急診醫師離職潮 要治本

成大醫學院公衛所 王榮德、王亮懿

日前長庚急診醫師離職潮引起社會重視,各方提出建議。有認為需改變財務計算方式,把急診開出的檢查收入部分歸入急診收益,以避免醫院將急診列為賠錢單位。也有主張應透過提高急診部分負擔,減少急診資源濫用。醫勞盟及醫改會更呼籲財團法人醫院應本著公益性質,救人先於營利;建議醫院財務須公開透明接受監督,醫療法應修法使董事會有醫院員工推舉出的非主管員工代表,保障員工健康與福祉。筆者認為上述建議能治標但未治本。

近年來浮出檯面的急診虧損、血汗醫院、五大科醫療人員出走等問題,根本原因之一,來自於人口快速老化所延伸的龐大就醫需求。根據健保署的數據,2015年65歲以上老人就醫次數,門診為整體國人平均的1.8倍(28次/年)、急診1.9倍(0.52次/年)、住院2.8倍(0.39次/年)。該年就醫總費用,老年人的門診、急診、住院的花費分別是國人平均的2.4、1.9、1.4倍。估計未來15年內老年人口將增為現今的2倍。若不積極從現在起預防老年疾病的發生,未來醫療需求會因高齡人口快速上升而急遽擴張,造成健保與社會的龐大負擔。

我國健保目前實施總額預算制度來控制收支平衡。但人口老化快速,即便各年齡層的醫療需求維持不變,整體醫療需求仍會攀升。當快速高齡化導致總額預算的成長趕不上實際醫療需求,醫療機構往往精簡人事及各種成本,壓縮醫療人員的勞動條件,形成現今血汗醫院與醫療崩壞等亂象。此次長庚急診醫師離職潮僅是上述結構性問題的前哨,未來各種嚴重問題會陸續浮出檯面。

根本解決之道,應是青壯年即全面開始預防疾病的發生;除了積極推動四癌篩檢、三高控制,也需順應世界潮流,透過實證數據評估各項醫療服務的價值,促使健保將給付制度導向「論價值計酬(pay-for-value)」,每塊錢買到最大量的健康;同時逐步淘汱低或無療效又昂貴之醫療,例如節制長期插管呼吸治療、C肝病毒治療藥取代Silymarin等。唯有從這個方向進行改革,未來才能順利過渡至「論人計酬」,讓醫療提供者與民眾有足夠誘因全面預防生病,根本解決健保困境。

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