臺灣自1995年開始實施全民健康保險（National Health Insurance， NHI）（以下簡稱全民健保），至2008年臺灣全民健保僅以GDP 6.2%的醫療費用支出，達成了「全民有保」、「就醫無障礙」及「費用低廉」的成效（衛生署2006年）。然而1998年全民健保開始出現財務赤字，政府遂開始實施總額管控措施（Global Budget Payment System，GBPS），其後雖然醫療費用逐漸被控制，但總額管控措施在三年期間實施了六項不同的支付制度，更迭之速舉世少見；自1994年到2008年臺灣醫院家數由719家降至485家，減少率為32.6%，顯現全民健保制度實施後醫院經營之困境，本研究目的在探討台灣健保總額管控措施更迭之演進，提供台灣特殊的健保發展經驗，並探討總額管控措施對台灣醫院之影響。
本研究進一步應用系統動力學（system dynamics）之因果迴路結構（feedback loop structure）觀念，建構結構區間總攬圖（sector overview diagram）及系統動態模型（system dynamics model），取用醫院實際營運數據，模擬情境分析行為變化型態（reference mode behavior ）並做醫療資源配置比較，研擬醫院如何透過醫療資源配置原則因應總額預算控管措施。
研究結果發現，健保局透過總額管控措施將財務虧損壓力轉移到醫院，致使醫院營運困難，臺灣健保總額管控措施實施中期醫院關閉家數最多，共關閉107家關閉比率為16%；多數醫院在自主管理及卓越計畫實施後的一至二年關閉；總額管控措施對醫院收入影響最大時期在自主管理實施期間，其實際服務點數與實際收入金額之差距損失為26.3%，平均點值是影響醫院淨利最重要的因素，如果健保局未實施提升點值政策，仍維持0.705，則醫院的淨利將顯著下降。此外，若點值恢復到總額管控措施實施前的水準，醫院淨利將可達現在的兩倍。故在總額管控措施下，醫療界之同儕制約以及健保局提升點值措施對醫院之經營最為重要；醫院在總額控措施下，有「平均每人次健保病患自費金額有逐漸升高」及「隨著總額控措施實施時間的增長，醫院漸能調控各項支出」等行為變化形態現象，因應總額管控措施之衝擊透過系統動態模擬發現在總額管控措施下，醫院經營者應同時實施開源節流等多重政策，短期內應先將管理重點放在節流政策，以穩定醫院的經營；長遠發展，則醫院之經營者應提升取得外在資源能力，以提高合作單位與自費收入比率，增加醫院總額外收入。
雖然台灣健保制度實施的成就揚名於外，但總額管控措施改變的速度亦是舉世少見，也顯現該制度對醫院產生相當程度的衝擊，故建議政府實施健保應有長期規劃，不宜快速變動醫療支付制度以穩定醫院的經營與品質發展。

Taiwan has implemented National Health Insurance (NHI) since 1995. Taiwan NHI has achieved the goals that are “individual civil with national health insurance”,”medicine without obstacle “and “low charge” just by occupying 6.2% of GDP as medical expenditures (DNHI, 2006). However, NHI had a deficit finance from 1998; therefore, the government launched to implement the Giobal Budget Payment System (GBPS) on hospitals in Taiwan. Afterward, medical expense is gradually controlled. Nevertheless, NHI implemented six various payment systems in GBPS during the three years. The changing is seldom in the world. There were just 485 hospitals out of 719 ones in Taiwan remaining till 2008 through
1994, whose reducing proportion is up to 32.6 %.
It is obvious that hospital operation meets difficult situation since the implementation of NHI. The purpose of this study is to investigate the effect of GBPS in Taiwan NHI, to offer the unique experience of NHI, and to explore the effect of GBPS on Taiwan hospitals.
This study is further to apply the concepts of feedback loop structure of system dynamics to construct sector overview diagram and system dynamics model and adapt the practical operating data in the hospitals to imitate the situation, to analyze reference mode behavior and to make a comparison of medical resources allocation. In addition, the research studies how the hospitals arrange GBPS through the principle of medical resources allocation.
This study found that DNHI transformed the pressure of the deficit finance to the hospitals by taking advantage of GBPS, which results in much difficult on hospital operation. The peak of hospitals closure is in the middle stage of the implementation of Taiwan NHI’s GBPS. About 107 hospitals ended up their business after Self-dominated Management and Excellent Planning were implemented about one to two years later. The closing rate is 16 %.
During the implementation of GBPS, Self-dominated Management has a great impact on the hospital revenue, whose gap lost between actual served points and actual revenue is 26.3 %. Average point value is the most important factor affecting hospital net profit.
If NHI does not promote average point value system instead of keeping at 0.705, the hospital profit will significantly decrease. Furthermore, if average point value goes back to the level prior to the implementation of GBPS, hospital profit will reach double now. Therefore, both peer review in the medical field and average point value are important factors for the hospital operation in GBPS. Hospitals in GBPS have reference mode behavior of “pay for service by average individual patient with NHI” and “varied aspects of expenditure that hospitals can adjust with time in GBPS. In order to cope with the impact of GBPS, the research applies system dynamics to simulate hospital operators should simultaneously implement multi-systems based on the rule, more revenue and less expense. Managed key points should first be placed on more revenue and less expense to stabilize the hospital operation in short term; hospital operators should increasingly obtain outside hospital resource to add up the rates of cooperated units and pay service in order to increase global budget extra revenue for hospital in long-term development.
Although the achievements of implementing NHI in Taiwan are very famous all around the world, the changing for GBPS also seldom occurs on the earth. It is obvious that GBPS has a quite influence on hospitals; therefore, it is hoped that the government should have long term plans in the implementation of NHI, instead of changing medical payment system fast to balance hospital operation and the development of the qualification.

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