健保復健治療支付方式改變對基層診所申報行為之影響

The Impact of Payment Mechanism for Rehabilitation Therapy on the Claim Behavior of the Primary Outpatient Clinics

曹昭懿(Jau-Yih Tsauo) ； 吳英黛(Ying-Tai Wu)

《物理治療》 29卷4期 (2004/08) Pp. 225-232

摘要

背景與目的：探討支付標準改變對診所申報物理治療費用之影響，即在不同支付標準期間，其申報總額、數量、項目比例之改變情形。方法：以 86 年申報資料為比較基準，採全民健康保險學術研究資料庫所提供 86－88 庫之「復健治療」特定主題檔之門診資料，系統抽樣檔之門診處方及治療明細檔與門診處方醫令明細檔及醫事機構基本資料檔為分析對象。結果：87年初，復健科診所支付標準降低，申報量大幅增加；5月後，復健科診所提供之中度以上物理治療項目提高點數，則發現其申報之項目比例有所調整，中度治療之金額與數量申報比例由原本佔全部申報之10－15 %，金額增加為35 %，數量則增為28 ％。88年9－12 月，復健科與骨科診所之申報未受支付方式影響。結論：健保局採取各種給付措施，似乎各診所皆可由調控申報方式達到維持總金額穩定的效果。建議當局支付制度之設計，應採以提供之服務品質及病人治療成果為衡量標準，方能達到醫療資源合理使用，並追求高品質之醫療服務，以嘉惠民眾。（物理治療 2004 ; 29 ( 4 ) : 225－232 )

關鍵字

支付標準 ； 醫療費用 ； 物理治療 ； 復健

並列摘要

Background and purpose: Nationwide data of medical cost offered by National Health Research Institute (NHRI) released from Bureau of National Health Insurance provides great help to study about the medical utilization and expenditure. The reimbursement policy for rehabilitation services changed three times, in Jan. 1998, May 1998 and Aug. 1999, since the beginning of the national health insurance. The purpose of this study was to explore the impact of reimbursement policy on the rehabilitation-service claim behavior of the local medical clinics. The changes of the total amount, treatment quantity, and the ratio of items in the different time periods of reimbursement policy were described. Methods: We used two sets of data files offered by NHRI in the years of 1997-1999. Rehabilitation Services file that offered the complete claim data of rehabilitation services was the first set used. The second set was the Registry for Contracted Medical Facilities, Ambulatory Care Expenditures by Visits, and Details of Ambulatory Care Orders that represented 0.2% of the claim data. Results: The results showed that the total claim quantity of rehabilitation clinics increased during Jan. to Apr. 1998 because the payment for rehabilitation clinics was lowered in this period. After May. 1998, the rehabilitation clinics claimed much more “moderate” and “complicate” treatment. The ratio of ′ moderate ′ treatment items increased to 35% and 28% from 10-15% in amounts and quantity respectively. We also noted that the claim behavior of the clinics was not influenced by the co-payment policy executed from Aug. 1999. Conclusions: Local medical clinics changed their claim behaviors in accordance to the reimbursement policy and keep their annual total claim amount inflation rate. Since the reimbursement policy till now was ineffective in controlling the rehabilitation-service expenditure, we suggest that the reimbursement policy should focus on promoting quality of services by requesting patients′ outcome while controlling the growth rate of quantity in the meantime. (FJPT 2004;29(4):225-232)

並列關鍵字

Reimbursement ； Medical expenditure ； Physical therapy ； Rehabilitation