率較高的醫界版本(4.992%)來計算，105年度的平衡費率也應僅為4.77%、補充保費則是1.94%，資料可是健保署自己算的啊！(二)若保險費率維持現行的4.91%，105年度總額成長率採付費者版本4.912%或是推估基礎5.8%，相較於過去，算是較高的成長率來推估(投影片第26頁)，到了108年，安全準備都還有2.58個月。這幾年間搞不好補充保費還有可能多收，或有其他補充性財源等其他收入。因此，到108年最悲觀都還有約當2.58個月保險給付的安全準備！到底有什麼道理，健保署要恐嚇我們106年就沒有錢？八、政府如果不想調整費率，還利於民，那就請提出對被保險人有利的方案。所以我還是支持，政府應當要提出費率調整、或健保改革、或回應保險給付問題等，真正還利於民的措施。鄭主任委員守夏我們已經談了一個小時，拜託接下來的干委員文男、李委員永振，發言能儘量簡短。干委員文男一、我會簡短發言。對醫界感到很不解，之前本會在談健保財務議題時，醫界都不關心健保整體收入；而今天談到調降費率議案，似乎醫界覺得可能影響醫療費用，才群起反應。二、衛福部打算調整補充保費扣費標準的臨時報告案有問題，在本會才會引發委員眾怒。剛剛謝委員天仁、何委員語已表達很多意見我都贊同，尤其兩位委員都談到應該先進行試算再來談如何調整費率，到底合理的安全準備該設定為幾個月？如此設定的理由為何？沒有實際的數據，今天即使再開3個小時的會議也沒辦法有結論，建議應實際試算，呈現結果及理由，於下個月委員會議正式審議費率時再來討論。三、要提醒政府，保費的調整，對外界要有公平且能服眾的說法，政府說這次調整補充保費扣費基準是同情菜籃族，但實際上，獲利的並非菜籃族，而是中產階級以上的人，他們才會有股票股利、房屋租金被扣繳補充保費的其他收入！對於那些真正繳不起保費的人，到底有誰在關心？保費調降應該要全面重新檢討，依法定程序，這是健保會要討論的問題，程序一定要完備。而不要只一昧討好這些所謂菜籃族的300多萬人。請問政府，全民的選票有多少？沒錢比有錢的多太多人了，沒錢的人都不是人嗎？四、會後煩請主委代表本會接受媒體訪問，告訴外界，委員一致認為，費率調整需要重新計算，也需通盤考慮收支連動，且補充保費也是其中一環。當初立法院在審議二代健保法時，補充保費其實是「西裝換內褲(台語)」，勉強把衛生署本來要推的家戶總所得制，改為補充保費。在立法院審議時，因為家戶總所得沒辦法讓全部的人接受，很不容易才另外弄出補充保費，算是比過去一代健保時，負擔上較為公平，理由是說要讓大戶多負擔；結果現在調整補充保費扣費標準，反而是降大戶保費！這樣對嗎？講得過去嗎？這絕對是錯誤的！(主席：干委員，時間所剩不多…)我剩下兩句話而已。五、我非常期待健保能永續經營，希望主委對此案所做結論，能納入趕快建立調節財務平衡機制的概念，健保法第26條當財務失衡時有調整給付範圍的機制，但健保法並沒有講到調降費率的機制，希望下個月健保署拿出這個機制，就可化解目前困境，未來也才不會為了政治因素而鬧得不可開交，讓媒體多報導好的事情、別再報這些無謂的紛擾。鄭主任委員守夏謝謝干委員文男，再請李永振委員。李委員永振我有3點意見說明：一、首先，依照健保署的評估，遲早一定會漲保費，這次的確是唯一可調降費率的機會，我們沒有理由不調。如果調降了，未來有需要調漲時，大眾比較沒話說，而且又可以回歸健保法的規定，剛剛委員們有提出一些制度上的問題，都可納入討論，從長計議。二、本會104年第7次委員會議臨時報告第二案，對國健署預告修正菸品健康福利捐分配及運作辦法(草案)有些討論，當時所做附帶決定，已提醒政府應該要考慮健保財務之永續，但是目前看來政府似乎未有這樣的考量。三、粗算一下相關數據，供委員討論參考：(一)若依今日18位委員提案，調降費率至4.41%。綜合以下各項因素每年影響健保財務約1,020億元(550億元+220億元+250億元=1,020億元)：1.費率調降到4.41%，降幅約10%。以目前的保費收入5,500億元計算，大約會減少550億元。2.目前政府推動的幾項措施計約影響220億元，其包括修正人類免疫缺乏病毒傳染防治及感染者權益保障條例(增加支出40億元)、修正菸捐分配健保比率(減少收入66億元)、健保法施行細則第45條將中央政府實質負擔之9項費用納入計算(減少收入72億元)，加上提高補充保費扣費標準至2萬元(減少收入42億元)。3.推估保險成本增加的情況，一年大概增加250億元。(二)到今年底，依健保署推估，安全準備餘額約為2,292億元。(三)就每年健保財務多出1,020億元的負擔而言，2,292億元的安全準備餘額應可撐2年，也就是到106年年底，安全準備會剩下252億元(2,292億元-1,020億元-1,020億元=252億元)，約當0.56個月的保險給付。四、因此，若想維持3年財務平衡的話，費率似乎沒辦法降0.5%這麼多，這要麻煩健保署再算。施行二代健保以來4.91%平衡費率至少也維持了5年，若此次調降幅度可維持3年財務平衡的話，方向也算正確。張代理委員嘉訓(黃委員啟嘉代理人)一、黃委員啟嘉出國，故由我代理出席。剛剛委員有點誤解醫界，醫界對任何事情都很關心，包括保險財務問題。我們的立場並非反對建立保險費率的調整機制，依據健保法第24條，總額協議訂定後一個月，要進行平衡費率審議，以此條文來看，並非基於安全準備多寡才調整費率。請問這樣的思維，是否正確？這是想先釐清之處。二、目前安全準備已經達到2,000多億元。請看業務執行報告第11頁(表6-3全民健康保險補充保險費收繳統計表)，二代健保自102年開始徵收補充保費，所收取的總金額，到104年累計約達1,100億元左右。若扣掉補充保費的貢獻，安全準備其實沒那麼多，所以要幫衛福部講幾句話。為何衛福部要調整補充保險費？先不論程序正義、正當性、或還利於民缺乏公平性，甚至對健保會上下其手等因素，看起來衛福部是考量安全準備會有這麼多，主要是補充保費徵收了1,100億元，此點請大家參考。三、我認同謝委員天仁及其他付費者的看法，費率的調整一定要建立制度；但若今天要做出調降費率的決定，我則是持反對立場。醫界的提案是建議費率暫時不動，而且時間沒有那麼急迫，希望各方代表利用一個月的時間好好商量，到底要用什麼樣的機制來調整費率。若要下建立費率調整機制的決議，我認同，但不能就此決議調降費率。四、何委員語建議費率的調降幅度為0.5%，這是怎麼算的？我想也有專家提出其他計算結果。因此我認為調降的Evidence-based(實證基礎)還不夠，尚需再詳加細算。健保財務一定要穩定，穩定才是未來應該走的方向。因此建議決議請大家回去討論調整費率的機制並提出意見，供下次會議討論。鄭主任委員守夏請謝委員武吉，希望發言能簡短。謝委員武吉一、在場都贊成健保財務應收支連動，兩方的意見也都非常正確。我最佩服何委員語作為發起人提出本案，另外衛福部「把肉吃掉、連皮也吞了(台語：欺人太甚之意)」的確應該改善。健保本來就應該收支連動，保險收入增加了，但對支出方面卻沒有提出較好的作法。二、本會上個月協商總額，當時的會議資料第64、65頁有列出醫院收載新藥、新特材、新科技的5年累計申報費用，由該資料可知，這方面的費用少給了醫界250億元，這件事衛福部、健保署都不講，也應補足返還醫界，這才符合公平、公正與正義。三、明年開始，所有醫療人員工時都由84小時改為80小時，因此需要增加5%人力，所須新增的費用高達50、60億元也沒給，應給醫界合理的補償。四、現在政府要推動住院醫師合理工時，但並無相對的財務編列，所需要費用30、40億元，但政府都未給予醫界正面回應與積極爭取。五、媒體治國，外界頻頻批判醫界五大皆空，醫療服務方面相對較低的支付標準沒有檢討，近來有聽聞醫學生念到3年級時，覺得未來沒希望，就轉讀其他科系的情況。支付標準真的應該好好審慎評估，故五大科將來對老百姓就醫產生嚴重的困難。六、政府接下來要推動主治醫師合理工時40小時制度，但也完全沒編列相關預算因應。七、去年總額編列20億元以提升護理人力(全民健康保險提升住院護理照護品質方案)，要求醫療院所調整護理人員薪資，經衛福部事後調查，實際將增加醫院部門成本約50億元，健保署及衛福部也沒有負責補足財源，而造成血汗醫院。八、依健保法規定，應落實財務收支連動與平衡，但當收入(健保費、補充保費)足夠後，對於支出不足該補給醫界的費用，卻沒有明確提出來，才會有今天的結果。九、最後，費率究竟是要調升、調降或保持不變？我們應要請政府部門、專家學者、醫院代表及精算師等專業人員經過審慎評估該調降多少與調升多少，之後再做最後的決定，這樣比較合乎常理。鄭主任委員守夏本案已經耗費很多時間，實在是應該結束了，請何委員與簡短說明。何委員語一、各位委員，誠如楊志良教授所言，健保費率應和油價一樣，該漲就漲、該降就降，以浮動的機制做調整，這也是我們在提案裡面表達的精神。二、其次，想回應醫界，剛才所提到之不確定狀況與遞延效應等影響保險財務之因素，其實每年都有專家學者協助預估明、後年成長，幫醫界算得清清楚楚，把你們照顧及保護得太好了，都不用操煩，我建議應該由醫界來自己來評估看看。付費者在以往3年已承擔過多的保費支出，也就是已經嚐3年苦果了，希望第4年(105年)是個快樂的年度，難道還要我們繼續嚐苦果嗎？坦白說，衛福部都高估保險成本，106、107、108、109年都以105年度行政院核定的總額成長率上限5.8%推估總額預算，其實高估很多，105年至109年平均成長6.22%，高估太多支出了。三、第三，我的委員任期只到明(105)年12月31日，後年也不知道還當不當委員，所以只能決定明年底之前的費率。頂多考量到下屆任期(106、107年)，不可能考慮到108、109年之後的平衡費率。我都不知道可否活那麼久，哪能考慮那麼長時間的費率。這屆委員有這屆委員的責任，做好應該做的事情，讓下屆委員來傳承，但不該擔負下屆委員的責任，我沒有那麼偉大！四、我們付費者很關心五大皆空問題，我也向衛福部建議再提高診察費加成17%(100年已調升外、婦、兒科醫師門診診察費)，但沒有得到回覆，既然沒有滿意的結果，收我們那麼多錢做什麼？因此，建議還是要調降費率。五、我剛才已清楚表達，建議105年度保險費率降0.5%，但無論最後結果如何，都會尊重全體委員的決定。至於為什麼要訂0.5%，我可以私下算給大家看，大家就會清楚。這個月28日我會向工總提出向政府要求保險費率降0.5%的建議，如果通過，我們九大工會團體就會朝著費率降0.5%的目標努力；今天的提案是建議一定要調降費率，至於調降多少，會尊重調整機制算出來的結果。六、說到苦果，付費者已經苦3年了，希望明年起的3年讓我們喘息一下。依照衛福部的計算，明(105)年3、4月的安全準備會超過2,500億元，這還沒有加上中央應撥補的170億元。試想，如果明年公布當年3、4月的安全準備餘額有2,670億元，我們這屆的委員將是歷史罪人、全民罪人，是不盡責、不負責的健保會委員，我對工總也很虧欠。七、若費率調降，請健保署試算107年12月31日時的安全準備餘額，如果是低於1個月保險支出，我們工商團體在公開場所、媒體前都會表示同意於108年度調升費率。健保經費不足時我們就支持調升費率，絕不會卡醫界的費用或是砍醫界的支出。我們講求的是，要還給全民一個公平、公道的保費收取責任，政府不能只調降特定族群的補充保費，而不調降全民的保險費率，這樣說不過去。即使在私人企業，也不能只幫喜歡的漂亮小姐加薪水、加福利，不幫其他員工謀福利，而是一切都需要公平處理。八、最後要向醫界表明，今天你們反對調降費率的理由並不充足，畢竟不是砍醫界的醫療費用。我認為安全準備真的太多了，如果明(105)年3、4月底超過2,700億元，我們每個人鐵定都挨罵，無論是在工總或是各工會的理監事會議，不會被罵嗎？我相信會被罵得臭頭。鄭主任委員守夏謝謝何委員語。兩邊並不是完全沒有共識，綜合大家的意見供參考：一、首先，對於衛福部修改補充保費扣費標準的方式，健保會委員表示不可取、不合理。應整體考量費率與費基，才是比較恰當的做法，原則上我們表示不贊成、不支持、不應該那樣做。二、對於保費費率是否調整及如何調，兩方都有的共識是應該要建立費率調整機制。健保署之前的預估一定不準，才會導致安全準備超出預期，目前大家手邊沒有完備的試算資料，但相關決定不僅要兼顧健保財源穩健，也需符合二代健保財務收支連動精神，所以需給健保署時間去重新假設與試算。剛才說的，沒有絕對的對與錯，財務穩健當然是大家期望的，但收支連動也是新健保法的精神，依照健保法，我們應該建立財務平衡機制，好幾位委員都有相同的共識。三、我的結論比較簡單，請健保署就下列論點準備提案，本會於下個月正式討論平衡費率：(一)請提出「財務平衡與收支連動的機制和標準」，機制是指如何啟動、須經過何種程序及作業；標準是指安全準備要設定1個月、2個月、3個月或幾個月的保險給付支出？是現金基礎或權責基礎？是用什麼base(基礎)來預估？費率調漲初期一定會先有剩餘，之後則漸漸不夠，不論三年或五年之財務平衡預估，費率遲早會漲。剛才謝委員天仁所言甚是，現在大概是唯一能調降的一次機會。當然，如果下次費率預估又估不準時，可能會再歷史重演，正因為無法預知，更應該建立機制和標準，這到目前為止沒有做過，請健保署提案。(二)其次是提出「不同費率(含一般保費與補充保費)的試算版本」，其中須包含財務預估，時間可以估長一點。雖然何委員語覺得三年就足夠，但估五年也會包括三年的資料，過去精算小組以穩健為基礎，習慣是預估五年。請健保署提出各種可能方案到會討論。四、原則上，大家認為費率並非不能動，而是可以討論。至於費率要調整到何種程度，因手邊沒有試算資料，且對調整標準也未有共識，所以今天沒有辦法做決定。請何委員語。何委員語我認為結論必須呈現事實，我建議紀錄要列入「健保會委員有18位連署，建議調降105年度健保費率，至於費率調降多少，應有完整機制呈現給所有委員參考」。鄭主任委員守夏兩案的案由及提案人都會寫在紀錄上。因為另一案提案委員反對調降費率，所以我是採取兩案有共識的意見，以及可行的做法。至於付費者代表要求特別強調提案連署調降費率，不知醫界是否也會要求強調連署維持現行費率。何委員語我不反對，可以將醫界6位連署反對調降費率的委員也列入紀錄。鄭主任委員守夏發言紀錄都會列入，我認為重點應該是如何走下一步。請陳委員聽安。陳委員聽安一、我也是付費者之一，站在付費者的立場，當然支持各位所提的意見，但因為我受過經濟學訓練，經濟學大師Alfred Marshall(英國劍橋大學教授)有句名言，解決經濟問題之一的財務問題，需要有溫暖的心，還要有冷靜的頭腦。所以我時時刻刻希望老百姓能夠受惠、希望自己能夠為大眾謀福利，但另一方面也會思考錢從哪裡來啊？二、個人認為不一定要提費率降或不降的議題，而是下次委員會議，應該請健保署提出財務新制。不知大家清不清楚，我們講收支連動，當收大於支，可能是收了太多，也可能是支出太少，不一定是收得多，支出少也會不平衡。因此，我認為需要有「建立財務機制，使收支能平衡的方案」，這比單單考慮費率降或不降的議題完整，以上淺見請參考。鄭主任委員守夏請戴委員桂英。戴委員桂英一、第一點，我非常支持主席初步的結論，衛福部理應更尊重健保會的法定職責。我們有審議費率的職責，該職責與任何財務變動都有關，不差1個月，沒有非這個月一定要審議的問題，這是我的看法。二、第二點，剛才陳委員聽安的建議與主席的結論，方向其實是一樣的，相信在場委員都有溫暖的心、冷靜的頭腦。三、最後一點，向主席確認一下，何委員語應是希望在決議中能明白地敘述兩案講什麼，不是大陸跟台灣(兩岸)講什麼，而是這兩個案子講什麼，主席應該會列入吧？如果能列入，何委員大概就能放心了。鄭主任委員守夏可以，紀錄裡面兩案都會呈現。謝委員天仁不是紀錄，而是需在決議中將連署委員的意思表達出來。講得直白一點，何委員語的意思是，要告訴所有人已經有18位健保會委員連署了，怎麼投票都會過，也希望健保署考量相關的方案。鄭主任委員守夏了解！請吳委員肖琪。吳委員肖琪想再釐清，應該是說這18位健保會委員連署的是收支連動，而非調降保費。我們支持收支連動，而不是只支持降費率這件事。謝委員天仁吳委員(肖琪)，您誤會了，誤會了，我們提案的案由寫得很清楚，是主張調降健保費率。何委員語一、第一點，吳委員肖琪沒有連署，怎麼可以更正連署內容，這樣是不對的，完全違反我們提案的宗旨跟精髓。二、第二點，我今天從頭到尾都沒有要動用會議規範(表決)來做決議，其實我們的提案有18位委員連署，已經超過健保會委員的半數，我沒要求動用會議規範，已經很仁慈了。三、我今天沒有堅持一定要降0.5%，表示我也理解健保制度的運作。上個月蔡副署長淑鈴應該也有聽到我的發言，為五大皆空問題，我建議診察費應再調升17%以上，但是蔡副署長沒有正式回應，只說以後再看看，我也是有考量到健保制度問題；當年剛進健保會比較傻，我提議診察費調升20%，最後變成17%，也不清楚為何如此。四、我的要求就是將「健保會委員有18位連署建議調降105年度健保費率」列入會議紀錄，也同意將「醫界代表6位連署105年度健保費率維持不動」列入會議紀錄，謝謝！鄭主任委員守夏好，還需要再討論嗎？(委員：不用，已經很清楚了。)滕委員西華提個建議，很多媒體都很關心此案，我們也不希望由個別委員表示意見，建議其結論由主席代表健保會統一對外發言，好不好？(委員鼓掌)我們也很困擾，會上沒有明確結論，下個月才要再討論，搞得各個團體必須在外面表示意見，這會逼得我們在外面講重話。外界都知道健保會今天在討論費率問題，很多委員媒體電話接不完，本案是重大議案，媒體正在下面等，各位委員支不支持請主任委員統一對外發言，表達健保會的決議。戴委員桂英那就偏勞主委了。何委員語我也接到電視台電話，我說健保會決議由主委發言，工商團體意見由工總發言，謝謝！鄭主任委員守夏你們都很為難，主委去就不為難喔！(委員大笑！)謝委員天仁我們要建立機制。(委員大笑！)鄭主任委員守夏一、依照本會組成及議事辦法第14條，會議決議事項，經主任委員認有立即對外說明之必要時，應由其本人或指定人員統一發布。因為兩案意見不同，比較難指定發言人員，不然就指定學者(委員：不行啦，學者的意見也跟我們不一樣。)好好，等一下我去好了。二、請幕僚問一下公關室媒體方便的時間，我們開完會大概4點半或5點了，看他們是否要等或是我們中間break(休息)一下。我們需要趕快進入討論案，請蔡委員宛芬。蔡委員宛芬我想問，剛剛主席提到臨時報告案「利息、股利、租金及執行業務收入補充保險費扣費標準提高到2萬元案」要併臨時提案討論，所以是要等臨時提案結束後再做結論，還是現在一起做結論？鄭主任委員守夏就在這邊做結論，剛才我已經說過，原則上我們都不贊成。蔡委員宛芬是反對嘛？鄭主任委員守夏基本上報告案並不是尋求我們同意或不同意。蔡委員宛芬就是表達我們的意見。鄭主任委員守夏對。蔡委員宛芬所以決議是反對嘛，我只是確認。鄭主任委員守夏好，如果沒問題，我們就進行討論事項第一案，請同仁宣讀。伍、討論事項第一案「105年度牙醫門診總額一般服務之地區預算分配案」與會人員發言實錄同仁宣讀鄭主任委員守夏請牙醫師公會全聯會理事長陳委員義聰說明。陳委員義聰主席、各位委員大家好，為節省大家時間，我就重點說明。簡單講，我們由一般服務預算移撥4.253億元，主要用於「偏鄉、醫療資源不足地區、弱勢到宅等服務」、「提升一般民眾就醫可近性，例如希望醫院能開辦急診，服務假日牙痛的民眾」、「強化牙周病統合照護第3階段服務，提升醫療品質、辦理口腔癌、口腔黏膜篩檢」並且「對就醫率最高的2區做一點點補貼，以求內部平衡」，細節部分會與健保署進一步討論，謝謝大家！吳委員肖琪請問一下，補貼內部平衡部分，大概需多少經費，補在哪些區？我還是要幫大家問一下。陳委員義聰經費列在會議補充資料第3頁三之(五)，分別以1千萬及5百萬元，挹注全國投保人口就醫率最高的中區與高屏區，經費總計1,500萬元。鄭主任委員守夏請問委員還有沒有意見？牙醫部門的R值(各地區校正人口風險後保險對象人數占率)早已達到100%的目標。目前是另外移撥一筆專門款項辦理特定項目。請問各位委員是不是同意(委員：同意)，有關計畫內容與細節請牙醫部門再與健保署共同討論，健保署有沒有意見？沒有意見，第一案就通過。接著進行討論事項第二案，請同仁宣讀。陸、討論事項第二案「105年度中醫門診總額一般服務之地區預算分配案」與會人員發言實錄同仁宣讀鄭主任委員守夏各位委員應該有拿到剛才中醫師公會全國聯合會分送的資料，請何委員永成說明。何委員永成一、主席、蔡副署長、各位委員、各位長官大家好，各位手上有本會對「105年度中醫門診總額一般服務之地區預算分配案」的說明資料，這是我們在本年10月18日召開中執會(中醫門診醫療服務審查執行會)第16次會議的結論。雖然結論這周才出來，但事實上，為了105年度的地區預算分配，我們內部已經研議了一年多，而且也邀請許多教授、專家、學者給予指導。二、中醫部門也希望地區預算分配，能依照衛福部的指示朝著「錢跟著人走」的方向前進，以照顧偏鄉、辦理巡迴醫療、減少無中醫鄉等，但礙於6區分配困難，每年分配會議上爭議很多，主要原因是中醫與其他總額部門不同。位於台中市的中國醫藥大學，幾十年來培養出許多中醫師，因此在台中市執業的中醫師也特別多，光中國醫藥大學附設醫院的中醫師就高達70多人，比苗栗縣、新竹縣的中醫師還多；中國醫藥大學附設醫院就像醫學中心一樣，特別有號召力，吸引鄰近縣市患者湧入求診，因此中區的利用率、平均每位病患的醫療費用也特別高。因為台中市的關係，「錢跟著人走」的政策很難推動。三、在一年前，中醫內部開始研擬地區預算分配方式，最後提出三個方案，經過票選後，決定採用施常務理事純全提出的方案，該方案主要希望打破6區的框架，將預算分配到22縣市。「錢跟著人走」政策的推動，最困難的是中區及台中市，如果我們按照「錢跟著人走」分配地區預算，中區減少的預算並不是分配到苗栗縣、新竹縣等醫師少的地區，反而是分配到醫師多、人口多的桃園縣、臺北市。中區受傷最重的不是台中市，而是與台中市綁一起的南投縣，可能台中市的中醫師還在，但偏鄉多的南投縣，醫師已經跑光了，這是此政策最大的盲點。四、未來希望在「錢跟著人走」的政策之下，也能多加強偏鄉、無中醫鄉的資源。改以22縣市分配地區預算的制度已經提出來了，但尚未試算，預計明(105)年第1季總額點數統計出來之後，再修正一下方案，如果沒有太大落差就推動實施，時間上可能會稍微delay(延後)一些。我們會邀請專家、學者、健保署一起推動新方案，希望這個方案可以成功。鄭主任委員守夏謝謝何委員永成的說明，請翻到會議資料第58、59頁，今天需要討論這6項分配參數的個別占率，先請委員表示意見，有無大原則要先提，請蔡委員登順。蔡委員登順一、從何委員的報告中，感受到中醫總額以人口占率分配預算的難度，中醫沒有住診，無法與其他部門相提並論，但對吳委員肖琪的看法予以尊重。二、「錢跟著人走」的政策在別部門都有配合推動，但其在中醫門診總額實施是對的嗎？因人口結構改變，推行此政策會使偏鄉及中醫師數高的區域點值更低，中醫師更不願去偏鄉服務。如同何委員永成所談，都會區工商業發達、就業容易，每年有許多青壯年人口遷往都會區，資源也隨著往都會區移動，再加上青壯年比較健康，就診率低，所以都會區點值較高；而其他縣市及偏鄉的醫療資源相對缺乏，偏鄉人口以老人及兒童居多，就診率、利用率相對偏高，點值當然下降，反而造成更多的不公平。三、雖然分配公式除人口占率外，還有其他調整的參數，但仍無法彌補人口結構改變造成的預算缺口，除非公式重新修正能調解不公平問題，人口占率才能往前進。我個人支持何委員永成的看法，在沒有更好的機制下，反對中醫總額繼續推行「錢跟著人走」的政策，另外中執會(中醫門診醫療服務審查執行會)已經有共識方案，建議就尊重他們的決議。鄭主任委員守夏謝謝蔡委員登順，請吳委員肖琪。吳委員肖琪一、大家好，請大家看會議資料第49頁倒數第四行字，牙醫門診總額地區預算「100%依各地區校正口風險後之保險對象人數」(R值)分配，所以是依據6分區人口數多寡，有多少人口就拿多少預算。牙醫也是歷經八年時間漸進，才走到100%依照R值分配地區預算。二、這幾年我對各部門總額地區預算的分配，看法都是一致的。雖然醫院部門囿於醫院設立後，有住院病床難以在區域間移動的先天因素，但也應該慢慢有依人口數分配區域總額的概念，才不會任由每個地方拼命蓋醫院、設病床的情形繼續存在。至於門診部分，牙醫已走到100%依照R值分配預算、醫院R值占率是46%、西醫基層是65%，然而中醫的人口占率只有7%。7%還是去年勉強拜託的結果，去年就認為人口占率應該提升到10%或15%；如果中醫部門總額的人口占率再不往前進，偏鄉資源無法發展，基於就醫習慣，以後就很難讓這些不使用中醫的偏鄉民眾會想利用中醫看病了。三、請看到會議資料第58、59頁，請問6個地區預算分配指標中，哪個指標跟牙醫部門一樣，是依照每個區的人口數分配預算？理想上，預算分配應該依據「人口數」而不是「利用率」，若以利用率分配預算，會促使醫療利用集中在都會區。在我看來，6個指標當中，只有指標2「各區去年同期人口數占率」符合人口數概念(R值)，而其他指標都還是以「醫療利用」為主，因此應該增加指標2的比重。四、個人支持依22縣市分配地區預算的方向，如果能這樣做，就可依照各縣市的需求細緻分配資源，會真正幫到偏鄉，而且也許能比牙醫部門做得更好，因非僅依6區分配。五、不過以中醫目前地區預算的分配參數及占率看來，醫療利用多的地區可分配較多預算，這樣是不對的。若以「錢跟著人走」的方式，苗栗縣會以其人口數來計算費用，則會有比現在更多的預算分配到苗栗縣，所以才能吸引更多的醫師願意去資源不足的苗栗縣開業。六、理論上人口占率(R值)應該要前進到100%，但對醫院部門，我不敢要求要達100%。就中醫診所而言，地區預算分配公式中人口占率不應該只有7%，希望「各區戶籍人口數占率」這項分配指標的占率應該提高。現在參數是直接用戶籍人口數計算，並沒有依照實際情形做校正(如：跨區就醫者預算回歸就醫分區，或校正人口年齡性別指數)，用校正後的人口數也許會比較好。戴委員桂英現在鄭主任委員正在接電話，我代理一下主席，請楊委員芸蘋。楊委員芸蘋一、有關剛才討論的臨時討論案，每位委員都講得很好，所以我都支持，但特別支持謝委員天仁之發言，需要建立一個費率調整的機制，以利費率審議。二、對於本案，剛剛吳委員肖琪所言我也頗為認同，但比較支持蔡委員登順的論點，因為中醫的特性與別部門不同，各區的醫療資源分布不平均，尤其是中區，中醫師多但人口數少。若「錢跟著人走」，對人口數少的地區不公平，可能會讓中區(包括彰化、南投)多數中醫師診所關門，無法再經營。三、其實中醫診所要經營得很好，也是蠻難的。這次中醫師公會全國聯合會(中全會)內部會議也討論過很多版本，最後才選出方案，委員是否也應尊重中全會的決定，畢竟他們才是實際的經營者，比較清楚要怎麼經營。四、希望中醫部門要符合社會大眾的期望，要做得更好，但不能浪費資源。戴委員桂英謝謝楊委員芸蘋，請何委員語。何委員語現在要稱呼戴委員為代理主席，中醫的醫病關係比較特別，跟西醫不一樣，所以應該要重新建立一個有效、合理的制度。建議中全會應該要制定一個更完善的體制，也建議健保署考量中醫特別的醫病型態，另外規劃一個合適的方案。我也支持中全會今日之提案，我們要用不同的角度來看待中醫，不可將西醫的模式硬套在中醫身上。鄭主任委員守夏剛剛是晚報記者來電話，由於晚報下午1點半截稿，所以須先接其電話。謝謝戴委員桂英擔任臨時主席。大家似乎還沒有一致的共識，請問委員有無其他意見，請健保署表示意見，執行面有無困難？蔡副署長淑鈴一、中醫地區預算分配是四個總額部門中最困難的，因為其醫療資源分布最不均，中區及台北區的中醫師最多，其他區相對比較少。對地區預算分配，原希望「人口占率」參數的比率逐年提高，但就中醫部門而言，這是個難題。二、健保保費是綜合費率，其中也包含中醫的部分，若大家對於中醫的醫療需求是等同的話，則理論上中醫醫療資源就應該要均勻分配，這樣的分配效果最理想。但是過去十年來，人口占率一直無法向上提高，以至於資源分布無法得到真正的改善，這是目前的問題。三、最近幾年使用中醫的人數在減少，但有使用中醫的病人，看診次數及醫療金額是上升的，這些問題出現在醫療利用較多或醫師較多的分區，以致其醫療費用不斷成長。中醫地區預算分配公式中，除第2項指標「各區戶籍人口數占率」外，其他指標都是從「醫療利用」的角度分配費用。四、剛剛中全會所發的資料，希望細分到22縣市，這在技術上非常複雜，是否需要分到這麼細？過去只分到6區，確實在同一區內，會有醫療資源較豐富的縣市及較不豐富的縣市，四個總額都有此問題，這也不是只有中醫部門才出現的問題。是否中醫的問題特別嚴重？我也相信確實比較嚴重。現在新中醫師的執業地點，就是集中人口多的都會區。五、建議人口占率還是要往前進，才能促進中醫醫療資源分配更平均些，至少會比過去前進。若人口占率不前進，則促進資源均衡分布的力量會很小。若人口占率可以提高，則中醫師多的分區，點值相對會降低，可給中醫界ㄧ些壓力。這是現實，也是委員需要決定及取捨的地方。六、對於中全會擬分到22個縣市乙節，建議是否考慮在預算分配到分區前，先提撥一筆預算分給資源較不足的縣市，這是現在牙醫部門的做法。或者依照人口占率往前進，預算分配到各區後，再由各區提撥一部分費用到其資源較不足的縣市，這都是比較可行的做法。如果要讓全民的中醫就醫權利逐漸趨於公平，對於中醫資源的分布，就需有導引力量來讓其更均勻，所以建議人口占率應往前進。有關技術上的問題，若有決議，健保署可以跟中全會再做細部的溝通與討論。鄭主任委員守夏一、請問委員還有意見？中醫地區預算分配一直是令人頭痛的問題，也就是希望人口占率(R值)前進的速度可加快，並能保障特定地區的點值。目前醫療資源集中在中區，尤其是台中市，其分配的預算較少，點值較低，但中區還涵蓋彰化與南投，其實醫療利用率高的地區是台中市，因為中國醫藥大學附設醫院就設立在台中市，結果彰化縣跟南投縣就跟著點值低。二、到底人口占率(R值)是否要往前進，以「錢跟著人走」方式分配預算，若效果不大，是否可能跟牙醫部門一樣，針對特定地區加強，如對中區的彰化縣、南投縣，給予特殊的保護或補償，看是先在全國或中區提撥一筆預算，不論是需要1%、2%、3%，都可以談，健保署也很有經驗。從過去分配就可知道哪些地區之預算不足，哪些地區需要鼓勵，至少執行面牙醫部門做得還不錯，可以考慮一下。三、何委員永成提出預算直接分配22縣市，若是這樣，健保署可能很難操作，所以個人建議不要破壞現行6分區的分配架構，如果有特別需要加強的地區，可以考慮剛剛蔡副署長的建議。四、對於人口占率(R值)是否要往前進，一直以來都不容易有共識，就算前進也可能只有1%，說實話其影響只有一點點，但這是象徵性的表示制度就是要這樣推動。雖然何委員語說委員任期才兩年，但這屬於制度面，如果認為這制度方向是好的，我們就盡可能維持，讓制度延續下去；也可以讓以後的中醫學系畢業生知道，這制度是不會變的，鼓勵離開都會區，若下一屆委員共識也很強，這政策就有延續性，中醫部門內部對何委員永成所做的決策，也就不會有太大的反抗聲。五、請委員參看會議資料第70頁，104年的「各區戶籍人口數占率」為7%，實際上非常低，其與「各區實際收入預算占率」參數之占率如何調整值得考量，至於其他4項參數的影響則都不大。吳委員肖琪認為「錢跟著人走」的政策，前進速度可以慢，但非常希望政策不要變，這樣的話，也可以讓何委員永成回去好交代。這部分是否有委員要表示意見？請謝委員天仁。謝委員天仁一、老實講這是個很為難的議題，外界對我們做這樣的引導是否會領情？因為每位消費者有自己的選擇權，所以各分區之就醫行為存在不同特性。若人口占率(R值)往前進，能夠呈現效果就繼續推；但假使無法呈現效果，我們將人口占率(R值)硬向前推進，就某個角度來看，資源配置反會失當，而使想尋求中醫治療模式的付費者受到排擠，這應不是我們想要的。二、中醫醫療需求在整個消費者的偏好中，不是那麼均勻，可能人口占率(R值)在過去5年內前進的幅度就已經到頂了(89年7月至94年照衛生署交付方案，依R值、S值兩項參數之權重分配地區預算)，若還要將人口占率(R值)硬向前推進，而使資源錯置，其實不見得會有效果，必須務實面對人口占率(R值)可能到頂的事實，而非一直往前進。三、我不認為中醫可以創造付費者的需求，想看中醫的人本來就會去看，不想看中醫的人，叫他去看，他也不會去。一直往前推人口占率(R值)，可能是沒有效果也或者是不好的效果，那為何要這樣繼續往前進呢？四、建議採用「觀察一段時間的執行情形再做檢討」的做法，並且研擬一個機制，先規劃人口占率(R值)要往前進幾年，並觀察這樣配置是否適當，若不行再做些調整。至於短期內(明年)該怎麼做，我認為若沒有比較好的方法，當然就照原來的機制，主委建議可比照牙醫部門，將一部分的預算先挪出來保障特定地區，我認為也可以考慮。鄭主任委員守夏謝謝，請吳委員肖琪。吳委員肖琪一、大家希望醫療資源不要只集中在都會區，中醫醫療資源均勻分布的效果一直顯現不出來，就是因為人口占率(R值)停留在7%，若是已經前進到10%、15%，效果就出來了。二、大家會覺得這幾年好像我始終在推中醫的人口占率往前進，其實是因為看到中醫的就診人數一直在萎縮。但如果大家同意中醫的人口占率停止前進，我沒有任何意見，今年是最後一次提人口占率是否要往前進，以後不想也不會再提了。鄭主任委員守夏一、這個就是難題所在，牙醫部門照規劃很快在8年內人口占率(R值)就前進到100%，相信當初牙醫內部也不是沒有抗議的聲浪。雖不敢說效果是否非常明顯，但保證會有效果。了解中醫部門希望人口占率盡可能不要再往前進，而內部意見其實也不一致，但人口占率才7%，事實上怎麼期望能有什麼效果。二、誠如剛剛謝委員天仁所提，制度需要觀察，不是馬上叫中醫部門明年要做什麼。這時候就不能說委員任期只有兩年，因為改變需要時間，所以我們可以提出往後5年人口占率從7%往前進到多少百分比的主張，這樣效果就很明確。每次何委員永成開會都很辛苦，回去一定會被部門的其他人責罵，若人口占率前進1%就罵一次，2%就罵兩次，誰當理事長都一樣。既然我們都是健保會的委員，吳委員肖琪大概已經不想多說，健保會委員共有35位，只有吳委員肖琪不斷要求人口占率(R值)要往前進，讓她感到有些無奈。三、再問一次，委員是否希望人口占率(R值)往前進，讓新的中醫師願意離開都會區，往資源較少的地區開業；或是認為中醫門診屬性特殊，人口占率(R值)不宜再前進，本屆委員就不要再談人口占率前進之事。人口占率(R值)之分配方式已推行多年，其中以中醫部門最辛苦，在場多位資深委員都相當了解，若把中醫與牙醫部門放在一起比較，應可以看出進步的情形。地區預算分配以「錢跟著人走」為概念，期望保障民眾就醫的公平性。四、最後一次詢問委員，中醫是否比照牙醫及西醫部門，要用總額地區預算的分配機制來誘導中醫醫療資源均勻分布，以漸進方式，增進地區預算分配公式之「人口占率」。請滕委員西華。滕委員西華一、我覺得要。剛剛提到的問題是一體兩面，不可能只有好處沒有缺點，人口占率(R值)應該提高，但是提高到多少才能有顯著進步，是由7%前進至12%嗎？中醫部門不可能從7%一次調高至20、30%，希望健保署提供以往經驗或資料，供委員參考。二、我們都知道，若沒有壓力，醫師開業偏好不會改變。誠如主席所言，只要設定年限，例如3~5年，讓人口占率(R值)提升至預訂比率，醫師及病人都會慢慢適應，但我們要確保能承擔這段改革期所產生的風險。相信何委員永成一定很為難，若何委員不為難，就是下一任的理事長為難。與其每任理事長都為難，不如讓健保會來為難，建議以3年為期，請健保署提供資料，計算R值並設定預期目標。鄭主任委員守夏請蔡委員登順。蔡委員登順一、基本上，人口占率(R值)應該前進，也可考慮主席所提，比照牙醫提撥一筆預算補足人口結構改變的缺口。青壯年人口往都會區移動，偏鄉留下來的多為老幼人口，醫療使用率相對較高。另外，中區中醫師人數較多，而這些都會造成該區點值下降。所以若公式中原本的參數無法彌補人口結構改變，就要研擬新的調整參數。二、建議應建立機制讓人口占率(R值)能往前走，若今年無法提出合適的公式或機制時，建議人口占率(R值)先維持不動。當提出合適的公式或好的機制時，再往前進。因為其他部門人口占率(R值)往前進，中醫部門當然也不能例外。中醫內部應該先達成共識，或與健保署合作研擬，讓人口占率(R值)發揮實質的功能。鄭主任委員守夏一、因為手邊沒資料，是否請健保署試算，人口占率(R值)前進比率與影響點值的數據。若有試算結果再來看如何處理較好。各年度醫療給付費用總額及其分配方式之協定結果，公告期程為12月份，建議中醫門診總額一般服務之地區預算分配案下個月再討論，並請健保署協助試算 (健保署回應︰好)。二、接下來，請吳委員肖琪代理主持會議，我受各位之託，要去向記者們說明今天委員會議對健保費率的看法。拜託吳委員肖琪。柒、討論事項第三案「105年度西醫基層總額一般服務之地區預算分配案」與會人員發言實錄吳委員肖琪(代理主席)請主席儘快回來！請參看會議資料第72頁，第三案是有關西醫基層總額一般服務之地區預算分配案，請問委員對本案有無意見？去年我曾說過，如果中醫門診地區預算的R值未前進，我對西醫基層部門就沒意見，不會要求R值前進。張代理委員嘉訓(黃委員啟嘉代理人)是否請幕僚人員先宣讀提案？吳委員肖琪(代理主席)請同仁宣讀。同仁宣讀吳委員肖琪(代理主席)謝謝同仁宣讀。請張代理委員嘉訓先說明。張代理委員嘉訓(黃委員啟嘉代理人)一、謝謝主席！謹代表西醫基層部門發表意見，西醫基層自98~104年R值就一直停留在65%，沒有變。我們認為以R值和S值比率分配地區預算有其一定效益，西醫基層總額之地區預算分配，基本原則是希望6區點值差異性不要過大，所以自98年起，會先提撥一部分預算到點值較差的地區。二、健保會對105年R值(65%)的意見是適度往前進，但我們認為不宜再往前進。請參看會議資料第75頁表1-1及1-2試算表，若R值比率由65%往前進至66%或67%，甚至70%，只有北區之預算成長率一枝獨秀；當R值比率落於65%，除東區外，對其他分區而言是最好的情況。若R值比率由65%往前進，可能獨獨嘉惠北區，但在6區之中，北區點值排名約第3名，R值往前進對其他分區是不公平的，尤其點值都是倒數第一、第二名的台北區與中區。三、我們希望R值比率停留在65%，不要再前進。西醫基層在各分區的分配上，仍然會考量偏遠地區的民眾需求，也非常鼓勵醫師到人口較少的地區執業，所以98~104年，東區點值幾乎維持在1。至於R與S值的公式，我不是很清楚當時的計算邏輯，「人跟著錢走」或「錢跟著人走」，是以論人的概念分配預算嗎？當時公式設計應該是以此為概念。四、台灣交通非常方便，加上就醫可近性很高，故就醫之流動性非常高，是否有必要堅持R值(人口占率)須像牙醫門診總額一樣推至100%？10月25日我們將召開會議討論105年度地區預算分配，請否容許我們內部再討論。另外，會議資料第75頁[表1-1 105年度西醫基層總額一般服務地區預算模擬試算表(未比照104年提撥5.5千萬元予東區)]有矛盾之處，當R值增加時，東區預算反變成負成長而須再補錢給他們，公式有討論之必要。吳委員肖琪(代理主席)請問付費者委員是否有其他看法？蔡委員登順對張代理委員嘉訓所言，頗有同感。「錢跟著人走」的政策是對的，但實務操作起來，會有很多問題。誠如張代理委員所提，如貫徹「錢跟著人走」，因東部很多年輕人到大都會地區工作，而大都會地區的壯年人口就醫率又較低，撥予較多醫療資源，他們也不會因此而多使用，反而是留在東部地區的老年人、幼童，需要用到較多的醫療資源，使得該區的點值變低，造成醫師更不願意去開業。能否從分配參數中，設調整機制來處理這個問題，以彌補人口結構改變的預算缺口。目前分配公式並未有此調整機制，建議再審慎規劃，我支持張代理委員的論述。吳委員肖琪(代理主席)一、回應張代理委員嘉訓所提，如R值繼續往前走，就是論人計酬的概念。此外，老年人口需用的醫療資源較多，因此需要進行費用校正，亦即利用校正參數來反映需求，老年人用的多，就分配較多醫療資源；年輕人用的少，相對分配較少醫療資源，而非單純以人頭數計算醫療費用。東區屬偏鄉且幅地很大，如實施論人計酬，對該區須有特別考量。二、張代理委員嘉訓希望可以讓西醫基層內部開會討論，委員如無其他意見，則同意本案延至下個月會議再討論。柯執行秘書桂女請西醫基層總額部門配合，於11月份的委員會議必須定案。張代理委員嘉訓(黃委員啟嘉代理人)10月25日我們將開會討論。吳委員肖琪(代理主席)好，進行下一案，請同仁宣讀。捌、討論事項第四案「105年度醫院總額一般服務之地區預算分配案」與會人員發言實錄同仁宣讀吳委員肖琪(代理主席)謝謝同仁宣讀，請醫院部門代表說明。潘委員延健每年總額協商後，都會討論地區預算分配，每次討論時心情都非常糾結。在總額不足情況下，很難討論分配的問題，6分區之中，一定是有些分得多，有些分得少。以醫院協會、醫學中心協會的角度來看，我們的醫院是分布在6個區，一定是反對R值往前進的多、贊成R值往前進的少。若以意見代表性而言，醫院部門反對R值往前；若從邏輯性角度，S值為總額開辦前1年各地區實際發生醫療費用比率，至今6區醫療費用的結構已不同於以往，且是很大的不同，故本項存有討論空間。在去年醫院協會討論地區預算分配的會議上，3層級醫院對地區預算分配方式已有共識，我就不再多言，等一下由楊委員漢湶說明。謝委員武吉其實每次談到R值，我們的心就糾結、痛苦。為面對這個痛苦，醫院協會也召開會議討論過，我們以最平常的心來對待醫院協會的同仁夥伴，希望能多多為全國老百姓來服務，提升服務品質與效率。還是由楊委員漢湶說明醫院地區預算分配方式。楊委員漢湶去年討論R值時，有人說我很勇敢地答應將住診服務的人口占率由40%調整為41%，因住診服務的人口占率40%已維持7年，我認為各區人口成長程度甚有差距，不調整也不對，故去年同意將其調整為41%。雖只調整1%，但一定會影響到內部的分配，這是免不了的。我並不是鐵金剛，雖有吵吵鬧鬧，但也謝謝大家的支持。今年我反覆研究各區點值變化等相關資料，是有些差距，但不太大，所以現階段不適合再調整人口占率。建議維持現制，即門診與住診服務之人口占率分別為46%與41%。吳委員肖琪(代理主席)其他委員有無意見。(未有委員表示有意見)若大家都沒意見，則本案通過，105年度醫院總額一般服務之地區預算分配，維持104年分配方式，門診、住院服務之人口占率分別為46%與41%。楊委員漢湶各地區之醫院型態不同，而住院會跨區就醫的機會較大，資料看起來，台北區的預算成長會較低。若為了拉高台北，將會得罪所有醫院，故我主張維持去年的人口占率。滕委員西華一、不是只有人口占率調整的問題，明年將全面導入DRGs(住院疾病診斷關聯群)，住診部分將會受影響；假若回應醫界延緩導入之建議，明年不導入，後年也會導入。同意楊委員漢湶所言，醫院總額的額度很大，R值變動1%，影響範圍就很大，但我覺得每年討論不是很好，建議配合DRGs全部導入對住診費用的變化，請醫院協會提早因應，例如至少規劃3年，如果等到明年再來討論，會有一點慢，所以建請醫院協會與健保署儘早討論全面導入DRGs後，可能會產生的醫療費用分配變化，特別是對3層級醫院的醫療費用分布，也應進行評估。二、依核減率來看，層級越上面的醫院核減越少，地區醫院的核減率稍微高一點，以後是否會因為DRGs全面實施而影響核減率？這部分可能比中醫門診總額還要複雜，因為醫院總額預算太大了，醫院代表楊委員漢湶、謝委員武吉及潘委員延健都在場，這部分可否提早討論？楊委員漢湶一、謝謝滕委員西華的意見！她真的把醫院看得很清楚，我向滕委員與所有委員說明，其實我們目前正在準備健保署的兩個偉大計畫，即是DRGs與ICD-10-CM/PCS(國際疾病與相關健康問題統計分類第十版臨床修訂及處置代碼系統)的實施。另外還有「論人計酬試辦計畫」，以後名稱修改為「區域醫療整合性計畫」。醫院的同仁都很忙，經常不知道政策上有何改變，因此，醫院協會須經常舉辦說明會教導醫院同仁，這些工作我們都已經在進行，日後會產生甚麼變化，現在還沒辦法說明。二、醫院協會並未反對全面實施DRGs，而是強調實施必須有配套措施。全面實施DRGs，對醫院會有相當大的衝擊，基本上我們一直都在做準備。醫學中心可能沒有問題，但並非每家醫院都像醫學中心，有些醫院沒有那麼多行政人力。我們一再提醒各醫院，希望他們清楚這個計畫，且知道如何正確申報醫療費用。DRGs已實施2個階段，對醫院有造成一些影響，全面實施後，可能會產生更大的衝擊，須再收集一段時間的數據，包括每家醫院收入的成長，才能知道實際影響。但可以預期，對醫學中心的衝擊一定比對小醫院大。說了這麼多，基本上是同意滕委員西華的意見，明年有新數據時再來討論。吳委員肖琪(代理主席)謝謝滕委員西華的提醒，DRGs的影響確實是很重要的議題，需密切觀察注意，尤其是各層級醫院如何因應全面實施DRGs。現在即應開始模擬其對醫院的衝擊，不要等到發生問題後才做評估。目前醫院協會是希望R值維持現狀，若委員無其他意見，請健保署回應。蔡副署長淑鈴一、醫院總額的地區預算分配，因為人口在改變及移動，部分分區長期訴求增加人口占率，但多數分區則希望維持現狀。醫院協會內部已做過溝通，健保署尊重醫院協會及委員的決定。二、至於明年DRGs全面實施後，是否會對醫院分區總額產生影響，必須經過實證才知道。行為的改變必須用實際證據來證明，可以等到明年年底全面實施一段時間，再來看，所以DRGs是否會對分區總額有影響，明年討論時就有數據做基礎。這部分建議可寫入決議以提前觀察，若有甚麼影響，明年實施後再討論。吳委員肖琪(代理主席)如果大家同意，就依剛剛委員的建議，明年提早讓我們知道執行情況。如果沒有其他問題就進入下一案，請看議程資料第100頁，討論事項第五案「105年度全民健康保險抑制資源不當耗用改善方案」，請同仁宣讀。滕委員西華請問這個討論案有無急迫性？可否移至下次(11月)委員會議討論，因為有些委員已經離開了(有委員回應︰移至下次委員會議討論)。吳委員肖琪(代理主席)好，這個討論案好像不急！似乎大家都同意移至下次委員會議討論。柯執行秘書桂女這個討論案是健保署依法每年必須提送下年度的抑制資源不當耗用改善方案至本會討論，若健保署同意就可以移至下次委員會議討論。蔡副署長淑鈴這個案子不急，同意移至下次委員會議討論。吳委員肖琪(代理主席)請問有無其他臨時動議？柯執行秘書桂女還有一個專案報告「『全民健康保險醫療辦法』第11、12、18條修正草案」需要提報。玖、專案報告「『全民健康保險醫療辦法』第11、12、18條修正草案研議報告」與會人員發言實錄吳委員肖琪(代理主席)這個報告案請問要進行報告，還是委員可以帶回去看？謝委員天仁這個專案有適法性的問題，健保法第51條規定很清楚，本來健保給付的項目，現在要將部分給付除外，依照該條第12款規定，法定流程是要提至健保會審議後才能實施。本案涉及保險對象於急診就醫時自行負擔費用範圍，也就是健保不給付項目，不能單純只以修訂全民健康保險醫療辦法處理，這會造成法律上的衝突。按照健保法第51條的程序，要提到健保會審議，若沒提到健保會審議，不可去修訂相關部分，基本上會有問題，請問這法案是衛福部公告？蔡副署長淑鈴還沒公告。謝委員天仁這個流程有問題，行政程序違反健保法第51條規定。吳委員肖琪(代理主席)請健保署說明。蔡副署長淑鈴有關全民健康保險醫療辦法的修正，之前委員會議已討論，並提供很多意見，經參酌委員意見修正後，再提至本會徵詢委員意見。剛剛謝委員天仁有提醒，因為醫療辦法修正涉及健保不給付的部分。其是否應該先回到健保法第51條討論，等有共識再修醫療辦法，本署會去考慮優先順序，最終還是回到制度面處理。吳委員肖琪(代理主席)謝謝健保署的說明。若各位沒有臨時動議，本次會議到此結束，謝謝大家！PAGE 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