衛生福利部全民健康保險會第2屆105年第6次委員會議議事錄中華民國105年6月24日衛生福利部全民健康保險會第2屆105年第6次委員會議紀錄壹、時間：中華民國105年6月24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 語何委員永成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)李委員來希李委員蜀平中華民國藥師公會全國聯合會古監事會召集人博仁(代)林委員至美 國家發展委員會陳專員靜雯(13:00以後代)林委員敏華林委員惠芳陽光社會福利基金會馬董事長海霞(代)邱委員泰源 中華民國醫師公會全國聯合會張副秘書長孟源(12:55以後代)侯委員彩鳳 中華民國勞工聯盟總會陳監事會召集人順來(代)張委員文龍張委員煥禎張委員澤芸黃委員啟嘉陳委員幸敏陳委員義聰中華民國牙醫師公會全國聯合會陳常務理事彥廷(代)陳委員聽安楊委員芸蘋楊委員漢湶葉委員宗義趙委員銘圓蔡委員宛芬潘委員延健滕委員西華謝委員天仁謝委員武吉羅委員紀琼肆、請假委員：黃委員偉堯陳委員平基莊委員志強伍、列席人員：本部社會保險司楊副司長慧芬中央健康保險署李署長伯璋 蔡副署長淑鈴 施組長如亮本會周執行秘書淑婉張副執行秘書友珊洪組長慧茹陳組長燕鈴陸、主席：戴主任委員桂英 紀錄：馬文娟、曾幼筑柒、主席致詞各位委員、健保署李署長及所有與會者，大家早！首先介紹新任的邱委員泰源，渠為中華民國醫師公會全國聯合會新任理事長，目前擔任國立臺灣大學醫學院教授及附設醫院主治醫師，歡迎邱委員的加入。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5)次委員會議紀錄，請鑒察。決定：一、修正「玖、議程確認」之「…流『應』疫情等相關非預期疾病發生所產生之醫療費用…」文字，為「…流『感』疫情等相關非預期疾病發生所產生之醫療費用…」。餘確定。二、有關「健保藥品政策研究小組」之成員名單及其運作方式，應先經本會討論通過後，再進行後續相關事宜。第二案案由：本會上(第5)次委員會議決議(定)事項辦理情形及重要業務報告，請鑒察。決定：一、上次委員會議決議(定)事項辦理情形：(一)追蹤項次3，非常感謝滕委員西華及所有參與立法院拜會小組之委員，對於「全民健康保險法施行細則第45條條文修法案」所投注之心力，能達目前進展，誠屬不易。本項繼續追蹤至衛生福利部完成修法程序後再行解除。(二)追蹤項次7，請中央健康保險署持續與立法院溝通及爭取預算，以利「健保藥品品質監測計畫」之執行，本項維持繼續追蹤。(三)餘洽悉。二、歷次委員會議未結案件辦理情形：除追蹤項次1解除追蹤外，餘均繼續追蹤。第三案案由：中央健康保險署提報「105年度西醫基層總額品質保證保留款實施方案」(草案)修訂內容，請鑒察。決定：「105年度西醫基層總額品質保證保留款實施方案」洽悉，請中央健康保險署依法定程序辦理後續事宜。第四案案由：中央健康保險署提報「全民健康保險中醫門診總額兒童過敏性鼻炎照護試辦計畫」(草案)之辦理情形，請鑒察。決定：請中央健康保險署會同中醫門診總額相關團體盡速擬訂計畫草案，並於7月底前提經本會通過後，預算始得動支。第五案案由：中央健康保險署「105年5月份全民健康保險業務執行報告」，請鑒察。決定：本案洽悉，委員所關注事項請中央健康保險署列入下次業務執行報告(含口頭報告)內容。拾、討論事項第一案提案單位：本會第三組案由：106年度總額協商程序案，提請討論。決議：照所擬草案通過。訂定106年度總額協商程序如附件一。第二案提案單位：本會第三組案由：106年度總額協商通則案，提請討論。決議：一、照所擬草案增列「五、其他預算：除總額協商已議定事項外，各項目之預算不得相互流用」乙項通則，餘照案通過。訂定106年度總額協商通則如附件二。二、有關六、其他原則之「(四)醫療照護整合與效率提升成效之效益，部分用以獎勵醫療服務提供者，部分回歸保險對象」乙項通則，其效益額度應於年度總額協商時，經保險醫事服務提供者及保險付費者代表委員確認。第三案提案人：干委員文男、謝委員天仁、何委員語、葉委員宗義、李委員永振、張委員文龍、李委員成家、趙委員銘圓、李委員來希、楊委員芸蘋、陳委員平基、莊委員志強、林委員敏華、侯委員彩鳯、李委員蜀平代表類別：保險付費者代表、保險醫事服務提供者代表案由：建請修改全民健康保險會組成及議事辦法第5條條文：健保會委員任期為二年，保險付費者代表及保險醫事服務提供者代表之委員，以連任一次為原則，每一屆並應至少更替五分之一；委員連署建議刪除「以連任一次為原則」和「每一屆並應至少更替五分之一」的限制文字，提請討論。決議：「全民健康保險會組成及議事辦法」係主管機關(衛生福利部)依據全民健康保險法第5條第5項授權訂定，委員所提意見，送請衛生福利部納入研修參考。第四案提案單位：本會第二組案由：「健保會討論自付差額特材案之作業流程，及健保署提案需檢附之基本資料表、檢核表」(草案)，提請討論。決議：一、將本會討論自付差額特材案之時程，由「半年討論1次」，調整為「每季討論1次」；並於「(3)醫療科技評估報告之重點」中納入「醫療倫理考量之相關資料」，餘照案通過。修訂「健保會討論自付差額特材案之作業流程」如附件三。二、請中央健康保險署於提案時填具自付差額特材品項「基本資料表」、「檢核表」，連同所提供之參考資料，照作業流程所列時程送會；並於各品項開放半年後及每年12月依「檢討改善報告內容」提報各該檢討改善結果。第五案提案人：趙委員銘圓、干委員文男、楊委員芸蘋、何委員語、侯委員彩鳳代表類別：保險付費者代表案由：建請中央健康保險署針對新型C肝口服藥與藥廠議價後，已取得與現行療程相等之治療費用前提下，應優先將新型C肝口服藥物納入健保給付，爭取國內C肝患者提早完成治癒，同步考量預算排擠問題，建請健保署編列足夠C肝治療預算，以提供穩定經費，期使治療政策吻合患者需求，確保國人健康案，提請討論。決議：委員所提意見，提供中央健康保險署於「全民健康保險藥物給付項目及支付標準共同擬訂會議」討論相關議案時參考。第六案提案人：趙委員銘圓、干委員文男、楊委員芸蘋、何委員語、侯委員彩鳳代表類別：保險付費者代表案由：建請中央健康保險署針對菸品健康福利捐分配於全民健康保險之安全準備金從70%調整至50%一事，重新審視其調整的比例，目前健保署提出105年健保收支餘絀預估值為負117億元，之後會由健保安全準備金來填補，如此一來健保安全準備金將每年被吞噬，最後回到過去赤字的狀況，再者，目前菸捐分配比率方式有違最初支應長照的原則，將其餘17%使用至非長照使用項目，有鑑於此，是否應將非使用在長照中的17%回歸到健保安全準備金中，提請討論。決議：菸品健康福利捐分配予全民健康保險安全準備之比率，前由70%調整為50%，委員建請將20%調降比率中，未運用於長期照顧資源發展之17%回歸健保安全準備之意見，送請衛生福利部參酌。拾壹、專案報告第一案報告單位：中央健康保險署案由：「全民健康保險藥品費用分配比率目標制」試辦方案執行成果，請鑒察。決定：委員所提建議請中央健康保險署參酌，並提供相關書面說明。第二案報告單位：中央健康保險署案由：全民健康保險業務監理指標之監測結果報告，請鑒察。主席裁定：保留至下次委員會議報告。第三案報告單位：中央健康保險署案由：DRGs相關診斷分類分組由ICD-9-CM轉換為ICD-10-CM/PCS之執行情形，請鑒察。主席裁定：保留至下次委員會議報告。拾貳、散會：下午2時。4912360-328295附件一00附件一106年度總額協商程序第2屆105年第4次及第6次委員會議(105.4.22及6.24)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106年度總額協商架構、通案性原則及協商程序。105年5月27日6月24日2.建立協商參考資料：(1)編具「全民健康保險醫療給付費用總額協商參考指標要覽-105年版」。(2)編具「全民健保各部門總額執行成果摘要-105年版」。105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104年度協定事項執行情形。4.106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。105年7月28、29日105年7月22日 (或8月26日)5.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。105年8月6.安排總額協商之相關座談會/會前會。(1)召開106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106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。105年8月26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。(3)另視需要召開座談會。105年8~9月105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。105年9月23~24日2.協定各部門總額一般服務費用之分配方式(地區預算)。105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。105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。105年10月~106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(105)年9月23日(星期五)及24日(星期六)上午，共一天半。(二)工作內容：1.協商共識會議(9月23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24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。5210175-248285附件二00附件二106年度總額協商通則第2屆105年第6次委員會議(105.6.24)通過一、基期以穩定為原則。若確需變動，應於前一年6月前提經議定；6月以後所議定調整事項，適用於下年度總額。二、醫療服務成本及人口因素各總額部門醫療服務成本及人口因素成長率，採衛福部報奉行政院核定之數值與計算公式。三、協商因素(一)健保署會同各總額部門研擬之年度協商草案：1.應配合全民健保財務狀況，回歸以提供醫療服務為意旨。2.給付項目之調整，請依本會第2屆104年第2次(104.3.27)委員會議討論通過之「全民健康保險年度總額對給付項目調整之作業原則與流程」辦理。(二)各部門之「品質保證保留款」：1.金額應全數用於鼓勵提升醫療品質，並以最近2年(105、106年)該保留款成長率之累計額度為限，其餘額度回歸一般服務預算。2.考量各部門對「品質保證保留款」之運用方式各異，同意總額部門於取得內部共識後，可視需要由一般服務移列部分預算至品質保證保留款，並須提經本會通過。(三)違反全民健康保險醫事服務機構特約及管理辦法之扣款：1.列為協商減項，但僅減列民眾檢舉及健保署主動查核所發現之違規案件，不減列總額受託單位或總額相關團體發揮同儕制約精神而主動舉發之案件。2.本項扣款，採計104年度資料，數值以協商時中央健康保險署提供者為準。(四)一般服務之協商因素項目屬計畫型預算者，應於年度實施前提出具體實施及監控方案(含預定達成目標及評估指標)，執行情形應即時檢討；若未能如期實施且可歸因於該總額部門，則應核扣當年度預算；實施成效並納入下年度總額協商考量。(五)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，請健保署會同各部門總額相關團體議定後送本會同意後執行。 四、專款專用項目(一)回歸原協定意旨，採零基預算直接協定預算額度，且其款項不得以任何理由流出。實施成效納入下年度總額協商考量。(二)新增計畫，視行政院所核定總額範圍及計畫需要，決定是否支持該計畫並協定預算。具體實施方案(含預定達成目標及評估指標)應於年度實施前擬定完成。(三)有特殊性、鼓勵性、目標性之新增計畫，宜列為專款項目，俟其執行具相當成效後，再移至一般服務項目。五、其他預算除總額協商已議定事項外，各項目之預算不得相互流用。六、其他原則(一)年度總額成長率及相關原則，經協定後不能再以任何理由或方式變動之。但書：醫療費用總額經衛福部核定後，對已協定各項目金額之增減應正式提案，在本會議決前，並應再經總額部門與付費者代表協定程序。(二)年度全民健康保險醫療給付費用成長率，應在行政院核定範圍內。(三)所協商總額應與社會經濟因素及全民健保保費收入情形連動，且對有限健保資源，應予合理配置。(四)醫療照護整合與效率提升成效之效益，部分用以獎勵醫療服務提供者，部分回歸保險對象。(五)對已協定之試辦性計畫，應嚴格監控，並提出評估報告供委員於協商時參考，若成效不佳即應退場；各項新計畫應有相對之退場機制。5335905-368300附件三00附件三健保會討論自付差額特材案之作業流程第1屆103年第3次委員會議(103.3.28)訂定第1屆103年第5次委員會議(103.5.23)修訂附表第2屆105年第6次委員會議(105.6.24)修訂程序時程說明1.健保署將提案送會3月1日前6月1日前9月1日前12月1日前健保署：將提案送會（含健保署提案需檢附之自付差額特材品項「基本資料表」、「檢核表」及參考資料）。(基本資料表如表一，檢核表如表二)2.本會幕僚檢視提案內容3月20日前4月10日前6月20日前7月10日前9月20日前10月10日前12月20日前次年1月10日前本會幕僚：檢視提案內容是否完整，並得視需要洽請本會專家學者委員提供建議，若資料不完備，再洽請健保署補充。健保署：提供補充資料。3.送請委員參閱4月15日前7月15日前10月15日前次年1月15日前本會幕僚：彙整各自付差額特材品項案之資料，送請委員參閱。4.委員會議討論5月8月11月次年2月本會幕僚：排入議程。委員會議：討論提案。健保署：參酌委員意見，依法報主管機關核定公告。5.健保署向委員會議報告各品項開放半年後之檢討改善情形次年5或12月份委員會議健保署：依「開放初期之檢討改善報告內容」提報委員會議。(報告內容如附件)本會幕僚：排入議程。6.健保署向委員會議報告整體檢討改善情形次年12月份委員會議健保署：依「整體檢討改善報告內容」提報委員會議。(報告內容如附件)本會幕僚：排入議程。註：議案排入委員會議討論或報告時間，得配合屆時議程之安排，酌予調整。4368377-114935附件三之表一00附件三之表一健保署提案需檢附之自付差額特材品項「基本資料表」我國資料項目自付差額品項健保全額給付品項(註2)1.基本資料名稱(特材代碼)許可證字號核准日期上市日期2.特性功能類別用途（適應症）相對效果（療效）相對風險（安全性）3.價格價格分布(NT)自費醫材比價網(參考資料1)中位數： (P2)最大值： 最小值： 平均值： 健保支付點數： (P1) 價格差距價格倍數(P2/P1) ： 以中位數估算民眾自付差額額度(P2-P1)： 4.健保財務影響評估提案當年預算提案當年度總額之新特材預算： 提案前已支用額度： 納入前後預估使用量前3年之預估使用量(自費)： 、 、 自付差額品項納入後預估3~5年之申報量： 、 、 前3年之申報量： 、 、 自付差額品項納入後預估3~5年之申報量： 、 、 納入後預估新增費用自付差額品項納入後，預估3~5年合計(含自付差額品項及全額給付品項)之新增費用： 、 、 5.同意納入自付差額特材之理由(參考註3填列) (1)綜合考量「2.特性」、「3.價格」及「4.健保財務影響評估」後，同意納入自付差額特材之理由： (2)摘述共同擬訂會議之結論(紀錄如參考資料2)： (3)醫療科技評估報告之重點(含醫療倫理考量之相關資料，評估報告如參考資料3)： (4)其他參考資料： 他國資料(註4)項目自付差額品項1.基本資料國別上市年度保險是否給付保險支付價/市價2.價格分布(NT)中位數：國別 / 元最大值：國別 / 元最小值：國別 / 元平均值：國別 / 元3.價格差距(註5)國家： 、 、 、 、 價格倍數範圍： 倍～ 倍健保署填報部門： 填報人： 日期： 連絡電話： 註1：本表價格均以新臺幣呈現。註2：健保全額給付品項如有1項以上，可增列供參。註3：本品項較相同用途且健保已納入全額給付之既有特材，有下列附加之功能或效果之一，且價格昂貴經認定無法納入全額給付者：□增加耐久性： □增加病人使用方便性： □有利於監控病情： □增加與特定設備或儀器之相容性： □因客製化而增加美觀或舒適性： □增加安全性(或改善副作用)： □其他醫療功能外之附加效果： □其他可改善醫療或生活品質之功效： 註4：他國資料以全民健康保險藥物給付項目及支付標準第52條之3所列之國家(韓國、日本、美國、澳洲)為優先呈現對象，其次為其他具官方公開網站可供查詢的國家價格。註5：請依我國資料「1.基本資料」之「名稱」欄所列2種品項，計算該國之價格差距；若無資料請說明。4266565-318135附件三之表二00附件三之表二健保署提案需檢附之自付差額特材品項「檢核表」為增進健保會討論自付差額特材議案之效率，並保障民眾基本權益及兼顧健保財務，爰以本檢核表就「資料完備」、「程序完備」、「保險對象權益保障」、「實證資料足以佐證」、「價格未偏離國際行情」等項目，協助檢視該品項宜否列入自付差額特材。本表由健保署先行填列，作為健保會討論之參據。檢核項目符合項目請打V，未符合項目請說明1.資料完備(1)完整填列基本資料表(2)提供我國醫療科技評估(HTA)報告 2.程序完備提經「藥物給付項目及支付標準共同擬訂會議」通過，並檢附會議紀錄3.保險對象權益保障(1)目前全額給付品項已提供基本照顧功能(2)未有「因病情需要，一定須使用本自付差額特材品項」者4.實證資料足以佐證已提供足夠且明確之實證資料，足以支持本自付差額品項較健保全額給付品項，其附加之功能或效果較佳5.價格未偏離國際行情本自付差額特材品項在自費醫材比價網之中位數，未高於國際價格之中位數或平均數健保署填報部門： 填報人： 日期： 連絡電話： 4097443-356023附件三之附件00附件三之附件健保署提報之「檢討改善報告內容」一、健保署於自付差額特材品項開放半年後，應提報各該品項「開放初期之檢討改善報告」，至少包含以下內容：(一)開放前、後病患的利用量及點數成長分析(含選用自付差額品項及全額給付相同用途品項之比較)。(二)醫事服務機構的收費情形(含健保署彙整各院所之收費標準，並置於網站供民眾查詢)。(三)民眾對自付差額特材的反映事項。(四)對哪些項目啟動檢討改善機制(含訂定自付差額上限之規劃)。(五)對健保財務之影響評估：預估值(3~5年)與實際值之比較。二、健保署每年12月應提報自付差額特材「整體檢討改善報告」，至少包含以下內容：(一)自付差額特材品項利用情形：現行各自付差額品項之申報數量及點數成長情形比較(含自付差額特材占率)。(二)相關管理規範之執行情形：醫事服務機構的收費情形、事前充分告知(療效及價格)，及資訊公開等病人權益保障措施。(三)醫事服務機構的收費情形，及訂定自付差額上限之規劃與執行情形。(四)自付差額特材品項改列全額給付之規劃情形：經健保署持續監測療效、安全性及成本效益，若有結合療效提升及價格下降之新事證，或已成為常規使用者，應檢討是否改列全額給付之時程，及其財源預估。(五)對健保財務之影響評估：預估值(3~5年)與實際值之比較。第2屆105年第6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5)次委員會議紀錄」周執行秘書淑婉報告主任委員、各位委員及所有與會者，現在委員出席人數已過半，達法定開會人數，請示主任委員是否宣布召開今天的委員會議。戴主任委員桂英一、各位委員早安！(委員回應：早)剛剛周執行秘書淑婉說明已可召開今天的委員會議。會議開始前，先介紹新任邱委員泰源(邱委員起立致意，委員拍手表示歡迎)，邱委員是中華民國醫師公會全國聯合會新任理事長，由該會推薦擔任本會委員，渠現任台大醫學院教授及台大醫院主治醫師，歡迎邱委員的加入。二、接著進行議程確認，本次會議共安排5項例行報告案、6項討論案及3項專案報告，請教各位委員對於今天議程的安排有無意見？(委員表示沒有意見)若無意見，則依議程安排進行。謝謝！現在進行例行報告第一案。三、第一案是「確認本會上(第5)次委員會議紀錄」，因議事錄已於會前寄送委員參閱，請問大家對上次會議紀錄內容有無修正意見？有2位委員舉手，請發言。蔡委員宛芬上次會議最後曾討論到「健保藥品政策研究小組」相關事宜，但紀錄並未呈現，是否表示其非正式決議？當時討論時曾提到藥品政策小組的運作方式須提報本會確認，是否須俟計畫送會後再進行確認，或是已經要正式成立？李委員永振對會議紀錄內容沒有意見，但有個文字可能是誤植，需要修正。請委員參閱會議資料第4頁，議程確認決定文字的倒數第三行，第三案「流應…」，應是「流感…」，否則和第7頁第三案案由「流感…」不一致。戴主任委員桂英謝謝！請周執行秘書淑婉先回應。周執行秘書淑婉蔡委員宛芬所提有關前次會議紀錄未呈現「健保藥品政策研究小組」部分，因討論時主席表示其不屬於臨時動議，僅就本(105)年2月份委員會議決議的處理事項交換意見，故未納入前次會議紀錄之決議事項；至於李委員永振所提意見，將遵照辦理。戴主任委員桂英感謝2位委員，就依周執行秘書的回應處理。請蔡委員宛芬。蔡委員宛芬一、會這樣問是因為李委員蜀平已草擬「健保藥品政策研究小組」計畫，內容我們沒看過，也不知道要討論什麼？但令人遺憾的是，小組名單並未先徵詢委員本人即逕予列入。二、建議該小組若要進行相關的討論，是否先確認小組成員名單及目標、內容等事項，會較為正式。否則在不清楚草案內容情況下，若業務單位未能掌握該小組會議時間及成員，或討論議題為本會不宜討論事項等，恐不合宜。建議本案納入會議追蹤事項，該小組參與委員及討論議題先至本會確認，再授權其進行後續之討論，將可事半功倍。戴主任委員桂英謝謝！追蹤事項列入蔡委員宛芬的意見，對本會的運作非常正向。「健保藥品政策研究小組」之運作方式及參與成員，應先在本會討論通過後，再進行後續事宜。蔡委員宛芬幫滕委員西華補充說明，因「健保藥品政策研究小組」草案所列成員包含滕委員及本人，她特別表示不參加該小組，並請列入紀錄。該草案並未事先徵詢滕委員及本人意見，就將我們的名字列入，並不妥當。戴主任委員桂英一、謝謝蔡委員宛芬協助滕委員西華說明，這部分列入紀錄。會議紀錄於修改部分文字後確認。二、接下來進行例行報告第二案，請周執行秘書淑婉報告「本會上次委員會議決議(定)事項辦理情形及重要業務報告」。貳、例行報告第二案「本會上(第5)次委員會議決議(定)事項辦理情形及重要業務報告」與會人員發言實錄周執行秘書淑婉請委員參閱會議資料第15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6點說明：一、說明一，上次委員會議決議(定)事項之8事項，依目前的會議資料，辦理情形建議解除追蹤為1項，但本日的補充資料已更新為解除追蹤2項，繼續追蹤由7項修正為6項，但最後仍依委員議定結果辦理。詳細的資料請委員參閱會議資料第17至19頁及補充資料第1至3頁之附表，以下謹就辦理情形簡要說明：(一)第1項，有關本(105)年4月26日修正發布的「全民健康保險辦理自付差額特殊材料之作業原則」，健保署已經依照委員意見暫緩實施，也在6月1日註銷公告，建議解除追蹤。(二)第2、3、5、7項等一下再參閱補充資料。請委員參閱會議資料第8頁第4項，有關「106年度全民健康保險醫療給付費用總額範圍」(草案)，衛福部已於本年5月11日函陳行政院，行政院也已送請國發會審查中。前次會議委員關心委員會議中所提意見是否有上呈行政院，社保司表示所有委員意見都已隨函附上。(三)第6項，有關「全民健康保險醫院總額品質保證保留款實施方案」，希望於實施1年後提出成效檢討報告，委員所提建議也納入106年方案研修參考，健保署將遵照辦理。(四)第8項，在會議資料第19頁，有關「其他預期政策改變及調節非預期風險所需經費」動支程序及評估指標應予檢討修正，我們會遵照辦理，並於完成檢討後再解除追蹤。(五)接下來請各位委員參閱補充資料第1頁，第2項是有關「向金融監督管理委員會表達反對運用健保卡處理非健保法規定之事務」，健保署已進行函稿的陳核，主要內容為對於整體機制尚未建置周延，且未達社會共識前，相關運用健保卡處理非健保法規定之事務，不予同意。(六)第3項，有關「全民健康保險法施行細則第45條條文」修法案，本會已安排部長於本年5月27日蒞會聆聽各委員的意見；另6月1日滕委員西華、謝委員天仁、干委員文男、何委員語及李委員永振等5位，也出席林立法委員淑芬及吳立法委員玉琴召開的協調會；6月22日林立法委員淑芬也安排在社會福利及衛生環境委員會，進行修正草案之審查，決議略以：1.第73條第2項發布追溯至104年1月1日施行部分，更正為自105年1月1日施行。2.第45條第1項第2款政府依法負擔之9項保費，刪除「失業被保險人及其眷屬健保費」及「經濟弱勢者健保費」之補助。(七)第5項，有關張委員煥禎所提核減率的呈現方式，健保署回覆現行自主管理方案為分區業務組與轄區特約醫院，依不同期間討論方案內容與管理指標，並依醫院是否違約、是否達成管理目標而定，若要進行分析有一定困難，署也於6月14日至壢新醫院與張委員進行溝通，等一下請健保署補充說明。(八)第7項，關於「健保藥品品質監測計畫」部分，委員所提有關投標廠商資格、利益迴避及檢驗品項等建議，將納入後續研議之參考。預算部分因仍在立法院審查，健保署回覆立法院已決議減列相關費用300萬元及凍結2,000萬元，目前仍有提案待黨團協商，將依立法院預算審核結果辦理。二、煩請各位委員再回到會議資料第15頁，說明二針對歷次會議未結案件辦理情形，依例應每半年彙報乙次，各項案件中，有些已納入本年度工作計畫項目，將依預定時程提報。截至5月底，未結案件計10項，依辦理情形建議解除追蹤3項，繼續追蹤7項，以下簡要報告，請委員參閱會議資料第20頁：(一)第1項，有關自由經貿區開放對醫療人力及全民健保之衝擊，醫事司回覆該特別條例尚未經立法院審查通過，所以已暫緩實施，建議解除追蹤。(二)第2項，針對政府欠費之溝通並依法辦理部分，健保署回應目前僅北、高二市政府積欠101年以前健保費補助款，已移行政執行並分別查封部分土地，該二市政府均已提出償還計畫，目前僅高雄市政府應償還38.98億元，尚有11.83億元未償還，後續將繼續溝通追償欠費及配合確保健保債權等行政執行作業。本項建議解除追蹤，辦理情形納入每月業務報告。(三)第3項，有關長期醫護人力改善計畫，衛福部醫事司與護理及健康照護司都有回應，醫事司已提出醫事人力規劃(如第23頁)，護理人員部分則有「護理改革近中長程計畫」(如第27頁)，請各位委員參閱，本項建議解除追蹤。(四)第4項，有關按月提供醫學中心、區域醫院之門、住診初(次)級照護及下轉等數據資料部分，健保署希望在預算許可下以委託計畫辦理研究分析。(五)第5項，對新藥、新特殊材料、新診療服務及放寬藥品適應症等項目，進行財務影響評估及替代效應分析，健保署希望蒐集完整案例及委託研究後再提報。(六)第6項，有關與部長建立定期對話溝通機制部分，社保司回覆部長已於本年5月27日至本會拜會，未來將視需要安排，建議解除追蹤。(七)第7項，關於「治療淺股動脈狹窄之塗藥裝置」自付差額特殊材料案，健保署回覆依委員意見，於實施1年後檢討是否訂定自付差額上限。(八)第8項，有關初級照護定義，健保署回覆已於106年編列相關研究，若預算通過，研究成果將作為後續政策擬定之參考。(九)第9項，對蔡前委員登順聘任資格事宜，國健署宜有正面回應之意見，目前仍持續與該署溝通當中。(十)第10項，有關「強制汽車責任保險法第27條條文修正草案」，3月下旬健保署已由李副署長丞華帶隊拜會提案委員李應元，建議維持現行條文不予修正，但因李委員目前已就任環保署署長，該修正草案後續若排入財政委員會審查，健保署將主動、即時提報本會。三、請各位委員再翻到會議資料第15頁說明三，中醫師公會全國聯合會於本年5月25、26日辦理「105年度全民健康保險中醫門診總額醫療資源不足地區改善方案」訪查，活動報告如第95頁，請委員參閱。四、說明四，牙醫師公會全國聯合會於本年6月2、3日針對「牙醫門診總額醫療資源不足地區改善方案」及「牙醫門診總額特殊醫療服務計畫」辦理參訪活動，報告如第99頁，請各位委員參閱。五、說明五，有關「104年全民健康保險年度監測結果報告書」，由本會與健保署合作編製，業與本次會議資料併送委員參考，也列入本次會議專案報告第二案。六、說明六，健保署本年3至6月份發布及副知本會之相關資訊如下：(一)本年6月1日註銷「全民健康保險辦理自付差額特殊材料之作業原則」，本案係參考本會5月份委員會意見處理，將持續蒐集各方意見再做修正。(二)本年6月4日公告修訂「牙醫門診加強感染管制實施方案」，並自105年7月1日起實施。依前次會議委員意見，幕僚須將修訂重點做簡單摘要，該方案主要針對考評不合格者及調整抽查比率部分進行調整。(三)本年6月6日公告105年「全民健康保險中醫門診總額乳癌、肝癌門診加強照護計畫」，新增承辦院所及醫師名單，計13家參與院所及22位中醫師。(四)本年3至5月公告暫予支付及修正「全民健康保險藥物給付項目及支付標準」部分項目，計藥品9件及特材9件，詳細資料請各位委員參閱會議資料第111頁。(五)104年第4季各部門總額每點支付金額，請各位委員參閱會議資料第113至125頁，以上報告。戴主任委員桂英謝謝周執行秘書淑婉非常用心的報告，包括上次會議決議(定)事項辦理情形、歷次委員會議未結案件半年內之辦理情形、各醫師公會團體安排的參訪活動，及健保署副知本會之相關資訊等，請問委員針對本報告案有無詢問？有3位委員舉手，先請滕委員西華。滕委員西華一、謝謝主席！各位委員大家早安，關於上次委員會議決議(定)事項辦理情形之其中2項，先談追蹤事項第3項，係有關全民健康保險法施行細則第45條修法案，6月22日上午我和干委員文男都在立法院社會福利及衛生環境委員會。誠如周執行秘書淑婉的報告，立法院對健保法施行細則的決議案，建議應退回第73條溯及既往的條文；對於第45條部分建議行政部門修正，刪除「失業被保險人及其眷屬健保費」及「經濟弱勢者健保費」2項。若退回第73條，主計總處須歸還104年的116億元；而2項政府依其他法令規定補助的健保費，如果從原本的9項中移除，每年將為被保險人爭取回來8億元的經費，本人謹代表健保會的立法院拜會小組，宣布此任務告一段落。二、當然很抱歉無法完全達到本會的期望，將這9項政府依其他法令規定補助的健保費全部保留在健保經費中，但還是要在此表達，當天在立法院向委員及部長報告時，還是重申健保會的立場是這9項都不應該算進去，因為這9項除了2項基金項目，雖然我的見解和社保司不同，這9項原本是政府代繳被保險人的保費，不是政府負擔，這是第一點澄清。第二點，這些保費原本是計算在64%裡面，也就是政府負擔不得少於36%以外的部分，都是付費者代表要負擔，包括雇主及被保險人，因此其在健保法原本就是計算在這64%當中。現在這7項已被重複計算在36%內。未來將如何處理我不清楚，但可以確定的是，如果健保每年其他的福利服務項目再擴張，因施行細則第45條並無指定項目，而是指其他法令規定，如果有規定全部都要納入36%，因此我們確定至少短收66億元。在此也謝謝大家這麼辛苦，我們在立法院也盡力了，只能保住這樣的費用，因為本項要解除追蹤，希望以上發言能列入會議紀錄。三、上次委員會議例行報告第4案，即追蹤事項第7項，有關「健保藥品品質監測計畫」(草案)，我查了立法院的凍結文書提案，健保署的說明好像不太對。確實立法院是刪了300萬元及凍結2,000萬元，但並無指定項目，所以在總額協商金額中，還是有錢可以進行藥品品質監測計畫，不宜以被凍結2,000萬元或刪除300萬元為由，而暫停執行該計畫，因為立法院並未指定不能執行，而要刪減該計畫的費用，在整體額度是匡定300萬元及凍結2,000萬元，當然還要經由立法院預算協商。請健保署及早執行該計畫，因為已經快7月，不要再以立法院預算案協商為理由，停止該計畫的執行，並不妥適。戴主任委員桂英謝謝滕委員西華，接下來請干委員文男。干委員文男一、接續滕委員西華的發言，謝謝很多委員為了健保法施行細則第45條修法案，跑立法院二、三趟，除向黨團報告了2次，最後1次在院會，也利用政黨關係請立法委員協助，在此特別謝謝滕委員西華的努力，本修法案最後才能翻盤，要不然本案要翻盤的機會，少之又少。二、感謝部長願意溝通再溝通，如果不溝通，我們也不會同意以這種方式妥協，因為仍損失60幾億元，對健保並不公平。但部長表示我們雖沒占便宜，但至少少吃一點虧，我們才同意最後的決定，當時在立法院會議室內不方便溝通，還移到走廊交換意見，最後才確定目前的結果。三、也要特別提醒衛福部，不要動不動就溯及既往，所有立法院的法規，沒有溯及既往向老百姓要錢的，如果是提供福利則另當別論。希望以後不要再發生類似情形，不然勞師動眾，對大家都不好。最後還是感謝所有參與的委員，對本次的結果，雖不滿意，但沒辦法還是得接受。戴主任委員桂英謝謝干委員文男，請李委員永振。李委員永振謝謝主席，以下有4點建議：一、剛才滕委員西華提到健保法施行細則第45條修正案，很遺憾我們原本期待減少更多，但沒辦法只能接受最後的結果。但有2點要注意：(一)第1點，剛才滕委員也有提到，將來若新增其他法令規定，補助項目是否會再增加，這是隱形的，我們不得不留意，不一定就是目前這7項而已，宜思考如果再增加項目應如何因應。(二)第2點，剛才滕委員提到的金額，依據媒體報導，去年的實際數是74億元，但要補回116億元，不清楚116億元是如何計算？我參考了去年8月提委員會議的資料，去年政府依其他法令規定補助健保費是72億元，而主計總處和健保署之間的差異是112億元，故應是74億元除以0.64，以此回推則為116億元。但用這種算法值得商榷，請健保署再行考慮，因為主計總處和健保署的看法，這9項的費用74億元，是保險對象先繳給健保署，再由政府補貼給他，因此照理講健保署和主計總處的算法，差異只是74億元而已，當然去年另外的42億元也沒有進來，所以去年要追回116億元是沒問題。(三)但未來刪除2項後，我試算了一下約68~69億元，雖媒體說省了8億元，但依我的推估應該只省5億元，計算方法是5億元除以0.64，所以是8億元，其中差異的3億元是本來就要繳的，因為這7項繳進來後，政府相對36%要進來，這是沒有辦法省的。(四)所以現在116億元這樣計算的話，連36%都省掉了，這是不對的，這點若不釐清，若以69億元除以0.64，就是要扣106~107億元，這樣健保的安全準備又少掉30幾億元。請健保署再行釐清，你們的主張和主計總處沒有差那麼多，但去年是將36%扣掉，追回116億元是正確的，特此聲明。二、依上次會議決議(定)事項第3項，「106年度全民健康保險醫療給付費用總額範圍」(草案)已送國發會審查中，但健保署業務執行報告顯示，今年5月份收支餘絀仍是負值，所以今年的保險收支已有3個月呈現收入不足，健保署是否應該重新檢討今年的保險財務狀況，並將資料提供國發會參考，因為這樣下去，健保的財務狀況會比預期的還糟糕，若明年的總額要再成長，就必須要慎重考慮。三、歷次會議未結案件第2項，有關政府欠費部分，感謝健保署積極努力的催繳，顯示有追有進度。但我不贊成解除追蹤，因為高雄市政府104年度應償還欠費，尚未完全償還，怎麼可以解除。四、歷次會議未結案件第3項，研擬中長期醫護人力改善計畫，也是不贊成解除追蹤。很感謝醫事司對本議題的回覆，辦理情形中提到已推動「充實五大科醫療輔助人力」及「重點科別培育公費醫師制度計畫」等措施，但這兩者之間並不直接相關。開辦「重點科別培育公費醫師制度計畫」是為達到偏遠地區醫師人力的均衡分布，這與社會上所關注的五大科別醫師人力短缺問題，意義不太一樣。可否請醫事司先將媒體對五大科人力短缺報導中錯誤的部分予以釐清，再就五大科別的最適合醫病比、目前醫護人力的缺口及所需經費成本等事項提出數據說明。我期待要有完整的說明及評估，才能使委員通盤理解，將來計畫執行時，追蹤辦理情形也才有所依據。戴主任委員桂英先請陳委員聽安，接著請何委員語。陳委員聽安對於政府欠費，我主張應繼續追蹤，理由如下：一、過去有不少縣市政府積欠健保費，現在多已清償完畢。對這個議題我曾表達過，財政狀況窘迫的縣市都按時繳交健保費，反而是一些財政狀況良好的縣市政府卻積欠健保費，賴著不繳，這是很不公平的。101年以後，中央對縣市政府所積欠的健保費提供補助，所以101年以前的政府欠費，現在僅剩北、高二市尚在償還中。 二、在104年度，臺北市政府已依還款計畫償還欠費，但高雄市就不同了，其應償還38.98億元，但截至目前卻尚有11.83億元未償還，即便法務部行政執行署高雄分署已核發執行命令，函請高雄市政府還款，但也是繼續賴者不繳。健保署已查封高雄市政府土地49筆，今年5月又查報了土地22筆，可是「查報」與「查封」不同，「查報」是沒有用的，要「查封」才可以。因此，在高雄市尚未償還104年應繳之11.83億元前，本追蹤事項不可以解除。戴主任委員桂英謝謝陳委員聽安，請何委員語。何委員語一、追蹤事項第3項，有關「全民健康保險法施行細則第45條條文修法案」的追蹤，尚不宜解除，理由是我們應該要知道修正後的結果，政府依其他法律規定之保險費補助項目有哪些，因此應該等衛福部完成修正程序，發函回覆我們後再行解除追蹤。二、部長在週末期間花了很長時間與委員們電話溝通，顯見部長之職確實不好當，職位越高越辛苦，在此要對部長的辛勞表達敬佩之意，更感謝滕委員西華、干委員文男及所有參與本案的委員所付出的心力。三、我建議未來政府的福利支出不應轉嫁至健保，未來若是還有類似的修法案，請先照會健保會委員。這個案子若事前有協調就不會演變至此，也會有比較好的結果。本案若不是有本會前任委員擔任立法委員，事情不會這麼容易解決，我們會全盤皆輸。所以希望將來還有更多本會委員以後會變成立法委員，要不然我們的力量不足。在此也要謝謝這次協助我們的立法委員們。最重要的是，社會福利不應與社會保險混為一談，這真的是不應該。戴主任委員桂英請趙委員銘圓。趙委員銘圓一、追蹤事項第2項，有關本會反對金管會運用健保卡處理非健保法規定之事務這件事，我認為這次的辦理情形寫的很好，過去幕僚單位與其他部會的溝通，如果立場過於溫和，寫的模模糊糊，人家就會軟土深掘，根本不理你。我知道幕僚單位其實也是很辛苦，但這次的立場比過去強硬，但如果將「不予同意」，改為「絕不同意」可能更好。二、全民健康保險法施行細則第45條條文修法案的結果，非常感謝滕委員西華、干委員文男、李委員永振、何委員語及所有參與本案的委員，當天親自前往立法院表達本會的立場，雖結果不如本會預期，畢竟大家也都盡力了，部長也很辛苦，至少結果比原來好。將來我們也必須持續關注，否則又有其他項目列入，會對健保財務造成很大的影響。三、剛才陳委員聽安談到有關政府欠費的議題，這一項真的不應該解除追蹤。101年以前的政府欠費，新北市早就繳清，臺北市也依照還款計畫清償中，唯獨高雄市就是賴著不繳，我呼應陳委員聽安的看法，若是高雄市政府繼續積欠，健保署該怎麼辦？在此請問法規單位，除了查封高雄市政府的財產外，是否還有其他更強硬的措施可以迫使其早日清償欠費？戴主任委員桂英謝謝，請張委員澤芸。張委員澤芸一、會議資料第21頁，歷次會議未結案件第3項「研擬中長期醫護人力改善計畫」，首先要謝謝各位委員及社會大眾長期以來的關心。這個議題本人認為不宜解除追蹤，原因是本會105年3月份會議中曾提及，即便護理人力空缺率已從最早的7.22%降至5.61%，但總離職率仍有10.5%，所以要繼續檢討，因此，雖然當時建議解除追蹤，但因為上述數據仍有檢討的空間，因此尚未解除追蹤，今天的資料，並未呈現明確改善數據，建議仍應繼續列管。二、此外，照護司的護理改革中長程計畫，執行期間自2014年至2017年才會結束，目前仍在計畫執行期間，成效尚不明確，而且大家也都知道，未來將有醫師納入勞基法後的人力缺口之變數，在這樣的狀況下，也會對護理人力的影響投入更多變數，因此本項議題應繼續追蹤。戴主任委員桂英謝謝，請謝委員武吉。謝委員武吉一、歷次會議未結案件第4項，會議資料第21頁，有關請健保署按月提供醫學中心、區域醫院之門、住診初(次)級照護及下轉等數據資料，但健保署的業務執行報告已經連續3個月，沒有提供相關資料。當時的解釋是初級門診照護定義之ICD-9-CM碼，對應至ICD-10-CM/PCS後尚須確認其正確性，故暫時無法提供，因此這一項要繼續追蹤，不可以解除。二、歷次會議未結案件第5項，請健保署對新藥、新特殊材料、新診療服務及放寬藥品適應症等項目，進行財務影響評估及替代效應分析，這個項目我也反對解除追蹤。我要請問醫審小組，罕見疾病的藥品是否仍有那種10年都沒有通過TFDA核可的項目，應該是有吧？這實在太凹蠻(台語)，因為這些藥品都是花費很多錢，藥商要賣多少錢，就賣多少。健保署每年或每兩年就會做藥價調查，藥價一直砍到原廠退出，而國內廠又無法生產，以penicillin 100萬單位為例(此藥用於治療淋病，每支大約10元)，健保署砍價砍到原製造廠成本不足而無法製造，結果變成授權健保署與國外廠商議價，每支要84元左右，付出的錢更多，這是否有圖利國外廠商之嫌？這種一直砍價的作法是不對的，應該要給藥廠一個活下去的空間。因為我有參加健保署的藥物給付項目及支付標準共同擬訂會議，所以這些狀況我都知道。安全針具是另一個例子，今年的評鑑特別多，所以安全針具賣的特別好，但是現在市場上的購買價比健保署核價還要高，國內某家最大的財團醫院用聯合採購的方式大量採購，但是購買價也是比健保署的支付價格高。所以這一項不能解除追蹤。 三、歷次會議未結案件第6項，是建請衛生福利部部長與本會委員能建立定期對話溝通機制，首先是很感謝林部長奏延在5月27日到委員會議拜訪，但林部長的任期會有多久我們也不知道，隨時都有被換掉之可能，如果以後換來一個蔣部長，但那個蔣部長應該不是蔣經國部長，如果是蔣經國部長也許會定期拜訪我們，但另外的蔣部長可能就不甩我們，那要怎麼辦呢？這一項若要解除追蹤，我堅決反對到底。戴主任委員桂英謝謝，請黃委員啟嘉。黃委員啟嘉一、主席，我想確認一下自己沒有誤解會議資料，剛才謝委員武吉所列舉歷次會議未結案件的第4項至第8項，若要解除追蹤必須要符合一些條件，但其實這些項目目前都未符解除追蹤的條件，因此都是繼續追蹤的狀態。二、歷次會議未結案件第5項，請健保署對新藥、新特殊材料、新診療服務及放寬藥品適應症等項目，進行財務影響評估及替代效應分析，這也是西醫基層部門非常關切的議題，因為健保署常會高估這些項目的替代率，卻又低估這些項目的財務衝擊，所以請健保署盡快將替代效應分析的資料，向委員會提報。但我的看法是，新藥、新科技的發展是持續的，因此新的項目會不斷增加，換言之，不斷推陳出新需要分析，根本不會有解除追蹤的一天。謝委員天仁一、健保署對於「健保藥品品質監測計畫」辦理情形的說明就是立法院已決議減列健保署預算300萬元及凍結2,000萬元，但這個計畫的預算是1,000萬元，所以立法院到底凍結的預算項目是什麼，說的不清不楚，而且我們所詢問的重點也不是這個。二、請健保署提供反對的立委名單，讓我們看看究竟是哪些委員在反對，這個事情必須面對全國民眾。潘委員延健對於委員會議決議(定)事項辦理情形是否解除追蹤，我的認知只有兩種，一個是解除，一個是繼續。我認為不應該去對解除追蹤的條件預設前提。舉例來說，歷次會議未結案件第9項，是委員建議國健署對於蔡前委員登順的聘任事宜，應有正面回應，請幕僚透過適當方式提醒該署適時回覆。這個事項解除追蹤的依據，應該不是國健署回覆就好，那形同是空白支票。因為在追蹤事項的運作過程中，有時委員會對業務的內容提出意見，因此解除的條件，不能僅是有處理就解除。 戴主任委員桂英謝謝，請張委員煥禎。張委員煥禎一、接到本次會議資料時，看到之前本人所建議「核減率的呈現，細分有無參加自主管理醫院的辦理情形」，係為「資料後附」但仍列繼續追蹤，直至溝通獲致結果後才可解除，這部分我可以接受，但要真的與我溝通才算。剛才進入會議室後，看到會議補充資料第2頁，則是更新辦理情形為「本署北區業務組組長已於6月14日至壢新醫院就目前總額運作、管理重點、有無參加自主管理醫院的管理方式與張委員溝通說明」，這部分我就不認同了。因為追蹤事項是委員會議所列管的，是署本部要處理的，分區業務組組長找我，討論的是另外的事情，所以不要去搞混，以上先說明。二、由於會前並未接到充分的資訊，現在雖然拿到資料，我也沒辦法立即同意解除追蹤，建議以後資料要早一點，我想不是只有我沒辦法，換做別的委員也一樣。若是昨晚拿到資料，至少我還有時間看一下，現場才看到資料，實在無法決定。戴主任委員桂英一、非常謝謝各位委員對追蹤事項所提意見，相關單位要瞭解繼續追蹤的理由，請參考委員的發言實錄。二、先綜整剛才討論的結果：(一)追蹤事項第3項，有關「全民健康保險法施行細則第45條條文修法案」，首先非常感謝參與委員投入的心力，在一般行政機關的經驗，已經是非常不容易的結果。有委員建議應等到社保司完成修正程序，看到條文內容後再解除追蹤，因此本項仍繼續追蹤。(二)追蹤事項第7項，「健保藥品品質監測計畫」，請健保署持續跟立法院溝通，所以也是繼續追蹤。(三)另，大家討論非常熱烈的部分，是會議資料第20~22頁的歷次會議未結案件。第2項有關政府欠費、第3項「中長期醫護人力改善計畫」、第4項請健保署按月提供醫學中心、區域醫院之門、住診初(次)級照護及下轉等數據資料案、第5項請健保署對新藥、新特殊材料、新診療服務及放寬藥品適應症等項目，進行財務影響評估及替代效應分析，及第9項有關委員建議國健署對於蔡前委員登順的聘任事宜宜有正面回應，請幕僚透過適當方式提醒該署適時回覆等案，皆改列繼續追蹤。另外，還有第6項原本就列繼續追蹤。三、以上建議處理方式是否妥適？如果沒有遺漏，本案就這樣處理。若健保署還有其他意見需補充，請於業務執行報告時說明。四、李署長伯璋今天因公務出國，稍後要提前離開去搭機，可否有一點時間，請李署長跟委員們致意。李署長伯璋主席及各位委員早！原訂今晚6點半搭機赴日本大阪出席國際會議，但受華航空服員罷工影響，因此改為搭乘長榮航空於下午1點半出發，很抱歉不能全程參加委員會，請各位委員諒解。本署的主管同仁皆在場，會針對委員的提問及建議提供說明，在此跟各位委員說聲抱歉。戴主任委員桂英謝謝李署長，接下來進行下一案。謝委員武吉主席！歷次會議未結案件的第8項和第5項、第4項都應繼續追蹤…。戴主任委員桂英對，有關初期照護資料的提供，也改列繼續追蹤。謝謝！干委員文男主席！「健保藥品品質監測計畫」的部分，不用等到報告案第5案，現在就可以說明。戴主任委員桂英請健保署依照委員要求，先說明「健保藥品品質監測計畫」的辦理情形，此為上次會議決議事項辦理情形追蹤第7項，係列繼續追蹤。蔡副署長淑鈴我們瞭解「健保藥品品質監測計畫」是委員們非常關切的議題，其實我們已經進行，但在立法院確實遇到預算減列及凍結的狀況，本署已準備相關資料向個別立法委員說明並爭取預算，目前仍待黨團協商及院會決定，預計最近就會有結果，屆時本署會再向健保會報告，也會優先執行，此一項目還是繼續追蹤。戴主任委員桂英接下來進行例行報告第三案，請委員翻到會議資料第32頁。謝委員武吉主席！剛才第6項繼續追蹤的會議，您並未針對部長與本會委員能建立定期溝通會議做出裁示，我們是否要定期與部長見面溝通或是臨時有事情時再加見面溝通會議，應該要有個明確的裁示。戴主任委員桂英有關希望部長與本會委員建立對話溝通機制案，事實上我們都會盡力安排，如同剛才其他委員所陳述，跟部長見面的場域，除了我們特別邀請蒞會，之前在立法院開會時，部長也是盡量與委員溝通。所以這部分還是以建議的方式來處理為宜，不須特別訂定時間。此建議尚祈委員可以接受。謝委員武吉問題是如同我剛才所舉例，並不是每一位部長都那麼容易約，部長的任期也沒有絕對，如果遇到這樣的狀況該如何處理？應該要有一個時間的規定！戴主任委員桂英一、我知道您很在意，不過如果將來有新任部長，我們一定會邀請他來與委員見面，不過還是希望林部長的任期可以很久，因為政務的延續很重要。本項(歷次會議未結案件第6項)還是繼續追蹤，就請您勉強接受，謝謝您的體諒！二、接著進行例行報告第三案，請同仁宣讀。參、例行報告第三案「中央健康保險署提報『105年度西醫基層總額品質保證保留款實施方案』(草案)修訂內容案」與會人員發言實錄同仁宣讀戴主任委員桂英謝謝同仁宣讀。本案曾於3月份委員會議討論，當時有委員提出一些建議，請健保署與西醫基層部門再行研商，現在雙方已參酌相關建議修訂後重新提出，請問委員有無意見？黃委員啟嘉一、案內計畫的修正係依據本年5月26日召開之西醫基層總額研商議事會議討論並獲共識的結果，同時也是回應去年各部門總額執行成果評核會議評核委員所提，品質保證保留款核發指標要提高指標鑑別度的建議。二、在品質保證保留款核發機制上，我們調整了核發品質保證保留款的篩選機制，也就是只取前80%之診所核發，80%之後的診所，不管是否有達標，也不核發。這一點是吳委員肖琪一直以來對西醫基層部門的期待，我們有聽到也做了修正。希望這次各位委員都能夠支持我們的方案。戴主任委員桂英請吳委員肖琪。吳委員肖琪一、謝謝，我覺得西醫基層部門有認真看待這件事，確實只取前80%之診所核發品質保證保留款是好的。二、我只是要確認一件小事情。在會議資料第32頁第三點(二)，藥歷查詢新增3項指標，達標者可再加5%，所以最高分者可達115%，這樣一來超過80%的診所就會很多，但這部分還需再依(三)規範的核發，就是只核發給前80%之診所的意思嗎？黃委員啟嘉沒錯，就是「強迫刷掉成績排在最後面的20%的診所」的意思，讓真正的優質診所取得獎勵。戴主任委員桂英依本次提報內容通過，本案洽悉，謝謝各位委員。接著進行例行報告第四案。肆、例行報告第四案「中央健康保險署提報『全民健康保險中醫門診總額兒童過敏性鼻炎照護試辦計畫』(草案)之辦理情形案」與會人員發言實錄同仁宣讀戴主任委員桂英謝謝同仁宣讀。由提案說明可以瞭解，健保署與中醫部門在研訂計畫內容的過程很努力，但中醫門診總額「學齡兒童過敏性鼻炎照護計畫」專款之協定事項為：「請於105年6月底前提送相關論質計酬或論病例計酬方案至全民健康保險會通過後預算始得動支」，所訂的時間點(105年6月底)將屆，本案所提報的結果，卻是計畫內容尚未擬妥。請教各位委員，可否同意延後時程，讓相關單位有多一點時間研提計畫？還是考慮計畫未如期提出，所以預算就不能動支？請委員表達意見。何委員永成代表中醫師公會全國全聯會(以下簡稱中醫全聯會)向委員說明：一、委員可由從提案內容看到，健保署及中醫全聯會業經多次努力。中醫全聯會對本計畫一直努力規劃，不敢懈怠，每次中醫門診總額研商議事會議，會前跟健保署長官進行溝通，會後則另請專家學者對計畫內容給予指導。迄今歷經多次修正，解決了部分疑義，當然也尚有未解決的疑義、或未有共識之處，例如對於飲片(水煎藥劑)的各種意見，另其亦涉及健保一直以來均不不給付的議題，中醫全聯會則是朝向包裹支付、論病例及論質計酬的概念及方向，去進行溝通與處理。二、會議資料第35頁，提案之說明二、(六)所提幾個疑慮，說明如下：(一)國內目前沒有供兒童使用的量表，所以中醫全聯會建議計畫量表由「鼻及鼻竇疾病評估量表」改為「過敏性鼻炎控制評估測試量表(RCAT)」。過敏性鼻炎控制評估測試量表(RCAT)主要用於12歲以上者，並於相關期刊文獻引用次數達20餘次，故本計畫擬延伸應用於收案對象(5至14歲者)。(二)過敏性鼻炎用中藥來治療的效果，衛生署(衛福部前身)中醫藥委員會，前已委託長庚醫院等好幾個醫院進行過相關研究，其研究內容更嚴謹，包括檢測IgE(免疫球蛋白E，其與人體過敏反應有關)、檢測嗜伊紅性白血球及過敏原等，好幾個研究計畫都做過了，成效都相當肯定。(三)為何要建議用飲片？干委員文男來自基層，他也很清楚為何要用，現在中藥材價格飆漲很厲害，以目前健保給付的中醫每日藥費31元(註：支付內容為科學中藥)，是沒辦法將比較高級的人蔘、黃耆等藥材放進去的，但對虛寒性體質又需要用這類藥；另外，飲片的藥效也較科學中藥較快、更提昇。以前大家擔心飲片沒有藥物許可證或健保不給付，但過去2年來，中醫全聯會持續與5家具有GMP認證的科學中藥的藥廠溝通，已達成共識，可委託他們來製作飲片，使用檢驗合格的安全藥材，保證沒有農藥及重金屬的問題，未來朝此方向努力。以上是對傳統飲片之疑慮的說明，中醫全聯會也再次表明會負起監督之責。(四)另一個問題，為何收案條件本來是訂「6歲至14歲」，後來我們又建議改為「5歲至14歲」，因為在文獻中指出，4至5歲是過敏的好發期，因為4歲年紀過小，表達能力可能不是很好，至於5歲大概可在父母的協助下表達，因此將收案條件酌予放寬，相信對過敏性鼻炎的治療，整體來說效果應該會更好。(五)目前已經快到6月底，建議本案可否再給中醫全聯會1個月的時間，讓我們在7月底之前，能與健保署尋求最後共識。以此延長的1個月時間，把協商時委員所交付本案的任務完成。以上報告，謝謝！干委員文男一、對於本案實在心有戚戚焉，老百姓真正需要什麼，我們都脫節了。五千年來的中華歷史文化，中藥的藥劑形式本來就是飲片，也就是水煎藥劑，現代則另可使用科學中藥，但其療效甚至不到飲片的四分之一；另外，治療兒童的過敏性鼻炎，一定要在13歲或15歲以前就開始，才能治療好。二、本計畫的進展，中醫全聯會還不夠努力，不夠積極去請教別人，不請教人家、難道天上會掉下來嗎？另也建議參與中醫總額研商議事會議的代表能有多元的看法，不要都用西醫的方式或規格，來看待本案，因為治療行為不同；至於要求中醫師所用的藥材一定要經過檢驗合格才可以做，問了好幾位中醫師，大家都說個別中醫師沒辦法自己檢驗。檢驗的工作，應該是藥材商要做的。三、請問中醫全聯會用1個月可以把本計畫內容完成嗎？(何委員永成：可以！)可以的話，那就尋求在場委員的同意，然後下個月把計畫內容提到本會報告。戴主任委員桂英先請謝委員天仁，再請楊委員芸蘋。謝委員天仁一、中藥本來藥性就比較溫和，所以似乎本案研議的速度也變的比較慢，我們可以理解(委員笑)。不過我們對各部門、各計畫的處理應該要有一致性，像是本案於協商事項所訂的期限到了，要怎麼處理，未來各部門應有同樣的邏輯，因此，我要求是要有一致性的標準。二、如同本計畫，其在協商事項所載並非限制性文字，因此所要求的時間僅為訓示性規定，主要是希望該總額部門能儘快研擬、讓機制趕快上路。因此，我認為若協定時沒特別講，就沒有理由在此時把預算收回，本案還是鼓勵中醫全聯會與健保署儘快再進行相關研商。三、在此要另特別指出，若中醫師本身需負責中藥的藥品檢測，那請問西醫基層及醫院部門，要不要負責西藥的藥品檢測？這應要有相同的標準，因此若健保署僅要求中醫部門要負責中藥藥品的檢測，這沒有道理。四、我的看法是，若要求本案需檢測飲片的藥品品質也可，因為可送到「健保藥品品質監測計畫」去檢測，我覺得這也很好。沒理由要求中醫全聯會需在本計畫去訂藥品檢測的規範，這沒有依據。再次重申，處理的重點就是各部門要有一致性的處理標準，公平的對待，這樣才合理。戴主任委員桂英楊委員芸蘋發言後，請健保署先口頭補充。楊委員芸蘋一、中醫全聯會是非常認真要去執行本方案，能看得到認真、但也看得出訂定計畫內容的難度。我蠻支持本案計畫之研擬，鼻竇炎的確是好發於小孩，因為雖有多運動就會痊癒的說法，但其實也要看小孩的體質。二、既然協商時給了本案這個機會，我想中醫全聯會應該要去找相關文獻，看看有什麼較好的方式，能讓方案內容可以儘量在短時間內達到完備。三、我也蠻贊成剛剛謝委員天仁的看法，如何遵循協商所訂時間點，無論在中醫或西醫等總額部門，標準都要一致，但本案的確也未言明，沒在特定時間點做出來，就不能支用費用的文字；況且本案的研擬，本質上也的確比較困難。因此，在此還是期許中醫全聯會能夠不負委員的高度期望，我贊成多給1個月的時間，能儘量把方案內容完成。中醫就是比較慢，既然慢是可以瞭解，但也不能慢到讓大家覺得太慢。戴主任委員桂英請蔡副署長淑鈴補充。蔡副署長淑鈴剛剛委員表達的意見，與本署中醫門診總額研商議事會議的實際情況有點距離，補充說明：一、中醫全聯會一開始所提出的proposal(計畫書)，係以西醫的方式撰寫，而不是用中醫的觀點在寫，也許中醫全聯會是有所誤解，以為要比照西醫proposal的方式來撰寫比較好。二、本署從未要求中醫全聯會，飲片的部分要經過TFDA(衛福部食藥署)許可，其緣由係因中醫全聯會主動表示會自行把關。確實目前中藥藥材製成科學中藥有管理的制度，至於飲片則是「藥材經過煎煮後變成水劑」，所以在煎煮的過程是沒有把關機制。因此，這部分本署是完全接受中醫全聯會的建議，讓該會由源頭幫忙把關。其實飲片亦並非本案未能達成共識的主要癥結點，委員們可能有些誤解，在此向委員說明。三、另外，收案條件及包裹支付的部分，實務上本署跟中醫全聯會有些看法不同，因此有交換一些意見，在此部分有些修正。爭議較大之處，是收案條件，到底是什麼樣的病人可以進入本計畫。剛剛何理事長永成也說明該會已再修訂出新版本，因此本署亦樂意於新的時限下，再與中醫全聯會進一步確認計畫內容。何委員語剛剛聽健保署長官報告，中醫的事情為何要交給西醫來把關？蔡副署長淑鈴不是不是，誤解了。我再跟何委員語報告一下，剛剛是說中醫的proposal(戴主委補充：計畫書)完全用西醫的方式來寫…何委員語中醫有中醫的格式，中文字就跟西方字不同，為何要用拉丁字來寫藥品？我認為交給西醫的全聯會來審核是錯誤的…蔡副署長淑鈴不是不是，我們不是這樣要求…戴主任委員桂英向何委員語說明，健保署的意思是「不希望」中醫全聯會將本計畫以西醫的格式撰寫，所以請該會調整為中醫的適用格式，跟您的意見一致！何委員語好，我的意思就是這樣。另，我想本計畫也值得參考衛福部中醫藥司的觀點，因為這是一項新的計畫。我也支持，希望本案能延1個月，到7月底前研擬出來。自從我參加健保會以來，據我瞭解中醫一直被打壓，希望能支持中醫，在目前以西醫為主的醫療體系中，也能建立出一個好的中醫體制。戴主任委員桂英謝謝何委員語，請趙委員銘圓。趙委員銘圓一、因為我有參與中醫總額研商議事會議，在此補充與會的情形，基本上健保署蔡副署長淑鈴講的是對的，會議中部分專家學者對中醫全聯會以西醫的格式撰寫計畫，提出不贊同的意見，中醫是我國國粹，建議中醫全聯會再找一些文獻把計畫轉化為中醫的用語。其實該會議討論時候，委員並沒有完全反對此計畫，只是希望用語能做改變。二、至於本計畫的時限問題，我也贊成再給中醫全聯會1個月，去完成後續的處理。戴主任委員桂英謝謝。本案有這麼多委員支持，中醫全聯會及健保署都很努力，就依委員意見，再給1個月的時間，請於本年7月底前提送計畫至本會。接下來，繼續討論下一案，請古代理委員博仁。古代理委員博仁(李委員蜀平代理人)一、剛剛聽到何委員永成所言，我有點訝異。20年前健保支付標準，中醫每日藥費是30元，現在則是略升至31元，但現在原物料漲價漲的那麼多，剛剛何委員永成也表示，因為成本考量，可能不會添加黃耆或人蔘等高貴藥材，因此似宜檢討中醫的每日藥費31元，到底是否符合成本？若不符成本，那現在消費者吃到肚子裡的健保中藥藥劑，到底都是什麼？是否符合政府的標準？還是都僅為乳糖之類的添加物？二、對於中藥是支持的態度，不過還是希望消費者能得到真正好的藥品，有好的藥效，而不是在低價管控之下，到底給消費者吃了什麼？真的不太瞭解，例如何委員永成所言，健保所給付的中藥裡，大概很難有黃耆等高貴藥材的成分，我對這部分頗有質疑。綜上，整體來說要考量中藥原物料合理的成本，並相對提昇健保中藥藥費的點數，要有合理的價格才有好的品質。謝委員武吉一、因為小時候的親身經歷，讓我非常贊同何委員語的說法。雖然我伯父是日本慶應大學的醫學博士，但當時我父親得了狹心症，病情很嚴重，接受西醫治療，但醫師說大概只能回苗栗老家準備「再見」(意指：生命結束)，但是被一位中醫師救起來，就是靠著喝中藥的水煎藥劑，例如一帖藥用3碗水熬煮成1碗藥，早晚喝一次之類的服用法，本來父親39歲就要「再見」了，最後活到73歲。這是我對中藥的信任。二、「6歲至14歲」放寬至「5歲至14歲」尚可。三、我曾經去新疆義診過，當地維吾爾族的醫院，也有使用熬煮的中藥水劑來治療，如果需要我手邊的相關資料，也可提供參考。因此，我並不反對水煎藥劑，好的方式還是值得參考，建議可以給其合理的空間，去研議適合照顧老百性的方式，這是我的希望及建議。戴主任委員桂英謝謝2位委員的意見，並未變更決議。請中醫全聯會及健保署於7月底前提送計畫至本會報告，並獲通過後，預算即可動支。接著進行例行報告第五案。伍、例行報告第五案「中央健康保險署『105年5月份全民健康保險業務執行報告』」與會人員發言實錄戴主任委員桂英本案係健保署105年5月份業務執行報告，本次不進行口頭報告，僅提供書面資料。請問委員對於業務執行報告內容有無詢問？另，李署長伯璋因公出國，雖然已先行離開去搭機，不過該署蔡副署長淑鈴及各單位人員都還在場，仍可提供相關說明。謝委員武吉一、對於超音波檢查應由醫師親自執行，我曾提過相關議案，當時同宗的謝委員天仁也表示應依相關法令辦理，依法行政！但後續的執行，健保署均未在此提供相關報告，希望下次要有資料。二、過去於業務執行報告有提供初級照護率資料，但因初級門診照護定義之ICD-9-CM碼，自105年起需轉換為ICD-10-CM/PCS版本之代碼，這部分因尚未完成，故健保署暫不提供初級照護率，但仍希望有相關資料以提供參考，健保署應盡快處理，讓委員盡快知道。三、業務執行報告第74頁，有關核減率的問題，各分區的核減率中都是地區醫院的核減率最高，原因為何？這樣的疑問，也間接與近日在立法院鬧的沸沸揚揚，要求審查醫師需具名之議題，有所相關，另外，張委員煥禎也很關心核減率的問題。四、核減率分成2種，一種是總額內的核減率，一種則是總額外的核減率，現在最主要發生的是，總額之外的核減率的問題。為何地區醫院核減率最高？難道地區醫院的醫師都是最笨最傻的嗎？或是診所醫師是最傻？他們都沒有經過專科醫師訓練或者執照不是衛福部發的？都不可能吧。以上各項疑問，請健保署幫忙解釋一下。戴主任委員桂英謝謝，請陳代理委員順來。陳代理委員順來(侯委員彩鳳代理人)業務執行報告第22頁「牙醫門診總額104年申請約32.4億點、部分負擔約1.2億點」，請問這1.2億點中是否包含植牙費用？怎麼這麼少？因為連中醫門診總額的部分負擔都有2.7億點，牙醫門診總額的部分負擔似乎太少了。戴主任委員桂英植牙不屬於健保的給付範圍，稍後請健保署再進一步回答。請干委員文男。干委員文男一、目前健保的財務狀況，是這幾年以來狀況最佳，因此再次提出詢問，健保署是否將多餘的錢投資於公債或私人債券？公債的利息是高的，若能買到公債，對健保財務也是不無小補。二、業務執行報告第19頁「表13-1 預期未繳保險費暨滯納金移送行政執行狀況統計表_按年度別」，移送金額中已結案的部分，有分列「取得債證」、「註銷標的」，但卻沒有看到打銷呆帳的金額，不要常常只報好的、壞的都不講。三、目前業務執行報告均有「業務推動重點摘要」，這部分很好，可以看出署的重點業務及努力的方向，例如八仙塵爆的處理在此敘述頗清楚，讓委員們瞭解到健保署的努力及辛苦，致上謝意！戴主任委員桂英先請滕委員西華，再請謝委員天仁。滕委員西華一、業務執行報告第81頁，持續溝通Tw-DRGs(全民健康保險住院診斷關聯群)支付制度案，其中(三)持續溝通說明之第4小點發函搜集分類意見，健保署提到105年3月底已發函請專科醫學再提供意見；另外在本會去年總額協商及後續其他會議，有提到今年不是1月、就是7月要實施Tw-DRGs。二、衛福部蔣前部長丙煌原計畫於今年3月公告實施，但各界有非常多的意見及反彈，因此當時就變成改由新政府上任後評估後再決定。105年度總額協商時，即已保留今年全面實施Tw-DRGs之費用，醫界代表也勉強同意，105年1月1日實施新疾病分類碼ICD-10-CM/PCS，經半年適應期後，於今年7月Tw-DRGs即可上路；當時並決定安排「DRGs相關診斷分類分組ICD-10-CM/PCS轉碼執行情形」專案報告，作為實施Tw-DRGs的參考，資料也在今天的專案報告第3案。三、眼看著下週就是7月了，請問健保署幕僚同仁對部長報告的情況為何？這個政策也是經總額協商並編列預算，但怎麼感覺好像隨隨便便就沒了？沒有追蹤後續執行情形，這也是很不好的。今年9月又即將展開明(106)年度總額協商事宜，因此總要知道Tw-DRGs實施的狀況如何。四、若我記憶沒錯，健保署李署長伯璋在剛上任時，就說要續推Tw-DRGs，今天很可惜人不在現場、去搭飛機，不過他看到紀錄就知道，你們現在也可以打電話詢問他：「到底是現在要繼續推動，還是幾年後、10年後才繼續推動？」我非常關心Tw-DRGs實施進度，希望能獲得相關說明，謝謝。謝委員天仁一、我關心的是，八仙塵爆已滿1年，而高雄氣爆也即將滿2年，健保的代位權相關機制應要檢討，健保署的打算為何？該機制要何去何從？因為這是關係到公平正義的問題。二、業務執行報告第71頁，有關醫學中心病床增減情形，台大醫院的急性病床少了6床，但該院急診壅塞的情況是最嚴重的，為何急性病床還會減少？問題出在哪裡？台北榮總急性病床也減了7床，但因其急診壅塞情形沒有台大醫院那麼嚴重，所以比較還能理解。三、醫學中心減床的情況，基本上是值得探討的，問題到底出在哪裡？合不合理？適不適當？總額給的錢是增加的，但急性病床反而少了，雖目前可見醫學中心床數增加的部分，是高雄的長庚醫院，但我覺得這是兩回事，每個地方的需求是不一樣的。所以我認為健保署應該要提出說明，不能任由各醫學中心，因護理人員不足，就用減床的方式來因應，更何況我們近年分配給醫院部門的總額都持續成長好幾個百分比，所以我認為健保署應合理交代急性病床關床的原因，並且清楚地去了解問題所在。戴主任委員桂英謝謝，請謝委員武吉。謝委員武吉一、不好意思，我再補充一點建議。請各位委員翻到業務執行報告第33頁「表15全民健保訪查特約醫事服務機構統計表-按訪查類別」，該表只將訪查機構分為西、中、牙、藥局及其他5類，我希望能再清楚細分類別，譬如西醫到底各有幾家診所、醫院，同時也希望再增加分區別與層級別之分析，建議分為台北、北、中、南、東、高屏6區，增加這些分析後可以較清楚看出是哪個單位、分區、層級較容易出差錯。二、業務執行報告第34頁「表16-1全民健康保險特約醫事服務機構查處統計-按處分類別」也是同樣的問題，除了終止特約、停止特約、扣減費用及違約記點之分類外，也應再做細部分析，把其中的區隔性(分區別與層級別)劃分出來，這樣會比較好。否則大家在不清楚的狀況下，若都把問題歸咎於醫院或基層診所那就不好了，謝謝。戴主任委員桂英謝謝，請健保署先回答委員詢問。蔡副署長淑鈴一、我先就知道的部分回答委員，其他問題稍後請本署同仁說明。有關謝委員武吉對業務執行報告第33頁表15及第34頁表16-1所提建議，將受查處的西醫機構及查處結果再作細部分析，健保署將於次月業務執行報告提供詳細資料。二、至於為什麼在這幾次(105年2~5月份)業務執行報告中未提供醫院總額各層級門診初級照護資料，是因今年在ICD-9-CM轉換成ICD-10-CM/PCS的過程中，需要將初級照護案件重新歸類，並檢視有無增刪需求。我們計畫將這部分工作以委託研究的方式進行，所以目前無法提供以ICD-10-CM/PCS之初級照護數據，但我們會儘速於新的定義產生後提供相關資料。三、有關謝委員武吉所提地區醫院醫療費用核減率偏高的問題，健保署在業務執行報告只是忠實呈現核減的結果，至於哪一個層級的核減率高、哪一個層級的核減率低，可能都會經常不定時發生高低的變化，本署目前也正在調查各界意見，研究是否要具名審查。四、有關陳代理委員順來問及牙醫門診總額申請的部分負擔點數為什麼較其餘各部門低，是因為牙醫部門有極高比例為診所，因診所部分負擔採定額50元，而牙醫門診總額平均每人次診療費用普遍都超過1千元，所以算出來的部分負擔率是較低的〔註：即計算部分負擔率的分母較西醫基層大，所以算出來的比率會較西醫基層低。以牙醫門診總額105年4月申請約32.4億點、部分負擔約1.2億點為例，牙醫門診總額的部分負擔率約3.57%，即1.2/(32.4+1.2)*100%=3.57%〕；而因為西醫基層總額門診平均每人次醫療費用相對於牙醫門診為低，所以西醫基層總額的部分負擔率看起來較高〔註：以西醫基層總額105年4月門診申請約83.5億點、門診部分負擔約8.5億點為例，西醫基層總額門診的部分負擔率約9.24%，即8.5/(83.5+8.5)*100%=9.24%〕。五、有關滕委員西華對Tw-DRGs的垂詢，如果李署長還在會場，就可以跟委員分享他的想法，或者可請委員在下次(7月份)委員會議徵詢署長意見。事實上署長指示在本月份的業務執行報告中，針對委員關心的Tw-DRGs進展，呈現書面報告(業務執行報告第81頁)。目前進度為本署已在本(105)年3月份發函給專科醫學會再次徵詢意見，目前我們也正在整理各醫學會陸續回覆的意見，並考量有無再修正Tw-DRGs版本的必要性。除專科醫學會外，我們也針對一些比較會有不同意見的團體如醫勞盟、相關的醫師團體做個別的溝通。我們已經陸續跟部長報告Tw-DRGs的整體推動計畫，如果有具體的進展時會再跟委員報告。六、再回應謝委員天仁所提八仙塵爆代位求償，及醫學中心病床增減的問題。事實上，我們的總額預算協商是跟整個醫院部門做協商，並非針對個別醫學中心做協商，所以雖然有個別醫學中心發生病床增減的情形，但整體醫院總病床數則是增加的。至於個別醫院為什麼會有非常少數的病床增減，因為這是屬於各地衛生局核定的權限，這樣random(隨機的)的改變，可能有非常多的原因，健保署並無准駁權，所以我們是著重於醫院總病床數的改變。七、另關於八仙塵爆，現在除了向泰安產物、蘇黎世產物兩家保險公司行使代位求償外，也已經直接向八仙樂園的負責人進行民事訴訟。現在民事訴訟等待刑事訴訟的結果，如果有結果我們會再以書面報告呈現。八、至於干委員文男提到財務相關問題，包括現在健保安全準備是否有投資公債、或一年打銷多少呆帳，請財務組唐研究員薏文補充說明，謝謝。唐研究員薏文主席，各位委員！目前健保資金運用的情況，約有100億元投資公債，收益率約0.8%；另有100億元投資公司債，收益率約0.985%(業務執行報告第17頁)。健保資金在債券投資上，因受限於債券發行的期間及資金流量的評估，所以我們目前是以定存為最大宗的運用，未來我們會隨時留意債券發行相關訊息，並配合健保資金流量再做整體考量，謝謝。戴主任委員桂英謝謝，請陳委員聽安。陳委員聽安一、業務執行報告第12頁「表8全民健康保險投保單位及保險對象保險費欠費收回統計表」的數據令人憂心忡忡，為什麼呢？從表8可看出100到104年來，投保單位及保險對象的保險費欠費應收金額越來越大，但收回率越來越低，從100年的97.22%、一直下掉到105年2月份的32.30%。不知道到底是什麼原因導致保險費欠費收回率每況愈下，是因為近年經濟景氣不佳？還是因為有了司法院大法官的解釋，使健保署不能對欠費者扣卡，欠費者卻能繼續享受健保的利益？原因到底在哪裡，為什麼欠費金額越來越多。(註：司法院大法官釋字第472號解釋「…惟對於無力繳納保費者，國家應給予適當之救助，不得逕行拒絕給付，以符憲法推行全民健康保險，保障老弱殘廢、無力生活人民之旨趣」)二、先不談政府欠費，因為這現象顯然和政府欠費沒有完全關係，估計是因還有其他人的欠費未繳，導致收回率越來越低，這樣的情況是否需進一步研究追蹤原因。另外，我更擔心的是在欠費應收金額越來越高、收回率越來越低的情況下，可能會影響到健保的財務機制。特別是本會委員在審議105年度保險費率時堅持要調降費率，並且建立「全民健保財務平衡及收支連動機制」，以「當年起(含)第3年年底安全準備餘額超出3個月保險給付支出時，調降保險費率；當年年底安全準備餘額不足1.5個月保險給付支出時，調漲保險費率」為原則調整費率。三、由於該機制是以權責發生制為基礎，而不是以現金收付制為基礎。因此，當保險費欠費越來越多時，雖然表面上(權責)的安全準備累計餘額看似越來越大，好像是超過2個月、3個月、4個月、甚至是5個月保險給付支出，依該機制應該要調降費率，但事實上我們的財務狀況是越來越差，這樣將使健保財務產生危機，是非常非常嚴重的事情。所以我建請健保署把欠費問題做個研究，了解原因在哪裡、提出對策，否則如果長期這樣發展下去，我非常擔憂健保財務，謝謝！戴主任委員桂英謝謝，請謝委員天仁。謝委員天仁一、我問東，結果蔡副署長淑鈴回答西。我問的是依據健保法95條第1項第2款規定，健保之保險人就公共安全事故提供保險給付後，只能對保險公司行使代位求償權，而不能對八仙樂園求償，高雄氣爆的代位求償也面臨一樣的情形，我的重點是在問這個問題怎麼處理啊！二、依據健保署訂定的「全民健康保險執行重大交通事故公害及食品中毒事件代位求償辦法」第5條第1項規定，代位求償金額以健保提供保險給付之日起，1個月內給付費用總額為限。這規定本身是自斷手腳，只要求事發1個月以內的金額，這樣規定到底合不合理？這些醫療費用是所有付費者的資源，是不是應該就代位求償的整體法規去作檢討。三、健保署打的那個官司，我看起來是空砲彈，自欺欺人。明明知道問題出在哪裡，還不去解決，這不是很糟糕嗎？這本來就要趕快邀請專家學者研討怎麼處理，研究以什麼樣的原則代位求償才合理適當。健保署如果有做這些相關努力，請提出報告讓我們了解；如果沒有，就應該好好檢討。戴主任委員桂英謝謝，請健保署再次回應。蔡副署長淑鈴一、非常感謝謝委員天仁對本署代位求償業務的諸多鞭策。在行使代位求償上，健保署礙於現行法令，確實受到非常多的侷限。譬如說依據相關法規，只能就第1個月的給付費用總額去求償，且只能跟該事故的保險人求償，本案該事件的投保保險金額是少的，健保給付的費用總額非常大，兩金額存在相當大的懸殊時，對健保署代位求償之結果就非常不利。二、有關事故的保險人應該投保多少金額，金管會在八仙塵爆事故發生後已透過相關管道，要求提高公共保險的保險金額(註：金管會於八仙案後擬定「公共場所或舉辦各類活動投保責任保險適足保險金額建議方案」，並函送各相關部會及各縣市政府參辦)。而健保署這端則是受限於我們自己訂定的求償辦法，規定只能求償第1個月的給付費用。因此，我們打算修訂該辦法，將「1個月內的給付費用總額」修訂為「3個月內的給付費用總額」，最近會提到我們的法律諮詢小組討論，確定可行修法內容後我們就會啟動修法事宜。三、這次八仙塵爆確實給了健保署經驗，當發生金額龐大的公共意外時，我們可求償的對象是否只有保險人，向事故的保險人求償時也會受限於它的投保金額，這也是我們今年會向八仙樂園主事者提出民事訴訟的原因。對健保署來說，這也是一種新的嘗試，雖然不知道結果如何，但我們也盡力一搏。因為這部分事實上是另外啟動的一個法律途徑，也許會如謝委員天仁所說，只是形式上的動作，但表示我們並沒有放棄努力。我們跟金管會要求提高公共大型活動的保險投保金額是雙管齊下，健保署並沒有放棄所有任何可以求償的途徑，謝謝。戴主任委員桂英提醒健保署，尚未回覆陳委員聽安的詢問。蔡副署長淑鈴陳委員聽安詢問的是有關保險費欠費回收率下降的問題，請承保組同仁做說明，謝謝。戴主任委員桂英請稍候，因為還有委員要提問，可否等委員發言後再一起說明。請何委員語。何委員語一、主席，各位委員。每次我拿到業務執行報告都會很用心去看有多少醫院違規、觸犯罰則，因為我認為如果當了醫生還違規犯法，真的是很不好的事情。至於違規的原因為何，我們的資料也看不出來；也不知道醫師公會全聯會每年收了會費之後，是否有好好去教育所屬醫師不應該違規、不應該犯法。二、我當然知道「賠錢生意沒人做、殺頭生意有人做」的道理，我一方面覺得像醫師這樣的高等知識份子違法是很可惜的事，另一方面我認為我們要重新檢討制度有無缺失。當然不可能有法律能規範到沒有人犯法，這個是很難的，但是我認為法規的宣導是很重要的。三、其次，我在端午節時碰到一個朋友的太太，她告訴我她先生在5月初過世，我問為什麼，她說因為先生得了口腔癌，在新北市某家醫院就診，本來安排好第2天要進行手術，可是那天發生八仙塵爆，醫院所有醫師都去支援八仙塵爆，所以他的手術受耽擱，一耽擱後就沒辦法醫治，所以死掉了。她先生自己當然也認為沒關係，因為八仙塵爆的患者都是年輕人，先救他們，他自己已經5、60歲了，慢慢來，可是一慢就救不回來。四、所以我認為八仙塵爆事件發生後，雖然醫界很辛勞、也投入很多人力、心血，把塵爆的死亡率降到非常低，是個很好的現象，可是同時也影響到社會上很多人的就醫權益。因此如果從這個角度出發，我很贊成剛才謝委員天仁的觀點，政府應該研究怎麼盡量爭取代位求償，能夠把7億多元的醫療費用拿回來，這是很重要的，這是我的觀點。另外我們當然也要很努力地推動社會公共安全，這是政府的責任，以上是我的看法，謝謝。戴主任委員桂英謝謝何委員語，請黃委員啟嘉。黃委員啟嘉一、感謝何委員語對醫界的指教。對於醫界因違規而遭懲處，深感遺憾；但違規占總額之比例小於1%其實並不高，當然我們希望比例是零。二、據悉懲處案件中一半以上是屬制度面的問題，最常見的是過去長久以來的就醫陋規~代拿藥，向付費者委員報告，查處追扣金額中約有4成多，係因為代拿藥所致。之所以會有代拿藥的情形，是因醫師為給病人方便，如先生臥病在家，太太拿先生的健保卡到診所領藥回去。就我獲得的資料，去年查處追扣金額最大的一項，將近一半的金額，即未經醫師診斷逕行提供醫療服務，也就是代拿藥。若是醫師故意違規，應嚴加譴責，但有很多是過去醫病關係長久以來的習慣，並未隨著社會的進步而改變所造成的，這部分我們會再加強宣導。經我們宣導，去年仍有1~2千萬元違規是上述原因。謝委員武吉還有一項超音波應由醫師親自執行的相關報告，至今尚未看到，另為何地區醫院的核減率較高？很感謝剛才蔡副署長淑鈴的說明，但我要再補充說明。在特管辦法中有一條規定提到雙方互惠原則，但健保署分區業務組並未做到此項，分區業務組同仁多具醫療背景，應看得懂相關表單，於抽審病歷時，應先檢視醫療院所檢附的資料是否齊全，如有漏件，應通知院所補件，應有此習慣、原則與必要性，不要所有責任皆歸屬於醫療院所，應在互惠的原則下，若行政人員可以先行處理的卻未處理，在打年終考績時應嚴加懲處。(註：全民健康保險醫事服務機構特約及管理辦法第2條，保險醫事服務機構之特約及管理，應依公平、對等、尊重及互信原則為之。)戴主任委員桂英請健保署說明。江專門委員姝靚一、主席、各位委員，大家好。陳委員聽安關心保險費欠費收回情形，其實我們也非常關心，並一直監控收繳率情形，因時間長短的關係，會變成愈接近現況的收回率愈低。欠費經催繳、回收後，仍有欠費，後續會再移送強制執行，執行情形如業務報告之相關數據，我們也很關心欠費的原因，保費收繳情形確實與經濟狀況有直接關係，我們會密切觀察。二、干委員文男關心呆帳的處理，欠費經催繳、移送強制執行後，依轉銷呆帳作業要點規定報列呆帳，呆帳轉銷須經相關行政作業程序後，再報審計機關備查，104年呆帳轉銷金額約36億餘元。(註：全民健康保險保險費及滯納金欠費催收暨轉銷呆帳作業要點第14點，經保險人查核無誤、呆帳轉銷審議小組認定已完成相關法令所定盡善良管理人應有注意之程序者，保險人依行政作業程序經其首長核准後先行轉銷，並應於年度終了後二個月內，列表報審計機關備查。)蔡副署長淑鈴查處部分，請高專門委員世豪說明。高專門委員世豪一、謝委員武吉希望查處統計表能提供分區資料，下個月我們會列入業務執行報告中。二、違規案件來源，在分區的執行狀況，除有例行的民眾申訴檢舉占30%多，本署也會進行檔案分析辦理專案稽核，這部分的案件數約有50%以上，故超過50%的案件係本署主動查核，來自檢調、衛生單位，則約10%多。違規查處作業有如準司法行動(即與司法單位的連結度很高)，在證據蒐集與作處分以後，醫事服務機構可以提出申復、爭議審議、訴願、行政訴訟等救濟，我們也要求同仁須於蒐集到非常完整的證據後，才據以核定處分。依往年查緝結果，經檔案分析，2萬7千多家特約醫事服務機構，查獲違規者僅1.3%多，並非如媒體報導去年訪查803家，處分383家，推論違規比例達48%，這是媒體斷章取義的說法。三、我們肯定絕大多數的醫事服務機構都是守法、良善的，僅有少部分真正不實申報醫療費用，其涉及刑法的公訴罪，依法必須移送法辦，在做停約、終止特約處分後，經申復確定的案件，會移送到司法單位。誠如黃委員啟嘉所言，有一半屬於行政管理的違規，這部分就以違約記點或扣減醫療費用來做處理。未來，我們會持續進行資訊分析並加強查緝作業，也會進行業務宣導，例如於健保特約醫事服務機構簽約時加強宣導，尤其是對老醫師的宣導、或利用VPN (健保資訊網服務系統)管道，提供違規類型與個案，供醫事團體對其會員進行宣導，並會進行民眾宣導。謝謝。蔡副署長淑鈴謝委員武吉關心應由醫師執行超音波檢查的部分，請陳副組長玉敏說明。陳副組長玉敏各類醫事人員可以執行那些醫療業務，須回歸醫療相關法規辦理；為品質考量，現行支付標準對部分特定項目限定須專科醫師執行。如委員認為有那些項目需做限定，可於醫療服務給付項目及支付標準共同擬訂會議中提案討論。蔡副署長淑鈴有關健保署能否協助檢視醫療院所之送核資料是否齊全，請施組長如亮說明。施組長如亮謝委員武吉表示分區業務組同仁具醫療專業背景，可以判斷醫療院所送審之資料是否齊全，其對分區確實有困難，因分區同仁未必都具醫療專業背景，目前是公衛背景居多，故須經審查醫師審查後，告訴我們須再補那些資料，我們再通知補件，審查時間雖會拖較久，但補件並不會造成費用核刪。謝委員武吉這也就是為什麼最近在立法院，專業審查的議題被吵的沸沸騰騰的最主要原因。做了什麼檢查、開什麼藥，於病歷上皆會清楚記載，可以列出審查清單。我絕不相信分區業務組同仁會不懂，連我沒讀什麼書的人都能懂，何況他們書讀那麼多，怎麼會不懂。我覺得應秉持平等互惠原則，若分區業務組同仁發現抽審病歷之資料不全，卻不通知醫療院所補件，責任應在你們身上，若你們已通知醫療院所，他們卻不補件，被核刪費用則是活該。地區醫院核減率高的原因、大家對核檢率非常不滿意的原因，就在此。對於醫師專業審查，我不予置評，但行政人員應有做為，卻不去做，我有很大質疑，並要求應改進。戴主任委員桂英謝謝，本案已進行41分鐘的熱烈討論，委員的發言都是為了讓健保制度的推動更好、更順暢。發言內容也都會列入會議實錄，因下次委員會議李署長會進行口頭報告，建請健保署針對委員關注的部分，盡量處理，並於下次會議更清楚地呈現。剛剛謝委員武吉不斷提醒，其用意係希望對於需要補件的案子，不要直接核刪，因為直接核刪，核減率會變高。至分區業務組同仁是否有能力協助檢視送核資料之齊全性，可透過內部教育訓練，相信藉由員工訓練可以克服這個問題。本案洽悉。謝委員武吉還有超音波，應由醫師親自執行的部分。戴主任委員桂英請健保署補充說明。蔡副署長淑鈴剛謝委員武吉在講話，未聽到陳副組長玉敏的說明，請陳副組長再說明一次。陳副組長玉敏各類醫事人員可執行醫療業務的範圍，須回歸醫療相關法規；至支付標準為品質考量，乃對部分特定項目，限定須專科醫師執行。委員如認為有那些項目需做限定，可於醫療服務給付項目及支付標準共同擬訂會議中提案。謝委員武吉這樣的回答，我無法接受。超音波檢查可以讓檢驗科的技術人員執行嗎？你們說沒有，我手中就是有相關資料，才會提出此要求，否則我不敢提出，我向來是講求實據。戴主任委員桂英健保署應已清楚謝委員武吉的意見，在醫療服務給付項目及支付標準共同擬訂會議，除了醫界可提出修訂支付標準的意見外，健保署若認為合理，也可以提出修訂案，大家共同努力。委員若無其他意見，接著進行討論事項第一案，請幕僚擇要說明。陸、討論事項第一案「106年度總額協商程序案」與會人員發言實錄陳組長燕鈴各位委員好，請看會議資料第39頁，106年度總額協商程序草案基本上是照105年度的模式，主要為今年9月份召開的106年度總額協商會議預作準備。摘要說明如下：一、協商會議的日期為9月23日及9月24日上午，共1天半，與會人員，包含付費方、醫界、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與相關幕僚人員。二、會議進行方式與原則，各部門協商順序將於7月份委員會議抽籤決定；各部門協商的時間表安排在會議資料第40頁，原則延續過去3年(102~103年)的時間安排，希望各部門協商時間盡量控制在表定的時間內，若需延長，則以不超過該部門之預算協商時間的50%為限。三、另外，其他相關原則、各方未能達成共識的處理方式、協商結論的確認，及協商共識會議實錄的製作與公開之相關規範等，都與過去相同，只是在日期上配合更新，以上報告。戴主任委員桂英謝謝陳組長燕鈴的報告。本案是下半年即將進行的106年度總額協商程序，幕僚所擬草案，請問委員有無修訂意見？干委員文男沒意見啦！戴主任委員桂英這是歷年沿用的程序，委員若無其他意見，本案就通過。請楊委員芸蘋。楊委員芸蘋聽說一直未有讓門診透析部門進行報告的時間，今年能否安排時段進行報告？ 戴主任委員桂英這部分等一下請幕僚說明，委員有無其他的意見？請幕僚說明。張副執行秘書友珊一、請參看會議資料第39頁，2.工作內容之 eq \o\ac(○,2)，考量門診透析服務為獨立預算，屆時會依西醫基層及醫院等二總額部門協商順序，於先協商的部門(依7月抽籤的協商順序)之後，安排單獨的討論時間。二、另有關協商共識會議之與會人員，請參看會議資料第40頁最上方 eq \o\ac(○,4)，討論門診透析服務時，除了西醫基層及醫院部門代表會參與協談外，也會邀請台灣腎臟醫學會推派代表列席說明。三、至於協商時間，請參看會議資料第40頁，4.協商共識會議進行方式與原則之(3)各部門協商時間，門診透析的部分，有安排提問與意見交換20分鐘，及20分鐘的預算協商時間。戴主任委員桂英委員若無其他意見，本案通過，接著進行討論事項第二案，請同仁宣讀。柒、討論事項第二案「106年度總額協商通則案」與會人員發言實錄同仁宣讀戴主任委員桂英謝謝同仁宣讀。本案係因9月即將進行各部門總額協商，會涉及基期、醫療服務成本及人口因素、協商因素等議題，如果可以事先議定一體適用之共通性原則，總額協商的效率會提高，過去實施至今，曾有部分項目不太容易達成共識，同仁已稍作修正，請問委員對於草案內容有無意見？請謝委員天仁。謝委員天仁歷年來只有對各總額部門預算訂定通則規範，其他預算的部分也應該考慮訂定一般性的通則，建議在四、專款專用項目下面，另立第五點，顯示其他預算適用的原則。本來過去對於健保署的作業都沒有疑義，但之前討論相關議案時，健保署曾提出各項目預算互相流用的觀念，此違反本會總額協商「各項目預算除協議訂定外，項目之間不得流用」一貫的想法，本次應訂定這項原則，不能只限制各總額部門，而其他部門卻來去自如，沒有規範，這樣很不公平。戴主任委員桂英請問委員有沒有其他意見？請潘委員延健。潘委員延健本次調整五、其他原則之(四)「健保節流措施之實際效應，應自總額扣除」，修訂為「醫療照護整合與效率提升成效之效益，部分用以獎勵醫療服務提供者，部分回歸保險對象」，這次的寫法較以往有彈性。但在效益評估及確認，後面提到的特約醫事服務機構違反全民健康保險醫事服務機構特約及管理辦法扣款之部分，若有效益時，其金額是否須經由雙方確認，因為過去醫界和健保署之間對於某些措施的效益，彼此認知有很大的不同，有時健保署認為屬於效益的範圍，醫界卻認為不是，所以，建議協商通則中加入但書，較無爭議。戴主任委員桂英謝謝潘委員延健，請黃委員啟嘉。黃委員啟嘉醫療照護整合與效率提升成效所撙節的費用，依照總額預算的精神，當醫療品質提升時，所節省的費用，本來就應全數回歸總額，卻將一部分回歸保險對象。在總額預算制度下，若效率不彰，醫療產生浪費，則點值就會下降；若醫療執行效率很好，且醫療品質提升，節省的費用應該讓點值提高，但卻部分要回饋給付費者使用。去年總額協商時，就發生類似的爭議，感謝付費者代表，體諒醫界的辛勞，同意以其他形式作一部分的補償，所以也突顯這樣的規定不合理，任何總額政策的績效，除健保署的努力外，也需要醫界的配合，若做如此修正，勢必影響醫療提供者在這方面的努力，也間接損害到民眾的權益，所以，懇請委員審酌總額預算的精神，將本項刪除。戴主任委員桂英謝謝，請蔡委員宛芬。蔡委員宛芬我可能要表達不同的意見。總額每年都有成長率，每年協定的總額，就是希望在一定總額預算分配下，民眾可以得到合理的醫療品質。而健保節流措施之實際效應，應自總額扣除的原因，在於健保署每年都會推行創新的政策如雲端藥歷等措施，若實施成效良好，總額就會有節餘，由於每項計畫均挹注預算，若繼續提供預算，政策本身也有預算，2項一起成長，就會重複，扣減費用與總額的精神並不相違背。重點在於每年協商總額時，都應該要重新思考，醫界自行努力或自律的部分不會做為減項，去年列入扣減項目為「全民健康保險高診次者藥事照護計畫」，今年到底要列入哪些減項？大家可以再討論，但是減項還是有存在的必要，所以，建議不要刪除。 戴主任委員桂英謝謝蔡委員宛芬，請謝委員天仁。謝委員天仁剛剛黃委員啟嘉所提到的，其實只是一項原則，重要是總額協商時如何訂定部門總額的數額，原則問題吵半天是沒有意義的，大家還要再表達意見嗎？應該把這個時間節省下來，等總額協商時好好溝通比較有用，好嗎？戴主任委員桂英一、謝謝各位委員提供寶貴的意見。剛剛已先徵求健保署意見，本案增列「其他預算：除總額協商已議定事項外，各項目之預算不得相互流用」乙項通則。二、另有關其他原則之「(四)醫療照護整合與效率提升成效之效益，部分用以獎勵醫療服務提供者，部分回歸保險對象」1項，因屬於衛福部106年度總額協商的政策目標，所以維持草案建議文字，至於其效益額度，同意於年度總額協商時，須經保險醫事服務提供者及保險付費者代表委員確認。本案通過，謝謝委員的幫忙。接下來進行討論事項第三案。捌、討論事項第三案「建請修改全民健康保險會組成及議事辦法第5條條文：健保會委員任期為二年，保險付費者代表及保險醫事服務提供者代表之委員，以連任一次為原則，每一屆並應至少更替五分之一；委員連署建議刪除『以連任一次為原則』和『每一屆並應至少更替五分之一』的限制文字案」與會人員發言實錄同仁宣讀戴主任委員桂英謝謝同仁宣讀。請問委員對於本案有無意見？請干委員文男。干委員文男一、本案係由許多委員共同提出，由於健保法條文並未訂定健保會委員連任條文限制，不是在法律的層次所定，而是由全民健康保險會組成及議事辦法(以下簡稱本會組成及議事辦法)中訂定連任限制和更替五分之一的文字。二、本案主要的問題在於知識的不對等，健保會的付費者委員均由各付費團體所指派擔任，消費者的專業知識與醫事服務提供者相差甚遠，尤其在總額協商及談判方面，須經多年學習才較熟悉，如果常常替換，且須更換五分之一，無法有效保障付費者的權益。所以建議刪除「以連任一次為原則」和「每一屆應至少更替五分之一」等文字。戴主任委員桂英謝謝干委員文男，還有哪位委員要發言？請陳代理委員順來。陳代理委員順來(侯委員彩鳳代理人)贊同本案，健保及醫療的業務非常複雜，個人過去曾擔任全民健康保險醫療費用協定委員會(健保會前身)委員，離開約7、8年，現在接觸又得重新學習，因為付費者代表對於健保業務應更熟練，才能保障所有付費者的權益。戴主任委員桂英謝謝陳代理委員順來，請楊委員芸蘋。楊委員芸蘋請大家不要誤解付費者代表非做委員不可，而是付費者代表，需要多一點時間學習，不只4、5年，甚至時間更長，在不違反健保法的原則下，修正本會組成及議事辦法，刪除連任原則及更替比率2項文字，使付費者代表多一點學習的機會，也可以增進總額協商及議事效率。戴主任委員桂英謝謝楊委員芸蘋，委員有沒有其他意見？請趙委員銘圓。趙委員銘圓本會組成及議事辦法其實是內規，並非法律，只要健保會內部討論後修訂，衛福部應站在高位應尊重本會委員決議。另，健保委員會議真的很複雜，與一般會議性質不同，需要許多的歷練和瞭解才能夠進入狀況，所以我支持干委員的意見。戴主任委員桂英謝謝趙委員銘圓，其他委員如果沒有意見，請本會幕僚說明本會組成及議事辦法的位階，若要修正，是健保會自行修正即可或屬衛福部權責？張副執行秘書友珊本會組成及議事辦法的依據是健保法第5條，其中第5項規定「前項代表之名額、產生方式、議事規範、代表利益之自我揭露及資訊公開等有關事項之辦法，由主管機關定之」。因此，訂定本會組成及議事辦法的權責機關是衛生福利部，幕僚單位則為社會保險司。戴主任委員桂英謝謝，請趙委員銘圓。趙委員銘圓組成及議事辦法根本不是所謂的法律，只要健保會內部討論通過後，送請衛福部審議通過即可。戴主任委員桂英本會組成及議事辦法雖然不是母法，但屬健保法授權訂定的子法規。既然權責在衛福部，建議將委員意見送請衛福部作為修法之重要參考，這樣處理可以嗎？請干委員文男。干委員文男本會組成及議事辦法是本會內部對於組成及議事辦法的訂定，嚴格來說應與法律沒有因果關係。戴主任委員桂英這部分是委員所關心的，有關健保法授權的事項，請幕僚再唸一遍相關條文。張副執行秘書友珊請同仁協助委員翻閱A4資料夾中的「全民健康保險主要法規要輯」以利瞭解。健保法第5條第4項針對健保會代表名額有所規範，並於第5項規定「前項代表之名額、產生方式、議事規範、代表利益之自我揭露及資訊公開等有關事項之辦法，由主管機關定之」。衛生福利部乃依據本項規定，訂定健保會組成及議事辦法。戴主任委員桂英一、謝謝幕僚再次說明，也指出資料供委員參看。二、本屆委員的聘期至105年年底，請幕僚將委員意見送請衛福部作為修訂法規之參考。接下來進行討論事項第四案。玖、討論事項第四案「『健保會討論自付差額特材案之作業流程，及健保署提案需檢附之基本資料表、檢核表』(草案)修訂案」與會人員發言實錄同仁宣讀戴主任委員桂英謝謝同仁宣讀。本案是鄭主任委員守夏主持會議時期的決議事項，請本會幕僚與健保署再檢討自付差額特材的作業流程，感謝許多委員提出具體的修正意見，幕僚已參酌委員意見擬具草案(如會議資料第58~62頁之附件一、二及表一、二)，請問委員有沒有不同的意見？請滕委員西華。滕委員西華一、會議資料第55頁，對於自付差額特材之作業流程，建議由「半年」改為「每季」討論1次，共有2位委員提出修改意見，我就是其中一位，理由略述：(一)健保署「藥物給付項目及支付標準共同擬訂會議」(以下簡稱「藥物共擬會議」)所討論的藥物品項中，另需經健保會確認的事項，即為自付差額特材之品項。大家都知道，藥物共擬會議(特材部分)是每2個月召開1次，而特材納入健保給付的提案係先經過專家會議後，再送到藥物共擬會議討論，討論後才會送至健保會。依以往經驗，健保署內部的流程少則半年，多則要1、2年，若連本會都採半年才討論一次，那很有可能因各單位的議事效率低落，而使保險對象合法使用自付差額特材的時程，又會被延緩；而在該特材在納入健保給付的審查期間，保險對象就算有需要，醫療院所也不能以收取全額自費的方式來讓病人使用。(註：依健保署之「全民健康保險保險醫事服務機構收取自費特材費用規範」，其第四項第(一)點規定為「已向本署提出核價建議並經本署受理，尚在審核中、議價中或議價未完成之品項，在完成核價程序之前，保險醫事服務機構可向保險對象收取全額自費」)(二)對於健保署送會討論的自付差額特材，如果本會不同意該特材納入差額給付品項，或是認為差額給付的價格還要調整，其原因可能是藥物安全、或不符合效益(例如僅多了美觀之作用)、或因適應症考量等因素，而使得本會不同意其納為健保自付差額特材品項，這些不同意的理由，對於保險對象可能是平常不太知道的資訊，但又是很重要的參考。(三)因此，我認為討論自付差額特材品項是健保會十分重要的職責，即使延長會議也應該討論，萬不可為加快議程或縮短會議時間，遞延被保險人之權益。按理本來應該是健保署送案至本會後，就隨到隨審，不過健保法亦無規定期程，但目前本會討論的頻率「半年」，實在太長了，建議原「每半年討論1次」之期程，應縮短為「每季討論1次」。二、會議資料第55頁「健保署前表示『他國價格倍數』資料蒐集不易，建議刪除」，個人認為不能刪除，建議應該還是要盡心盡力去蒐集，若蒐集不到再敘明無相關資訊，這與直接刪除的意義是不盡相同；或是健保署也可請廠商提供資料，這是另一個方法，因為廠商方面也許有在其他國家有販售或上市的相關資料，請廠商填具不得提供不實資訊之切結書，即有一定可信度；至於若該自付差額特材剛好是以台灣為第1個上市國家，以致於沒有他國價格倍數資料的情形，應該是不多，搞不好還沒有呢。他國資料之「價格倍數」資訊，絕對是本會委員對於是否同意該特材納入健保自付差額特材品項，在價格方面，十分重要的參考數據。三、會議資料59頁「健保署提案需檢附之自付差額特材品項基本資料表」之項目「5.同意納入自付差額特材之理由」除了(1)綜合考量「2.特性」、「3.價格」及「4.健保財務影響評估」外，應再加入對醫療倫理的考量，此係源自健保法第42條，該條文除了HTA(Health Technology Assessment，醫療科技評估)，也談到應考量醫療倫理。因此，建請亦需摘要HTA報告有關醫療倫理之評估內容，以供委員參考。(註：健保法第42條略以，藥物給付項目及支付標準之訂定，保險人得先辦理醫療科技評估，並應考量人體健康、醫療倫理、醫療成本效益及本保險財務)戴主任委員桂英謝謝滕委員西華，請林委員敏華。林委員敏華同意滕委員西華看法，討論自付差額特材為本會職責，不應延遲，建議「每季」討論，但建議避開1、4、7、10月，其為健保署署長對該署業務執行報告進行口頭報告之月份，可避免例行議案集中於特定月份。戴主任委員桂英謝謝林委員敏華，請趙委員銘圓。趙委員銘圓先前回覆本案修改無意見，但經滕委員西華發言說明後，同意滕委員西華意見，修改為「每季討論1次」。戴主任委員桂英謝謝趙委員銘圓。委員所提意見綜整如下：一、有關「健保會討論自付差額特材案之作業流程」，請問委員是否同意將「每半年討論1次」改為「每季討論1次」？(未有委員表示反對)好，就依之修改。二、有關「健保署提案需檢附之自付差額特材品項基本資料表」：(一)會議資料第60頁，他國資料之「3.價格差距」(含國別及價格倍數範圍)，本會幕僚亦建議保留，今日委員再度表達此資料之重要性，所以還是請健保署儘量提供。若確實無資料時，再加註說明。(二)委員建議將「醫療倫理考量」納入我國資料之「5.同意納入自付差額特材之理由」(會議資料第59頁)，該欄位目前共分為(1)~(4)項，「醫療倫理考量」似乎可新增為第(5)項，或可納入現有的欄位中呈現。請問健保署(填報單位)以何方式填列較佳，或填寫有無困難？施組長如亮有關滕委員西華之建議部分，可於「醫療科技評估報告之重點」中加入關於醫療倫理考量之相關資料，供委員參考。戴主任委員桂英針對滕委員西華建議，健保署將於基本資料表「5.同意納入自付差額特材之理由」之「(3)醫療科技評估報告之重點」中，納入醫療倫理考量之相關資料供委員參閱，不另增欄位。委員若無其他意見，接著進行討論事項第五案，請同仁宣讀。拾、討論事項第五案「建請中央健康保險署針對新型C肝口服藥與藥廠議價後，已取得與現行療程相等之治療費用前提下，應優先將新型C肝口服藥物納入健保給付，爭取國內C肝患者提早完成治癒，同步考量預算排擠問題，建請健保署編列足夠C肝治療預算，以提供穩定經費，期使治療政策吻合患者需求，確保國人健康案」與會人員發言實錄同仁宣讀戴主任委員桂英謝謝同仁宣讀。請委員發表意見，請趙委員銘圓。趙委員銘圓一、針對本案已在提案與說明敘述的部分，不再重述。在台灣新藥引進落後先進國家7~8年，不利於被保險人醫療照護，對健保財務也是沉重負擔。若小病在第一時間使用新藥便能治癒，但時間拖延，將造成更嚴重的損害，這議題希望委員理性思考。二、部分的媒體或錯誤資訊誤導民眾對C肝新藥的認識，是最被詬病的。前衛生署署長在媒體上表示C肝新藥須花費260萬元~300萬元，但這是事實嗎？在美國也許是，但其他國家應該不是，C肝新藥國際參考價：韓國每人29萬元(約9,000元美金)；印度4萬元；埃及2.9萬元，各國藥費落差相當大，故在醫療費用與健保整體溝通、與藥商議價上，仍有很大的空間。目前台灣C肝患者以雷巴威林治療，每人藥費需22萬元，干擾素為12萬5,000元，合計34萬5,000元，若使用C肝新藥僅花費30萬元，反能節省健保醫療費用。三、治療疾病是為讓民眾早日脫離疾病之苦，尤其是C型肝炎是能治癒的疾病。目前國家就業率、勞動率一直下滑，若C肝患者治癒後，就能回到職場，提供勞動力，以助國家整體經濟發展。四、不是很清楚為何排斥C肝新藥納入健保給付，若在不增加預算下，應該儘速將C肝新藥納入健保給付，預算編列非一次增足2,600億元，反觀各國對C肝新藥預算編列，也非一次到位。五、有關補充資料第4頁，健保署意見二「日本及韓國已給付C型肝炎新藥且未設有治療及給付條件限制乙節」的部分，容我再說明，2014年7月，在日本C肝患者收入大於7萬元者，需負擔1.8萬元之部分負擔，年收入小於7萬元者，仍需負擔9,000元之部分負擔，每年約治療1.8萬人；在韓國C肝治療費約30萬元，於2015年7月收取1成部分負擔，約9萬元；在澳洲於2016年3月C肝患者自付約900元，低收入戶者自付150元。六、另沒有給付限制的部分，是指「沒有限制疾病的嚴重度」，只要篩檢為C肝患者，即可使用新藥，不須經雷巴威林治療失敗或承受干擾素治療後之不適副作用後才使用新藥，建議C肝新藥早日納入健保給付。七、在座有藥物共擬會議代表，建議本案應在共擬會議中討論，但健保會對議案是以合議方式進行，所以本案在此提出係屬合理，相關說明供委員參考。戴主任委員桂英謝謝趙委員銘圓，請滕委員西華。滕委員西華一、提案委員相當用心及關切民眾權益，確實國人肝炎盛行率仍高，治療花費不斐。先代表謝委員天仁表達對本案立場「本提案立意良好，但依據健保法之位階及權責，本案係屬藥物共擬會議討論事項，若藥物共擬會議尚未討論，基於健保會權責，不宜對藥物共擬會議未通過給付之藥品給予任何建議，否則將導致權責不相隨的情況」。二、我的看法與謝委員天仁類似，健保法設計是符合權責相隨之法理，且具重要的意義，在藥品納入健保給付前，需經專家評估後，再送藥物共擬會議討論，倘使藥物共擬會議尚未討論，健保會強制要求健保署編列該等藥物之預算並給付該費用，是越俎代庖，相當不合適。三、若藥物共擬會議的決定與健保會決議有衝突時，又該如何處理？C肝不會是最後一個昂貴的藥品，只是C肝新藥是藥價昂貴且用量大，所以爭議性較大。健保會不曾對特定罕病、癌症用藥等過度干涉審查期程，所以對C肝新藥納入健保給付之期程，個人偏向保留態度，建議暫緩本案的討論。四、若涉及預算編列，建議在總額協商時共同討論，以保留協商之彈性。本案在此若達成協議或任何結論，將不利於總額協商。五、曾在李委員蜀平將成立健保藥品政策研究小組提出，應重視藥品的支付價值，再討論是以加保費方式，或是以公務預算支應部分藥品費用。特定藥品在PBRS(藥物共擬會議)未經過討論前，不宜提案討論。在此向提案委員致歉，提出這樣的建議。戴主任委員桂英謝謝，請潘委員延健。潘委員延健一、剛剛委員所提的意見，不再重複。請參看補充資料第5頁幕僚意見三，幕僚對預算編列，建議以調整因素內涵包括「新增給付項目(高科技醫療及新藥)40億元」，但因C肝新藥非新療法，在醫院及基層都會發生，不易區隔。二、預算編列其實不容易精算，依過去經驗，訂定適應症後，往往2~5年內會爆量，所以類似新增的藥品、療法，建議放在其他預算，若醫療費用使用的少，則省下來，若使用的較多，亦有充裕的財源支應。戴主任委員桂英謝謝，請蔡委員宛芬。蔡委員宛芬一、對C肝新藥納入健保給付，應有前提才能討論，剛滕委員西華提到可能與藥物共擬會議產生競合問題，藥品納入健保之前，應提報藥物共擬會議，透過專家意見及HTA(醫療科技評估)，再決定是否納入健保給付。目前有4個藥廠能提供C肝新藥，但尚未看到相關的HTA資料之前，不宜直接決定。二、從提案及說明來看，C肝新藥似乎已確定價格，也許健保署能與廠商再議得更低的價格，建議讓健保署有發揮的空間。因尚不知藥價，無法提供健保財務衝擊評估。建議暫緩討論。戴主任委員桂英謝謝蔡委員宛芬，請楊委員芸蘋。楊委員芸蘋一、本案立意良好，C肝患者因新藥而治癒，應能減少健保醫療費用，這是未來的趨勢。我可以接受委員意見，應依行政相關規定提報藥物共擬會議討論，建議C肝新藥能儘早於該會議討論。二、至於潘委員延健建議C肝新藥之經費，可考慮編列於其他預算。這一點是可以考慮，讓患者可以儘早使用新藥或新醫療科技，這對我們將來的醫療給付是會有成效的，既然具有成效可以看到其結果，不是不可以討論的，我贊成可以儘早在藥物共擬會議加以討論，讓需要者可以早點使用到這些新藥品，以上建議。戴主任委員桂英謝謝。請葉委員宗義。葉委員宗義我贊同謝委員天仁對於這個案子的看法，如果藥物共擬會議不通過，我們通過，這樣怎麼解決？這會產生很多的矛盾問題，我講過很多次。為何最近藥物共擬會議流會2次，理由是與會人數不足，第2次會議還只剩下5、6位，最主要議題是在對健保財務總額預算的衝擊，每次提到藥物共擬會議討論的藥物，不只是本案C肝新藥，包括治療眼疾等各項藥物所需總醫療費用嚇死人了，本案依台灣肝臟研究學會估算，1年建議治療人數約為1~1.5萬人，若屬民眾免費治療的話，健保可能負擔不只原預估這樣，所以只要涉及萬元的新增藥物，絕對沒有一次通過，都是我在那邊跟他們在大小聲(台語，吵架)，因為政府需要將新藥物、新醫療科技納入健保，所以本案應該回歸到藥物共擬會議去討論。戴主任委員桂英請何委員語。何委員語一、我的意見是最近參加許多藥品計畫工作，也參考9個國家的藥品計畫內容，我認為趙委員銘圓提這個案，我對他非常欽佩，因為他晚上沒睡覺在提這個案子，所以我們應該可以通過，建議決議內容為通過本案，移請藥物共擬會議參考辦理。二、我認為我們每個委員都有提案權，我們不能否決別人的提案權，至於提案內容適不適當，則屬見仁見智，我的看法是贊成本項提案，既然藥物共擬會議沒有討論，則移請其參考辦理，我們並沒有裁決健保署針對本案執行辦理。我的建議是這樣。戴主任委員桂英請黃委員啟嘉。黃委員啟嘉一、我想除了C肝新藥外，後面新藥是排山倒海要來納入健保給付，對於醫界而言，我們希望幾點能夠守住，第1點，事前財務評估能夠精準，需要編列有充足的預算，確實能夠專款專用，並且實施年度定額，對於剛才各位委員的高見，我認為涉及藥物共擬會議、健保會、總額協商會議等的整合，我對於提案委員的努力非常肯定，就何委員語建議決議內容，我修正補充一下，那就是建議本案決議為：原則通過，但需在下列程序完成後才通過，首先需仔細評估財務衝擊並經過總額協商會議編列足夠預算後，移請藥物共擬會議決定後才通過。二、我要突顯的是往往藥物共擬會議通過案子後，健保總額才去協商編列預算，而協商出的預算卻往往編列不足，怎麼辦？這些都造成醫界的困擾，所以我覺得健保應該先編列好預算，再去藥物共擬會議討論是否通過，此屬專款專用，否則就是困局，基於財務崩盤的恐懼，醫界往往對於新藥物、新醫療科技都拒絕通過讓健保給付。二代健保最重要的精神是收支連動，所以我的意見希望大家考慮。戴主任委員桂英謝謝。先請謝委員武吉，再請李委員永振。謝委員武吉一、剛才很多委員已經提過的，我不再多說了。我想C型肝炎藥品由健保給付已經一段時間，我想請問B型肝炎、C型肝炎防治，是屬於國健署或疾管署管轄的？我記得好像是國健署負責的，應該不是健保署管轄，我在此提出1個很大的question(疑問)。二、今天討論事項第6案，國健署取得原菸品健康福利捐分配健保安全準備20％，使健保收入少約66億元，另外健保每年因為愛滋病費用會多支付約40億元，都要我們這些委員負責、健保負責，造成我們及健保寸步難行，他們到底花到哪裡去？這需要說清楚講明白，新政府是轉型正義的開始。目前補充保險費比較充實，他們都想辦法來挖錢，他們不知道，再過幾年，我們的補充保險費就不夠了。戴主任委員桂英謝謝。請李委員永振。李委員永振一、黃委員啟嘉剛剛的發言，使我想起102年間我們討論Statins(降血脂藥品)及Lucentis(黃斑部新生血管藥品)給付的經驗，當時吵了半天，後來健保署有說明辦理情形，建議下個月健保署可以報告當時的爭議及如何解決。回到本案，因涉及藥物共擬會議，再看看提案內容及健保署意見，有點花花(台語，不清楚)，如果在傳統的醫療方法下，醫療費用約11~22萬元間，到底需要治療幾年，新的藥品如果可以治好的話，幾個月醫療費用約30幾萬元，若原療程1年22萬元需要3年，則新療程當然較划算，建議詳細評估這種情況，呈現在藥物共擬會議，甚至我們在總額協商會議時可以擁有具體數據加以考量，這樣可能會比較好，也就是需要比較具體周全的規劃，對於本案會有比較好的結論。二、剛才謝委員武吉說明將來健保收入可能不夠支出，今年已過了5個月，其中3個月(1、4、5月份)收入已經少於支出了！需要下個月健保署提出分析是怎麼回事，目前也需要儘快把這些訊息通知國發會，否則明年醫療費用總額的低推估與高推估一旦決定，我們只能在那範圍內協商。戴主任委員桂英趙委員銘圓您要最後還是要先發言？(趙委員銘圓示意請干委員文男先發言)請干委員文男。干委員文男趙委員銘圓提這個案子，我是連署人，之所以連署，我是認為有需要，目前C型肝炎患者約55萬人，若以200萬人估算則價格差頗多，我們的迷思是使用者確實那麼多？趙委員銘圓提案內容有關各國此部分醫療費用應屬確實，這些與媒體報導差太多了，我聽說1顆藥價格很高，印度進口才幾美元，台灣報價為100美元，1次要吃很多個月，確實很貴，若沒那麼昂貴，我們健保可以給付看看，要從這裡面看事情，如果不需要那麼多，請健保署評估可行性，若可行，規劃時程，例如於今年或明年納入健保給付，否則永遠無法納入健保給付。我們也希望下個月看到Statins(降血脂藥品)降價情形，包括市面上價格與實際購買價格的差異是否很大。戴主任委員桂英請趙委員銘圓。趙委員銘圓一、謝謝主席及各位委員指教，本案內容與委員意見並無相違背，有關預算部分，可以分為2個區塊，首先是現有的治療方式，可以利用C肝新藥取代的話，這可以減少健保支出，若費用超出現有部分，我們建議行政院編列預算專款專用，至於是否提到藥物共擬會議討論，我想一項重要的議題，不會經過一次提案討論就通過，假設沒有經過不斷討論，針對各項問題研究解決方法，則永遠不會通過健保給付。二、剛才葉委員宗義提到最近藥物共擬會議流會2次，另據我所知，該共擬會議部分與會者認為，健保會沒有討論過的案子，該共擬會議為何需要討論，若藥物共擬會議講他的，我們這邊又不能提案，則病患的醫療權益在哪裡？對於罹患C型肝炎病人，若能早一天治癒，既可減少健保醫療費用支出，也可恢復其健康，對國家或社會都是好的，我認同剛才何委員語所提建議部分，我想還是讓這個案子成案，請藥物共擬會議辦理後續事宜，這對C肝新藥或其他新藥，若相關醫療費用，屬健保財務可以接納的範圍內，應該儘快讓其通過健保給付，這需要優先處理，此為站在維護全民健康的角度來看。而不是像有些病每年固定花那麼多錢治療，但卻沒辦法醫好，但對於可以治療好的病卻不給付！我的意思並不是反對對於醫不好病就不醫治，他們還是要醫治。但可以醫好的病更應該早點醫治，以上，謝謝。戴主任委員桂英還有2位委員，請葉委員宗義。葉委員宗義一、目前健保對於C型肝炎患者給付干擾素，本案藥品是升級給付，以後隨著用量增加而使醫療費用上升幅度可能會減緩，這當然重要，但最重要的是在醫院執行上。二、我想本案還是需要回到藥物共擬會議討論，其通過後就可以執行，不見得需要報到健保會，我想請施組長如亮表達對於這個案子的看法，跟各位委員詳細說明。以上是我的建議。趙委員銘圓主席，我想補充一下。戴主任委員桂英抱歉，請稍候一下，先請之前舉手發言的委員。請張委員文龍。張委員文龍一、主席，各位委員，我非常佩服趙委員銘圓等五位委員提出本案，出發點都是為我們國民的健康著想，但是權限在於藥物共擬會議，因為我跟葉委員宗義都是本會參加該共擬會議的代表，這個程序我們非常清楚，本案也非常單純，還是需要尊重藥物共擬會議的決定，此與何委員語所講的一致。二、我在這邊需要稍微解釋一下，葉委員宗義提到最近藥物共擬會議流會2次，當時我都有出席，係因病友團體代表需要透過視訊瞭解該共擬會議進行情形，因其部分與會者有些考量才流會，並不是我們被推派的委員怠惰，各位委員可以思考，若病友團體代表等可以透過視訊瞭解我們會議進行情形，則屆時大家可能有不同的想法。戴主任委員桂英謝謝，請何委員語。何委員語一、主席，各位委員，據我所知，有關C肝新藥，美國某藥廠來台申請上市，整個療程預計需要80萬元。二、我認為我們需要尊重藥物共擬會議的決定，所以我建議通過本案，移請該共擬會議參考辦理，本會參加該會議有2位委員，屆時他們辦理也有2條路，1條是參考完畢不辦理，另1條是參考完畢請健保署編列預算支應，所以今天我們對於每位委員的提案予以支持與尊重，讓相關權責單位作最後決定，我的建議就是這樣。戴主任委員桂英謝謝，請趙委員銘圓。趙委員銘圓向張委員文龍澄清，我並非意指議事怠惰，我了解是因部分委員退席抗議，才造成最近2次流會。另補充說明，前天(105.6.22)本會吳前委員玉琴，也是現任立法委員，於立法院質詢衛福部林部長奏延有關C型肝炎用藥問題，相信幕僚對於部長的回應都很清楚，在此不佔用太多時間重述。戴主任委員桂英謝謝！本案已討論約40分鐘，委員們分別從病患需求、預算編列方式、價格議價程序等不同角度切入，各位委員的意見都很重要，所有發言都會加以記錄，送請健保署於共擬會議討論相關議案時參考。可否往下進行討論事項第六案？(未有委員反對)謝謝各位！接下來進行討論事項第六案。拾壹、討論事項第六案「建請中央健康保險署針對菸品健康福利捐分配於全民健康保險之安全準備金從70%調整至50%一事，重新審視其調整的比例，目前健保署提出105年健保收支餘絀預估值為負117億元，之後會由健保安全準備金來填補，如此一來健保安全準備金將每年被吞噬，最後回到過去赤字的狀況，再者，目前菸捐分配比率方式有違最初支應長照的原則，將其餘17%偷渡至非長照使用項目，有鑑於此，是否應將非使用在長照中的17%回歸到健保安全準備金中案」與會人員發言實錄同仁宣讀戴主任委員桂英謝謝宣讀，各位委員有無意見？請趙委員銘圓。趙委員銘圓一、本案說明已很清楚，不再重複贅述。二、全民健康保險安全準備從105年2月2,352.52億元，折合約5.19個月保險給付，到3月最高，有2,357.18億元，4月降為2312.48億元，5月再降為2290.33億元，折合約5.01個月保險給付。從5.19個月降到5.01個月，其中調整菸捐分配比率後減少100多億元，造成很大衝擊，當然健保法施行細則第45條修正政府應負擔健保總經費部分，也是很大的因素。三、當初調整菸捐分配比率主要是為長照資源發展之用，但實際上用於長照只有3%，另外17%卻挪作它用，對健保安全準備造成很大影響。當初既然是為支應長照，20%若全數投入，我們不會有意見；但國健署卻用偷天換日作法，移作其他用途，過程中本會委員均表達反對意見。尤其在之前會議，對於分配予健保安全準備之比率，由70%調降為50%，所有委員也都一致反對。既然17%非用於長照，就應回歸到健保安全準備上，以上補充說明。戴主任委員桂英謝謝趙委員銘圓，請干委員文男。干委員文男原擬投入長照卻未使用的菸捐，應回歸安全準備。部長很能溝通，也答應再將部分菸捐回歸安全準備。回歸的菸捐也可依趙委員銘圓所希望的專款專用。建議通過本案，讓部長再行考慮及溝通。戴主任委員桂英請楊委員芸蘋。楊委員芸蘋認同趙委員銘圓及干委員文男的意見，希望能通過本案。當初菸捐分配予健保安全準備比率由70%調降為50%，委員們即一致反對，但無法阻擋，仍被強行過關。當初強行通過調整，事後又未確實執行，委員很難接受。考慮未來健保財務壓力，國健署自有辦法籌錢，無須為其擔心太多，健保署應顧好自己。戴主任委員桂英請黃委員啟嘉。黃委員啟嘉對於付費者的意見，醫界雖未發言，但大多是支持的。預算移撥目的與實際運用不符時，就應回歸原用途。戴主任委員桂英請楊委員漢湶。楊委員漢湶當初「菸品健康福利捐分配及運作辦法」的修正有些奇怪，唯一增加的文字是「由農政機關使用於有利癌症防治之相關產業輔導」，主要目的應是減少蔬菜、豬牛等農產品的致癌因子。除健保安全準備調降20%外，供癌症防治的分配比率增加5.5%，是調整最多的項目，但從文字上無法看出其用途。我認為既然要用於長照，就應真正投入，因長照很花錢，也是政府的重要政策。但從修正文字來看，分配於長照的比率僅有5%，尚未高於癌症防治，顯然修正方向與邏輯並不一致。不知目前該辦法修正進度如何？戴主任委員桂英衛福部已於104年10月15日修正發布「菸品健康福利捐分配及運作辦法」，至今已實施7、8個月，快滿1年了。楊委員漢湶那我們現在能做什麼？戴主任委員桂英一、可以建議再修正該辦法。二、會議資料第67頁原擬辦文字建議加上「建請」二字，因本案屬衛福部權責，故建請將移撥20%的菸品健康捐中，並非使用在長照中的17%回歸到健保安全準備。三、本案是對衛福部提出建議，衛福部會先交由權責單位國健署研議，建議將案由及說明中提及「偷渡」至非長照項目，修改為「使用」至非長照項目，意思一樣，可以嗎？趙委員銘圓可以。楊委員漢湶沒有偷渡，是明渡。(眾人笑)戴主任委員桂英相關單位間宜以尊重立場相互溝通。感謝各位，目前討論案均已議定，接下來進行專案報告第一案。請教各位委員，目前專案報告共三案：第一案與總額協商有關，了解藥品分配比率目標制之執行結果有助協商；第二案是監理指標監測結果，該案須定期提報；第三案是DRGs相關診斷分類分組ICD-10-CM/PCS轉碼執行情形。建議視時間狀況，因委員對議程安排未有調整建議，可否先進行第一案，若發言結束時已超過2點，可否將其餘2案移至下次報告，或請委員自行參閱書面資料？滕委員西華一定要討論。戴主任委員桂英今天一定要全部討論？滕委員西華不一定要今天。戴主任委員桂英逐案報告，以2點結束為原則，未及報告的專案移至下次會議。請健保署報告。拾貳、專案報告第一案「『全民健康保險藥品費用分配比率目標制』試辦方案執行成果」與會人員發言實錄施組長如亮報告戴主任委員桂英謝謝施組長如亮報告，針對本專案報告，請各位委員提出意見，請干委員文男。干委員文男請教保障藥品每點1元法律根據為何？每年藥品費用都占總額1/4以上，其支出目標訂在何處？有無法律依據？每次協商時，未見藥品支出目標，而是隨著醫療費用成長。對於這2點，我比較疑惑。戴主任委員桂英謝謝，請滕委員西華。滕委員西華一、先幫蔡委員宛芬表達意見，首先，DET(Drug Expenditure Target，藥品費用分配比率目標制。依健保署投影片資料，以下簡稱藥品支出目標制)上次已有決議，不宜再試辦；其次，對於DET成長率採總額成長率，質疑為何要與總額成長率連動或一致，與干委員文男意見類似，並不清楚其間的關聯性。二、以下為本人意見，第4張投影片「全民健康保險法規定」，雖然在二代健保法條文第61條第3項及第62條第4項提及醫療給付費用總額分配相關規定，但須扣連第5條第1項第3款規定，亦即涉及保險醫療給付費用總額分配時，應屬健保會權責。因此，第5張投影片提及在101年費協會經3次討論均未獲共識，即謝委員天仁常說的，當時決議無共識，就是不希望也不同意健保署試辦藥品支出目標制，結果衛福部不顧費協會健保協商權責的意見，仍堅持試辦，這也是多年來謝委員天仁一直反對的原因。三、我也不支持試辦DET，理由是從健保法第46條來看，當時的立法背景是希望不因藥價調查及調整過度頻繁或不穩定，影響民眾用藥。我們認為藥價調整機制應存在，希望藥品利潤在逾專利期後，逐年調整至合理價格，我記得2008年全國藥政會議上也有提到。因此，我們希望上市超過一定年限的藥品不須再調查，上市超過15、20年的藥品，給付僅3、4毛錢，還在藥價調查，就算百分之百有價差，其實影響不大，卻很擾民。四、藥品給付不論採10國中位價或最低價，在原廠藥申請給付時，都會先定價，再進行藥品價量協定(price-volume agreement)及藥價調查(Drug price survey)，我們認為這樣的手段，足以控制藥價。若健保署在逾專利期的5年內，或第1階段原廠藥給付，還不能透過這些手段，為人民保住合理價格，在逾專利期5年內都還能任意調整到合理價格；超過第6年的，亦即5年以上除非有價格異常，否則都不應頻繁調查及調整藥價，除非自認藥價訂定策略及方法出現問題。因此，若給付藥品都是民眾必需的，例如剛才討論的C型肝炎高價用藥，卻又透過不斷調整藥品價格的手段，將影響醫療體系抑制處方，以管理目標制上限，影響醫療自主性及效果。更何況目前已有雲端藥歷及藥品重複使用不給付等手段的管控，我們認為不應再實施DET。五、第17張投影片「藥價調整之架構」，分為3大類，其中僅有3a給付不超過15年沒有R值，我認為也沒什麼道理，只是為配合藥價調整架構，有自己一套方法。新聞也多次報導，健保署將試辦3b或3a類別差額給付，甚至蔣前部長也多次提及，就是由此衍生而來。因此，我認為目前藥價調整策略過於混亂，建議應視明年度是否實施藥品支出目標制，進行統一整理。戴主任委員桂英謝謝滕委員西華，請潘委員延健。潘委員延健一、本試辦計畫從名稱定義上來看，既然叫做目標，就應有很好的標的，也就是想要達成的理想性目標。但從公式來看，較像是數字管理，如同在實驗室裡將統計數字計算後，按成長率設定目標，就像先射箭再畫靶。第7張投影片的基本公式中，目標額度=基期值*(1+成長率%)，基期值是101年的藥費核付金額，第2年起，採前一年之藥費目標值作為基期，亦即以101年基期值加上以後每年的成長率，這就牽涉到涵蓋的範圍，105年的目標額度是以101年為基期，加上102年、103年、104年的成長率，其涵蓋範圍未考量102~105年的新藥額度，當有大量新增藥物時就會侵蝕到目標額度，並不合理。藥價調整大多針對第三大類藥品，純粹調降其單價，但藥費是數量及單價組成，在藥量介入管控措施後，雖有成效，但人口老化、疾病嚴重等整體醫療因素，將會造成用量的成長，通通反應在單價調降上面，因而造成各界有諸多不平的聲音。二、目前的藥量管控措施包括高診次保險對象藥事照護、門診處方用藥品項數監控、同院門診重複用藥核扣方案等，都有顯著成效，建議循此方向繼續執行。至於藥價是否需要調整？健保署藥價調查機制依舊存在，應該審視每項藥品合理價格，而不是為了達成藥價調降目標，刻意尋找標的物來分配調降額度，如此一來不易找出藥價合理點。戴主任委員桂英謝謝。請何委員語。何委員語一、我提出幾點意見，我建議以各藥廠每年藥品銷售數量成長率做為調整藥價的基礎，例如A項藥品今年賣100萬顆，明年賣150萬顆，此時藥廠就該自動降價，否則就依成長量折付。有些藥品使用量少，若再以調降總額度來分攤調降金額，不符藥廠成本。二、綜觀先進國家藥品管理機制，是由隸屬行政院的中央藥品管理委員會執行，負責核定藥品許可證、決定藥價及訂定藥品政策。反觀台灣，食藥署隸屬於衛福部，而衛福部又是使用方，由使用方核定價格並不合理。建議政府重新考量體制問題，成立隸屬行政院的中央藥品管理委員會，以發展藥品相關政策。三、國外藥廠不願進入台灣藥品市場，除人口少使用量不足外，等待期長也是原因之一，申請許可證耗時1.5~2年，再加上衛福部採用亦須1.5~2年，走完流程至少需要3~4年。另建議國外藥品採購次數由1年1次改為3年1次，雙方可於合約訂定使用數量，若第1年使用量超出額度，第2年就應自動降價10-15%，第2年如又超過額度，第3年又可以降價10-15%，藉以健全藥品採用制度。戴主任委員桂英謝謝何委員語。請謝委員武吉。謝委員武吉一、謝謝施組長如亮的報告。依「全民健康保險藥品價量協議原則」，假設健保署與藥廠協議藥品費用限量額度為1億元，最後院所申報金額是1.3億元，超出的3千萬元要償還健保署，我認為償還的金額應該回歸總額而非健保署，在報告中並未提及此部分。二、許多老藥，如MGO(Magnesium Oxide，氧化鎂，醫學上做為軟便劑)，1000顆才2、3百元，對此類藥品進行藥價調查實在是浪費時間及人力，即使有藥價差，差價也很少，請健保署不要做這些無意義的事情。三、在會議補充資料第21頁的「不列入例行性調整之藥品」，第1項的罕見疾病用藥，已經使用15年了，竟然還可再使用10年以上，且沒有食藥署的許可證，有沒有圖利廠商之嫌，我感到非常懷疑。第2項的必要藥品及第3項的特殊品項，應該將定義清楚列出。四、我們醫院的藥品都是由我採購、議價，我非常清楚其中的內容與過程。面對1年1次的藥價調查，藥廠常常叫苦連天，醫院更是天翻地覆，除了藥價調查還有特材調查，什麼調查都有，導致醫院人事成本增加不少，醫院已被認為是嚴重血汗，請不要再增加不必要的人力負擔，也不要給業界增加困擾，希望健保署多加考量。戴主任委員桂英謝謝，請吳委員肖琪。吳委員肖琪請看到會議補充資料第22頁「DET之執行成效」，藥費成長率大幅下降，其中有多少是執行雲端藥歷的成效？DET的目標額度是隨著總額成長率增加，健保開辦之初，醫療費用總額約2千多億元，其中25%是藥費，現今醫療費用總額6千億元，藥費依舊占25%，請問DET的功能何在？如果雲端藥歷已經可以深入細部管控，是否還需執行DET？請健保署參考。戴主任委員桂英謝謝吳委員肖琪。藥品支出目標制方案試辦到年底，未來是否繼續執行，將由社保司提至健保會議定。除針對DET的討論外，委員的建議大多涉及藥價調整規定，請問健保署有無回應，或於會後提供書面說明？施組長如亮因建議事項較多，請容我們會後提供書面說明。戴主任委員桂英請問委員可否同意健保署做法，請健保署參酌委員的意見提出書面說明，謝謝。干委員文男主席，剛才我提的法律問題還未回答，請問藥費每點1元的法源為何？楊副司長慧芬依健保法第62條第1項「保險醫事服務機構應依據醫療服務給付項目及支付標準、藥物給付項目及支付標準，向保險人申報其所提供之醫療服務之點數及藥物費用」，藥品係費用的概念。干委員文男字面上沒有寫每點1元。曲委員同光費用就是指實際數。干委員文男實際數為何？曲委員同光費用的概念即是不浮動的點數。干委員文男依照法律條文，並沒有藥費有每點1元保障字樣，請問實施藥費保障依據何在？法律是不講概念的，每一年被圖利多少錢？曲委員同光依健保法，健保開辦時藥品就以費用申報。戴主任委員桂英謝謝社保司的說明，目前醫療服務的訂價是點數，藥物的訂價是費用，也就是錢，訂價為2就是2元，因法律字眼不易了解實際執行方式，請雙方會後多加溝通。干委員文男這有法律問題，我要提出請大法官解釋，這會圖利藥廠與醫事機構，母法並未寫明藥費有每點1元保障。另外，藥費占醫療費用總額四分之一的法源何在？若只講過去經驗而不提法源，總額調藥費就跟著調，調到最後付費者受不了，這部分請說明。戴主任委員桂英這部分口頭說明難以清楚表達，請以書面再補充說明。非常感謝各位委員參與至下午2點，因為時間關係，專案報告「全民健康保險業務監理指標之監測結果報告」與「DRGs相關診斷分類分組由ICD-9-CM轉換為ICD-10-CM/PCS之執行情形」移至下次委員會議。今天會議進行到此，謝謝各位，散會！3044190-64770詢問(委員會議)日期：105年4月22日電子郵件回覆委員日期：105年4月27日020000詢問(委員會議)日期：105年4月22日電子郵件回覆委員日期：105年4月27日健保會委員會議陳順來委員請本署說明全民健康保險業務執行報告中表18-5B，105年2月基層門診透析件數大幅成長，成長率22.43%一案，本署說明如下：經查105年2月基層門診透析之申報件數，有4家診所申報錯誤，致該月件數大幅成長，本署已輔導院所正確申報並修正相關數據。105年2月基層門診透析申報件數為3.3萬件，成長率4.90%，平均每件醫療點數44,522.3點，較去年同期成長4.24%。(詳附表)105年1-2月基層門診透析申報醫療點數為30.1億點，成長率5.17%，係因105年2月為29日較去年同期增加1日，故費用較去年同期為高。5543550-224790附表00附表3004185-102870詢問(委員會議)日期：105年5月27日電子郵件回覆委員日期：105年6月20日020000詢問(委員會議)日期：105年5月27日電子郵件回覆委員日期：105年6月20日健保會委員就例行報告第四案「中央健康保險署提報『健保藥品品質監測計畫』(草案)」與會人員發言實錄(議事錄P.57~59) ，請本署提供所需參考資料，本署說明如下：項次委員意見健保署回復說明1謝委員天仁本案是年度健保收入去支應總額支出的「提升保險服務成效」項目，錢是健保支付的，立法院憑什麼來審查這項預算？ 滕委員西華因健保署是附屬單位，依預算法應呈報立法院進行審議及備查，甚至可將基金併入決算。不知道附屬單位的特種基金預算的審查是否有這樣的規定？戴主任委員桂英委員提出許多具建設性的建議，蔡副署長也提到部分會予採納，至於跟立法院溝通預算動支的部分，有些委員希望可以再提供資料，請健保署在可能範圍內儘量提供。為評估健保給付同成分不同廠牌藥品之品質現狀，以了解各廠牌間品質是否保持相同水準，確保醫療使用健保藥品應有之藥品品質，故本署依健保會105年度全民健康保險總額協商會議之決議，規劃針對治療指數狹窄、藥品使用量大及醫療機構或民眾對藥品品質有疑慮而通報之品項，以委託檢驗方式進行品質監測。另本案預算於立法院第9屆第1會期社會福利及衛生環境委員會第21次全體委員會議已決議減列300萬元及凍結2000萬元，且目前仍有提案待黨團協商，本署將俟立院預算審核結果辦理。27622500委員會議日期：105年6月24日會議現場發送資料(中央健康保險署提供)020000委員會議日期：105年6月24日會議現場發送資料(中央健康保險署提供)center42100500PAGE \* MERGEFORMAT86PAGE PAGE PAGE PAGE \* MERGEFORMAT18PAGE \* MERGEFORMAT17PAGE \* MERGEFORMAT3AQAAAGwAAAAAAAAACAAAAJEDAACmBQAAAAAAAAAAAADkfQAAO8gAACBFTUYAAAEAUNEAAAUGAAAK
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