中醫住院納入健保可行性評估

楊哲銘
臺北醫學大學
我國全民健康保險自1995年3月開始實施以來，迄今已有16年，初期規劃時，以中醫門診支付列為給付項目，然而歷經數年，中醫住院醫療照護因支付標準尚未建立，中醫住院治療項目仍未有一致共識，故仍尚未獲准健保給付，因此目前國內僅少數中醫部門的中醫住院業務以病患自費方式進行醫療服務，因此有病患權益受損的呼聲，此外對中醫臨床服務與教學也有連帶之影響，本研究因此以中醫住院治療健保給付之可行性為探討主題。
台灣目前有三十六家中醫院、六十七家醫院附設中醫部門、二千八百餘家的中醫診所，因為台灣中醫長期以門診為主要醫療型態，所以民眾鮮少接觸到中醫住院的臨床治療。儘管現行全民健保不給付中醫住院的情況之下，事實上，台灣的中醫住院病床並非沒有設置，有少數地方中醫院或中醫診所仍有設置中醫病床，但病床的使用率並不高，原因之一是目前中醫住院並未納入健保給付，病人住院要自掏腰包，但以現在全民健保養成的就醫行為模式下，病患很少會選擇中醫住院診療。
由於台灣人口高齡化的趨勢，中醫可以展現其養生保健、抗衰老、以及改善慢性疾病的特色，提高病人的生活品質。中醫住院的設立可能會有利於中醫的發展，有了中醫病床的設立，便可以對疾病的演變作一個全盤性的了解，也能密切觀察使用中醫醫療的療效，更能累積中醫的實證經驗，還有教育訓練中醫師的功用。現行成立中醫住院的團隊架構方向主要考量以中醫師診斷及處方、中藥師開發特別劑型、中醫護理師提供中醫護理照護、營養師提供藥膳開發及行政人員提供整體行政作業的規劃與執行，以專業的醫療人員團隊來面對住院照護的實行。
本研究將先進行國內外文獻的收集，接著召開相關專家座談會，邀請中醫相關領域專家共同研議中醫住院納入健保可行之方案，並配合健保經驗值，研擬可能之給付項目、支付標準及配套措施，以提供相關單位作為政策擬訂之參考。
關鍵字：中醫住院、全民健康保險、給付項目、支付標準

A feasibility study of Chinese medicine inpatient admissions reimbursed by the National Health Insurance in Taiwan

Che-Ming Yang
Taipei Medical University
Taiwan had implemented the Naitonal Health Insurance (NHI) for 16 years since the March of 1995. The initial design only included outpatient visits for Chinese medicine. Due to the lack of consensus on what should be included and reimbursed for Chinese medicine inpatients, the NHI has not approved of benefits for Chinese medicine inpatient admissions after so many years. As a result, there are outcries to the effect that patients are shortchanged and there are adverse influcnces on the clinical services and teachings of Chinese medicine. Therefore, this study aims at assessing the feasibility of incorporating Chinese medicine inpatient admissions into the NHI benefits.
At present, there are 36 Chinese medicine hospitals, 67 Chinese medicine departments in general hospitals and over 2,800 Chinese medicine clinics in Taiwan. The treatments provided are primarily outpatient based and people hardly have inpatient experiences in Chinese medicine. Although the NHI has not reimbursed Chinese medicine inpatient admissions, we are not completely void of Chinese medicine inpatient beds. A few hospitals do allow Chinese medicine inpatient admissions, but the occupancy rates are low. The major reason is lack of the NHI reimbursement for Chinese medicine inpatients. Due to the care seeking behavior shaped by the NHI, patieints hardly choose to hospitalize for treatments out of their own pockets.
Due to the problem of aging in Taiwan, Chinese medicine is well situated to distinguish itself by showcasing its capability in health promotion, antiaging and chronic care, and in increasing quality of life. The establishment of Chinese medicine inpatient admissions could be beneficial to the development of Chinese medicine. With inpatients, physicians can have a more global understanding of the natural courses of diseases and more close observations of the efficacy of Chinese medicine so as to accumulate empirical evidences for Chinese medicine and strenghten the tranings of Chinese medicine physisicans. Chinese medicine inpatient admissions will require team work to provide state of the art care, which includes diagnoses and prescriptions from physicians, special medication regimens developed by Chinese medicine pharmacists, specialized nursing care provided by Chinese medicine nurses, herbal medicine based diets developed by nutritionists, and the integrated framework excuted by the administrative staff.
This study will start with both domestic and international lietraute reviews. The seond step is to conduct expert meetings in which relevant experts will be invited to discuss the possible avenues for Chinese medicine to have inpatients reimbursed by the NHI. Lastly, we will come up with a tentative plan and reimbursement packages based upon the past experiences of the NHI for future policy consideration.
關鍵字：Chinese medicine inpatients, National Health Insurance, benefits, reimbursement