衛生福利部全民健康保險會第2屆105年第10次委員會議議事錄中華民國105年10月28日衛生福利部全民健康保險會第2屆105年第10次委員會議紀錄壹、時間：中華民國105年10月28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：干委員文男何委員 語何委員永成中華民國中醫師公會全國聯合會林榮譽理事長永農(代)吳委員肖琪李委員永振李委員來希李委員偉強 李委員蜀平林委員至美 國家發展委員會林專員美娟(13：20以後代)林委員敏華林委員惠芳邱委員泰源 中華民國醫師公會全國聯合會張副秘書長孟源(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中華民國區域醫院協會劉秘書長碧珠(11:10以後代)張委員澤芸商委員東福黃委員淑英黃委員啟嘉黃委員偉堯陳委員平基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：李委員成家莊委員志強伍、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 龐組長一鳴 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(略)捌、議程確認決定：確定。 玖、例行報告第一案案由：確認本會上(第9)次委員會議紀錄，請鑒察。決定：確定。附帶事項：請中央健康保險署就委員所詢有關「C型肝炎藥費」預算移列專款之估算原則，及相關檢驗費用之計算方式與支應款項等事項，提供書面說明。第二案案由：本會上(第9)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)事項辦理情形中，除「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」案改列「解除追蹤」外，餘洽悉。二、委員針對全民健康保險法施行細則第45條規定修正後之財務影響評估所提相關詢問，請中央健康保險署於11月份委員會議(105.11.18)前提供詳細資料，以利審議106年度保險費率。第三案報告單位：本會第三組案由：106年度全民健康保險醫療給付費用總額成長率報告，請鑒察。決定：106年度總額成長率及預估金額確認，如下表：項目牙醫門診總額註2中醫門診總額註2西醫基層總額註2其他預算註3醫院總額註2年度總額註2成長率及金額(基期為校正投保人口差值後之費用)2.841%(418.48億元)3.643%(239.33億元)4.789%(1,285.72億元)112.639億元付費者代表方案5.493%(4,482.94億元)5.166%(6,539.1億元)醫院代表方案註14.871%(4,456.54億元)4.741%(6,512.7億元)成長率及金額(基期為105年度核定總額)3.246%(418.48億元)4.066%(239.33億元)5.157%(1,285.72億元)112.639億元付費者代表方案5.881%(4,482.94億元)5.546%(6,539.1億元)醫院代表方案註15.257%(4,456.54億元)5.120%(6,512.7億元)註：1.醫院代表方案尚未包含「新醫療科技」、「C型肝炎用藥」、「後天免疫缺乏病毒治療藥費」等3項移列其他預算支應之費用，若以健保署估算額度合計82.18億元(分別為20.63億元、26.55億元、35億元)。2.年度及各部門總額為預估值，最終仍以健保署結算資料為準。3.其他預算較105年度增加9.05億元。第四案報告單位：中央健康保險署案由：中央健康保險署「105年9月份全民健康保險業務執行報告」，請鑒察。決定：針對委員關切議題，請中央健康保險署就尚需補充說明事項，提供書面資料，餘洽悉。拾、討論事項第一案提案單位：本會第三組案由：106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後，於105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：106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：請中醫門診總額相關團體依循本會104年11月份委員會議(104.11.20)決議，研提促進民眾就醫公平及各區醫療資源均衡發展之分配草案，提下次委員會議(105.11.18)續議，最遲應於105年12月份委員會議定案。並請中央健康保險署協助模擬試算，亦可提出所建議之分配方案，以利討論。第三案提案單位：本會第三組案由：106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：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66%依各地區校正「人口風險因子及轉診型態」後保險對象人數，34%依西醫基層總額支付制度開辦前一年(89年)各地區實際發生醫療費用比率分配。(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西醫基層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西醫基層總額相關團體議定後，於105年12月底前送本會同意後執行。第四案提案單位：本會第三組案由：106年度醫院總額一般服務之地區預算分配案，提請討論。 決議：請醫院總額相關團體於提升各區民眾就醫公平性之原則下，研提地區預算分配草案，提下次委員會議(105.11.18)續議，最遲應於105年12月份委員會議定案。並請中央健康保險署協助模擬試算，亦可提出所建議之分配方案，以利討論。第五案提案人：何委員語、張委員文龍、李委員永振、葉委員宗義、李委員成家代表類別：保險付費者代表案由：有關原中央健康保險局於94年9月15日健保藥字第0940026378號函，取消指示用藥制酸劑健保給付品項暨價格明細表共176項，既然公文取消支付，為何每年尚支付健保費用，提請討論。決議：基於中央健康保險署已依本案擬辦意見提供書面說明，爰依提案委員建議不進行討論。第六案提案人：謝委員武吉代表類別：保險醫事服務提供者代表案由：為鼓勵民眾配合分級醫療推動，籲請檢討現行健保管理措施與支付制度，以強壯社區－基層診所、地區醫院醫療照護體系，提請討論。 主席裁定：依提案委員意見予以撤案。拾壹、散會：下午1時35分。第2屆105年第10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9)次委員會議紀錄」與會人員發言實錄周執行秘書淑婉報告主任委員、各位委員及所有與會者，目前委員出席人數為20位，已達法定開會人數，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！現在是9點32分，委員出席人數已過半，依規定開始今天的委員會議。本次會議共安排4項例行報告案及6項討論案，請教各位委員是否按照議程安排的順序進行？(委員表示沒有意見)若無特別意見，則依議程進行。二、第一案是「確認本會上(第9)次委員會議紀錄」，因議事錄已於10月5日函送委員參閱，並於前一天(10月4日)上網公開，請問大家對上次會議紀錄內容有無修正意見？請楊委員漢湶。楊委員漢湶一、確認會議紀錄部分我沒有意見，但對部分內容不是很清楚。總額預算協商應以數據為基礎，所有的數字皆由健保署提供，有個問題我請教過很多人，但都沒有人能說明。請委員參閱會議資料第7頁，106年醫院總額付費者代表方案，由原105年一般服務項目移列15億元至「C型肝炎用藥」專款項目，該項資料應該只有健保署有，但健保署也不知道有這個數字，是否請健保署或哪一位委員可以說明。二、現在討論的雖然是藥品，但治療C型肝炎需要很多的費用，共擬會議也請到肝炎專家，中研院院士暨台大醫院講座教授陳培哲教授參與討論，其表示每位C型肝炎患者的檢驗費用約需4萬元，若接受新藥治療的患者為8千人，乘以4萬元則約需3.2億元。惟通常做檢驗的人會比接受治療的人更多，不清楚該筆費用是否包含在治療C型肝炎的26.55億元？或是須由一般服務費用勻支，因一般服務費用大部分已被移列，如何從一般服務費用勻支？是否又會排擠其他醫療服務？請健保署或其他人協助說明。戴主任委員桂英謝謝，先確認會議紀錄無須修改。至楊委員漢湶另外提出的疑問，有關移列15億元部分，請健保署說明。趙委員銘圓主席。戴主任委員桂英請趙委員銘圓。趙委員銘圓現在是確認會議紀錄，若會議紀錄沒有問題，楊委員漢湶所提的疑問，建議以書面資料回應，以免占用會議時間。戴主任委員桂英健保署能否以書面資料回應？蔡副署長淑鈴「C型肝炎用藥」預算本署原建議移列9.43億元，後來大會決議付費者方案移列15億元，本署能說明的部分是9.43億元，無法說明為何移列15億元，以上，謝謝。戴主任委員桂英楊委員漢湶的第2個問題，是每人檢驗費用4萬元如何支應。為節省時間，請問以上這2個問題健保署可以書面回覆嗎？李署長伯璋表示可以，請健保署以書面回覆楊委員的提問。請謝委員武吉。謝委員武吉楊委員漢湶提問為何移列15億元及陳教授培哲所說的C型肝炎檢驗費用4萬元，在共擬會議都曾經討論。剛才蔡副署長淑鈴說明健保署的資料是9.43億元，付費者方案多移列了5億多元，在確認會議紀錄時，一定要有非常清楚的說明，包括原因始末，才能讓付費者及醫療服務提供者代表，在雙方很和諧的狀況下接受，而非僅以書面資料回應。戴主任委員桂英第1個問題健保署已經答覆，第2個問題健保署現在可以馬上回應嗎？趙委員銘圓也希望在會議紀錄的確認上，不要占用太多時間。蔡副署長淑鈴我們還是書面答覆，現在還在整理資料。戴主任委員桂英請楊委員漢湶。楊委員漢湶雖然是確認會議紀錄，但移列15億元確實是付費者代表所提出，所以我才表示對付費者所提意見和會議紀錄沒有意見。但現在進行會議紀錄確認，是可以修改的機會，如果提出的數字不正確，仍有機會更改，否則一經確認，根本沒有更改的機會，大家要去遵守。我覺得健保會應該要對所提出的每一個數字真正的負責，而不只是隨便講一講，就要扣人家的錢，這樣的做法並不好。戴主任委員桂英李署長請龐組長一鳴補充說明。謝委員天仁不是那個問題，現在的問題是楊委員漢湶說我們扣15億元是否有錯，要不要更正的問題。我們沒有錯，當時就是這樣講，議事錄沒有問題，如果有其他提案，請在適當的議程提出，否則會亂掉。戴主任委員桂英好。其實楊委員漢湶一開始就表示，對會議紀錄沒有修正意見，只是有疑問。現在他的2項疑問健保署已經答覆了1項，另外1項健保署現在能不能回答？龐組長一鳴有關移列C型肝炎藥費至專款項目，健保署所提供的資料是9.43億元，至於15億元並不是健保署計算的資料，所以無法回答。戴主任委員桂英第2個問題是C型肝炎每人檢驗費用4萬元，費用列在專款或一般服務？謝委員天仁這不是本案要處理的問題，應該在其他適合的議程處理，怎麼會變成對實質內容有疑問都要在本案處理呢？那整個議程不都亂掉了嗎？戴主任委員桂英好，會議紀錄確認。至於楊委員漢湶所提的問題，請健保署在業務報告時補充說明。黃委員淑英健保署當然可以回答這個問題，不管原來編列多少預算，原本的用意為何？付費者有無刪減預算不重要，而是原來編預算時有沒有包含檢驗費在內？原來的數字有沒有含檢驗費，怎麼不能回答？當然可以回答。戴主任委員桂英還是請健保署回答，因為很多人不太清楚。會議紀錄先確認通過。健保署若現在回答有困難，可以等一下再說明。李署長伯璋對於治療C型肝炎病人必要的檢查，對於楊委員漢湶所提的4萬元，我們需要再確認，因為如果單獨做HCV(hepatitis C virus，C型肝炎病毒)的RNA(Ribonucleic acid，核糖核酸)，檢驗費用是2千多元，但如果是整套檢查，需要確認後再以書面回覆。戴主任委員桂英好，就依李署長的說明處理。請楊委員漢湶及謝委員武吉諒解，因為資料要正確才能清楚說明，以書面資料答覆有助於所有委員理解，包括我個人及黃委員淑英，也想知道到底怎麼回事。例行報告第一案確認，請謝委員武吉。謝委員武吉對於C型肝炎的檢驗費用，陳教授培哲講的是4萬多元，李署長講的是2千多元，相信付費者代表也希望了解，水清澈石頭就看得很清楚，我們希望知道檢驗費用到底是多少錢？ 4萬多元和2千元差20倍，到底是院士還是署長講的正確，一定要向所有的委員說清楚、講明白。戴主任委員桂英謝謝，謝委員武吉只是再度提醒。例行報告第一案已經確認，接下來進行第二案，請周執行秘書淑婉報告。貳、例行報告第二案「本會上(第9)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一、第二案案由，本會上(第9)次委員會議決議(定)事項辦理情形及重要業務報告，提請鑒察。說明一，上次委員會議決議(定)事項，計有3項次，依辦理情形建議解除追蹤1項，繼續追蹤2項，但最後仍依委員議定結果辦理。該3項辦理情形追蹤表，請委員參閱會議資料第40頁，以下逐項向各位委員報告：(一)擬解除追蹤1案，有關「請健保署於106年度總額協商前，提供該年度總額範圍之財務影響評估及未來健保財務收支之概估資料供參」乙項，健保署的回覆是已依委員建議提供106年度總額範圍之財務影響評估資料供協商參考；也將過去5年總額平均成長率，納為健保財務試算假設條件，試算結果已經提供本會在105年10月17日召開之「106年度全民健康保險費率審議前意見諮詢會議」參考。本項擬解除追蹤。(二)擬繼續追蹤共2案：1.第1項，「請社保司提供政府每年度應負擔全民健康保險總經費法定下限36%之認列範圍，並請健保署參考委員意見重新推估未來健保財務資料」，相關單位辦理情形如下。健保財務及其詳細推算方式與說明資料，已列在今天補充的書面資料，請各位委員參考。(1)本會於10月4日請辦社保司及健保署，經社保司回覆認列範圍後，本會也在10月12日請辦健保署，就社保司提供的認列範圍，推估未來健保財務資料及其詳細推算公式與說明。社保司回覆，依105年6月22日立法院社會福利及衛生環境委員會第33次全體委員會議決議，政府每年度應負擔全民健康保險總經費法定下限36%之認列範圍，自105年1月1日起包含如下，請各位委員參閱會議資料第41頁。(2)健保署回覆，健保法施行細則第45條修正規定納入7項中央政府已實質負擔保險費68.5億元，減少保險收入107億元，係該7項保險費68.5億元原列計保險對象及民營雇主負擔，改列為政府負擔後，因該負擔數已計入政府已實質負擔保險費，致政府應負擔健保總經費法定下限36%不足數相對同額減少68.5億元外；為維持政府應負擔健保總經費占總保費負擔之36%，應需再減少68.5億元換算為健保總經費之36%部分，即38.5億元，二者合計減少保費收入約107億元。詳細說明在第43頁，已併上開諮詢會議簡報資料送委員參考。2.第2項，針對106年度醫院、牙醫門診、中醫門診、西醫基層醫療給付費用總額及其他預算案，健保署回覆將依會議決議辦理。二、請各位委員參閱會議資料第38頁說明二，本會業於105年10月17日召開「106年度全民健康保險費率審議前意見諮詢會議」，會議紀錄已列入今天的書面補充資料，請各位委員參考。三、說明三，衛福部及健保署本年9至10月份發布及副知本會之相關資訊有3項：(一)衛福部於本年10月3日發布「災區受災全民健康保險保險對象保險費及就醫費用補助辦法」，詳細資料在會議資料第121頁。重點簡單說明如下：1.本補助辦法法源為災害防救法第44條之4。2.災區受災之保險對象，保險費之補助資格及補助期間為受災當月起6個月。3.災區受災之保險對象就醫應自行負擔部分醫療費用及住院一般膳食費用之補助資格，及予以補助災害發生之日起3個月期間內之就醫。其他部分請各位委員參考。(二)健保署於本年9月30日公告「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」承辦院所及醫師名單，計270家院所及549位中醫師參與，詳細公文如第125頁附錄二，名單已置於該署全球資訊網。(三)105年第1季各部門總額每點支付金額，詳見會議資料第126頁至140頁， 請各位委員參閱，以上報告。戴主任委員桂英謝謝周執行秘書淑婉的報告，請教各位委員有無詢問？干委員文男沒有啦！戴主任委員桂英好，請李委員永振。李委員永振一、剛才周執行秘書報告的追蹤事項第1項，今天也有書面補充資料。感謝主委在10月17日的「106年度全民健康保險費率審議前意見諮詢會議」請健保署提出說明，也謝謝健保署蔡科長佩玲很用心的準備資料，並個別向我解釋。大概掌握到的重點是，她以為我說她算錯，雖說照公式計算應該是不會錯，但若依我的模式來看，中間就卡卡的。所以我也向她說明，今天如果我本來繳64元，政府應相對負擔36元，現在不曉得什麼原因，政府幫我繳64元，但他是拿錢給我去繳，所以這64元算政府支出，可以計入政府負擔的36%，但這筆費用是我繳的，怎麼可以免除政府應相對負擔的36%，我的疑問在此。二、今天的書面補充資料提到，計算公式係依103年7月的健保會議決議，應該是沒有問題，但是所列有關對104年和105年的影響數，並不能證明健保署的說法是對的。我剛才跟蔡科長提到，104年原本要扣116億元，結果現在不能追溯執行，116億元當然要還回來，但只能證明104年還回來和105年會減少的保險收入算法一致，與我上述的算法無涉。三、蔡科長也跟我討論到，如果照我的算法，政府的負擔比率會變成36.44%，這樣會有問題嗎？健保法本來就規定政府每年負擔健保之總經費至少要36%。因此，我的想法是先依健保署的公式計算，再計算政府已負擔的經費，如果超過36%，就不用撥補，不足36%的部分再撥補。過去政府已實質負擔的保險費68.5億元不能納入36%，現在則可以納入，可再將其計算進去。若最終希望維持36%，這屬會計上的平衡，計算方式比較細節，因為沒有完整資料，所以無法評論。四、對於本項是否繼續追蹤，當時是請健保署提出說明，現在該署已經很盡力的說明，同意解決追蹤。但對於剛才所提的部分，建議在11月18日委員會議審議費率時，再提供詳細的財務評估資料及說明，以利委員了解。此外，10月17日的會議我也建議，請提供二代健保實施4年來，政府、保險對象、民營雇主負擔的費用及其占率，因為有4年的累積資料，權責制和現金制差異應該不會很大。戴主任委員桂英會議資料第41頁追蹤事項第1項改列解除追蹤，對於李委員永振的建議則列為新的追蹤事項。請滕委員西華。滕委員西華一、對不起腦袋不好，看不懂會議資料第43頁第三項及補充資料第1頁的說明。就像李委員永振所提，原本是被保險人要付的錢，例如原來是我滕西華繳錢給健保署，今天不管我的錢是怎麼來的，是跟黃委員淑英借的、是我自己的、是跟銀行貸款的或是政府給我的，就是被保險人繳的錢。二、現在被保險人繳給健保的錢，因為是政府補助給我的，就從政府原本負擔健保總經費的36%扣除，也就是政府同額減少68.5億元，這可以理解，68.5億元就內含在政府負擔的36%。沒有辦法看懂的是，為什麼36%去換算之後，政府還能再減少？為什麼68.5億元還要除以64%，然後再乘以36%？可不可以說明這中間的邏輯是什麼？實在是看不懂。吳委員肖琪主席，其實我剛才比滕委員西華早舉手，也是同樣的問題，會議資料第43頁我也看不太懂。標題是「納入7項中央政府已實質負擔保險費68.5億元，預估1年將減少68.5億元」，怎麼會變成107億元？這部分確實看不太懂。戴主任委員桂英謝謝，請健保署王組長沬玉說明。王組長沬玉一、現在納入7項中央政府已實質負擔保險費，原本是民眾、雇主負擔64%部分，現移到政府負擔，亦即政府可以少付68.5億元，因為這只是64%部分，所以需要還原，也就是68.5億元須要除以64%換算成整體保費。因此，保險收入減少部分，除了68.5億元，還有政府應負擔的36%部分為38.5億元，兩者相加才是對整體保費收入的影響數，不知道以上說明是否清楚？二、因為68.5億元只有64%，所以須要還原到整體100%的保費後，再乘以36%，也就是政府除了應負擔36%不足部分可以減少外，還可以減少因為整個餅縮小而隨之減少的36%部分，這樣不知道大家可不可以了解？滕委員西華我能了解，但我沒有辦法同意。戴主任委員桂英先請李委員永振，再請何委員語。李委員永振一、健保署的財務組很辛苦，真的是講不清楚，為什麼會講不清楚，因為這是今年6月22日立法院的決定。若照健保署的公式計算，一定會是107億元，但是主計總處會說一條牛剝二層皮，事實上我們已經被剝二層皮了，政府先剝了我們的皮。二、社會福利的部分是68.5億元，他們拗不過來，所以算不出來。事實上餅並沒有縮小，以現在的7項政府已實質負擔保險費，無論有沒有納入政府應負擔部分，這筆錢同樣進來，這是被保險人或團體繳的部分，因此政府相對要負擔的36%，就是不能少，以前未納入的68.5億元，還是會透過這些人繳進來。在今天的書面補充資料第8至9頁，10月17日的會議紀錄我有說明整個過程，就不再贅述。三、若以原本的公式計算，政府要出多少才足夠36%，對於政府實質負擔金額多少，應提出數據，若已超過36%，則不須再撥補；若不足36%，就補至36%。過去這68.5億元不計入政府負擔，現在則計入，我的邏輯就這麼簡單。現在也談不出結果，建議保留至下次會議審議費率，進行財務評估時再詳細說明。戴主任委員桂英謝謝，請何委員語。何委員語一、104年政府總稅收約2兆1,130億元，歲出還不到2兆元，約1兆9,085億元，因此，政府不是沒錢，不應用這種方法處理。二、這7項福利支出是政府的福利政策，雖說健保也是福利政策之一，但政府應負擔健保總經費認列範圍並未修法改為包含所有福利支出，若有修法通過，我們沒話說，但目前並不包含政府自行決定的7項福利支出。今天我在中國時報投稿「恐嚇破產造成對立」，就像健保造成政府與付費者對立，這是不對的。若政府認為這7項福利支出應包含在內，就應透過修法，依法行政；但現在卻是政府任意行政，這是很要不得的。若認同104年應補足差額，為何105年又不承認，這是政府知法違法。若要採目前的認列範圍，就應自二代健保開始實施時納入，而非以前負擔，之後又不承認。我認為這是政府施政的缺失，一直在製造社會對立，這是很不應該的事。此事邏輯很簡單，政府應將這7項經費透過村里辦公室發給相關被保險人，再由其至區公所繳納健保費，照理講應該要如此處理才對。戴主任委員桂英謝謝，請陳委員幸敏。陳委員幸敏102年二代健保實施時，針對政府應負擔健保總經費法定下限36%算法，主計總處與衛福部有不同版本，但最後行政院核定採衛福部算法，因此，目前均採衛福部與健保署版本計算，並無主計總處版本。在此向委員澄清，現在的算法並非主計總處的堅持。戴主任委員桂英謝謝，請滕委員西華。滕委員西華一、針對健保署的說明，我可以理解，但無法接受的理由在此說明，其實我的統計並非很好，我就是靠邏輯思考來推論結果，請大家多多包涵。首先是原本這68.5億元包含於64%時，政府就已提列36%，現在這68.5億元移出後，請問原本是民眾、雇主負擔64%的部分是否還包含這68.5億元？因其在公式中原屬被保險人負擔。二、假設這68.5億元未包含在被保險人所負擔保險費64%內，那麼減列68.5億元後，健保署以其換算還原，在邏輯上尚有點道理，但也不算完全有道理。因為在原本的68.5億元，政府已提列應負擔36%，若再去換算還原，不是等於重複減列嗎？請問這68.5億元中原本政府應負擔的36%有沒有扣掉？因為如果沒有扣掉，又再以36%去還原，對我而言，就是重複扣抵，保費收入減少的也就不只是68.5億元。三、萬一這68.5億元還列在被保險人負擔的64%的公式中沒有被扣掉，那麼保費收入將會少更多錢，將來被保險人要付更多錢，因為被保險人那邊的數字是虛的，就是說有一筆被保險人要負擔的68.5億元放在那裡，可是兩邊都被減列，而不是像剛才何委員語及李委員永振所提，政府將這些保險費補助款交由被保險人去繳納，照理說應該要這樣才對。實際上卻是政府直接去繳，變成政府去繳也沒關係，但政府去繳的時候，又假裝自己有繳那36%的應負擔費用，其實這是不對的，我的邏輯是這樣。四、原本在民眾、雇主負擔64%部分的這68.5億元，當移到政府應負擔的36%後，健保署要還原成100%，我可以理解。但如果沒有先將其中政府原本負擔的36%扣除，那就不對了。假如你們有扣除，就是我誤會了！因為我不知道原來的差距應該是多少錢，但如果這筆錢沒有扣除，還要還原計算，對我來說就是重複扣列。 戴主任委員桂英一、委員關心的是不希望減列太多保費收入，大家都希望少扣一點比較好，現在的問題是因為委員擔心會被重複減列，而健保署的說明還未能讓大家明白。 二、現在進行的是上次會議追蹤的辦理情形，剛才李委員永振建議將會議資料第41頁所列項次1改為解除追蹤。請健保署針對委員所提疑問，重新整理後，在下次委員會議審議費率時提出說明。也許健保署的答案還是一樣，但請嘗試用更容易了解的方式來解析。這個議題先這樣處理好嗎？請謝委員天仁。謝委員天仁我的看法是，問題出在公式上面，原來的公式沒有問題，因為原來的算法並沒有將政府的福利支出列在政府應負擔保險總經費的36%裡面，原來的公式計算上沒有問題，但將政府的這7項社會福利支出灌進去之後，就會有再多扣36%的問題，也是問題癥結之所在。我認為健保署應該要對相關的計算公式進行研析，因為它已出現長短腳的現象，若繼續用原來的公式計算，當然會出問題啊！戴主任委員桂英依照李委員永振剛才所提建議，將會議資料第41頁所列項次1改列解除追蹤，而委員今天的發言是新的詢問，請健保署準備資料，在下個月審議費率前提供，因為這些問題屆時還是會被提出。請李委員永振。 李委員永振延續剛才滕委員西華的發言，我要補充新的問題，請健保署說明一下。這68.5億元是政府直接繳，還是將補助的費用讓付費者自己繳？如果是政府直接繳，那問題更大，因為就可以將那36%直接扣掉，政府以雇主角色所應繳的費用也直接繳，那麼政府應負擔的36%有沒有提撥呢？因為政府直接繳的方式，相對的就不用去算，那請問政府當雇主身分應繳的費用是如何收繳的呢？戴主任委員桂英一、好，請問要請健保署現在說明，還是下次委員會議時一併說明？(李委員永振表示同意健保署於下次委員會議說明) 二、全民健保已經實施20年，無論政府補助款或是政府作為雇主角色應該負擔健保費之收繳，健保署都有明確的作業方式。接著進行下一案。參、例行報告第三案「106年度全民健康保險醫療給付費用總額成長率報告」與會人員發言實錄戴主任委員桂英例行報告第三案「106年度全民健康保險醫療給付費用總額成長率報告」，請幕僚同仁說明。陳組長燕鈴一、本案係每年例行將總額協定結果向委員會議提報，協定結果於剛才的會議紀錄已經確認。請委員翻閱至會議資料第45頁，經過9月的協商會議，牙醫門診總額、中醫門診總額、西醫基層總額及其他預算都已經達成共識，醫院總額部分則分別有付費者代表及醫院部門的建議方案，請委員參閱會議資料第45頁整理之協定結果，表格第2列成長率部分，基期以105年度之核定總額或金額計算，則106年度協定總額成長率，若醫院總額採付費者代表的建議方案，整體總額成長率是5.546%，若採醫院部門所提建議方案，整體成長率是5.120%。以上協定結果，本會已於10月19日以衛部健字第1053360132號書函將結果報請衛福部核定及決定。二、另俟地區預算分配方式完成協定後，本會將另案報部並於核定後，依行政程序辦理「106年度全民健康保險醫療給付費用總額及其分配」公告事宜，以上報告。戴主任委員桂英本案將俟衛福部核定及決定後，辦理公告事宜，並於委員會議報告。請謝委員天仁。謝委員天仁成長率可否用括弧的方式列出對照金額，這樣會比較清楚，例如牙醫門診總額經校正人口差額後，成長率是2.841%，請併列出對照金額是多少錢，這樣表達會比較允當，不要只寫成長率。戴主任委員桂英請幕僚同仁製作會議紀錄時，將各總額部門成長率之對照金額列出。委員若無其他意見，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『105年9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例行報告第四案在會議資料的第46頁，但相關的內容在健保署所準備的書面報告，本次請李署長伯璋進行口頭報告。李署長伯璋報告戴主任委員桂英謝謝，李署長伯璋10分鐘完成報告，李署長表示請委員就尚需進一步了解的部分提問，健保署同仁會做適當的解釋。先請趙委員銘圓。趙委員銘圓一、針對業務執行報告第6頁「表4全民健保財務資金流量分析表」及次頁的表「5-1全民健保財務收支分析表(權責基礎)」，這2張表的保費收入都包含滯納金收入，但保費收入總計在表4是79,568.17億元，表5-1是80,836.64億元，兩者之間的差異達1,268.47億元，請健保署予以說明。二、業務執行報告第8頁表「5-2收支餘絀情形表」顯示，菸捐分配收入的累計實際數與去年同期比較，減少52.34億元，負成長30.25%，主要的原因就是菸品健康福利捐分配比率調降所致，這部分大家都已經很清楚，我所要提出的是本會過去曾完全無異議通過，請李署長伯璋要適時向部長爭取檢討菸捐比率，當時菸捐分配比率從70%調降為50%的原意，是要將那20%的額度用於長照，但統計數據顯示，只有3%用於長照，所以剩下的17%，理應歸還給健保的安全準備金。這個決議的追蹤其實並沒有結束，但後來的追蹤資料就沒有呈現，到底這個決議的處理情形如何，是否可請李署長伯璋說明，因為從業務執行報告中，可清楚看見健保的安全準備一直在往下降。三、針對雜項收入部分，累計實際數與去年同期比較，減少 491.26億元，負成長98.79%，依備註說明5，在排除去年同期依行政院協商結論補列102及103年政府補助36%差額489.94億元後，負成長18.08%，主要係藥商藥品價量協議返還金收入減少所致，本人過去未曾聽過「藥商藥品價量協議返還金」這個名詞，不知道是否與藥價黑洞有關係？我相信不是啦！但請健保署說明。戴主任委員桂英請干委員文男。干委員文男一、有關保險對象人數統計，業務執行報告第3頁的表2顯示，截至104年8月底，投保人數共有23,677,370人，我始終不確定這其中有多少是本國籍，多少是僑、外人士，而目前不在籍的國民又有多少？過去曾向內政部詢問不在籍的人口數，依據他們提供的統計顯示，此類人口並不在少數，約有30幾萬人，另詢承保組表示，短期納保的保險對象，因其來來去去的特性，屬於動態的統計數據，因此僅能提供範圍數(range)，儘管如此，我還是希望對保險對象人數有所掌握，請健保署再進一步提供說明。二、針對北、高兩市政府的欠費，依照健保法第28條，他們這些欠費若未在8年還款計畫期限屆滿時清償，健保署可以執行假扣押，今年是105年，距離各還款計畫的期限只剩3年，但業務執行報告中，始終看不到健保署代墊直轄市政府欠費所應繳交利息的相關數據，從以前到現在都沒有將資料呈現，相關金額是多少也不知道，若這些資料無法呈現在相關的統計表，請健保署至少也要在備註中說明，讓我們知道北、高市政府的這些欠費都有繳交利息，大家心裡才不會不平衡，否則就這個議題一直唸叨，也不是很好。以上請健保署說明。戴主任委員桂英請李委員永振。李委員永振一、延續干委員文男所提政府欠費處理情形，就我記憶所及，本年6月才剛將這個議題解除追蹤，但是現在看來，健保署在高雄市政府的欠費處理上，卻是越處理還款速度變越慢。依統計顯示，高雄市政府104年應償還38.98億元，待撥付款11.83億元；105年應償還31.75億元，待撥付款達到30.13億元。另外如干委員剛才所提，還款計畫會有執行期限屆滿的問題，以高雄市政府96年度的欠費計15.65億元，執行期限將在106年1月起陸續屆滿，也就是執行期限2個月後將到期，雖然健保署自本年2月起一直積極與該市政府溝通，但處理至今仍未有結果！接下來只剩2個月的時間，健保署要如何更積極去協調，才不會讓全國民眾有所損失？二、業務執行報告第11頁「表6-1全民健保保險費收繳執行狀況表」顯示，政府保險費補助款的收繳率在105年1至4月的收繳率是99.44%，看起來還蠻不錯的，將近100%，但為什麼更早以前的104年收繳率卻只有75.23%，是因為102年及103年政府補助36%差額的490億元嗎？可是從資料上看，這筆錢並未列在保費收入，而是列在其他收入，請健保署說明差異的原因。三、第11頁表6-1的備註，提到依立法院105年第9屆第1會期衛環委員會的決議，也就是關於健保法施行細則第45條修正，要補列104年度不納入9項政府已實質負擔保險費所增加之待撥數116億元。從備註資料顯示，加上這116億元後，政府應負擔經費總計待撥數應為638億元。針對上述待撥數，主計總處已規劃其中471億元將分3年逐年攤撥157億元，其餘尚有51億元須循預算程序足額編列，至於補列的116億元則未說明處理方式。我相信這638億元最終都要撥付給健保，但依備註的措辭來看，這116億元的處理方式似乎仍未定，不知道這116億元會如何處理？四、第12頁表6-2是過去5年間投保單位及保險對象保險費收繳統計表，第6類保險對象的收繳率只有86.35%，如果沒有記錯，第6類保險對象的保險費是最低的，也可能因為這類人口多為弱勢，相對於其他類別第6類保險對象的保險費收繳率偏低，請問健保署有無因應措施，需要用社會救助的方式補助，抑或是維持現有作法？五、業務執行報告第14頁，有關直轄市政府應負擔保險費補助款欠費統計，備註有關台北市政府的部分，Ａ項的說明是99年以前欠費還款計畫展延至106年，但從統計表的資料看，台北市政府在99年以前各年度未收保險費是0，顯示其欠費已經還清，既然欠費已還清，為何還有展延到106年的情形。六、業務執行報告第15頁，有關健保欠費的回收率統計，近期的回收率就先不談，以103年的數據看，經過快2年的催繳，回收率只有70%。另依昨日自由時報報導，關於補充保費的收繳，歷年來有55萬人積欠將近5億元未繳。稍早有委員提到，健保署自本年6月起，推動弱勢民眾健保欠費協助措施，並逐步採弱勢民眾健保欠費與就醫權脫鉤處理，也就是不再鎖卡。若將這些事情擺在一起看，以前有鎖卡措施時尚且如此，以後不再鎖卡，不知健保署會如何處理？在宣布解卡政策當時，健保署曾說會有配套處理，不知道配套措施的效益如何？以上幾點請教健保署。戴主任委員桂英可否請健保署先針對剛才3位委員的提問進行說明(李署長伯璋表示先聽委員意見)。請趙委員銘圓。趙委員銘圓一、不好意思剛才漏掉一點，就是關於直轄市政府欠費這件事，從本人第一次參加委員會議時就提過，在欠費的直轄市政府中，模範生新北市政府很早就已繳清欠款，台北市政府也按計畫還款，只有高雄市政府一直拖，雖然幕僚單位很盡責的一直追蹤，但顯然一點效果都沒有，到底健保署真正可以採取的措施有哪些，我認為既然已經查封他們的財產，期限一到就應該拍賣，要給高雄市政府壓力，不然他們一拖再拖，現在不逼他們，搞不好等到年底，陳菊市長會擔任行政院長，屆時健保署要如何處理，所以應該要趕快有所行動。另，之前也有提過，健保署可以考慮公開表揚這些依約清償欠費的直轄市政府，甚至對媒體揭露高雄市政府未依約清償欠費的事實，以對該市政府形成壓力，逼他們早一點還錢。二、若再繼續讓高雄市政府拖欠，將來陳菊市長當上行政院長，說不定高雄市政府的欠費，健保署連一毛錢都拿不回來。希望健保署盡快想辦法處理，若欠費的直轄市政府有依約還錢，透過公開的儀式，該表揚人家就表揚。這件事唯有讓民意的壓力進來，才可能讓高雄市政府早日清償欠費。戴主任委員桂英請健保署就委員提問回應，蠻多問題是針對健保財務，少部分是針對承保業務。李署長伯璋一、委員針對菸捐分配比率所提建議，已向部長及主計總處主計長說明，希望分配比率能夠改善，但是老實講，錢一旦進到別人口袋，想再掏出來，真的很困難，但我們一定會繼續爭取。二、何政務次長啟功來自高雄，一直都很關心直轄市政府欠費議題，所以每次跟高雄市政府協商時，都會商請何次長幫忙。剛才委員所提的建議，我們會再跟高雄市政府繼續溝通，找出最好的處理方式。有時公家機關間處理事情還是會有盲點，但我們一定會盡全力去催繳，其實高雄市政府也很清楚，當8年還款計畫期限屆滿，若還不能清償，被扣押之財產就會被拍賣，若真的弄到要拍賣，也不是開玩笑的。其他部分就請同仁補充。蔡副署長淑鈴委員的提問多數屬於財務，有少數是承保以及藥品價量協議返還金的議題。先請財務組王組長沬玉回應，接著再請江專門委員姝靚及藥材組施組長如亮。王組長沬玉一、財務組綜合補充說明如下：趙委員銘圓所關切第6頁及第7頁保費收入的部分，一個是現金制，一個是權責基礎制，第6頁的現金制是今年度截至9月底止實際收到的現金數，第7頁的權責制則是依法開單應收保險費的數字，因此兩者之間的數字會有所不同。二、關於政府欠費有無計息的問題，這部分詳細的資料並未表列在業務執行報告，因為利息的計算涉及欠費時間的長短，屬於動態的統計資料。實際上政府欠費都有加計利息，到105年9月底止，台北市政府欠費的利息是24.58億元，高雄市政府是12.27億元，本署每個月都會詳細計算，但因與欠費時間長短有關，因此並未表列。三、第11頁「表6-1全民健保保險費收繳執行狀況表」，104年度政府保險費補助款收繳率是75.23%，是因為104年與主計總處協商政府應負擔保險費36%時追溯補列490億元的欠費。當時累計欠627億元，分4年攤還，1年攤157億元；其他待撥的51億元，是因為當時結算到102~104年，51億元則是104年度決算新增不足數，這部分將會於下次預算編列時補足；至於立法院新的決議(立法院105年第9屆第1會期衛環委員會決議)，因為要配合目前施行細則的修訂，還未三讀，所以帳列數還沒有進來，因此我們先附註說明，若該條文三讀後，中央政府的欠費會增加116億元。四、第14頁「表7全民健保直轄市政府應負擔保險費補助款欠費情形統計表」，就是李委員永振關心部分，因為該表為北高兩市最新修正還款計畫還款情形，台北市都有落實還款，至於表末備註文字是在說明各市政府曾經提過的展延。李委員永振已經還完的部分(台北市政府99年度以前欠費已繳清)，備註文字應可不需再敘述過去展延情形。王組長沬玉下次會改進呈現方式。蔡副署長淑鈴第15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」，委員所提103年度收回率為70.16%之問題尚未回應，稍後由江專門委員姝靚回答。江專門委員姝靚一、有關委員提問納保人數，請參閱第3頁「表2全民健保各類保險對象人數統計表」，首先說明因保險對象加保之承保作業有時間落差，其包含轉入及轉出等異動資料，因此，該表之統計數字係呈現105年8月底保險對象之在保人數(註：製作資料日期為105年9月30日)；若要跟戶籍人數相比，經本署統計分析，目前本國籍人士投保率為99.7%，外國籍含大陸、港澳地區投保人數則有約70萬人。二、第12頁「表6-2投保單位及保險對象保險費收繳統計表」：(一) 6種類別投保身分保險費應自付保費各不相同，保費負擔分三部分，包含投保單位、保險對象負擔及政府補助的部分都不一樣，而第6類保險對象每月需「自付」之保費為749元，其應自付保險費並不是各類保險對象中最低的，故第6類保險對象係以個人負擔為主。該類人口中，確實有部分為弱勢，也有部分為高所得且無職業者，為相對平衡繳費義務，對於後者如有補充保險費規定之所得或收入，也還要再收取補充保費。(二)剛剛委員關心，若屬弱勢者，是否有相關的社會福利會進來，其實是有弱勢保費協助措施。除了菸捐、公益彩券，還有本署的愛心捐款，都會依資格補助保費，亦可辦理紓困基金貸款。或若不符合前開補助資格時，仍無法按月繳納而有欠費，可在接獲本署催繳通知或嗣後送強制執行時，至本署辦理分期繳納。因此，依保險對象的經濟狀況，有不同的協助與處理方式。三、李委員永振亦提到第15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」， 103年度的收回率雖僅為70.16%，惟若以長期來看，經催繳及強制執行，有10年的執行期間，按往年處理欠費統計分析，大概到第5年時，欠費收回率就可到達98.66%、甚至到達99%。針對收回率，本署向來都有持續追蹤並觀察變化趨勢，請委員放心。四、至於大家關心解除鎖卡後之因應措施，對於欠費收回率，其實本署有好幾項措施來加強處理欠費，例如：保險對象找到工作後，成為第1類受僱員工時，其欠費移送強制執行後，執行分署會去函公司查扣其部分薪資；甚至於欠費之保險對象若有資本利得或補充保費的相關所得或收入，執行分署也會去進行查扣等。五、剛剛委員還關心報載補充保險費收繳的情況，因本年補充保費之股利利息的部分係於8月開單，其繳納期限為本年10月15日，所以目前收繳情形尚未達到相當程度的收繳率。不過，若比較歷年收繳情形則可看到，收繳率幾乎可達98.82%。當然如有欠繳的部分，就會循欠繳催收的程序，甚至以強制執行的方式去查扣相關財產來處理。戴主任委員桂英還有一個提問需回應，請施組長如亮。施組長如亮一、委員詢問第8頁「附註2.(5)雜項收入負成長18.08%，主要係為藥商藥品價量協議返還金收入減少所致」乙節，有關價量協議的機制，過去曾回覆過委員詢問，在此再次簡要說明，其為一種財務衝擊的風險分攤機制。二、新藥收載或已經給付的藥品給付範圍擴大，廠商預估生效後的5年內有任一年，新藥總費用超過2億元、給付規定擴大而增加之費用超過1億元，我們就會跟廠商簽訂價量協議。若廠商原來提出的財務預估不準確，每年藥費結算時「超過」廠商原預估金額，例如前述之新藥2億元、給付規定修正1億元，會請廠商將部分金額返還，這是一種財務衝擊分攤的方案。至於會返還多少不一定，因為還要看實際支出之金額，若實際支出金額未超出，就不需返還。戴主任委員桂英健保署已儘量回答各項詢問。還有委員有意見嗎？請謝委員武吉。謝委員武吉一、第24頁醫事服務機構特約情形，呈現出本月中醫醫院減少1家，西醫醫減少3家，西醫診所與中醫診所持平，牙醫診所增加3家，總計減少1家特約醫療院所。針對西醫醫院減少3家的部分，請問健保署是否有輔導的機制？其次，這3家的分布情形如何？還有這3家想要把醫院改成診所或關門的原因為何？希望能有明確說明。二、第25頁，本年8月份各總額別醫療費用之申報情形，醫院門診為195.0億點、住診161.1億點，但看不出較去年同期之成長或衰退情形，希望相關表格中能呈現。三、第28頁，全民健康保險藥局申報情形，醫療點數(含部分負擔)較去年同期增加9.46%，而件數增加亦達10.14%，剛剛署長報告是歷年增加幅度最大的一次。想請問成長的部分是在那一塊？例如是癌症藥費或其他藥費？若是癌症的藥品成長，也想釐清其究竟屬有效或無效醫療？若是成長在其他方面，也希望能表列呈現。三、第29頁，醫院總額部門105年第1季專款項目支用結算情形，血友及罕病藥費支用19億元，占全年預算21%。據我所知，健保所支付的血友及罕病藥品，有部分藥品經過10、20年都還沒拿到食藥署核發之藥品許可證，這樣健保還要繼續支付嗎？為何該藥廠在這10、20年間都不去申請許可證？這是我感到很疑惑之處，並認為該去處理。四、第31~32頁，醫療費用之核付部分，即核減率，之前張委員煥禎也談過不少。在此可看到，門診初核核減率和申復後核減率是有下降，但爭審後核減率幾乎是和申復後核減率相同，表示爭議審議似乎是個無效的單位，而醫事機構會提出爭議的原因為何？希望能予分析，並讓我們了解，分醫院總額、西醫基層、牙醫總額、中醫總額及門診透析等5部門分別呈現，謝謝。戴主任委員桂英委員還有沒有詢問？請張委員文龍。張委員文龍一、據報載，積欠保費者很多都在300元以下，那光是為了催收所花費的掛號郵資相關費用就很龐大，總金額約5億多元，因此很好奇積欠300元以下保費的件數到底有多少？如果寄2次掛號來回郵資就要100元了。當然還是要催繳，因為即使欠稅1元也是會催繳，只是要思考是否能有機制，來處理大量的小額欠費，使之數量下降，否則郵資真的是很浪費。二、第10頁，提到中央協助解決北高兩直轄市的健保欠費，既然有錢來補助，也就是中央並不是沒錢、還有錢去補助直轄市，那第11頁政府應負擔健保經費不足法定下限36%，分數年攤還給健保，尚未攤還的部分，應該也要有機會來補助才對。謝委員武吉主席，我再補充1句話就好，剛剛漏講了，對干委員文男歹勢(台語，不好意思之意)。第32頁，關於核減率的現況，在檢驗檢查方面，可發現大醫院軍備競賽的各項檢查，很少見到被核刪，但小醫院、小診所，例如像CBC檢查(Comeplete Blood Count，全套血液檢查，或稱為血液常規檢查，評估血液中白血球、紅血球、血小板的數量及品質)這樣的小檢查，若做出來是Normal(正常)又剛好被核刪，也是要被放大回推的。希望下次能看到各分區的改善方式。戴主任委員桂英謝謝，接下來請何委員語、干委員文男、吳委員肖琪。何委員語一、第9頁保險費收繳執行情形，呈現出高雄市96年度欠費尚有15.65億元，但執行期限將於106年1月起陸續屆滿。但根據民間流傳，高雄市陳菊市長最快於明年2月1日、最慢則是5月20日後，才會來接行政院院長。若在她上任前，高雄市健保欠費即執行期限屆滿，這樣就等不及她上任後，再以行政院的經費來處理此筆欠費。萬一超過執行期限，健保署都沒有去執行土地假扣押，那以後健保署署長、財務組組長及相關人員，有可能被監察院彈劾及公務人員懲戒。二、所以在此發言並納入紀錄，讓李署長拿著這段紀錄為依據，去與高雄市長溝通(李署長伯璋：謝謝)，否則付費者會請監察院彈劾，那署長就很倒楣了，再次重申，在此督促署長，不能讓執行期限屆滿而追不到該筆欠費，否則付費者及民意代表可能都會要求來查核健保署，這樣對署長很不利。干委員文男一、歷年來北高兩市欠費所衍生出之利息，其數字並未呈現在業務執行報告中，我想是可能不至於以複利方式計算利息，不過實際上利息的帳目如何，仍希望以表列方式呈現，另行提供資料委員參考。二、之前談過具名審查，是這個月還沒有開始嗎？希望能呈現出實施前後審查案件的相關數據。若核減較少，就等於是放水，但過嚴也不一定是對的。先前委員即請健保署於實施後提供執行情形，希望儘快提供。李署長伯璋具名審查10月1日已開始試辦。干委員文男一、10月已經開始辦理，若有數據時，即應按月提供。二、趙委員銘圓剛才提到，應對有還款的市政府予以鼓勵，對尚未還款的也要展示及公開。主動發新聞的價值就在於此，可以罵人不帶髒話，開記者會表揚有繳清的市政府，也讓所有的高雄市、台北市市民知道，該繳的健保費還沒繳清，用民意壓力作為督促，也讓兩市的民意機構知道，應該要編列預算來還款。建議記者會開大一點，不要僅在衛福部或健保署開，到立法院舉辦的話，記者們就都會到。戴主任委員桂英請吳委員肖琪。吳委員肖琪請看第118頁「表33-6醫院總額醫療費用核減率-層級別」，剛剛謝委員武吉提到醫學中心核減率不一樣，由此表數據可見，這種情況好像只有在高屏區的醫學中心層級，其申報情況甚佳，門診初核核減率只有0.02%，遠低於台北業務組(2.62%)及南區業務組(2.55%)。若因為高屏區的醫學中心比較會申報的話，有機會應該要讓他們跟台北區及南區的醫學中心分享，要如何申報，才不會核減率那麼高。所以這部分可否說明一下。因高屏區之區域醫院及地區醫院的門診核減率，是跟其他業務組差不多，僅在醫學中心層級，看到高屏區核減率不同於其他分區的情形，因此希望了解一下。戴主任委員桂英本案已經用了46分鐘，其中李署長只用了10分鐘報告，其餘時間皆用來討論。為節省時間，請健保署儘量精簡回答，若仍不足的部分，再另以書面資料補充。李署長伯璋一、有關北高兩市欠費議題，這部分我認為就是依法行政，剛剛委員的意見也很好，就是藉由鼓勵還款者，來催繳剩餘欠費。二、高屏區醫學中心層級的初核核減率低，我覺得很好。在署內若有對某項業務推動特別好的分區，也會希望分享給其他分區業務組。例如中區業務組對於醫事服務機構簽約的部分做得很好，採用網路方式簽約，另對於年紀較大的醫師，怕有些人比較不會用電腦，也個別去了解及協助。三、剛剛謝委員武吉提到爭審後核減率與申復後核減率幾乎沒差別，以致於爭審單位似乎變成是個假機關。這可能是因為健保署的審查是第一關，為使核刪合理，因此目前採用雙審制；至於去到爭審會的時候，民不與官鬥，在那邊因為法律見解每個人都不一樣，因此對我們的同儕似乎有點不公平，健保署致力於審查及核減的合理化，仍繼續努力中。四、具名核刪的部分目前是試辦性質，請干委員文男放心，因為衛福部及立法院也會追蹤本署辦理情形。至於目前有些學會也主動表示想要加入，我們希望這能取得平衡點，且試辦也需要些時間才知道效果如何。我今天也特別拜託醫院協會楊理事長漢湶多幫忙，如何讓審查醫師能夠盡責是很重要的。說白一點，專業審查是醫師在審醫師，並非健保署行政人員在審查醫師的醫療案件。如同我剛剛提到桃園某醫院的減肥手術卻申報胃潰瘍的案例，這就是虛報，因此同儕(審查醫師)調出病歷看的時候就應該要看出來。目前有請本署同仁查清楚，若這些虛報的案例，有審查醫師審過、卻還過關的，就該把那個審查醫師fire(解聘)了，減肥申報為胃潰瘍這麼簡單的東西還看不出來，等於是白看了。五、因此這部分我是很務實，專業審查的部分，其實還是相信醫界的自律，因為做的好就是大家都好。因此拜託楊理事長漢湶，希望醫院協會能來投標明年的專業事項事務委託案；並且也另外拜託醫師公會(承攬西醫基層總額專業事項委託案)，希望專款要能專用，健保署給的經費要用在專業審查，不要把經費用於他處，而讓審查醫師只拿到一點點審查費，審查醫師會覺得審查費這麼少要怎麼做事。總之，健保署目前在審查及核減方面，逐項努力改善中，希望未來能做的更好。蔡副署長淑鈴有關謝委員武吉提到西醫醫院少3家，請龐組長一鳴說明；至於罕病的藥品許可證問題及藥費成長率方面，則請施組長如亮說明。龐組長一鳴這3家都是地區醫院，2家在新北市，1家在宜蘭。在此不做太具體的陳述，其中1家係涉及詐欺行為，前段時間報紙曾有相關報導，另其他部分則查證後，再另以書面回覆。施組長如亮一、有關罕見疾病用藥的許可證問題，其實今年已修正全民健保藥物給付項目及支付標準，新規定實施後，若3年內該藥品仍未取得許可證，則健保支付價需被減價。因為持續使用中的罕見疾病用藥，若直接將之delisting(意指於健保支付標準被除名，也就是健保不支付)，可能對病人有很大的傷害，因此才會以此種方式來督促藥廠或藥商儘快拿到許可證。二、有關藥費成長問題，內部已在進行探討，看看成長究竟在哪裡；如果真的是在癌症，會再進一步看看這部分的花費，是否有檢討之必要。戴主任委員桂英請吳委員肖琪。吳委員肖琪剛剛提過的第118頁「表33-6醫院總額醫療費用核減率-層級別」，不同分區間的核減率竟然會相差達100多倍，實在很怪，究竟是什麼原因，我想會後應可再進一步了解。戴主任委員桂英謝謝各位委員這麼用心提出意見，也謝謝健保署的回答。剛剛委員要求補充書面資料的部分，請健保署於會後補充。請謝委員武吉。謝委員武吉還有一點施組長如亮可能忘了報告，對於醫院總額之藥費申報情形，本年8月份各層級醫院的門住診藥費分別成長多少，或衰退多少，希望能讓委員了解。蔡副署長淑鈴有關藥費成長率，委員詢問處為業務執行報告第28頁，其中第八大項其實是藥局申報情形，第七大項為整體藥費成長率。這部分請施組長如亮再回應一下。施組長如亮我們會再分析藥費成長的原因，分析後再另以書面資料回覆。戴主任委員桂英好，請另以書面回覆。謝委員武吉希望不只下次書面補充，未來能於這本(業務執行報告)中看到。戴主任委員桂英謝委員武吉的意思是，希望不只是本次補充書面資料，未來於業務執行報告時，若藥費呈現成長過高的情形，請署長在報告時也能有相關說明。本案洽悉，須補充書面資料的部分，請健保署配合辦理。接著進行討論事項第一案，請同仁說明。伍、討論事項第一案「106年度牙醫門診總額一般服務之地區預算分配案」與會人員發言實錄陳組長燕鈴一、請委員參閱會議資料第49頁，本案係106年牙醫門診總額一般服務之地區預算分配案：(一)本會之任務職掌，除了協定總額外，還需協定地區預算分配，今年9月已協定牙醫門診之一般服務成長率為2.340%。(二)至於歷年地區預算執行概況，臚列於說明二供參，牙醫部門的分配參數中，校正人口風險後保險對象人數占率(R值)於各年協定情形詳如說明二(三)之表格，其自95年起R值即已達到100%。(三)另提供歷年各分區一般服務預算、牙醫師數、就醫人數、就醫率、就醫次數、點數及點值等資料供參，如附表1至7， 會議資料第50~54頁。二、另外，過去牙醫師公會都會另行來文，提供自一般服務提撥預算撥補方式之建議，不過目前尚未收到來文。以上報告。戴主任委員桂英今天有4個地區預算分配的討論案，一般來說都是在總額協商後，安排於本(10)月份討論，本案為牙醫部門，也是最早依保險對象人數占率100%分配地區預算的部門。請問委員有無意見？干委員文男牙醫沒有意見，我們就沒有意見。戴主任委員桂英委員沒有意見，請問牙醫師公會陳代理委員彥廷有無需要補充說明？陳代理委員彥廷(陳委員義聰代理人)一、主席、各位委員早，歷年在這次委員會議，都會提出一般服務之地區預算分配下小總額概念，主要用於「偏鄉、醫療資源不足地區」，因各分區醫療資源不足地區需求不同，將由一般服務預算支應醫療資源不足地區。二、另外是「牙周病統合照護計畫」，因預期明年執行數將會超出預算，也會自一般服務預算提撥經費分擔其需求。三、牙醫師公會內部尚未定案的部分，除醫缺地區外，還有次醫缺地區之需求，也就是說都會區以外的牙醫師，近10年來幾乎都沒有成長，甚至還有一些流失，我們也希望透過努力，讓牙醫的醫療資源能留在醫缺地區，避免醫缺地區的擴大，此部分將會在健保署11月份總額研商議事會議進行討論之後再提至本會。戴主任委員桂英本案依幕僚之擬辦意見通過，委員若無其他意見，接著進行討論事項第二案，請同仁說明。陸、討論事項第二案「106年度中醫門診總額一般服務之地區預算分配案」與會人員發言實錄陳組長燕鈴一、請委員參看會議資料第55頁，本案為106年度中醫門診總額一般服務之地區預算分配案，依本會今年9月委員會議決議，中醫門診總額一般服務成長率為3.291%。二、中醫總額歷年地區預算執行概況分三階段，臚列於第55頁，第三階段為99~105年，採修正後試辦計畫，人口占率以「戶籍人口數」為依據，其分配方式：東區預算占率2.22%，其他5分區再依6項分配指標進行分配，請參看第56頁，以105年為例，委員可參考分配指標2「各區去(104)年同期戶籍人口數占率」，105年前進至8%(104年7%)，在這6項分配指標中，以第1項「95年第4季至98年第3季之5分區實際收入預算占率」為最高，其餘分配指標及占率請委員參閱書面資料。本案主要討論此6項分配指標之占率，或中醫師公會將提出新的分配方案，不過截至目前，本會尚未接獲相關分配方案。三、請參看會議資料第56頁，衛福部曾召開「全民健康保險總額支付制度地區預算分配政策方向」座談會，相關結論請委員參看書面資料。四、會議資料第57頁第四點，104.11.20委員會議討論105年地區預算分配之相關決議與本案有關，在此說明，去年因決議105年度人口占率提升，故同意中醫門診總額自一般服務費用移撥部分經費，作為風險調整基金。另決議：自105年度起，分配參數中之「各區戶籍人口數占率」，以5年調升10%為目標。請中醫師公會與健保署研提符合前開條件之分配草案；屆時若未能提出，則106年地區預算之分配參數「各區戶籍人口數占率」應調升3%。五、請參看會議資料第57頁第五點，本會於105.3.4依104年第11次委員會議之附帶決議，召開「西醫基層、醫院與中醫門診總額地區預算分配方式」座談會，會中對於中醫門診總額部門之相關建議及改善方向，臚列於會議資料第57~58頁，請委員參考。六、請參看會議資料第58頁，本會前於105.9.22函請中醫師公會依據104.11.20委員會議決定事項，於105.10.7前提送所建議之分配方案及健保署協助試算之相關資料，以利今日會議商議，目前尚未接獲建議之分配方案。七、幕僚依據目前分配方式，試析「各區去年同期戶籍人口數占比8~13%」分配之各區預算估計值，如第60頁附表，請委員參考。戴主任委員桂英謝謝陳組長燕鈴報告，請各位委員表示意見，或需進一步詢問健保署及中醫部門代表。謝委員武吉對於「錢跟著人走」分為三種，一是「投保人口」；二是「留在鄉下之老年人口」；三是「留在鄉下之幼兒人口」，我不了解「錢跟著人走」的定義，可否說明一下。戴主任委員桂英謝謝，請吳委員肖琪。吳委員肖琪一、請教一個問題，會議資料第56頁分配指標1「95年第4季至98年第3季之5分區實際收入預算占率」占率為72%，問題出在分配指標所引用的數據(95~98年)，現在已是105年，若印象中數據無誤，不同地區如新興地區，人口數已經增加，以全國增加100萬人口為例，主要增加在台北區及北區，人口數增加，非中醫界或醫界可調控，若仍以95~98年之5分區實際收入預算占率資料作分配指標，實屬不合理。二、若此部分以95~98年之5分區實際收入預算占率，似乎未反映人口數之增加與調整，在其他總額部門似乎無此現象，僅在中醫門診總額部門出現，想請教此分配指標之合理性，若台北區或北區人口增加，就應該進行調整，而非使用95~98年之資料。戴主任委員桂英謝謝，請林代理委員永農。林代理委員永農(何委員永成代理人)一、主席、各位委員午安，闊別6年，今天參與健保會議有點陌生。剛才委員提到人口占率分配問題及以95~98年之資料作為分配指標是否合理，是否反映人口增加之因素；以及另幕僚同仁報告：若今年中醫師公會及健保署未能提出106年度合理的地區預算分配方式，則該年地區預算之分配參數「各區戶籍人口數占率」應調升3%。二、我當6年中醫師公會理事長，是身歷其境，有幾點說明，第1點，人口占率不宜再前進，R值的前進應考量費用移動後實質效益與衝擊。第2點，R值前進只會將費用移動到都會區，反而擠壓偏鄉地區生存，費用若移動至偏鄉地區如南區、東區，我們沒有意見，但費用卻移動至人口增長的台北區及北區，請問都會區是偏鄉地區嗎？應該再審慎思考。三、第3點，過去的衛生署、費協會及健保局最在意的是，台中市每萬人口中醫數過高，但光是中國醫藥大學附設醫院就有51位；台中榮總醫院11位；中山醫學大學附設醫院10位，這3家醫院就有72位中醫師，新竹縣、嘉義縣、花東地區之中醫師都比這3家醫院來的少。四、若說台中市中醫師多，其原因不外乎台中有一所中國醫藥大學，培育中醫師，台中市中醫師多不是原罪，一昧指責中區醫師過多，不盡公平。彰化、南投2縣市每萬人口中醫師數僅2點多人，較全國其他縣市少，彰化是農業縣；南投縣屬山地、偏鄉地區，但這2縣市很倒楣與台中市為同一分區，因調整台中市而影響彰化及南投縣，似乎不合理，請一併考量。五、第4點，R值一直前進，難道中部地區民眾就醫權利、品質不需考慮嗎？請翻閱中醫部門資料，中部地區民眾中醫利用率是最高。再來中區的點值從89年總額開辦以來一直幾乎都是最後，點值約0.9上下，這已經是一種警告、懲罰，讓中醫師不會想來台中市開業，我想這已經夠了。六、89年總額開辦時，設計一套「錢跟著人走」8年方案，當年也沒經過詳細試算，經過4年後(93年)，中區浮動點值曾一度下降到0.7，我手邊有一份資料，若主席同意，將發給各位參考，請問錢跟著人走之政策能繼續執行嗎？ 92、93年約5季之平均點值也只有0.8多，當時人口占率R值走到30%，由此可見，不能一昧要求前進R值。七、現在交通便利，城鄉距離縮短，如果說偏鄉地區要獲得好的醫療照顧，應該加強無中醫鄉巡迴醫療服務，再落實鼓勵中醫師至無中醫鄉開業，這才是長久之計，而非一直前進R值。八、每個總額部門結構及需要性不同，不宜強迫所有總額部門適用同一套分配制度，實應考量各總額部門之特性。一昧的前進R值，是會重蹈覆轍過去89~94年未經試算之「錢跟著人走」政策，讓某些地區之中醫師生計受到影響，加深中醫內部的不團結與衝擊。請各位委員體諒及三思。戴主任委員桂英謝謝，請何委員語。何委員語一、主席、委員好，我認為每年都在討論中醫門診總額部門人口占率問題，這是一個偏頗的觀念，違反憲法給予人民的工作權，及同工同酬的平等權，我認為非常不應該的事。因中醫的獨特性，與西醫不相同，不宜以西醫的觀點及理論，套用在中醫門診總額身上。前陣子有一位高中生，因免疫缺乏症至2家醫學中心治療，但多年都未改善，最後尋求中醫治療，目前口服中藥加針灸治療，免疫系統問題已改善80%。二、多數人對中醫的態度是信者恆信；不信者仍不信。尋求中醫治療多半以中高年齡層居多，若將嬰、幼兒數列入計算，是不合理且不公平。我認為健保署應該重新評估每地區人口數及年齡平均數之分析，若偏鄉地區以老年人居多，而又要以人口占率當分配指標，對偏鄉地區是不公平的，對該地區民眾之醫療利用及可近性也是不公平。三、我強烈反對「以前進人口占率為訴求」，我認為「人口占率」之議題，應由健保署與中醫師公會共同討論。我僅就比例來說，嬰兒不可能去看中醫，學齡前期幼兒看中醫的比例也很少，但中年以上民眾看中醫的比例就較高些。我認為地區預算是整體醫療政策，不能以一個方案適用各總額部門，「人口占率」分配指標之占率，應尊重中醫師公會評估分區之醫療利用及民眾就醫行為而定。戴主任委員桂英謝謝，請楊委員芸蘋。楊委員芸蘋一、主席、各位委員好，首先贊同何委員語，我覺得中醫是中華民國的國醫，歷史悠久，不宜輕忽它。每年在總額協商後，接著討論「錢跟著人走」之地區預算，但中醫有其特殊性，何委員語已經提出很多觀點，我認為能否重新討論「錢跟著人走」政策，對中醫門診總額而言是不公平且不合理。二、另外照顧偏鄉民眾之醫療服務，應鼓勵醫師到偏鄉服務，何不利用地區預算分配時，加入照顧偏鄉的概念，不要用「錢跟著人走」之政策，試想偏鄉人口較少，錢如何能到偏鄉呢？三、剛才林代理委員永農說了多項困難點，但沒有看到中醫師公會好好地與健保署溝通其困境，而健保署只是一昧地要求前進人口占率，以達到「錢跟著人走」之政策，應該公平對待中醫門診總額部門。戴主任委員桂英謝謝，吳委員肖琪。吳委員肖琪一、很高興今天林代理委員永農一起參與討論，請參看會議資料第63頁，中醫門診總額就醫率100年為29.13%，也就是100個人當中29.13人使用中醫，當時已提醒中醫部門，就醫率已經下降至3成以下。我只是想幫忙中醫部門，不希望中醫就醫率愈來愈少，少到最後成為附加保險，我真的替你們擔憂。二、就醫率由100年29.13%下降到104年28.65%，誠如何委員語，中醫已不再大力推廣，只是等待使用中醫的老年人逐漸凋零。我本是想努力讓中醫就醫率達30%以上，但10年來，104年較95年就醫率成長僅2.11%。再參看會議資料第64頁，中醫門診件數104年較95年成長22.44%，雖然看中醫的人數呈現減少，但中醫的服務量其實是增加22.44%。三、參看會議資料第65頁，中區平均每人門診點數為1,349點，也許如同林代理委員永農所言，中區民眾較喜歡看中醫。曾看過一份資料，台中市確實是全國中醫師數最高地區，彰化也不遑多讓，是第三名，在此善意提醒，當醫師集中於少數縣市，其實中醫師數較少的縣市，如新竹、苗栗縣等民眾而言，是不知道有良好的國粹可以利用的。四、多年來，肯定中醫師公會對東區提供特別保障點值，相對在西部地區，建議一定要做分區分配指標之調整，否則中醫就醫率將會節節往下掉。戴主任委員桂英謝謝，請干委員文男。干委員文男主席、與會委員好，剛才何委員語、林代理委員永農都已經說得很清楚，吳委員肖琪所提出的議題，我們也應該要注意，對於醫療利用率、人口占率及R值與S值往前進是原則性。中醫部門有你們的困難，但每年都會為這地區預算在委員會中討論不休，都無法有合理解決方案，也不是辦法，建議中醫師公會邀請吳委員肖琪討論，找出一個方案解決你們的問題，要不然每年都是為了相同問題，與所有委員溝通超過半小時以上。R值與S值是一個指標，西醫總額的地區預算分配方式強行使用於中醫總額，你們覺得不適合，請提出相對的解決方案。戴主任委員桂英謝謝，請趙委員銘圓。趙委員銘圓謝謝主席，我也是反對將西醫總額的地區預算分配架構，強硬的架在中醫門診總額上，誠如何委員語及楊委員芸蘋所言，我不再贅述。對於吳委員肖琪所提出的論點，也請中醫師公會注意，中醫的醫療利用情形呈下降趨勢，對中醫門診部門來說，是一個警訊，如何讓國人能多加利用中醫，應是你們儘快去推動。中醫是我們的國粹，反而國人使用率低，也許如同何委員語所說，嬰幼兒是不可能使用中醫，真正使用中醫的年齡層屬於中高齡人口。考量整體制度，煩請健保署與中醫師公會多盡一點心力，重新思考整體架構，不要再按照現行架構分配地區預算，對中醫門診總額是不盡公平的。戴主任委員桂英謝謝，請滕委員西華。滕委員西華一、請看會議資料第57頁，在座所說的論點及理由，去年已經說過，前年未擔任委員我不知道，委員會去年所做的決議：「自105年度起，分配參數中之「各區戶籍人口數占率」，以5年調升10%為目標」，105年調整前進1%，不是只有中醫門診總額，牙醫總額已經是100%，另外包括醫院總額及西醫基層總額都前進1%，我們都要求R值前進，這是第一個原則。二、R值也可以不要前進，去年R值前進的條件下，你們希望區中有區，大家都有共識，提撥一筆風險基金使用於區中有區，換句話說，也就是提撥一筆經費撥補都會區裡的貧民窟。剛才所提R值前進會擠壓偏鄉地區或無中醫鄉地區，很抱歉，這些地區全部都有保障點值，東區點值已經超過1，東區是太低的問題嗎？不是嘛！三、若要推翻委員會所做的決議，要有合理的理由，去年討論地區預算所做重大決議略以：「我們可以不要進R值，但須提出更好的分配機制，若沒有提出，106年就是前進3%」，也就是最近2年4%之平均值而已，1年前進2%。今天我們不能只聽R值不要前進的理由，近3年理由都一樣，去年曾說不要再用95~98年的參考值，但今年也沒看到中醫部門提出改變分配指標之方案，所以依健保會幕僚之建議，請於12月底前提報分配方式。四、去年討論地區預算分配時，曾要求健保署提供意見，今年已經提出8~13%各區預算分配估計值。另外，健保會今年有針對地區預算分配方式辦理委託研究，不知年底能否結案，如研究結果顯示模型與我們慣用的S值、R值或西醫的Trans(門診市場占有率或稱為轉診型態)不同，就在年底前改變往後的地區預算分配機制。五、牙醫R值已達100%，中醫部門希望人口占率不前進，西醫基層部門及醫院部門或許也有其他想法，原則都一樣，去年決議可以推翻，但請提出理由及建議分配方案，去年沒有接納的理由今年怎麼會接納？請提出不前進的理由，例如有重大政策介入導致地區預算分配方式需改變、區中有區要提撥的經費等。六、民眾就醫行為與醫療提供者及政策介入有關，10萬人口的鄉鎮，不會因為看牙醫人數就變多，看西醫人數就變少，人口是固定的。吳委員肖琪提到，100人中只有約29人看中醫，與政策介入有無關係？與人口占率關聯為何？如果有這些資料才比較好討論，中醫部門未能提出說明，我無法做結論，即無法表態是否支持中醫。七、按去年決議人口占率應前進3%，中醫部門如不想前進，請於12月底前提出建議方案。戴主任委員桂英謝謝滕委員西華，請謝委員天仁。謝委員天仁先請黃委員偉堯發言。戴主任委員桂英好，先請黃委員偉堯。黃委員偉堯一、主席、各位委員，中醫人口占率問題不是近年才有，健保開辦至今都在爭議。先請教大家1個問題，我們是「健康保險」還是「全民健康保險」？如為全民健康保險，為何中醫僅能照顧特定民眾而非全民？其次，中醫如只照護老人，不能照護小孩，豈非自打嘴巴，去年才爭取通過「兒童過敏性鼻炎照護試辦計畫」，怎能說中醫只能服務特定對象。二、基於上述2點，先不論中醫有無特殊性，既然是全民健康保險，全民皆有繳保費，不是應該無差別對待嗎？如中醫服務的對象真有差異性，也不是沒有解決方法，可以將中醫改為附加保險，這時就不需考慮全民，而是以附加保險方式辦理。人口占率反映該區人口數多寡，應該擁有相當的醫療照護資源，如有醫療資源過剩的問題再做彈性考量，我認為是基本原則。三、中醫部門已緩衝多年，民國95年改成2區制及事後結算，是體諒當時中醫現實困境所做的退讓，因中區中醫師過多，點值下降；民國99年蔡副署長淑鈴提出修正後試辦計畫，使用至今。歸結原因，只有1個問題，即中區中醫師人數高出其他分區許多，如以人口占率分配預算，因其他分區中醫師數較少，使中區點值相對偏低。四、考量中區問題，人口占率已緩衝10年之久，其實也具初步成效，請大家翻開會議資料第62頁「表3歷年各分區中醫師數」，台北、北區不僅中醫師數增加，每萬人口中醫師數亦有提升，現在如以人口占率分配預算，不會造成各區點值差異過大。人口占率前進產生的問題已經與10年前不同，中醫師逐漸分散至各區，按人口占率分配地區預算才能鼓勵中醫師至醫療缺乏地區服務，讓更多民眾獲得中醫醫療服務，而非聚焦中區，難道只有中區民眾能接受中醫服務，其他區都不能？關鍵在於看待事情的角度，是中醫醫療服務提供者，還是全民就醫公平性。五、至於偏鄉問題，6分區都有偏鄉，與地區預算分配之間並無太大關聯，此為區中區問題，應於中醫總額研商議事會議討論，不應在本會處理，設計中區區內分配計畫，保障偏遠地區中醫師，而非集中於台中市市中心。偏鄉問題不是人口占率不前進的因素，其應歸於區內分配，且目前地區預算分配方案之指標6「偏鄉人口預算分配調升機制」，已自中醫總額撥出1%，補足偏鄉浮動點值至每點1元，我認為偏鄉問題與人口占率並無太大關係，反而需關注如何讓國人可公平接受中醫照顧。戴主任委員桂英謝謝黃委員偉堯，請謝委員天仁。謝委員天仁一、中醫狀況較特殊，民眾從小到大的習慣是看西醫，中醫僅有少數使用族群，談分配，需先考慮公平性問題，即醫療使用者自身選擇的醫療模式，基於尊重使用者，如使用者不選擇使用中醫，即是提升中醫就醫可近性，依然難以產生效果，以人口占率左右中醫醫療資源分布，或許效果不如大家所預期。當然，仍要尊重去年決議，只是提醒中醫部門，如能於年前提出委員認同的建議方案，就可把R值擺一邊。二、以我的角度，我認為人口占率分配有點粗糙，如果是考慮分配的公平性，應以中醫利用率、人口數為基礎，間隔一年度，由人口增加數推估中醫利用率，比較相互間的關係以決定分配，比較合乎公平。三、既然去年已有決議，基本上就應尊重，毋須特別討論，端看中醫部門能否於12月底前提出委員認可之分配方案，同時考量中醫本身利用情形並合乎未來醫療資源發展，不要每年都討論人口占率問題，大家都很累。中醫部門不提方案，則按去年決議，如要提方案請在12月底前，請好好思考如何調整，首要考量分配公平性，至於醫療資源發展或許不是最重要的。戴主任委員桂英謝謝，請林委員敏華。林委員敏華一、主席、各位委員大家好。依國人就醫習慣，民眾看西醫通常選擇醫院規模大者，由於中醫大多為診所型態，據我私下了解，民眾選擇中醫常是口耳相傳，或是自身體驗覺得有效向親朋好友推薦。二、林代理委員永農提到，中國醫藥大學於台中辦學已久，故而中部中醫醫療資源充足，我看中醫時也常遇到來自北部或南部的病患，病患其實不受就醫可近性影響，而是中醫師提供的醫療服務能否符合他的需求。三、我贊同謝委員天仁的看法，請中醫部門規劃分配方式，提出建議方案，希望盡量能找出兩全其美的解決之道，而非單純以戶籍人口數占率調整，對中醫而言是較不公平的。戴主任委員桂英謝謝，請謝委員武吉。謝委員武吉許多委員提出寶貴的意見，中醫界有其困難存在，先前討論中醫水煎藥時，我已說明過不再贅述，中醫有優點也有缺點；對於人口占率調整問題，建議給予中醫部門一些時間，盡快討論出建議方案，對他們也比較公平。戴主任委員桂英謝謝，請林代理委員永農。林代理委員永農(何委員永成代理人)一、主席、各位委員，首先答覆吳委員肖琪，有關中醫就醫率約29%，我是罪人，93年我上任中醫師公會理事長，當時中醫界生存困難，經過磨合，最後地區預算分配方式於95年起採用試辦計畫，且6區同意設有多項申報限制，時至今日仍未取消，包括：(一)每位患者每月內科僅能申報6次，第7次起由診所自行吸收醫療費用，不能申報，雖少數診所仍會申報，但數量不多，嚴重抑制成長空間。(二)針灸、傷科每月僅能申報14次，然而最簡單的腳踝扭挫傷，即使敷藥14次都難以痊癒，院所都自行吸收，才有如今的點值。(三)設有內傷交替率管控，患者於針灸、傷科治療期間常有內科疾病，如感冒、腸胃炎、頭痛等，限制療程間的內科次數。(四)限制開藥日數重複率。因有諸多申報限制，中醫就醫率才僅有29%。二、黃委員偉堯提到中醫地區分配方案，中醫部門自99年起採用修正後試辦計畫，楊前署長(衛福部改制前)志良及鄭前主任委員守夏也支持採事前分配，區分6區預算，80%採用95年第4季至98年第3季各區實際收入預算占率，實施之初為4項指標，現在已發展為6項指標，不再是事後分配。戴主任委員桂英謝謝各位委員的意見，請李委員永振。李委員永振分配有如國家進行改革，重新分配後，必定是有失有得，中醫部門對R值前進有困難，但如要改變去年決議，一定要有合理理由。幕僚擬辦建議是12月底前提送本會，時間尚有餘裕，請中醫部門盡快討論提出解決方案。戴主任委員桂英謝謝，請林代理委員永農。林代理委員永農(何委員永成代理人)為避免每年吵人口占率問題，我提2個方案，第1個方案，依縣市別分配地區預算，請健保署一起討論解決台中市問題，百分之百依縣市人口占率，一次到位，吳委員肖琪也贊同吧！吳委員肖琪中醫6區都無法到位，如何改用縣市別。林代理委員永農(何委員永成代理人)以前有提過此方案，我看過當時的會議記錄，吳委員肖琪也贊成。吳委員肖琪我知道，但中醫連6區都做不到。林代理委員永農(何委員永成代理人)一、中醫6分區都同意以縣市別來分配地區預算，百分之百錢跟著人走，當然台中市問題要解決，不然點值可能只剩0.5、0.6。二、第2個方案，因中醫師公會新理事長5天前才上任，內部團隊亦有重新改組，如果上述方案不適用，請給我們3個月的緩衝時間，與健保署再研議新方案，106年1月底前提出。戴主任委員桂英請葉委員宗義。葉委員宗義中醫人口占率問題是長年的病，既然中醫部門提出緩衝時間，我贊成給予3個月時間以解決問題。戴主任委員桂英先請教健保署，中醫部門希望能緩衝3個月提出建議方案，實務面可不可行？蔡副署長淑鈴須在年底前定案。戴主任委員桂英健保署表示必須在年底定案，幕僚有無補充說明？張副執行秘書友珊一、請委員翻開會議資料第59頁擬辦二，對需保障或鼓勵之醫療服務項目，於105年12月底前送本會同意後執行。查過去各部門相關的點值保障項目包括：藥費、門診手術等；至於地區預算之分配方案，依過去的討論時程，原則上應於10或11月份委員會議完成，以利送衛福部核定後公告。二、另補充說明，因本會11月份委員會議需審議保險費率，故之前已安排提前1週，於11月18日召開。戴主任委員桂英一、依據104年11月20日委員會議決議，中醫部門尚未與健保署商議出替代方案，該方案應以民眾就醫公平、各地區醫療資源均衡發展為目標。二、林代理委員永農希望有3個月緩衝時間以提出建議方案，惟實務作業無法延至明(106)年1月，幕僚建議於11月18日委員會議提出，請中醫部門盡量配合辦理，如真有困難，則延至12月委員會議，屆時將壓縮行政作業時間，請各位諒解。三、接著請參看幕僚的分析資料，以下不是決議，請委員翻到會議資料第62頁「表4歷年全民健保各分區每萬人口中醫師數」，下方表格最右邊欄位「104較94年成長率」，東區每萬人口醫師數10年成長率為54.99%，而需管控的中區則為30.73%，表示中醫地區預算分配方案不論是94年前衛生署(102年7月23日改制為衛福部)交付方案、95~98年試辦計畫，或是99年後修正後的試辦計畫，於促進醫療資源的均勻分布，皆有若干成效。四、再請參看會議資料第63頁「表5 95、100~104年中醫門診總額各分區就醫人數及就醫率」下方表格，就醫率之定義為區域內使用醫療服務之人數，而非中醫部門方才所解釋的醫療利用情形，許多委員相當重視中醫發展，希望就醫人數占人口總數之比率能提升或至少維持。五、本案討論到此，接著進行討論事項第三案「106年度西醫基層總額一般服務之地區預算分配案」。柒、討論事項第三案「106年度西醫基層總額一般服務之地區預算分配案」與會人員發言實錄陳組長燕鈴請委員翻開會議資料第77頁，討論事項第三案「106年度西醫基層總額一般服務之地區預算分配案」：一、依本會105年9月24日委員會議決議，一般服務成長率為3.963%。二、地區預算執行概況：(一)西醫基層總額地區預算分配參數包括：「各地區校正風險後保險對象人數」(R值)及「總額開辦前一年各地區保險對象實際發生醫療費用」(S值)。另R值的風險校正因子包括：人口風險(年齡性別指數占90%，標準化死亡比占10%)、轉診型態(西醫基層門診市場占有率)。(二)分配參數中，R值占率於各年協定情形：98~104年為65%，105年為66%。三、請委員參閱會議資料第78頁，有關衛福部於103年8月6日召開「全民健康保險總額支付制度地區預算分配政策方向」座談會，及本會105年3月4日召開「西醫基層、醫院與中醫門診總額地區預算分配方式」座談會，相關建議及決議請委員自行參閱。四、上述建議提報105年4月22日委員會議，請總額部門相關團體與健保署配合辦理並請及早作業，故本會於105年9月22日函請中華民國醫師公會全國聯合會，將所建議之分配方案及健保署協助試算之相關資料提送本會，以利商議。五、醫師公會已於昨日提送地區預算分配建議方案，請委員參閱今天會上提供之單張補充資料「中華民國醫師公會全國聯合會函」，該會建議維持R值66%及S值34%，其餘分配方式待其內部開會研議後提報。六、有關西醫基層歷年各區一般服務預算、醫師數、就醫人數與醫療利用情形等資料，請委員參閱會議資料第82~86頁。戴主任委員桂英謝謝陳組長燕鈴說明，請委員表示意見，請干委員文男。干委員文男一、本案與前案類似，都是針對R值，會議資料第77頁中間表格，98~104年R值占率為65%，105年為66%，不只中醫有R值問題，西醫基層也一樣，從歷年協定結果來看，R值雖有進步但近年略有停滯。二、會議資料第84頁「表4 95、100~104年西醫基層總額各分區門診就醫人數及就醫率」下方表格，台北區104年門診就醫率只有78.3%，比95年少1.7%，請問是R值問題還是S值問題？門診就醫率最高為高屏104.6%，可能如謝委員武吉先前所述，鄉下以老人、小孩居多，比較有時間就醫，台北民眾比較沒時間，造成就醫率下降。三、台北區投保人數占率約36%，預算占率只有約32%，雖然點值尚可，但問題是就醫率實在不高，健保會先前發文請醫師公會提出建議分配方案，邱理事長泰源卻回覆R值不動，請問要怎麼解決問題？戴主任委員桂英請問委員有無其他意見？暫時沒有委員提問，請黃委員啟嘉先回應。黃委員啟嘉一、請委員翻開會議資料第80頁「表1-1 106年度西醫基層總額一般服務地區預算模擬算表」，我們以台北區為例，台北區投保人數占率約36%，但預算占率僅32%，當R值(校正人口風險及轉診型態後保險對象人數)為66%時，預算成長率為4.49%，R值67%時，成長率變成4.48%，若R值一直往前走至71%，預算成長率變成4.44%，為何台北區人口成長與人口占率那麼高，預算成長率會一路往下，向各位委員報告，若R值往前走，預算成長率只有北區增加，其他區都減少。二、其實北區點值不是最低，在104年北區點值是排第3或第4名，並不是最低，所以R值往前走，會造成北區預算變多，其他5區都減少，因為西醫基層的R值是比其他總額部門更複雜，R及S值是一種經濟分配模型，並非西醫的醫學模型，我在讀醫學系時，沒學過經濟學，所以這並非是專屬西醫的東西。既然是模型，就會依不同學術與學理產生多種模型，有很多假設必須在現實中成立，否則就會出現問題。三、R值有個最大的參數是Trans(門診市場占有率或稱為轉診型態)，今天台北區人口成長但Trans不好，所以R值必然吃虧。這主要是因為台北區醫院服務供給面太大了，扭曲了轉診型態。這裡也必須了解現行R值有個前提，那就是醫院和診所的病人是完全連動，也就是當醫院門診病人增加時基層門診必然會下降的假設必須成立。但其實不然，因為去醫院與基層看診的是2群人，習慣在醫院看診的病人不會跑去基層，所以醫院人數增加，基層人數減少是有限的。台北區在這種情況下是吃了大虧，R值往前走，台北區似乎人口成長很高，但預算成長率會繼續減少，所以西醫基層才會提出將R及S值固定在66%及34%。這個部分太複雜，合理的經濟模型實在沒有辦法提出來，只好在妥協下，經過6區共同思考的結果，就是以維持現行66對34的比例可以最適切反應地區分配的合理需求。四、若R值往前走，5個區預算成長率減少，只有1個區增加，R值至71%，全區才成長4%多，北區就成長7.09%，但是有增加那麼多需求嗎？其實很多東西是一個模型，需要實證，我們必須遷就事實與民眾的就醫習慣，老百姓最大。S值是當年老百姓呈現出來的醫療需求，可以隨著時間減少，但是到了一個時間，發現誤差太大，無法解決分配的問題，只好遷就事實。五、希望106年度R與S值，仍維持在66%與34%，這是西醫基層有共識的部分，希望各位委員能夠審酌，台北區投保人數占率約36%，但預算占率僅32%，若R值往前走，預算數減少，成長率也減少，這對台北區不公平，東區更不用提，預算成長率早就是負值。戴主任委員桂英謝謝，請李委員偉強。李委員偉強一、大家好！請大家一邊用餐一邊聽我說，R及S值是過去及未來10年都在討論的部分，但關鍵不在R值，是在S值，R值是將年齡及性別當作風險校正因子，在座有專家，我似乎有點班門弄斧，因我過去有研究過：用健保資料庫分析，以年齡、性別與標準化死亡率檢視當年門診使用率，大約只有5%的準確性，預測次一年健保利用率是2%，這是門診的部分，住院費用的預測率更低。二、什麼預測率會較高？是S值，S值是去年實際醫療費用發生的比率，會受病人需求與醫療供給2個因素影響，目前看到不管是西醫基層或醫院總額，台北區醫療點值往往是敬陪末座，R及S值加起來100%，調高R值，就會降低S值，預測率會下降，所以關鍵不在R值調高1%或2%，而在S值下降。三、支持西層基層總額維持現狀，因為需要有更好的公式來計算。現在國際上有很多成熟的費用預測模型，可以將病人除了年齡與性別之外，更加入個人疾病一起放進來分析，才能更精準反映R值，所以要再加上病人過去1至3年左右實際上的疾病負荷(morbidity burden)，建議健保署邀請專家學者好好討論，在沒有更好的公式前，或許R值可以維持在66%，同樣的理由也適用下一案醫院總額是否調整R值，支持暫時維持105年的比率不動。戴主任委員桂英若其他委員沒有意見，徵求各位委員目前的建議。請黃委員偉堯。黃委員偉堯一、我沒有特別要對本案表示意見，只是就我理解的部分稍微說明，剛才李委員偉強的說明是對的。而Trans確實會受到影響，但不是因為R值的關係，是因為Trans造成衝擊，導致對R值有所保留。至於Trans，就我理解應該是西醫基層與醫院總額部門之間在醫療市場上的占率，也就是說，假設以台北區為例，全部台北市的人口在就醫時，有多少人至西醫基層看診，有多少人至醫院看診，各區之間比率不同，醫院與診所之間就醫比率也不同，就透過這個Trans來校正。二、若台北的民眾都不喜歡去西醫基層看診，都跑去醫院看診，此時完全照人口與風險性校正，而不含Trans時，相較於其他地區的西醫基層，台北市的西醫基層就會分配到過多的預算在他們身上；但Trans怎樣設計到大家認為的合理值，是蠻大的學問。若要根本解決，就是將西醫基層總額與醫院總額合併，就不會有Trans存在的問題，這是制度本身設計上所造成的，為了校正制度所以產生Trans，讓總額預算可以進行較佳的分配。至於最後怎樣，是大家可以一起做決定。戴主任委員桂英請楊委員芸蘋。楊委員芸蘋我認為黃委員偉堯所提意見很好，我也有天真的想法，若西醫基層與醫院總額合併，就什麼問題都沒了，所以黃委員的意見很有道理，至少在公平的狀況下，讓西醫基層維持現狀，不要讓他們有太多困擾，以及不易進行的狀況。戴主任委員桂英今天聽了委員的意見，支持維持現狀的委員還不少，請參看會議資料第79頁，分配比率請依105年的分配比率填寫，其他擬辦依幕僚所擬的意見處理。委員若無其他意見，接著進行討論事項第四案，請同仁說明。捌、討論事項第四案「106年度醫院總額一般服務之地區預算分配案」與會人員發言實錄陳組長燕鈴一、請委員參看會議資料第91頁，本案是有關106年度醫院總額一般服務之地區預算分配。依據今年9月協定結果，目前已將2個方案報主管機關決定；其中對一般服務成長率的建議，付費者代表方案為4.442%，醫院代表方案為5.289%。(一)醫院總額地區預算的分配也是用R及S值做為分配參數；R值的風險校正因子，門診是人口風險因子(年齡性別指數占80%，標準化死亡比占20%)、轉診型態(醫院門診市場占有率)，住院是人口風險因子(年齡性別指數占50%，標準化死亡比占50%)。(二)分配參數中，R值各年的協定情形，門診的部分在102~103年為46%，104~105年維持46%，住院的部分在102~103年為40%，104~105年前進至41%，這是醫院總額近年R值提升的狀況。二、會議資料第92頁，衛福部於103年8月份及本會於今年3月份所召開的座談會相關結論與西醫基層一樣，請委員參考。另，本會已函請台灣醫院協會於這次的委員會議前提送建議之分配方案，及健保署協助試算的資料，以利委員商議。該會回覆還需要召集會議討論，等凝聚共識後再行提供。三、幕僚模擬106年度依「校正人口風險因子及轉診型態後保險對象人數」占率，分配之各區預算估計值如會議資料第95~97頁附表，請委員參閱。戴主任委員桂英謝謝，請問各位委員有無意見？請陳代理委員順來。陳代理委員順來(侯委員彩鳳代理人)一、我記得93年我剛擔任費協會的委員，R值都有調整，10年內會再逐漸調高，在94年，R值為15%、後來95年調至38%，96年凍結，97年調為45%，後來又凍結好幾年，至103年為46%。二、我認為錢跟著人走，公平來說，醫院總額當然是和中醫門診總額不同，算起來，我認為在整個6區裡，北區最少，R值若調高，其他地區預算當然會減少一點，北區會增加一點，本來北區就很少，當然會增加，大餅都一樣，其他區會減少是必然的，不是北區增加，這不一樣。為了公平性，我認為R值要調整，西醫基層R值都到66%，目前是維持不動，我認為醫院總額應該要調至60%，才能和西醫基層吻合，就醫才有公平性。戴主任委員桂英陳代理委員順來的意見是希望R值要略微調高，請問其他委員有無意見？請李委員蜀平。李委員蜀平一、我echo(附和)陳代理委員順來的意見，實際上某公家單位也向我提過這件事，我認為基於公平正義與比率原則，大家應該要有共識，但是這些共識非常敏感，健保署的長官都不願談論這部分，因為餅難分，太複雜了。二、這裡有桃竹竹苗北區的資料，若以健保的投保人口占費用比，103年全區平均為15,091元，但北區為12,971元，當然在不同的時間點或年代，都會有所改變，因為新竹地區有很多高科技園區，人口較多，桃園區可能因工業發展的不錯，且消費較低，所以人口成長最多，生育率似乎也最多，雖然這些因素不能與問題相提並論，但也是要列入考慮。確實北區平均每人占健保的費用偏低，這也會造成醫師不願意去北區行醫的副作用，某些委員可能對我的想法不認同，但希望基於公平正義及比率原則，將R及S值做比例調整，這些傷感情的問題，主要就是因為健保費用不足，希望大家相忍為民眾，因為這是一個公平正義的事情，期望R及S值能調至60%，以示公平。戴主任委員桂英李委員蜀平所提意見是希望R值要略為調高，請劉代理委員碧珠。劉代理委員碧珠(張委員煥禎代理人)一、醫院總額部門就這議題，楊理事長漢湶已召集我們討論，對於R值調整，6個區有3個區認為要往前進，3個區認為不要動比較好，其實站在協會代表的立場，若以法上面來看，在沒有更好的方式前，我們認為R值要往前走是較為妥適。二、剛剛醫學中心的代表李委員偉強提及關鍵在S值，可是好幾次我們都提到S值影響的關鍵是各區供給面的醫療提供量，醫療提供者的服務點數就會決定各區的點值，健保署各分區在管控醫療服務利用的作法上，放寬點數成長的情況也會影響到點值，所以S值絕對是造成預算分配的一個關鍵因素。三、大家可以看到在整個醫療服務的利用率，請看會議資料第102頁，平均每人就醫點數，剛才中醫門診總額也有同樣的情況，在門診裡面只要R值不往前，S值一直往上升情況，6個區平均每人門診就醫點數，門診最高與最低差了2~3千點，住院也是一樣。為何會這樣，因這關係到各區拿到預算後，我沒有特別強調是哪個區，預算分配下去，各區如何管控醫療資源的利用，而資源耗用情況又反應到各區點值上。四、大家也提到，R及S值公式我們爭論很多年，若爭論這麼多年，大家認為公式該改就要改，若無法修訂前，建議還是要往前進，因為依法還是要往前走。戴主任委員桂英現在發言的委員大多支持R值要往前進。請謝委員天仁。謝委員天仁一、R值是否要往前進，我沒有確定的立場，我認為最主要的原則是總額本身在我們這邊做分配，分了6個區，最主要的原則是要符合公平性，這是最主要思考的東西，假使R值不動，分配公平性有問題，沒有理由不去調整R值，若不調整，公平性一樣沒問題，我當然支持R值不動。二、很多的爭執，基本上都在學理上公式的呈現，其實健保已經超過20年，資料庫是最大的資產，可用資料庫實證資料去試算各年度各區產生的變化，我認為這個東西最有說服力，基本上希望以後能有這些資料，大家在判讀上會比較清楚，不然R值要調升多少才會公平，若調升超過，也會衍生另外一個不公平，因為要處在平衡狀態。三、有時邏輯上思考不是那麼合理，假設我的戶籍在北區，但我都跑去台北市的醫學中心看初級照護，請問要如何解決這個問題？我認為某個角度這些部分沒那麼細膩，最細膩的是資料庫所存在的資料，每一年從各區是可看出些端倪，我的看法是若不公平，R值就要往前進。戴主任委員桂英請問委員有無其他詢問？請謝委員武吉。謝委員武吉一、其實台灣醫院協會是較早回公文給貴會，但是台灣醫院協會是在前天才開會討論R值是否要動，但是當時沒有做出很大的建議，所以R值才沒有動。早上一開始，我就說了錢跟著人走會產生很多的問題，老人、小孩，還有投保在別的地方都會產生一些問題，剛才謝委員天仁提到最重要的就是看診的病人，我認為R及S值要調整，我也聽到一些風聲，有人動用很多資源在處理這件事，我不希望將這些東西攤開來說，建議本案讓我們拿回去討論後再送給健保會。二、向各位委員報告，請問大家知道有某一區，有百分之多少的預算跑到哪一些醫院？這是很嚴重的問題，請各位深思熟慮，大家用公平、公正、合情、合理、合法的狀況處理這件事，請再給我們一些時間討論。戴主任委員桂英請問各位委員還有無意見？請李委員蜀平。李委員蜀平有位公職藥師向我說，我提此看法一定有人會反對，剛剛謝委員武吉也提及，這牽涉到很多問題，最後的結果若沒結果，一定會敬呈部長，部長也會有很大的壓力，如果不公平，結果一定會造成很多的民怨。最公平就是要如何改變制度，改變後，怎樣處理到最公平，這才合理，為了健保費用，6分區一定有各自的想法，我是藥師不能涉入醫界的事，但懇請大家稍微退一步，事情就可以圓滿。戴主任委員桂英請楊委員芸蘋。楊委員芸蘋剛剛謝委員武吉提及的問題，其實蠻嚴重，是否會對某個單位特別優惠？若R值提升，我們站在公平正義的一方，怎樣能讓醫院平均享用這個資源，我認為這是我們該有的立場，在公平下，用最好的方式來處理這件事情，大家都同意R值提升，但是問題沒解決，還是老問題，不要說圖利某個單位或醫院，不用說我們心裡都有數，但是本案要如何處理，是要等你們討論後再決議，或是可先調升一點R值，是否能這樣考慮？這是我的建議，我也不是很清楚哪個方案會比較好，只是提醒一下。戴主任委員桂英先請劉代理委員碧珠，再請楊委員漢湶。劉代理委員碧珠(張委員煥禎代理人)一、我再回應一下，剛才有幾位委員提及投保及醫療費用使用在哪的問題，這一點健保署也可做點補充說明，若投保人口在中區，卻至北區就醫，中區就必須回算給北區，錢跟著人走，預算是跟著回算，是有跨區就醫的校正因素。二、剛才提到偏鄉問題，健保署對偏鄉有點值保障每點1元，還有很多委員提到目前對偏鄉的保障過多，我不能論述保障是否過多，確實偏鄉醫療也被保障，但不能在討論分區預算時，將偏鄉的問題混在一起討論，跨區就醫是有回算的，並不是跨區就醫就是圖利哪個地區或醫院。戴主任委員桂英請楊委員漢湶。楊委員漢湶一、分配本來就是一件很困難的事，何況在座的人係居住在某一分區或代表某個機構來討論，當然會希望能分配到多一些的預算；若要完全公平，並不容易。健保的人口定義，有很多種，例如投保人口、就醫人口、居住人口等，所代表的意義通通都不一樣。以前北、高兩市也曾發生過人口定義的爭議，公司設在台北，但人並沒住在台北，如同謝委員武吉剛提的人口定義是個問題。二、從會議資料第100頁，會發現與我們原本想像的不同，台北區就醫率最低，104年為52.8%，東區70.3%則為最高。是否因台北區就醫率最低，就需鼓勵設立更多醫院？我想結論又會不一樣，我看蔡副署長淑鈴一直搖頭，故基本上這是一個問題。三、會議資料第101頁，104年北區平均每人就醫次數僅3.65次，是最低的，但從人口統計資料來看，北區的人口數成長確實是最高的，為何會有這樣的現象？顯然新竹、桃園科學園區的人身體狀況較好。剛謝委員武吉也提到年輕人離鄉外出工作，年紀大的人留在嘉義、屏東等地，醫療的費用當然會不一樣，請大家記住這個數字。四、接下來請參考第103頁，各區浮動點值係反映各區醫院提供之醫療服務所得到的點值，點值最高的是高屏區，是否要把高屏區的預算降低、提高點值最低的台北區，但台北區有少拿錢嗎？在這種情形之下，我們已做了很多討論，但確實存有實質上的困難。我要講的是，我們已經討論過，不是沒有討論。醫院還有分3層級，所占的費用比例也是最高，且病人會跨區流動，與中醫的屬性並不相同，中醫跨區就醫的比例不高，但醫院跨區就醫的比例相當高，在這種情形下，委員能否同意依我們內部討論的共識。自我接任理事長後，已面臨很多次的R值調整，每次調整都承受相當大的壓力。五、對於會議資料第94頁的擬辦，我有2點建議：(一)門住診費用比45：55，與實際數值差太多，從會議資料的相關表格看，都找不到這樣的費用比例。若要接近事實，應把門診改為54、住院調整為46。付費者覺得住院的費用比例，應要高一點，雖並沒錯，但因過去很多住院做的手術，現在已變成門診手術，即或不改為門診手術，住院的日數也大幅縮減，故住院的費用會下降，門診的費用當然就會增加。我覺得用離事實太遠的比例來計算並無意義，建議將門住診費用比改為54：46。(二)建議R值不調整，106年門診仍維持46%、住院則為41%。若要調整，以後再來思考。以上報告。戴主任委員桂英依會議資料第95頁，R值若增加1%，門診地區預算之成長率超過平均值4.99%者，為北區與東區；住院若調高1%，預算成長率超過平均值4.77%者，僅有北區。楊委員漢湶提到他們內部討論時有許多的問題，當然錢跟著人走，是希望較多人口的區域，能分配到多一點預算。但因其牽涉的因素很複雜，剛剛主張R值要調高的李委員蜀平已說他不介入了，謝委員天仁則希望健保署提出相關數據，以利判斷是否公平，有些委員支持調高R值，有些則認為應維持，謝委員武吉則建議讓醫院部門再回去討論，請問大家的看法如何？謝委員天仁建議讓醫院內部再討論，下一次再提會討論。地區預算分配主要是醫界內部能達共識，除非有特別不公平的地方，付費者原則上不太會去介入，但我們對門住診費用比例會有意見。戴主任委員桂英先請楊委員芸蘋發言，再請陳代理委員順來。楊委員芸蘋剛楊委員漢湶也提到內部還有分歧的聲音，我覺得還是需要再討論，是否與健保署再達成共識，或提出更好的方案。要調多少，我們當然沒什麼意見，只要對消費者有幫助的，我們都樂觀其成。因事關醫院整個團隊的運作，需再慎重一點，最好能獲得大家的共識，減少紛爭。陳代理委員順來(侯委員彩鳳代理人)R值調高是政策，但大家對調高有意見的話，可見這個政策是有問題的，應檢討，不然逐年調高應係正常的。我認為應以就醫公平性的方向著眼，這是我們付費者的要求。戴主任委員桂英此議題是需要再檢討，請楊委員漢湶。楊委員漢湶一、105年台北區的浮動點值最低，僅0.8636，調高R值，還要再讓它更低嗎？R值調整影響的層面並不單純，不是預算挪過去，公平性就能產生，這也是為何我們會討論再討論。我剛也提到，若單純從人口數字看，我了解北區的人口是成長的，但問題是其人口年齡的組成，相對於其他區可能較為年輕，故其就醫率較低，是否要把此因素納入考慮。二、剛李委員偉強也提到單算R值並不客觀，故我們內部討論才會決議仍維持，並已於今日早上還是昨天下午回覆健保會。若要我們再回去討論，仍會是相同的決議，只是把時間往後拖而已。謝謝委員考慮到醫院團體的和諧，雖然所影響的錢並不是很大，但為內部和諧，我們每年都很慎重地經多方討論，希望能讓每家醫院都能接受所討論出來的結論。以上報告。戴主任委員桂英楊委員漢湶說他們再帶回去討論的結果也是一樣。有關公平性部分，健保署有無意見？李委員蜀平報告主席，我的意思是我是藥師不適宜involve(涉入)，並非是不involve，我們應該聽署長意見，有哪些壓力、公平正義的point(重點)在哪裡，不然到最後又是一樣，又是一些民怨，會有很多的副作用，以上報告。戴主任委員桂英請健保署就公平性進行說明。李署長伯璋我是不分區的署長，各位覺得怎樣做較公平，我會支持那個方向。當然很多人對這個議題有不同的意見，我還是尊重健保會委員覺得怎樣對民眾較好。戴主任委員桂英署長沒有特別的意見，尊重委員的意見。滕委員西華一、健保署對地區預算分配應表態，謝委員天仁講的，我們都很贊成，但主席下結論前又展開了另一波的戰場，又要再發言，現在健保署應表示意見，不是壓力的問題，是資料庫在健保署的手上，我不相信健保署沒有定見，我再說一遍，我不相信健保署對R值沒有主張。二、向來行政部門的說帖、內容，具有相當程度的重要性，完全不表態，也沒關係。你說哪一區有濫用、醫療資源分配過剩，也不考慮，把所有結果都賴給病人愛看病，卻不去整理、盤點醫療資源，在台灣整體的負擔及分配上面，是否合理。每個人都講自己不可以的理由，卻沒人告訴我們什麼可以。今天問健保署的意見，無非就是希望能在中間取得一個平衡。三、對醫療體系的意見，我們都很尊重，就像謝委員天仁講的，若這是內部調控與分配的問題，說實在的，大總額已匡在那裏，付費者只對門住診分配有意見，希望區域級以上的醫院能降低初級照護率，我們把重症的支付點數提高、讓你們做DRGs (Diagnosis Related Groups，住院疾病診斷關聯群)、同病同酬，不然就醫院一級化，國家分兩級就好了－門診/住診、基層/醫院，不然就做門診總額，要不然就改制度，醫院的給付現在也慢慢變成一元化。四、現在是各分區對R、S值有不同意見，你們要考慮分配，不然你們就自己來，你們不自己來，健保署又不告訴我們內部分配的機制應怎樣分配，technically(技術上)較可行的，付費者代表手中無資料，在這裡討價還價，不然你們來遊說，看誰的論述較有道理能讓人接受，專家學者已講2次了，老實講，很累，如果不要，我們沒關係，我們就切，但不要去外面講付費者不懂、胡亂來為何R值一定要往前進。一切都按照規矩，我都講一樣的話，在沒有更好的證據以前，R值就是往前進；但醫界卻是講在沒有更好的證據以前，R值不要往前進，到底證據是什麼？若我們不follow(遵循)謝委員天仁的建議，R值就是要往前進，不然1%，大家來喊價，就變成這樣，有比較好嗎？如果不要12月討論，我覺得沒有差，老實講這種話每年都要上演一遍，讓人很疲倦。謝委員天仁我也贊成。何委員語一、剛聽到謝委員武吉說有什麼不公平的內幕，但他又不清楚講明白，李署長伯璋的回答也讓我們霧煞煞(台語，模糊不清)，我們不知道地區預算分配的內幕是什麼，醫院協會理事長楊委員漢湶講了很多意見，希望R值不要往前；付費者的原則，與滕委員西華、謝委員天仁剛講的一樣，我們希望的是公平、公正，不要發生有醫院的醫師向我們抱怨一大堆。二、106年醫療服務成本指數改變率所增加的預算，至少有60%用來調整重症支付標準，另外醫學中心與區域醫院之初級照護案件數不得超過105年的90%，已有分級醫療的概念。我參加健保會委員會議至今，我覺得很奇怪，為何每年都要討論R值，照理講你們數據那麼多，應可以分析是否有不公平處、怎樣才是公平的。健保署既有很多數據，理當早點提供給付費者，讓付費者可以了解R值是否需要提高、還是不應提高。我理解楊委員漢湶講的，R值增加對台北區不利，包括其他項目都是這樣，因都會區、人口密集度的關係。三、門診與住診的費用比例，我認為醫療體系有重症的體系、門診初級照護的體系，組成為較健全的醫療體系。我的看法是請醫院再回去討論，謝委員武吉講有不公平的地方，到底哪個地方是不公平，我們也不知道，你們就回去講到很公平，12月份再提會討論，若11月份委員會議可以提出來，更好。若你們再討論後，如同楊委員漢湶所提，仍會是原案送來，屆時我們再來決議。戴主任委員桂英請干委員文男。干委員文男要回到醫院協會討論，是另一個問題。R、S值的分配參數已使用多年，大家也清楚，若不清楚，能否請吳教授肖琪再重新講一次，R、S值有什麼關係，大家都講R值往前有困難，困難在哪裡、好處在哪裡，大家了解後，決定該怎樣做就怎樣做，就不會原地踏步又說人家不好，若真的不好，以後都不要用就好了。請吳老師再次說明，讓大家回去後還可說給不曉得的人聽，讓他們也能清楚。以上，謝謝。戴主任委員桂英請吳委員肖琪。吳委員肖琪一、每年總額協商時，都會考慮到非協商(醫療服務成本及人口)因素，其中的投保人口預估成長率、人口結構改變率(反映性別、年齡別的醫療費用)，即是反映被保險人數、老年人口的增加，例如下年度因老人增加、被保險人增加，需增加多少錢。二、R值，從某個角度，類似非協商因素的概念，這個區域有這麼多人口、這麼多的老人，就照它的性別、年齡別算出它的費用應該是多少。例如這個區域是醫療資源較少的，用這樣的方式算出來要給到100億元，但他們就醫很不方便，需要孩子請假、還要孩子開車載他們去看病，才能看到剛說的名醫，這時候它的醫療利用率就會較低，醫療利用低、點值就會高，就會push(推動)醫師願意去那裏開業，因去那裏開業就可以拿到較高的點值。這就是我們希望藉由R值往進，可以鼓勵醫師的流動。三、每次要講最極端的例子，就是牙醫師，他們發現北區的牙醫師較少，但用性別、年齡別校正後的人口數計算，他們會獲得較多的預算，但因其牙醫師少、民眾利用少，點值會比較高，牙醫師就會往北區流動，有些牙醫師住在台北市，到北區執業，民眾就不用跑到台北來就醫。四、S值，就是醫院在哪裡、錢就給到哪裡。目前台北區有8家醫學中心，或說所有的醫院都在台北區，我是用較極端的例子說明，當然不可能所有的醫院都在台北區，哪一區的醫院家數多，就用各區醫療費用的多寡去決定預算，這就是S值。若我們希望醫學中心、或醫院可以分散，就要促使它往外走，不要集中在一個區。當然，我要講一句實在話，醫院R值不可能走到100%，因為蓋醫院的成本太昂貴了，蓋起來後也沒辦法長腳移動，醫院R值要達到什麼數值才要停，我不知道，這是實話，但我知道它絕對不可能達到100%，是要到40幾就停、還是50幾、60幾，我不清楚，因沒有足夠的數據可佐證。五、綜上，R值就是類似非協商因素，考量到各區的年齡、性別、人數差異；S值就是哪區資源多、哪區用得多，錢就拿得多。如果要幫助資源較少的地區，要往R值增加的方向走，才能幫助到資源較少的地區。我再重申，醫院我沒有支持R值要到100%。牙醫R值已達100%，中醫才8%，你們會發現討論基層與醫院時，我都沒有發言，因中醫是從94年的30%，走回頭路到非常低，我覺得至少在我們還沒退休前要再努力往前走，不然中醫100多年都走不完。這是我自己在看地區預算分配的問題。謝謝。戴主任委員桂英請黃委員偉堯。黃委員偉堯一、關於醫院總額，我的建議是，如果可以的話，我覺得門診的R值可以往前進一點點，住院則可以維持。因醫院的門診與西醫基層的門診雖然在屬性上有差，但終究還是門診，其就醫方式與地域性是相近的。但住院則有可能因醫院的專長、屬性不同，而跨比較遠的地區就醫，因此住院可能需再研究是否有其他方式可處理。 二、R值往前進，台北區是否損失較大，需要試算。可能台北區的人口風險因子相較於北區，在總額預算分配上算是弱勢，但其Trans(醫院門診市場占有率或稱為轉診型態)未必會較低，當人口風險因子與Trans合併計算時，台北區不一定會降太多，因其雖人口風險因子的比例低一點，但Trans比其他區還高，故兩者相乘後可能變成增加，當然這需要試算才能知道結果。Trans為各區內醫院門診與西醫基層的市場占率，不是6區之間的占率。台北區醫院的Trans在上升中，北區是維持原來的，如果R值往前進，台北區不一定減少。醫院的門診有地域性，且屬性較接近西醫基層，否則就無需計算雙方的市場占有率。以上是我的建議，謝謝。(註：醫院門診的R值=人口風險因子x Trans )戴主任委員桂英請羅委員紀琼。羅委員紀琼一、本來是不想講話的，但因這個問題吵很久，難有共識。但若要有一個答案，以做統計模型為例，會有很多假設，當每個假設丟進去模型時，會造成一些改變，而假設與假設之間通常是有關聯的，但大家不會這樣想，常都單獨來看每一個假設。二、我贊成謝委員天仁與滕委員西華所說的，健保署應分析相關數據。多年前我們已講過，人口的定義，即有常住人口、投保人口、戶籍人口。你以為每次都用戶籍人口，應該是很穩定，不見得！這些變數的變化方向及幅度，你不知道。剛才提到總額的非協商因素，是總體概念；全台灣的醫療費用去年與今年相比，需要成長這麼多，這沒問題。但當整體成長到這麼多時，分區間如何分配就變得非常複雜；因人是流動的、供給量也是在變動的，裡面牽涉的因素太複雜了，我覺得自己沒有能力做決定，所以本來我是不想說話的。但剛才有人提到學者已講了第二輪，我一輪都還沒講，似乎沒有善盡職責。我會把事情弄得有點複雜，但我要提醒大家注意，這本來就是個很複雜的問題，變數彼此間互相關聯；但要用簡單的方式切割，亦即單獨考慮每一個變數，並不是好的辦法。應該一勞永逸，不要每年都在討論。三、剛才有說我們需有指標可以反映公平、效率，這是最大的原則。但什麼是公平？是分配的公平、供給的公平？亦即每地區每千人一定要有多少醫生、護士、儀器？還是需求的公平？我有需求時，你的供給一定要在什麼範圍內讓我看到；光是這些定義就不易講清楚。回過頭來，剛剛講到北區，就算調整人口年齡結構，然因北區是高所得區，那些人的就醫成本很高，就算供給在那裡，他們可能也沒時間去看病，時間成本還要考慮進來。這些都在我們剛剛討論的範圍之外，但卻是決定最後數據背後非常重要的因素。四、我講這些是要提醒大家，問題並沒有這麼簡單，不是單純的往前走即可。我剛與黃委員偉堯提到，我以前帶孩子時訂有很多原則，到最後卻通通放棄，因為我發現到，有這麼多原則會讓親子關係緊張。所以，如果這些規則是規範醫界，若是他們有意見，如果從總體來看，這些意見並不會造成太大的問題，我們就應該接受。如果他們高興、心裡舒坦，或許就很樂意去做那些該做的事。因為討論的是明年度的總額，即使今天不做成決議也沒有關係，請醫院協會回去再進行內部討論；如有需要，可請健保署提供數據協助判斷。今天不做決成議，反而是幫醫院部門爭取到更多時間。我認為即使下個月醫院協會還是提出同樣的版本也沒有關係。五、我們常以為委託研究可以幫助我們解決問題，其實往往並沒有辦法。委託研究的概念是總體的概念，例如加拿大按照年齡、性別等因素分配經費到各省。委託研究提供的是世界性的模型，與我們實際碰到的問題是不一樣的，即使研究結果有提供模型，通常也不能用。回到問題的癥結，如同謝委員天仁所說，所有的數據都在健保署，所有的制度、政策也都在健保署，所以健保署需要先提供相關資料；且在很多問題的前提之下提供我們答案，我們可再根據答案形成共識。戴主任委員桂英謝謝，請謝委員武吉。謝委員武吉一、我和李委員蜀平可能不太適合講話，因為高雄市政府積欠最多健保費補助款。高雄市老年人口占率約14%，高於全國老年人口占率12.5%，並不是高雄市老人老而不死，而是子女都在外地工作，造成老年人口比率高。二、如同剛謝委員天仁所說，為了3層級醫院、健保6分區及醫院協會內部和諧，希望健保署能提供相關資料，讓醫院部門可以在內部和諧的氣氛下，提出合理的方案到健保會。干委員文男主席，請讓我補充幾句話。戴主任委員桂英請干委員文男。干委員文男還是希望健保署能提出數據，我們是比較相信健保署提供出來的數據會比較公正，並且能提供醫界參考。戴主任委員桂英委員本來就希望請健保署提供相關數據，現在大家的期待是請健保署除進行更完整的分析外，也能提出分配的具體建議方案，請李署長伯璋。李署長伯璋一、謝謝滕委員西華給我們的指正，我們並不是沒有想法，我是新手上任，不敢莾撞。請委員參閱健保署提供的補充資料，在R值部分，站在全國不分區的健保署署長立場，從政府照顧民眾觀點，對離島、偏遠地區的付出要比較多，這是一個概念。二、關於S值，健保署幕僚告訴我這是以總額開辦前一年各地區保險對象實際發生醫療費用做分析，個人認為，隨著時代改變，每個地區的狀況可能不太一樣，有必要進一步分析最近5年的情況，95年的數據與現在可能會不太一樣，我的看法是應該要比較靈活，只是因為時間較匆促，不敢輕易說出自己的想法，想先聽聽委員的意見。從戶籍人數或投保人數來看，的確可以看到台北區及北區人數較其他區有明顯上升，提供委員參考。三、剛才謝委員天仁提出的意見也是問題，不同區的人可能會覺得分配有些問題，但我並沒有做出承諾，還是要看健保會委員的意見，剛剛謝委員天仁的建議是一個思考的方向，楊委員漢湶所提的意見也是可以考慮，若今天沒有做成決議，雖然可能下個月各區的意見還是沒有改變，但還是可以再溝通，我並不是完全沒有想法，今天健保署並沒有強勢地要求做出什麼樣的決議。戴主任委員桂英本案與中醫部門一樣，都請醫院部門與健保署進一步研議，提供相關資料或方案，最好能於11月份委員會議時提出，若時間真的來不及，最慢希望能於12月份委員會議提出。請干委員文男。干委員文男建議由醫院部門與健保署各自提出版本，讓我們可以對照討論，最起碼讓我們知道癥結點，我們是比較相信健保署。戴主任委員桂英中醫部門、醫院部門會有內部協商的版本，但還是須要請健保署分析資料，另外，但是健保署也可以提出方案。干委員文男我們不反對醫院部門提出方案，但希望各總額部門及健保署都可以提出方案及算法，讓我們更正確明瞭哪一個才是對的，至於如何做，還是要協商決定。戴主任委員桂英多數委員的意見是要看到證據才做決定，委員若無其他意見，接著進行討論事項第五案，請同仁宣讀。玖、討論事項第五案「有關原中央健康保險局於94年9月15日健保藥字第0940026378號函，取消指示用藥制酸劑健保給付品項暨價格明細表共176項，既然公文取消支付，為何每年尚支付健保費用案」與會人員發言實錄同仁宣讀戴主任委員桂英請提案人何委員語說明。何委員語謝謝宣讀同仁用心地把整篇議案宣讀得很完整，我接受健保署的書面說明，建議本案不進入討論。戴主任委員桂英謝謝，那我們就進行討論事項第六案。謝委員武吉主席，剛剛…。戴主任委員桂英請謝委員武吉。謝委員武吉一、剛剛何委員語已經說明，我再提出補充說明，94年10月1日起取消給付176項指示用藥，請健保署說明自97年至105年10月27日止，總共取消幾項指示用藥，為何每年還繼續支付1億多元的指示用藥，請說明原因。二、關於MGO(Magnesium Oxide，氧化鎂，醫學上做為軟便劑)，健保署提供的資料包括好幾家藥廠，但據我了解，目前台灣僅剩1、2家藥廠有製造，1千顆藥才2、3百元，完全沒有成本概念，藥廠總經理找我協助解決指示用藥問題，請健保署說明從94年到現在已經停止給付多少項指示用藥。三、依照健保法規定，應該停用的指示用藥請趕快停止給付，並讓委員知道。戴主任委員桂英請李委員蜀平。李委員蜀平一、主席，各位委員，小弟已經卸任理事長，職位已止，其言必善。我想請教健保署指示用藥與處方藥的區別，藥師公會的幹部之前常請我向法院提告健保署，為何指示藥健保署還給付，這很不公平，最近至少有多件藥局販售處方藥被罰款3~15萬元的案例，可是醫院一直在使用指示用藥，健保給付，也沒受到處罰，這很不合理，請教健保署指示用藥的定義，健保到底可不可以給付。實際上，健保到現在還給付指示用藥，可能受許多的壓力，不得不付，最主要可能只有一個原因，就是指示藥有藥價差。二、說不定下次我就不當委員，因為我在這裡發言都沒有人重視。上個禮拜參加「全民健康保險藥物給付項目及支付標準共同擬訂會議」，從上午9點半開會卻為了小利益一直爭執，一直到下午4點，我請求大家心平氣和的談，如何解決問題，結果有些委員很不理性，我就告訴他們若不理性，我也會更不理性，結果他們就離席，這些委員離開之後許多項藥品就順利通過。請教主席，到底行政院預備金、其他的預算，其他的特別預算，這些費用到底是真的，還是空穴來風，我們常在新藥、總額協商時都有討論到這個問題。請教李署長，C肝新藥編列約30億元經費，估計，未來如果可以成功的治癒，應會減少多少健保費用，假設所有C肝病人若不使用新藥，最後C肝病人會不會花費更多健保醫療費用，包括檢驗、超音波，如又變成肝硬化、肝癌，未來的總醫療費用，會不會更多，這對健保是不是短空長多，健保會應該精算後，到底是優點還是缺點應向委員溝通，讓委員知道，如是節省健保費用，又對C肝病人有益，是否應大力提倡，並以此為例，是否有其他類似的疾病者有此類似的問題，一併提出檢討，以上報告，希望署長能提更多的短空長多的問題，大家一起來解決。戴主任委員桂英本案健保署依擬辦意見很快提出書面資料，符合提案委員的期待，本案就不繼續討論，2位發言委員關於指示用藥之相關詢問，請健保署以書面資料提供委員參考。委員若無其他意見，接著進行討論事項第六案。拾、討論事項第六案「為鼓勵民眾配合分級醫療推動，籲請檢討現行健保管理措施與支付制度，以強壯社區－基層診所、地區醫院醫療照護體系案」與會人員發言實錄戴主任委員桂英本案不需要請同仁宣讀，請提案人謝委員武吉說明。謝委員武吉一、本案撤案。二、我擔任台灣社區醫院協會理事長的任期還有將近三年，但是參加健保會會議讓我心有戚戚焉，內心的感受非常不好，如下一次健保會委員續期聘任，本人會審慎考量，「全民健康保險跨層級醫院合作計畫」是104年的計畫，照理應該在105年提出檢討，但健保署並沒有處理，我已送健保署計畫修正建議，本案先撤案。戴主任委員桂英本案撤案，請問委員有無臨時動議，請何委員語。何委員語主席，我提出建議案，希望健保署依據97~105年行政院核定全民健保年度醫療給付費用總額協定範圍2.466%~4.767%，推估未來5年醫療總額成長率，而不是用費率審議前意見諮詢會議提出的未來5年總額成長率6.252~6.434%[註：健保署於諮詢會議所提106年度保險費率審議方案(草案)附錄第3頁，保險成本採高推估，預估107~111年之總額成長率]，已經超出法定6%的保費上限，這樣比較務實，供我們下個月討論費率審議參考。戴主任委員桂英李署長伯璋答應依何委員語的建議，請健保署同仁準備資料。本次會議到此結束，散會。3181350-346710委員會議日期：105年10月28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10月28日會議現場發送資料(中央健康保險署提供)例行報告第二案-後附資料政府實質負擔健保費推算公式及說明105/10/28一、法令依據(一)健保法第3條規定：政府每年度負擔本保險之總經費，不得少於每年度保險經費扣除法定收入後金額之36%。(二)依105年6月22日立法院社會福利及衛生環境委員會第33次全體委員會議決議，納入政府已實質負擔之保險費減為7項，自105年度起施行。二、政府應負擔健保總經費計算公式政府應負擔健保總經費= (保險經費－法定收入)36%政府應負擔健保總經費法定下限36%不足數=政府應負擔健保總經費－政府已負擔保險費註：上述公式係本署依103年7月25日健保會第1屆103年第7次委員會議決議事項，於第8次委員會議配合提供「102年度政府應負擔健保總經費不足36%部分」說明資料，並經與會有表示意見之委員，全數認為中央健康保險署之計算方式較符合實務。三、對政府應負擔健保總經費法定下限36%不足數之影響單位：億元項目104年影響數105年影響數政府應負擔健保總經費法定下限36%不足數104年不納入9項已實質負擔政府相對應增加之不足數74.25-105年納入7項已實質負擔政府相對應減少之不足數--68.48±政府應負擔增(減)不足數換算為健保總經費36%104年＝36%74.25／64%41.76-105年＝36%68.48／64%--38.52合 計116.01-107依上式，104年不納入9項已實質負擔政府相對應增加之不足數約74.25億元，加計政府應負擔增加不足數所換算為健保總經費36%金額約41.76億元，保險收入合計增加約116.01億元。同理，105年納入7項已實質負擔政府相對應減少之不足數約68.48億元，加計政府應負擔減少不足數所換算為健保總經費36%金額約38.52億元，保險收入合計減少約107億元。-574040-585470003509010-194310委員會議日期：105年10月28日會議現場發送資料(中醫師公會提供)020000委員會議日期：105年10月28日會議現場發送資料(中醫師公會提供)討論事項第二案-現場補充資料-61595-9437370討論事項第三案-後附資料4000020000討論事項第三案-後附資料3318510-9616440委員會議日期：105年10月28日會議現場發送資料(醫師公會提供)020000委員會議日期：105年10月28日會議現場發送資料(醫師公會提供) 中醫門診總額地區預算執行情形：一、第一期(89.7~90.6)至94年，照衛生署(102年7月23日改制為衛生福利部)交付方案，分六區以「各地區校正人口風險後保險對象人數」(R值)、「總額開辦前一年各地區保險對象實際發生醫療費用」(S值)兩項參數協定後權重分配地區預算。※總額分配按基期醫療費用與投保對象人數校正分配表：89.07至90.1291年92年93年94年95年96年97年原規劃費用占率95%85%75%60%45%30%15%0%人口風險5%15%25%40%55%70%85%100%協定結果費用占率95%85%80%70%70%改良式分區分配方式人口風險5%15%20%30%30%二、95年至98年，採試辦計畫，事後結算，分配參數未含人口因素。(三)99年104年，採正後試辦計畫，事前分配預算，分配參數含人口因素：1、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。2、分配方式：(1)東區預算占率2.22%，其他五分區預算占率97.78%。(2)五區預算分配參數及其占率如下表(以104年為例)，另99~101年人口因素占率為5%，102~103年人口因素占率為6%，104年人口因素占率為7%：占率分配指標備註73%(103年為74%)95年第4季至98年第3季之五分區實際收入預算占率反映過去醫療利用狀況7%(103年為6%)各區去(103)年同期戶籍人口數占率反映過去1年民眾就醫需要9%各區去(103)年同期每人於各分區就醫次數之權值占率反映過去1年民眾就醫需要5%各區去(103)年同期人數利用率成長率與醫療費用成長率差反映過去1年民眾就醫需要5%當(104)年前1季各分區各鄉鎮市區每萬人口中醫師數反映前1季醫師分布之均衡狀況(如該區各鄉鎮市每萬人口中醫師數<全國平均值，則鼓勵進駐，為正值；若>全國平均值，為負值)1%「偏鄉人口預算分配調升機制」，補足偏鄉浮動點值至每點1元。符合本計畫「偏鄉」定義之中醫醫療院所，當季結算之醫療點數，除依一般部門結算外，若該區前一季浮動點值低於每點1元者，補至最高每點1元，其經費由本項預算支應。本項預算當季若有餘款，則餘款按「95年第4季至98年第3季之五分區實際收入預算占率」分配予各區註：前述分配方式，全年各區預算與去年比較不得負成長，如為負成長則補至零成長，所需預算由其他分區按比例撥補。3623310-80010委員會議日期：105年10月28日會議現場發送資料(醫師公會提供)020000委員會議日期：105年10月28日會議現場發送資料(醫師公會提供)-723905676900024320597790討論事項第三案-後附資料4000020000討論事項第三案-後附資料3318510-194310委員會議日期：105年10月28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10月28日會議現場發送資料(中央健康保險署提供)討論事項第四案-現場補充資料-61595-9437370討論事項第三案-後附資料4000020000討論事項第三案-後附資料3318510-9616440委員會議日期：105年10月28日會議現場發送資料(醫師公會提供)020000委員會議日期：105年10月28日會議現場發送資料(醫師公會提供) 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