1996年3月

駕馭市場機能：歐美醫療體制改革中的市場策略對我國的相干性
Harnessing Market Forces: The Relevance of Market Strategies for Taiwan's National Health Insurance Reform

研究論文 Research Article

陳孝平
Michael S. Chen

1-51

以市場競爭機制作為醫療體制改革的策略，從1980年代以來為大西洋兩側的若干國家所採納：美國源於其多元醫療制度的傳統，與公共保險的管制相併行的是民間部門各式各樣帶有市場競爭意涵的醫療施予方式。在此基礎上，原由 Jackson Hole Group 提出，而由 Alain C. Enthoven 總其成的管理式競爭被克林頓的全民健保小組取為其「健康保障法」的基本架構，試圖藉市場失靈的防止以發揮正面的市場機能；在英國則採內部市場的策略，將競爭導進公醫制度中；北歐國家（瑞典、芬蘭）則採公共競爭，將公立醫療機構可獲得的資源與市場占有率掛勾；荷蘭也試圖泯除疾病基金與商業保險之間的分際，在醫療保險及醫療服務雙方面促進競爭。競爭策略雖以提升效率作為主要的訴求，但事實上乃是為因應各國環境變遷以及原有體制的困難，而在新的政、經條件之下的選擇。以此來看各國市場策略對臺灣全民健保制度的意涵，則發現：從現行全民健保制度在臺灣民主化社會中的處境來看，由於政府業已無力協調社會上互相衝突的利益，似乎必須將競爭模式作為未來可能的替代方案之一，然而從實施市場模式的環境來看，有許多條件臺灣似乎尚未具足。本文建議擇一醫療資源尚稱豐富的都會區試辨市場模式，以期進一步鑑定市場模式對臺灣未來健保改革的相干性。

On both sides of the Atlantic Ocean, health care reforms based on market mechanisms has been a prominent trend since the 1980s. In the United States, along with a heavily regulated public health care sector, there exists a private health care sector that employs various market strategies. Based on this tradition, managed competition, first proposed by the Jackson Hole Group, then advocated by Alain C. Enthoven, became the basis for Clinton' reform. Market mechanisms were also introduced into the Nordic countries: the United Kingdom created an internal market by splitting the purchasing and buying authorities in the National Health Service; Sweden and Finland allocate budgets according to "market shares" to the public medical establishments. The Netherlands demonstrated how a health system organized on solidarity can employ market forces. The main argument for competitive strategies is that of efficiency; yet, market strategies can be looked at as a way of responding to the changing political and economic situations in the countries. When examining the feasibility of market strategies for Taiwan, this paper finds that, a NHI model based on market mechanisms may be a way of alleviating the burden on the government, since government is incapable of defending itself from the invasion of rent-seeking advances from special interests, which have mushroomed as Taiwan democratized. The environment for a market­-based model, however, is not so promising. This article calls for a market model be experiment in an area with rather abundant medical resources. Then one can identify the relevance of market strategies for Taiwan.

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