{"id":152078,"url":"https://ivod.ly.gov.tw/Play/Clip/1M/152078","video_url":"https://ivod-lyvod.cdn.hinet.net/vod_1/_definst_/mp4:1MClips/6f015fe8e6787db19e77f48799a3173ad575e50b9cd8685a55be169921a0a717fbc34bea683b19dc5ea18f28b6918d91.mp4/playlist.m3u8","委員名稱":"林淑芬","委員發言時間":"11:19:49 - 11:32:32","影片長度":"00:12:43","會議時間":"2024-05-02T09:00:00+08:00","會議名稱":"立法院第11屆第1會期社會福利及衛生環境委員會第14次全體委員會議（事由：審查\n一、委員王育敏等19人擬具「全民健康保險法第六十二條條文修正草案」案。\n二、委員蘇清泉等28人擬具「全民健康保險法第六十二條條文修正草案」案。\n三、國民黨黨團擬具「全民健康保險法第六十二條條文修正草案」案。\n【以上議案，如經復議則不予審查】）","date":"2024-05-02","meet":{"tmpMeeting":null,"title":"第11屆第1會期社會福利及衛生環境委員會第14次全體委員會議","term":11,"type":"委員會","sessionPeriod":1,"sessionTimes":14,"committees":[26],"id":"委員會-11-1-26-14"},"duration":763,"end_time":"2024-05-02T11:32:32+08:00","start_time":"2024-05-02T11:19:49+08:00","features":["ai-transcript","gazette"],"type":"Clip","gazette":{"lineno":685,"blocks":[["林委員淑芬：（11時19分）謝謝主席，我請薛部長。"],["主席：請薛部長。"],["薛部長瑞元：委員好。"],["林委員淑芬：部長，雖然你剩下十幾天了，不過我想你從選舉前到現在，態度大概看起來都還算是一致，就是說其實都要很務實的去討論，而不是基於一些因素就可以隨便說說。","蘇委員剛才也講到，我們是不是要把這個制度改成支付目標制，所以今天的修法看起來，如果朝這個方向去的話，我們討論的可能不是只有點值這個問題，可能還會談到到底要不要取消總額制度。剛才講超過支出目標的時候，在外國超過的部分也是會打折的，並不是沒有打折。你預估一個目標值，超過也是一定要打折。","我現在看到你們的報告裡面講到，如果是0.95的方案，總支出要增加705億元，如果點值是1點1元方案的話，要增加1,155億元。但如果我們還沒有談論要不要改變總額的時候，還在現行制度裡面的話，餅就是固定這樣的總額。","但是還有一個問題，量變大了，現在醫界反彈就是因為疫情過後，各種病毒同時併發，所以看診的量變大了，點值就下降了。我現在問的是，這是一個非常時期的、暫時的、一時的變化，還是整個必然的趨勢？就是說整體的看診量會一直持續的，一直往上漲？如果是一時的疫情過後，各種病毒跑出來，是一時的現象，那我們還可以討論，但如果是總體必然的趨勢，看診的量永遠一直要往上漲的話，那我們就要討論，這個總額或是這個餅一定要變大。","但餅要怎麼變大？不外乎當然是漲保費，漲保費就要把餅做大，這種狀況我們當然要討論。我們要告訴使用人，就是醫療制度服務的使用者，病人啦！其實你說漲保費以外，當然保費漲的是僱主的會居多，但對病人而言，我們現在並不是說保費看我們繳的那樣子，並不是，我們實質的自費項目非常多。","然後現在漲掛號費，我們這個病人，事實上並不是說只有繳健保費，繳部分自負額，不是，真的變相的名目很多很多。在這種狀況裡面，我今天比較想跟你討論的就會變成，到底這個總額制度是不是罪魁禍首？這個總額管制到底是不是問題啊？"],["薛部長瑞元：基本上這些年來推動總額之後，對於整個醫療的費用……"],["林委員淑芬：當初為什麼要引入這個總額管制的制度？因為一開始不是嘛！從91年，2002年才開始的，為什麼？"],["薛部長瑞元：主要還是基於費用控制的問題。"],["林委員淑芬：當時的費用控制有什麼問題？"],["薛部長瑞元：因為在過去如果費用成長比超出預期之外的話，唯一能夠做的就是由健保那邊去做核刪。"],["林委員淑芬：因為這個醫改會有數據，以87年為例，投保金額成長率大概成長5%，但醫療費用成長超過10%。在這種狀況，面臨巨額虧損的時候開源不易，當時大家都認為要朝向總額管制的方向，最後才變成總額管制。所以當時總額管制制度的引入，是因為醫療費用急速成長，造成保險嚴重虧損。現在如果大家回過頭來說，我們要不要再拿掉總額管制，那這條路會怎麼走呢？"],["薛部長瑞元：這就必須要同時有配套去控制那個量的成長。"],["林委員淑芬：但是理論上，當初在執行這個總額管制的時候，我們是希望透過預估年度的預算總額，然後以醫事服務提供者要去發揮同儕制約的效果，因為當時沒有總額管制以前就有一種衝量，也在衝量計價，過度醫療的問題都不斷的跑出來。希望採取總額管制，就是要發揮同儕制約的效果，促使醫療費用的成長趨於合理，減少衝量的誘因，使醫事人員服務不再需要透過合理門診量來約束，發揮他們的專業和自主。","第二、在執行過程中，也邀請醫事服務的提供者討論訂出支付標準，以及主導醫療服務的審查角色。第三、保險人角色為統籌輔導政策評估和規劃，提高醫療專業團體的自治空間。以上是當初2002年要實施總額管制，當時理論上的理想，但是大家多年到現在，都覺得總額管制的制度早已名存實亡，為什麼呢？真正的現實面到現在理想為什麼幻滅？","這是醫改會講的，醫改會說從實務面來看，政府透過保障收入、補點值，這種本來都不是總額管制裡面該有的制度，早就打破了總額的規範。而健保方案計畫的制定，各種各式各樣的方案，更是違背了總額下的評估和管理精神，以至於協議難以順利進行。從制度面來看，當時要配套，要有家醫制度、分級醫療制度、論人論病例計酬、支付標準衡平性的檢討，可以改變病人的就醫行為，還有醫師診療行為的配套措施，也都沒有辦法真正的落實。","所以專業團體的同儕制約、自主審查也不健全，大家漸漸的就覺得，到最後都是劣幣驅逐良幣。所以醫改會的講法是說，無論是醫界或使用者，或者是專業的團體都認為，總額制的確已經走到一個像是名存實亡的地步了。但是我覺得這裡面，整個社會的變化太大，我們有一點沒有考慮到，你知道當時要實施總額管制的時候，那時候65歲以上的老年人口多少數量你知道嗎？"],["薛部長瑞元：10出頭……"],["林委員淑芬：沒有，是9%左右，就是……"],["薛部長瑞元：差不多啦！"],["林委員淑芬：就是200萬而已，你知道實施到現在，65歲以上的人口從197萬、200萬，到現在是多少萬嗎？450萬！所以我在講，這個量的增加就是一個必然的趨勢，因為超高齡社會，還不是高齡化社會，是超高齡社會來臨了。在這種狀況中，無論有沒有總額制度，如何減少衝量的誘因，使醫療費用趨於合理成長，對有健保的國家來講，一直都是一個要解決的課題。","但是你遇到人口老化，你看，光是老年人口從總額管制到現在，增加了一倍以上，一倍是250萬喔！未來還要再增加欸！再加上疾病慢性化、少子女化，未來健保的財務，繳的人少，用的人多更多，不是增長百分之幾，是倍數成長。在這種狀況下，包括健保、勞保，各項保險都一樣，都面臨這個問題，所以這個挑戰是非常嚴重的，很嚴峻的。","今天我們在這裡要面對的就不只是點值，也不只是總額制度要何去何從，這根本的問題，你人都要走了，可不可以講一句你客觀的看法？"],["薛部長瑞元：當然委員剛剛講的其實大部分都是現在的狀況，不過健保這個部分，本來就是很複雜，剛剛提到的總額支付制度執行了這麼多年，的確有達到費用控管的成效，不能完全都否定掉，但是未來如果總額的部分要去做修正，這個我個人也覺得……"],["林委員淑芬：但是這個財務，本來就已經是建立在一個非常岌岌可危的基礎上了。"],["薛部長瑞元：是。"],["林委員淑芬：結構上。"],["薛部長瑞元：所以這部分，當然在收入面的話，還有去做討論……"],["林委員淑芬：不只是收入面啦！"],["薛部長瑞元：但是支出面也是更重要，就是說支出面你如果沒有用這個總額預算制度去框的話，那就必須要有其他取代的方式。比方說某種程度、某種對象的論人計酬，另外的話當然就有一些特殊的一些狀況。"],["林委員淑芬：當時理想的啊！沒有落實。"],["薛部長瑞元：我們其實都在進展當中，尤其是剛剛委員提到的這些老年人、慢性病者，這部分其實就是我們現在正在推的，在健保制度之下正在推動的。但是這個要轉變醫療界長久以來的作業模式，這個是需要時間。"],["林委員淑芬：所以醫改會有提出幾點，提升資源可近性、強化資源分配的效率、照顧近貧和弱勢、拒絕便宜行事的政策補貼、遏止未盡周延的選舉買票，大家都要很嚴肅的去面對。他還提出一個總額是否存續，財務改革的腳步都不應該停止，你知道嗎？就是財務改革也一定要處理。","在這種狀況中，像是推動論病例計酬、論人計酬、論質計酬、提升服務的效率、減少低效的浪費，也必須從系統面強化衛生政策，讓醫療資源合理分布，確保醫療服務品質及民眾就醫的可近性。就是你在談點值，你在談這些問題，事實上有量、有健保，可是品質的問題也是一直很嚴重，這就是一開始我就講的，其實你不要以為對病人來講，我們就繳納健保費用，然後就使用很多，病人被變相剝削的自費項目真的非常非常多啦！"],["主席：好，謝謝林淑芬委員的質詢。"],["林委員淑芬：好啦！這個的確是很多困難，但我們還是想說，最後主席讓我講一點，你說你固定點值，打破了總額管制，等於架空了總額，但是你說沒關係讓公務預算去買單。公務預算，我們並不是沒有歲入短絀，然後財政赤字過，有。現在看到順風順水都覺得有盈餘，要那麼多錢，趕快拿出來，沒問題。可是馬英九時代就曾經短絀，也曾經財政赤字過，這些到底要怎麼辦？所以這真的不是一個根本解決的方法，謝謝！"],["主席：謝謝林淑芬委員，接下來我們請林德福委員質詢。"]],"agenda":{"page_end":242,"meet_id":"委員會-11-1-26-14","speakers":["王育敏","蘇清泉","陳昭姿","陳菁徽","林月琴","黃秀芳","邱鎮軍","涂權吉","廖偉翔","劉建國","王正旭","林淑芬","林德福","賴士葆","李彥秀","盧縣一","楊瓊瓔","黃國昌","賴惠員","陳瑩","楊曜"],"page_start":167,"meetingDate":["2024-05-02"],"gazette_id":"1133901","agenda_lcidc_ids":["1133901_00004"],"meet_name":"立法院第11屆第1會期社會福利及衛生環境委員會第14次全體委員會議紀錄","content":"審查一、委員王育敏等18人擬具「全民健康保險法第六十二條條文修正草案」案；二、委員蘇清\n泉等27人擬具「全民健康保險法第六十二條條文修正草案」案；三、國民黨黨團擬具「全民健康\n保險法第六十二條條文修正草案」案","agenda_id":"1133901_00003"}},"transcript":{"id":"152078","pyannote":{"name":"ronny","tool":"pyannote","data":{"url":"https://ivod.ly.gov.tw/Play/Clip/1M/152078","tool":"pyannote","id":"152078-pyannote"},"job_id":"9hQidBDEJm4x4QTz","queued_at":"2024-05-31 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{\"word\": \"短\", \"start\": 742.142, \"end\": 742.462, \"score\": 0.861}, {\"word\": \"促\", \"start\": 742.462, \"end\": 742.722, \"score\": 0.852}, {\"word\": \",\"}, {\"word\": \"然\", \"start\": 742.722, \"end\": 743.022, \"score\": 0.767}, {\"word\": \"後\", \"start\": 743.022, \"end\": 743.242, \"score\": 0.881}, {\"word\": \"財\"}, {\"word\": \"政\", \"start\": 743.242, \"end\": 743.503, \"score\": 0.957}, {\"word\": \"赤\", \"start\": 743.503, \"end\": 743.723, \"score\": 0.905}, {\"word\": \"字\", \"start\": 743.723, \"end\": 743.943, \"score\": 0.905}, {\"word\": \"過\"}, {\"word\": \",\"}, {\"word\": \"有\", \"start\": 743.943, \"end\": 743.963, \"score\": 0.0}, {\"word\": \"。\"}], \"language\": \"zh\"}","srt":"1\n00:00:06,316 --> 00:00:21,525\n議員,雖然你剩下十幾天,不過我想你從選舉前到現在,態度大概看起來都還算是一致。就是說其實都要很務實的去討論,而不是基於一些因素就可以隨便說說。\n\n2\n00:00:24,444 --> 00:00:47,352\nbicyn剛才蘇委員剛才也講到說這個我們是不是要把這個制度改成支付目標制這樣子所以今天的修法看起來如果朝這個方向去的話我們可能討論的不是只有點值的這個問題可能還會談到到底要不要取消總額制度那剛才講的那個超過這個支出目標的時候在外國裡面\n\n3\n00:00:48,172 --> 00:01:03,445\nbicyn蘇清泉等28人擬具:「全民健康保險法第六十二條條文修正草案：立法院第11屆第14次全民健康保險法第16次全民健康保險法第16次全民健康保險法第17次全民健康保險法第18次全民健康保險法第18次全民健康保險法第19次全民健康保險法第20次全民健康保險法第21次全民健康保險法第22次全民健康保險法第23次全民健康保險法第24次全民健康保險法第24次全民健康保險法第25次全民健康保險法第26次全民健康保險法第27次全民健康保險法第28\n\n4\n00:02:46,804 --> 00:03:07,258\nbicyn並不是說只有繳健保費獎部分這個致富而不是真的變相的名目很多很多那在這種狀況裡面啊我我我今天比較想跟你討論的就會變成說到底這個總額制度是不是罪魁禍首這個總額管制到底是不是問題啊\n\n5\n00:03:09,075 --> 00:03:12,916\n為什麼要引入這個總額管制的制度?因為一開始不是嘛,從91年2002年才開始的。為什麼?那當時的費用控制有什麼問題?\n\n6\n00:03:32,717 --> 00:03:43,060\n因為在過去的話那如果說費用成長那比超出預期之外的話那唯一的能夠做的話就是由健保那邊去做核酸。\n\n7\n00:03:44,313 --> 00:03:53,062\nnetes看到就是說因為這個醫改會有數據他說87年為例投保金額成長率大概成長5%但醫療費用成長超過10%所以在這種狀況面臨巨額的虧損的時候開源不易所以當時就大家都認為說要\n\n8\n00:04:06,394 --> 00:04:31,900\nbicyn要朝向總額管制的方向所以最後才變成總額管制所以當時的總額管制的制度的引入是因為醫療費用急速成長造成保險嚴重虧損那現在如果大家回過頭來說我們要不要再拿掉總額管制那那這個條路會怎麼走呢這個必須要同時有配套去控制那個量的成長\n\n9\n00:04:33,060 --> 00:04:52,688\n但是理論上當初在執行這個總額管制的時候我們是希望透過也是透過預估年度的預算總額然後以醫事服務提供者要去發揮同儕制約的效果因為當時沒有總額管制以前就有一種充量也在充量計價不斷的在過度醫療的問題都跑出來嘛\n\n10\n00:05:12,637 --> 00:05:29,680\n第二、在執行過程當中也邀請醫事服務的提供者討論訂出支付標準以及主導醫療服務的審查這個角色。第三、保險人角色收卸為統籌輔導政策評估和規劃提高醫療專業團體的自治空間。但是這個是當初2002年要實施總額管制當時的理論上的理想\n\n11\n00:05:40,962 --> 00:06:09,486\n但是大家多年到現在都覺得總額管制的制度早已經名存實亡。為什麼呢?真正的現實面到現在理想為什麼幻滅?這是一改會講的啦一改會說從實務面來看政府透過保障收入補點值這一種本來都不是總額管制裡面該有的制度裡面早就打破了總額的規範而健保方案計畫的制定\n\n12\n00:06:09,946 --> 00:06:37,287\nbicyn更違背了各種各式各樣的方案違背了總和洽的評估和管理精神以至於協議難以順利進行從制度面來看當時要配套要有加一制度分級醫療制度論人論病病例計酬支付標準和平性的檢討可以改變病人的就醫行為還有醫師診療行為的配套措施也都沒有辦法真正的落實\n\n13\n00:06:39,589 --> 00:07:04,381\nbicy專業團體的同儕制約自主審查也不健全。大家漸漸地就覺得說到最後都是劣幣驅逐良幣。所以依改會的講法是說大家不論是醫界或是使用者或者是專業的團體都認為總額制急切已經走到了一個很像是名存實往的這個地步了。\n\n14\n00:08:08,695 --> 00:08:35,129\n但是你遇到人口老化你看光是老年人口從總額管制到現在增加了一倍以上喔一倍250萬喔未來還要再增加欸那再疾病慢性化再加上少子女化未來健保的財務繳的人少用的人多多更多不是成長幾%是倍數成長\n\n15\n00:09:06,781 --> 00:09:07,201\n講一句這個你的客觀的看法。\n\n16\n00:09:14,321 --> 00:09:36,198\n當然委員剛剛講的大部分都是其實就現在的一個狀況那不過健保這一個部分的話本來就是很複雜那剛剛提到的總額總額支付制度的話執行了這麼多年的確有達到費用控管的一個成效不能完全都否定掉\n\n17\n00:09:36,838 --> 00:09:50,144\n但是未來如果說要總額的部分的話要去做修正這個我個人也覺得但是這個財務本來就已經是建立在一個非常岌岌可危的基礎上了結構上\n\n18\n00:10:07,955 --> 00:10:25,923\ntatto必須要其他取代的方式,比方說某種程度某種對象的論文記酬,另外的話當然就有一些特殊的一些狀況當時的理想的啊,可是你們都沒有執行啊,沒有落實啊\n\n19\n00:10:27,344 --> 00:10:50,379\n我們其實都在進展當中啦尤其是剛剛委員提到的這些老年人慢性病者這個部分的話其實就是我們現在正在推的在那個健保制度之下現在正在推動的但是這個要轉變醫療界的他的長久以來的作業模式那這個是需要時間啦\n\n20\n00:10:51,560 --> 00:11:10,569\n所以依改會有提出幾個,提升資源可敬性,強化資源分配的效率,照顧近貧和弱勢,拒絕便宜形式的政策補貼,遏止未進周延的選舉買票。大家都要很嚴肅的去面對。那他還提出了一個就是說,這個總額是否存續,這個財務改革的腳步都不應該停止。\n\n21\n00:12:02,196 --> 00:12:23,963\n好,謝謝林淑芬委員的質詢。好啦,這個比確實很多困難,但是我們還是想說,最後主席我講一點,就是說你說你固定點值,然後打破了總額管制,然後等於架空了總額,但是你說沒關係,這個叫公務預算去買單,公務預算我們並不是沒有稅入短促,然後財政赤字過,有。\n\n","tsv":"start\tend\ttext\n6316\t21525\t議員,雖然你剩下十幾天,不過我想你從選舉前到現在,態度大概看起來都還算是一致。就是說其實都要很務實的去討論,而不是基於一些因素就可以隨便說說。\n24444\t47352\tbicyn 剛才蘇委員剛才也講到說這個我們是不是要把這個制度改成支付目標制這樣子所以今天的修法看起來如果朝這個方向去的話我們可能討論的不是只有點值的這個問題可能還會談到到底要不要取消總額制度那剛才講的那個超過這個支出目標的時候在外國裡面\n48172\t63445\tbicyn 蘇清泉等28人擬具:「全民健康保險法第六十二條條文修正草案：立法院第11屆第14次全民健康保險法第16次全民健康保險法第16次全民健康保險法第17次全民健康保險法第18次全民健康保險法第18次全民健康保險法第19次全民健康保險法第20次全民健康保險法第21次全民健康保險法第22次全民健康保險法第23次全民健康保險法第24次全民健康保險法第24次全民健康保險法第25次全民健康保險法第26次全民健康保險法第27次全民健康保險法第28\n77176\t96254\t�\n96254\t126254\t​​​​​​​​​​\n126254\t140282\t\n140828\t166664\t\n166804\t187258\tbicyn 並不是說只有繳健保費獎部分這個致富而不是真的變相的名目很多很多那在這種狀況裡面啊我我我今天比較想跟你討論的就會變成說到底這個總額制度是不是罪魁禍首這個總額管制到底是不是問題啊\n189075\t192916\t為什麼要引入這個總額管制的制度?因為一開始不是嘛,從91年2002年才開始的。為什麼?那當時的費用控制有什麼問題?\n212717\t223060\t因為在過去的話那如果說費用成長那比超出預期之外的話那唯一的能夠做的話就是由健保那邊去做核酸。\n224313\t233062\tnetes看到就是說因為這個醫改會有數據他說87年為例投保金額成長率大概成長5%但醫療費用成長超過10%所以在這種狀況面臨巨額的虧損的時候開源不易所以當時就大家都認為說要\n246394\t271900\tbicyn 要朝向總額管制的方向所以最後才變成總額管制所以當時的總額管制的制度的引入是因為醫療費用急速成長造成保險嚴重虧損那現在如果大家回過頭來說我們要不要再拿掉總額管制那那這個條路會怎麼走呢這個必須要同時有配套去控制那個量的成長\n273060\t292688\t但是理論上當初在執行這個總額管制的時候我們是希望透過也是透過預估年度的預算總額然後以醫事服務提供者要去發揮同儕制約的效果因為當時沒有總額管制以前就有一種充量也在充量計價不斷的在過度醫療的問題都跑出來嘛\n296510\t312517\t\n312637\t329680\t第二、在執行過程當中也邀請醫事服務的提供者討論訂出支付標準以及主導醫療服務的審查這個角色。第三、保險人角色收卸為統籌輔導政策評估和規劃提高醫療專業團體的自治空間。但是這個是當初2002年要實施總額管制當時的理論上的理想\n340962\t369486\t但是大家多年到現在都覺得總額管制的制度早已經名存實亡。為什麼呢?真正的現實面到現在理想為什麼幻滅?這是一改會講的啦一改會說從實務面來看政府透過保障收入補點值這一種本來都不是總額管制裡面該有的制度裡面早就打破了總額的規範而健保方案計畫的制定\n369946\t397287\tbicyn 更違背了各種各式各樣的方案違背了總和洽的評估和管理精神以至於協議難以順利進行從制度面來看當時要配套要有加一制度分級醫療制度論人論病病例計酬支付標準和平性的檢討可以改變病人的就醫行為還有醫師診療行為的配套措施也都沒有辦法真正的落實\n399589\t424381\tbicy 專業團體的同儕制約自主審查也不健全。大家漸漸地就覺得說到最後都是劣幣驅逐良幣。所以依改會的講法是說大家不論是醫界或是使用者或者是專業的團體都認為總額制急切已經走到了一個很像是名存實往的這個地步了。\n424821\t443183\t​​​​​​​​​​​​\n443183\t458029\t​​​​​​​​​​​​​​\n458695\t488575\t\n488695\t515129\t但是你遇到人口老化你看光是老年人口從總額管制到現在增加了一倍以上喔一倍250萬喔未來還要再增加欸那再疾病慢性化再加上少子女化未來健保的財務繳的人少用的人多多更多不是成長幾%是倍數成長\n518251\t546340\t\n546781\t547201\t講一句這個你的客觀的看法。\n554321\t576198\t當然委員剛剛講的大部分都是其實就現在的一個狀況那不過健保這一個部分的話本來就是很複雜那剛剛提到的總額總額支付制度的話執行了這麼多年的確有達到費用控管的一個成效不能完全都否定掉\n576838\t590144\t但是未來如果說要總額的部分的話要去做修正這個我個人也覺得但是這個財務本來就已經是建立在一個非常岌岌可危的基礎上了結構上\n592005\t607875\t�\n607955\t625923\ttatto必須要其他取代的方式,比方說某種程度某種對象的論文記酬,另外的話當然就有一些特殊的一些狀況當時的理想的啊,可是你們都沒有執行啊,沒有落實啊\n627344\t650379\t我們其實都在進展當中啦尤其是剛剛委員提到的這些老年人慢性病者這個部分的話其實就是我們現在正在推的在那個健保制度之下現在正在推動的但是這個要轉變醫療界的他的長久以來的作業模式那這個是需要時間啦\n651560\t670569\t所以依改會有提出幾個,提升資源可敬性,強化資源分配的效率,照顧近貧和弱勢,拒絕便宜形式的政策補貼,遏止未進周延的選舉買票。大家都要很嚴肅的去面對。那他還提出了一個就是說,這個總額是否存續,這個財務改革的腳步都不應該停止。\n673951\t703951\t�\n703951\t721869\t\n722196\t743963\t好,謝謝林淑芬委員的質詢。好啦,這個比確實很多困難,但是我們還是想說,最後主席我講一點,就是說你說你固定點值,然後打破了總額管制,然後等於架空了總額,但是你說沒關係,這個叫公務預算去買單,公務預算我們並不是沒有稅入短促,然後財政赤字過,有。\n745043\t762500\t�\n","txt":"議員,雖然你剩下十幾天,不過我想你從選舉前到現在,態度大概看起來都還算是一致。就是說其實都要很務實的去討論,而不是基於一些因素就可以隨便說說。\nbicyn 剛才蘇委員剛才也講到說這個我們是不是要把這個制度改成支付目標制這樣子所以今天的修法看起來如果朝這個方向去的話我們可能討論的不是只有點值的這個問題可能還會談到到底要不要取消總額制度那剛才講的那個超過這個支出目標的時候在外國裡面\nbicyn 蘇清泉等28人擬具:「全民健康保險法第六十二條條文修正草案：立法院第11屆第14次全民健康保險法第16次全民健康保險法第16次全民健康保險法第17次全民健康保險法第18次全民健康保險法第18次全民健康保險法第19次全民健康保險法第20次全民健康保險法第21次全民健康保險法第22次全民健康保險法第23次全民健康保險法第24次全民健康保險法第24次全民健康保險法第25次全民健康保險法第26次全民健康保險法第27次全民健康保險法第28\n�\n​​​​​​​​​​\n\n\nbicyn 並不是說只有繳健保費獎部分這個致富而不是真的變相的名目很多很多那在這種狀況裡面啊我我我今天比較想跟你討論的就會變成說到底這個總額制度是不是罪魁禍首這個總額管制到底是不是問題啊\n為什麼要引入這個總額管制的制度?因為一開始不是嘛,從91年2002年才開始的。為什麼?那當時的費用控制有什麼問題?\n因為在過去的話那如果說費用成長那比超出預期之外的話那唯一的能夠做的話就是由健保那邊去做核酸。\nnetes看到就是說因為這個醫改會有數據他說87年為例投保金額成長率大概成長5%但醫療費用成長超過10%所以在這種狀況面臨巨額的虧損的時候開源不易所以當時就大家都認為說要\nbicyn 要朝向總額管制的方向所以最後才變成總額管制所以當時的總額管制的制度的引入是因為醫療費用急速成長造成保險嚴重虧損那現在如果大家回過頭來說我們要不要再拿掉總額管制那那這個條路會怎麼走呢這個必須要同時有配套去控制那個量的成長\n但是理論上當初在執行這個總額管制的時候我們是希望透過也是透過預估年度的預算總額然後以醫事服務提供者要去發揮同儕制約的效果因為當時沒有總額管制以前就有一種充量也在充量計價不斷的在過度醫療的問題都跑出來嘛\n\n第二、在執行過程當中也邀請醫事服務的提供者討論訂出支付標準以及主導醫療服務的審查這個角色。第三、保險人角色收卸為統籌輔導政策評估和規劃提高醫療專業團體的自治空間。但是這個是當初2002年要實施總額管制當時的理論上的理想\n但是大家多年到現在都覺得總額管制的制度早已經名存實亡。為什麼呢?真正的現實面到現在理想為什麼幻滅?這是一改會講的啦一改會說從實務面來看政府透過保障收入補點值這一種本來都不是總額管制裡面該有的制度裡面早就打破了總額的規範而健保方案計畫的制定\nbicyn 更違背了各種各式各樣的方案違背了總和洽的評估和管理精神以至於協議難以順利進行從制度面來看當時要配套要有加一制度分級醫療制度論人論病病例計酬支付標準和平性的檢討可以改變病人的就醫行為還有醫師診療行為的配套措施也都沒有辦法真正的落實\nbicy 專業團體的同儕制約自主審查也不健全。大家漸漸地就覺得說到最後都是劣幣驅逐良幣。所以依改會的講法是說大家不論是醫界或是使用者或者是專業的團體都認為總額制急切已經走到了一個很像是名存實往的這個地步了。\n​​​​​​​​​​​​\n​​​​​​​​​​​​​​\n\n但是你遇到人口老化你看光是老年人口從總額管制到現在增加了一倍以上喔一倍250萬喔未來還要再增加欸那再疾病慢性化再加上少子女化未來健保的財務繳的人少用的人多多更多不是成長幾%是倍數成長\n\n講一句這個你的客觀的看法。\n當然委員剛剛講的大部分都是其實就現在的一個狀況那不過健保這一個部分的話本來就是很複雜那剛剛提到的總額總額支付制度的話執行了這麼多年的確有達到費用控管的一個成效不能完全都否定掉\n但是未來如果說要總額的部分的話要去做修正這個我個人也覺得但是這個財務本來就已經是建立在一個非常岌岌可危的基礎上了結構上\n�\ntatto必須要其他取代的方式,比方說某種程度某種對象的論文記酬,另外的話當然就有一些特殊的一些狀況當時的理想的啊,可是你們都沒有執行啊,沒有落實啊\n我們其實都在進展當中啦尤其是剛剛委員提到的這些老年人慢性病者這個部分的話其實就是我們現在正在推的在那個健保制度之下現在正在推動的但是這個要轉變醫療界的他的長久以來的作業模式那這個是需要時間啦\n所以依改會有提出幾個,提升資源可敬性,強化資源分配的效率,照顧近貧和弱勢,拒絕便宜形式的政策補貼,遏止未進周延的選舉買票。大家都要很嚴肅的去面對。那他還提出了一個就是說,這個總額是否存續,這個財務改革的腳步都不應該停止。\n�\n\n好,謝謝林淑芬委員的質詢。好啦,這個比確實很多困難,但是我們還是想說,最後主席我講一點,就是說你說你固定點值,然後打破了總額管制,然後等於架空了總額,但是你說沒關係,這個叫公務預算去買單,公務預算我們並不是沒有稅入短促,然後財政赤字過,有。\n�\n","vtt":"WEBVTT\n\n00:06.316 --> 00:21.525\n議員,雖然你剩下十幾天,不過我想你從選舉前到現在,態度大概看起來都還算是一致。就是說其實都要很務實的去討論,而不是基於一些因素就可以隨便說說。\n\n00:24.444 --> 00:47.352\nbicyn剛才蘇委員剛才也講到說這個我們是不是要把這個制度改成支付目標制這樣子所以今天的修法看起來如果朝這個方向去的話我們可能討論的不是只有點值的這個問題可能還會談到到底要不要取消總額制度那剛才講的那個超過這個支出目標的時候在外國裡面\n\n00:48.172 --> 01:03.445\nbicyn蘇清泉等28人擬具:「全民健康保險法第六十二條條文修正草案：立法院第11屆第14次全民健康保險法第16次全民健康保險法第16次全民健康保險法第17次全民健康保險法第18次全民健康保險法第18次全民健康保險法第19次全民健康保險法第20次全民健康保險法第21次全民健康保險法第22次全民健康保險法第23次全民健康保險法第24次全民健康保險法第24次全民健康保險法第25次全民健康保險法第26次全民健康保險法第27次全民健康保險法第28\n\n02:46.804 --> 03:07.258\nbicyn並不是說只有繳健保費獎部分這個致富而不是真的變相的名目很多很多那在這種狀況裡面啊我我我今天比較想跟你討論的就會變成說到底這個總額制度是不是罪魁禍首這個總額管制到底是不是問題啊\n\n03:09.075 --> 03:12.916\n為什麼要引入這個總額管制的制度?因為一開始不是嘛,從91年2002年才開始的。為什麼?那當時的費用控制有什麼問題?\n\n03:32.717 --> 03:43.060\n因為在過去的話那如果說費用成長那比超出預期之外的話那唯一的能夠做的話就是由健保那邊去做核酸。\n\n03:44.313 --> 03:53.062\nnetes看到就是說因為這個醫改會有數據他說87年為例投保金額成長率大概成長5%但醫療費用成長超過10%所以在這種狀況面臨巨額的虧損的時候開源不易所以當時就大家都認為說要\n\n04:06.394 --> 04:31.900\nbicyn要朝向總額管制的方向所以最後才變成總額管制所以當時的總額管制的制度的引入是因為醫療費用急速成長造成保險嚴重虧損那現在如果大家回過頭來說我們要不要再拿掉總額管制那那這個條路會怎麼走呢這個必須要同時有配套去控制那個量的成長\n\n04:33.060 --> 04:52.688\n但是理論上當初在執行這個總額管制的時候我們是希望透過也是透過預估年度的預算總額然後以醫事服務提供者要去發揮同儕制約的效果因為當時沒有總額管制以前就有一種充量也在充量計價不斷的在過度醫療的問題都跑出來嘛\n\n05:12.637 --> 05:29.680\n第二、在執行過程當中也邀請醫事服務的提供者討論訂出支付標準以及主導醫療服務的審查這個角色。第三、保險人角色收卸為統籌輔導政策評估和規劃提高醫療專業團體的自治空間。但是這個是當初2002年要實施總額管制當時的理論上的理想\n\n05:40.962 --> 06:09.486\n但是大家多年到現在都覺得總額管制的制度早已經名存實亡。為什麼呢?真正的現實面到現在理想為什麼幻滅?這是一改會講的啦一改會說從實務面來看政府透過保障收入補點值這一種本來都不是總額管制裡面該有的制度裡面早就打破了總額的規範而健保方案計畫的制定\n\n06:09.946 --> 06:37.287\nbicyn更違背了各種各式各樣的方案違背了總和洽的評估和管理精神以至於協議難以順利進行從制度面來看當時要配套要有加一制度分級醫療制度論人論病病例計酬支付標準和平性的檢討可以改變病人的就醫行為還有醫師診療行為的配套措施也都沒有辦法真正的落實\n\n06:39.589 --> 07:04.381\nbicy專業團體的同儕制約自主審查也不健全。大家漸漸地就覺得說到最後都是劣幣驅逐良幣。所以依改會的講法是說大家不論是醫界或是使用者或者是專業的團體都認為總額制急切已經走到了一個很像是名存實往的這個地步了。\n\n08:08.695 --> 08:35.129\n但是你遇到人口老化你看光是老年人口從總額管制到現在增加了一倍以上喔一倍250萬喔未來還要再增加欸那再疾病慢性化再加上少子女化未來健保的財務繳的人少用的人多多更多不是成長幾%是倍數成長\n\n09:06.781 --> 09:07.201\n講一句這個你的客觀的看法。\n\n09:14.321 --> 09:36.198\n當然委員剛剛講的大部分都是其實就現在的一個狀況那不過健保這一個部分的話本來就是很複雜那剛剛提到的總額總額支付制度的話執行了這麼多年的確有達到費用控管的一個成效不能完全都否定掉\n\n09:36.838 --> 09:50.144\n但是未來如果說要總額的部分的話要去做修正這個我個人也覺得但是這個財務本來就已經是建立在一個非常岌岌可危的基礎上了結構上\n\n10:07.955 --> 10:25.923\ntatto必須要其他取代的方式,比方說某種程度某種對象的論文記酬,另外的話當然就有一些特殊的一些狀況當時的理想的啊,可是你們都沒有執行啊,沒有落實啊\n\n10:27.344 --> 10:50.379\n我們其實都在進展當中啦尤其是剛剛委員提到的這些老年人慢性病者這個部分的話其實就是我們現在正在推的在那個健保制度之下現在正在推動的但是這個要轉變醫療界的他的長久以來的作業模式那這個是需要時間啦\n\n10:51.560 --> 11:10.569\n所以依改會有提出幾個,提升資源可敬性,強化資源分配的效率,照顧近貧和弱勢,拒絕便宜形式的政策補貼,遏止未進周延的選舉買票。大家都要很嚴肅的去面對。那他還提出了一個就是說,這個總額是否存續,這個財務改革的腳步都不應該停止。\n\n12:02.196 --> 12:23.963\n好,謝謝林淑芬委員的質詢。好啦,這個比確實很多困難,但是我們還是想說,最後主席我講一點,就是說你說你固定點值,然後打破了總額管制,然後等於架空了總額,但是你說沒關係,這個叫公務預算去買單,公務預算我們並不是沒有稅入短促,然後財政赤字過,有。\n\n","segments":[{"start":6.316,"end":21.525,"text":"議員,雖然你剩下十幾天,不過我想你從選舉前到現在,態度大概看起來都還算是一致。就是說其實都要很務實的去討論,而不是基於一些因素就可以隨便說說。"},{"start":24.444,"end":47.352,"text":" bicyn 剛才蘇委員剛才也講到說這個我們是不是要把這個制度改成支付目標制這樣子所以今天的修法看起來如果朝這個方向去的話我們可能討論的不是只有點值的這個問題可能還會談到到底要不要取消總額制度那剛才講的那個超過這個支出目標的時候在外國裡面"},{"start":48.172,"end":63.445,"text":" bicyn 蘇清泉等28人擬具:「全民健康保險法第六十二條條文修正草案：立法院第11屆第14次全民健康保險法第16次全民健康保險法第16次全民健康保險法第17次全民健康保險法第18次全民健康保險法第18次全民健康保險法第19次全民健康保險法第20次全民健康保險法第21次全民健康保險法第22次全民健康保險法第23次全民健康保險法第24次全民健康保險法第24次全民健康保險法第25次全民健康保險法第26次全民健康保險法第27次全民健康保險法第28"},{"start":77.176,"end":96.254,"text":"�"},{"start":96.254,"end":126.254,"text":"​​​​​​​​​​"},{"start":126.254,"end":140.282,"text":""},{"start":140.828,"end":166.664,"text":""},{"start":166.804,"end":187.258,"text":" bicyn 並不是說只有繳健保費獎部分這個致富而不是真的變相的名目很多很多那在這種狀況裡面啊我我我今天比較想跟你討論的就會變成說到底這個總額制度是不是罪魁禍首這個總額管制到底是不是問題啊"},{"start":189.075,"end":192.916,"text":"為什麼要引入這個總額管制的制度?因為一開始不是嘛,從91年2002年才開始的。為什麼?那當時的費用控制有什麼問題?"},{"start":212.717,"end":223.06,"text":"因為在過去的話那如果說費用成長那比超出預期之外的話那唯一的能夠做的話就是由健保那邊去做核酸。"},{"start":224.313,"end":233.062,"text":"netes看到就是說因為這個醫改會有數據他說87年為例投保金額成長率大概成長5%但醫療費用成長超過10%所以在這種狀況面臨巨額的虧損的時候開源不易所以當時就大家都認為說要"},{"start":246.394,"end":271.9,"text":" bicyn 要朝向總額管制的方向所以最後才變成總額管制所以當時的總額管制的制度的引入是因為醫療費用急速成長造成保險嚴重虧損那現在如果大家回過頭來說我們要不要再拿掉總額管制那那這個條路會怎麼走呢這個必須要同時有配套去控制那個量的成長"},{"start":273.06,"end":292.688,"text":"但是理論上當初在執行這個總額管制的時候我們是希望透過也是透過預估年度的預算總額然後以醫事服務提供者要去發揮同儕制約的效果因為當時沒有總額管制以前就有一種充量也在充量計價不斷的在過度醫療的問題都跑出來嘛"},{"start":296.51,"end":312.517,"text":""},{"start":312.637,"end":329.68,"text":"第二、在執行過程當中也邀請醫事服務的提供者討論訂出支付標準以及主導醫療服務的審查這個角色。第三、保險人角色收卸為統籌輔導政策評估和規劃提高醫療專業團體的自治空間。但是這個是當初2002年要實施總額管制當時的理論上的理想"},{"start":340.962,"end":369.486,"text":"但是大家多年到現在都覺得總額管制的制度早已經名存實亡。為什麼呢?真正的現實面到現在理想為什麼幻滅?這是一改會講的啦一改會說從實務面來看政府透過保障收入補點值這一種本來都不是總額管制裡面該有的制度裡面早就打破了總額的規範而健保方案計畫的制定"},{"start":369.946,"end":397.287,"text":" bicyn 更違背了各種各式各樣的方案違背了總和洽的評估和管理精神以至於協議難以順利進行從制度面來看當時要配套要有加一制度分級醫療制度論人論病病例計酬支付標準和平性的檢討可以改變病人的就醫行為還有醫師診療行為的配套措施也都沒有辦法真正的落實"},{"start":399.589,"end":424.381,"text":" bicy 專業團體的同儕制約自主審查也不健全。大家漸漸地就覺得說到最後都是劣幣驅逐良幣。所以依改會的講法是說大家不論是醫界或是使用者或者是專業的團體都認為總額制急切已經走到了一個很像是名存實往的這個地步了。"},{"start":424.821,"end":443.183,"text":"​​​​​​​​​​​​"},{"start":443.183,"end":458.029,"text":"​​​​​​​​​​​​​​"},{"start":458.695,"end":488.575,"text":""},{"start":488.695,"end":515.129,"text":"但是你遇到人口老化你看光是老年人口從總額管制到現在增加了一倍以上喔一倍250萬喔未來還要再增加欸那再疾病慢性化再加上少子女化未來健保的財務繳的人少用的人多多更多不是成長幾%是倍數成長"},{"start":518.251,"end":546.34,"text":""},{"start":546.781,"end":547.201,"text":"講一句這個你的客觀的看法。"},{"start":554.321,"end":576.198,"text":"當然委員剛剛講的大部分都是其實就現在的一個狀況那不過健保這一個部分的話本來就是很複雜那剛剛提到的總額總額支付制度的話執行了這麼多年的確有達到費用控管的一個成效不能完全都否定掉"},{"start":576.838,"end":590.144,"text":"但是未來如果說要總額的部分的話要去做修正這個我個人也覺得但是這個財務本來就已經是建立在一個非常岌岌可危的基礎上了結構上"},{"start":592.005,"end":607.875,"text":"�"},{"start":607.955,"end":625.923,"text":" tatto必須要其他取代的方式,比方說某種程度某種對象的論文記酬,另外的話當然就有一些特殊的一些狀況當時的理想的啊,可是你們都沒有執行啊,沒有落實啊"},{"start":627.344,"end":650.379,"text":"我們其實都在進展當中啦尤其是剛剛委員提到的這些老年人慢性病者這個部分的話其實就是我們現在正在推的在那個健保制度之下現在正在推動的但是這個要轉變醫療界的他的長久以來的作業模式那這個是需要時間啦"},{"start":651.56,"end":670.569,"text":"所以依改會有提出幾個,提升資源可敬性,強化資源分配的效率,照顧近貧和弱勢,拒絕便宜形式的政策補貼,遏止未進周延的選舉買票。大家都要很嚴肅的去面對。那他還提出了一個就是說,這個總額是否存續,這個財務改革的腳步都不應該停止。"},{"start":673.951,"end":703.951,"text":"�"},{"start":703.951,"end":721.869,"text":""},{"start":722.196,"end":743.963,"text":"好,謝謝林淑芬委員的質詢。好啦,這個比確實很多困難,但是我們還是想說,最後主席我講一點,就是說你說你固定點值,然後打破了總額管制,然後等於架空了總額,但是你說沒關係,這個叫公務預算去買單,公務預算我們並不是沒有稅入短促,然後財政赤字過,有。"},{"start":745.043,"end":762.5,"text":"�"}]}}}}