美國管理式醫療照護契約言論限制條款之評介與反思A Comment and Reflection on Gag Clauses in U.S.A MCO-physician Contracts

摘要
　　管理式醫療照護契約是美國醫療照護成本控制之核心，但是卻促使醫師與病患產生利益衝突，使得醫師專業遭受質疑，醫病信賴關係惡化。其中言論限制條款限制醫師提供病患之資訊，違反告知後同意原則。本文分析管理式醫療照護契約言論限制條款之內容及其對醫病關係之影響，與美國立法、司法對言論限制條款之回應與處理。從這些回應與評價發展的歷史軌跡中反思全民健保改革，也顯現管理式醫療照護成本控制與病患權益維護二者之衝突與平衡，以及醫師承擔角色平衡之兩難。
關鍵詞：管理式醫療照護契約、成本控制、言論限制條款、告知後同意、信賴義務
Abstract
　　The MCO-physician contract is the core of cost containment in U.S.A., but it also causes conflict of interest between physicians and patients, induces questioning about the physicians professional practice and deterioration of the physician-patient relationships. Gag clauses restrain the information from physicians to patients and violate the doctrine of informed consent in terms of MCO-physician contract. This paper analyzes contents of gag clauses in the MCO-physician contract and its impacts on the physician-patient relationships, as well as the responses and measures from the U.S.A. legislative and judicial. We also need reflection about National Health Insurance reform from these developmental responses and evaluations, reflect the conflict and balance between cost containment of managed care and patient’s rights, as well as the dilemma for physician to take roles.
Keywords: MCO-physician contracts, cost containment, gag clause, doctrine of informed consent, fiduciary duty.