本研究從經濟社會學的觀點，探討健保作為國家去商品化的福利制度，支付制度成為國家、醫療機構與被保險人之間的特殊社會意義的經濟活動。國家透過全民健保落實社會福利政策的去商品化精神，卻因為唯經濟論的支付制度運作機制，導致醫療服務落入再商品化的弔詭中。唯經濟論的支付制度不只侵蝕醫病信任關係，也使全民健保陷入嚴重的財務危機。
論人計酬試辦計畫具有政策上的重要意義是，此支付制度改革企圖扭轉論量計酬的問題，明確以全人照護為導向，藉由促進區域醫療體系整合，聚焦於健康社區化，實踐全民健保為民眾買健康的理想。本研究以論人計酬試辦計畫團隊、社區醫療群及社區醫療工作者的經驗為研究基礎，討論論人計酬支付制度的政策期待與其產生的非意圖後果。研究發現，論人計酬試辦計畫意圖穩定的醫病信任，醫病關係依舊脆弱，社區家庭醫師仍是難以在制度鼓勵之下，融入社區生活，成為社區民眾個人健康管理與社區健康知識共作平台的中介者。
以社區為基礎的健康政策，除了指出照護場域的社區化，更重要的關鍵是，社區民眾產生對健康的共同渴望，使社區有集體行動的基礎，藉由制度設計促進社區行動與健康政策結合。因此，論人計酬支付制度對於台灣具有重要意義的原因正是這是一個以社區健康為基礎的支付制度改革，透過建立社區健康中心的運作方式，重新定義未來台灣人口特色的健康照護體系。
本研究首先從社區醫療、福利社區化與社區營造的經驗中，檢討國家政策對於社區發展邊緣化與片段化的過程，凸顯了論人計酬試辦計畫嘗試落實以社區為基礎的健康促進政策，試辦結果仍是難以突破家庭醫師與社區生活的去鑲嵌關係。
其次，唯經濟論主導的論量計酬支付制度意識形態，影響論人計酬試辦計畫的政策導向，以至於試辦計畫還是又以節約醫療資源、強化財務控管的績效目標。承辦團隊為了順利獲得計畫的會員個案管理回饋金，只能妥協於健保署幾乎一致的品質評估指標，限制承辦團隊發展開展具有社區健康獨特性的方案。
研究發現，社區照顧關懷據點在財務與人力資源匱乏的情況下，卻得力於台灣人際信任的特殊性，突破制度束縛，展現社區醫療工作者與社區民眾的韌性。面對社區財務壓力，部分社區團隊嘗試發展具有分享經濟意義的社區產業，創造社會賦權的社區利益極大化平台，最後也因為政策法規限制，使得社區難以獲得永續發展的能力。
本研究以社會經濟、社會信任與社區健康為核心軸線，嘗試提出整合醫療、社會福利與文化的健康社區化可能性。在真實烏托邦的精神下，本研究提出「社區健康迴路」的概念。「社區健康迴路」進行社區培力，使社區具有社會、財務、環境與跨領域協作平台的能力，最終的目的是實現將論人計酬制度融入社區健康為基礎的生活共同體。

關鍵字：支付制度、全民健保、論人計酬、社會信任、健康促進

In the tradition of economic sociology, this study aims to investigate the paradox of national health insurance (NHI) in terms of both the de-commodification and re-commodification of national welfare policies. Our focus is on payment systems that facilitate the transactions among the state, medical institutions, and the insured with specific social missions.
The state government provides medical services for people via mechanisms of payment systems under the scheme of NHI. On the one hand, these mechanisms de-commodify national welfare policies. On the other hand, the underlying economistic fallacy drives the recommodification of medical services, hence erodes doctor-patient trust relationships and caused severe financial crises of NHI system.
Taiwan Capitation Pilot Study (TCPS) is an important step in reforming our national health policy. This innovative payment system was meant, in the spirit of “holistic health care” to achieve the ideal of “purchasing health for the people instead of purchasing medical services” through the integration of regional medical systems and the establishment of community-based health promotion programs. Our field study was predicated on experiences of experimental teams of TCPS, teams of ‘family physicians integrated delivery systems,’ and those of community medical workers. We find that TCPS failed to establish stable doctor-patient relationships, nor did it encourage family physicians to be fully embedded in community lives to create a mediating platform for personal health management and community health promotion.
The community-based health policy points to the importance of grounding health care in communities, arousing inspirations for health, and generating the social space for collective action through innovative institutional design. In this sense, TCPS is important to Taiwan’s health policy precisely because it is a payment system reform predicated on community-based health promotion. Through operations of community health center, TCPS redefine a new health care eco-system to cope with future population structure of Taiwan.
First of all, I review the implementation of main community policies, including medical services, social welfare and community building. The marginalization and fragmentation of community policies made it difficult for TCPS to implement community-based health policy. In the end, TCPS is hard to overcome the problem of the disembedded relationships between family physicians and community.
Secondly, the ideology of fee-for-service payment distorted the policy orientation of TCPS, making, unfortunately, the cost-down of medical services and the budgetary control the ultimate goal of healthcare reform. In order to obtain reimbursement for case management, TCPS medical teams had to compromise with NHI by accepting its key performance indicators. This kind of benchmarking reduced the latitude of TCPS medical teams to develop community-specific kind of health promotion projects.
Our fieldwork observations showed that under the monitoring by Departments of Social Welfare community development associations managed to sustain, facing the shortage of money and human resources. The main reason why community development associations were able to continue the operation of community care system is attributed to the inter-personal social trust of Taiwanese society. Interpersonal trust helped break the policy constraints and consolidate community to overcome financial challenges.
Some community organizations tried to develop sharing economy and community enterprises to solve financial problems. They aspired to create a socially empowered, democratic and maximized community interests platform to solicit as much resource as possible. Unfortunately, it is hard for community organizations to acquire sustainable development ability due to the legal and institutional limitations.
In conclusion, this study attempted to explore the possibility of integrating medicine, social welfare and culture from the vantage point of social economy, social trust and community-based health. In the spirit of real utopia, we proposed a solution dubbed ‘community health circuit’. ‘Community health circuit’ empowers communities and cultivates social, financial, environmental proficiency as well as the ability to build up a cross-disciplined cooperative platform, the ultimate goal of which is to fully ground TCPS in local communities to promote health for all the concerned citizens.

Keywords: payment system、NHI、capitation、social trust、health promotion

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