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| 題名: | 當審議參與遇上專業不對稱─以全民健康保險藥物給付項目支付標準共同擬訂會議為例之研究
When Deliberation Participation meets Professional Asymmetry：Using Pharmaceutical Benefit and Reimbursement Scheme Joint Committee(PBRS) drugs as an example |
| 作者: | 鄭燕淑
Cheng, Yen-Shu |
| 貢獻者: | 陳敦源
Chen, Don-Yun
鄭燕淑
Cheng, Yen-Shu |
| 關鍵詞: | 審議式民主
專業不對稱
代理人理論
Deliberative Democracy
Professional Asymmetry
Principal-Agent Theory |
| 日期: | 2020 |
| 上傳時間: | 2020-02-05 18:07:01 (UTC+8) |
| 摘要: | 我國自2013年起，新藥給付採「審議式民主」(deliberative democracy)的治理機制，決策需經「全民健康保險藥物給付項目支付標準共同擬訂會議」，然藥品給付政策屬高度專業的實證科學(evidence-based)議題，決策過程須具備醫藥法規、藥品核價作業原則、支付標準及醫療科技評估等專業知識，倘若以多元審議的方式運行，必須面對參與者「公民能力」(citizen competence)的問題，再者，審議式民主精神強調審議的場域必須有涵容(inclusion)、知情(well-informed)、說理(reasoning)、反思(reflections)及公共利益(public interest)等原則，而屬性多元的參與者在健保資源的集體競逐下，又有各自的價值與偏好，因此，審議與專業「如何」調和，便是公共管理者在治理上的重要課題。基於上述，本研究選定「藥品共同擬訂會議」作為研究個案，聚焦在「審議」及「專業不對稱」(Professional asymmetry)兩大主軸，探討現行審議機制下的專業不對稱與審議品質狀況。
研究方法採質性研究方法中的參與觀察法、深度訪談法及內容分析法。首先，在參與觀察法部分，選定2017年10月至2018年10月，產生8次共同擬訂會議錄音實錄作為研究資料的基礎，並將此錄音實錄繕打成文字稿，錄音實錄(議程)總共分成四大部分，前三大部分逐案繕打，第四部份之討論案則以隨機分層抽樣方式，抽取三分之一的討論案進行分析。接續，在深度訪談部分，選定15位利害關係人進行半結構式訪談(semi-structured interview)，並將訪談結果整理成逐字稿。最後將前述錄音實錄稿及訪談稿兩份資料，依「內容分析法」的原則予以編碼，並進行概念化的分析。
研究發現，其一、審議過程存有專業不對稱現象，健保資源(財務)配置與價值偏好是主因。其二、專業不對稱造成，會議過程中出現雞同鴨講的狀況、參與者重複性的提問有關支付標準與核價原則的問題、不具醫藥背景的參與者必須依靠具有醫藥背景的參與者協助，才敢針對專業性的問題作回應。而公部門的幕僚對於處理共同擬訂會議的業務充滿挫折，其挫折在於，審議互動中有情緒性的發言，參與者缺乏尊重、包容與作決策的共識。其三、為降低審議的專業落差，公部門的作法為，在資訊提供部份，朝向簡化專業模式，如將議案做分級，不同議案提供的資訊不相同，會議手冊不呈現艱深且專業性的文字，幕僚必須不斷調整及修改會議資料，以防止專業性較低的代表產生質疑；此外，公部門會主動召開「共同擬訂會議會前會」，邀請非醫療背景的代表、外部幕僚及專家參加，模擬真實會議中可能會發生的狀況。在正式會議中則邀請專科醫師或專家代為宣讀案件基本資訊，借用專家的權威取代公部門幕僚或醫療科技評估的角色。在團體性方面，主張性較強列的代表，因受總額制度影響，審議的價值聚焦在健保財務面向上，在會議上出現故意不談專業的現象，如同樣的問題做重複性的提問。而決策外層的廠商，面對專業不對稱的困境，則是主動尋找專家進行解說，藉此降低評估的落差。整體而言，審議的品質及運作的效能不理想，審議過程有情緒性的態度及衝突，會議的專業性及公正性沒有受到重視，但健保新藥案件的通過率不受專業不對稱影響，代表公部門處理專業不對稱的方式有某種程度的成效。
研究建議，健保政策須建立在實證科學(evidence-based)的專業上；首先採審議式民主模式的會議須面對「公民能力」有落差的問題，公共政策管理者應該在審議式民主性質的會議中扮演決策資訊提供者的角色，將決策資訊作「常民式」(layman)的公開，以解決專業不對稱的問題。再者解決審議的落差並降低審議參與所產生的不信任感，須從「機制設計」下手，並建立協力合作的關係；最後公共政策管理者應邀請不同利害關係人進行溝通，找到雙方可以調和的決策共識。
Taiwan`s national health insurance authority employs Pharmaceutical Benefit and Reimbursement Scheme Joint Committee (PBRS), a model of Deliberative Democracy, to decide what new drugs to be reimbursed since year 2013, and the process of PBRS is of highly professional and evidence-based, and in need of knowledge of medical regulatory laws, guidelines of drug reimbursement, criteria of health insurance reimbursement and capability of Health Technology Assessment (HTA). And considering PBRS is of deliberative democracy, with problems of Citizen Competence, and with problems of participants competing for the resources of national health insurance and problems of participants` self-value and preferences, and considering the Deliberate Democracy demands “Inclusion”, “Well-Informed”, “Reasoning”, “Reflection” and “Public Interest”, how to accommodate PBRS with deliberate democracy is becoming of much importance. This research focuses on the quality of PBRS with the coexistence of “Deliberate Democracy” and “Professional Asymmetry”, and explores the deliberate and professional asymmetry.
This research employed methods of participant`s observation, deep interview, content analysis. Firstly, respecting to participant`s observation, take all eight times of PBRS meetings during October 2017 and October 2018 as raw material of this problem, and translate meeting recording into paper record in words. The meeting comprised four parts, and the first three parts are translated word by word, and the fourth part are drug cases discussed, which are randomly sampled in one third by stratum for analysing. Secondly, respecting to deep interview, choose 15 participants of PBRS as the subjects of semi-structured interviewing, and make full record of interview in context word by word. Thirdly, make the meeting record and the interview record encrypted according to the rule of content analysis, and make conceptual analysing.
The research finds that, firstly, there is information asymmetry and professional asymmetry in PBRS, and the resources allocation of national health insurance and bias of evaluation are the reasons why. Secondly, the professional asymmetry causes "at cross purpose" talks during the meeting, participants keep asking questions of the standard of reimbursement and the criteria of drug pricing repeatedly, and participants of not medical back ground only dare to response to professional issues with the help from participants of medical back ground. The members of authority get frustration while dealing with PBRS, and the reasons are that there are emotional argument, participants` lack of respect for the other participants, lack of consensus in toleration and decision-making. Thirdly, in order to reduce the difference of professional background, the discussion issues should be put in grading, and offered with plenty footnotes without technical, difficult and obscure wording. The authority should keep adjusting the information for each discussion topic as to reduce the doubtfulness from the comparatively unprofessional participants. Besides, the authority should actively hold a prerun meeting for PBRS, and invites experts of not medical background, outsiders and related specialist to join, and to simulate the scenario of PBRS. When it comes to the real PBRS, the authority should invites the specialist doctors or experts to introduce and explain the discussion topic, and to take place of the roles of authority and roles of HTA. As for the participants,of which the strongly subjective ones, affected by the “Global Budget System” of NHI, prefer focusing on the financial solving than on choosing new drug for diseases curing. And they often speak of what they prefer on instead of professional medical discussions. The drug companies, who are away from the decision core and face with the professional asymmetry, would struggle to explain to the participants as to reduce the difference of evaluation and the gap of expectation. As conclusion, the delegation runs unwell and the quality is poor, and the profession and justice of the meeting is poor. The permission rate of new drug to the NHI is good though, it implies that some measurements the authority takes to deal with the professional asymmetry work out to a certain degree.
The research suggests that the national health insurance system should work on the foundation of evidence-base profession. Firstly, the meetings with deliberate democracy are facing with the gap problems of Citizen Competence, and the authority should play the role of information providing in deliberate meetings, and open the decision information to the public in a way of layman as to solve the informational asymmetry and professional asymmetry. Secondly, as for reducing difference of deliberate and reducing untrustfulness from deliberate participate, the authority should reinforce the design of mechanism, and establish the alias relationship. Finally, the authority should invite participants of different interests for conversation and for consensus as to a final conclusion. |
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| 描述: | 碩士
國立政治大學
行政管理碩士學程
106921007 |
| 資料來源: | http://thesis.lib.nccu.edu.tw/record/#G0106921007 |
| 資料類型: | thesis |
| DOI: | 10.6814/NCCU202000051 |
| 顯示於類別: | [行政管理碩士學程(MEPA)] 學位論文
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