健康照護管理計劃之成效分析：以蘭陽糖尿病照護網為例

Assessing Effectiveness of a Health Management Plan: A Study of I-lan Diabetics Caring Network

錢慶文(Ching-Wen Chien) ； 邱震山(Jen-Shan Chiu) ； 黃三桂(San-Quei Huang)

《醫務管理期刊》 2卷2期 (2001/06) Pp. 58-71

https://doi.org/10.6174/JHM2001.2(2).58

摘要

自從民國84年3月1日全民健康保險開辦以來，我國國民對醫療資源的利用有顯著的增加。快速成長的健保支出不僅表示醫療資源有被濫用之虞，間接也等於「警示」衛生主管單位和健保局，若再不改善這個情況，未來健保局以「用高價格買低品質」醫療服務的情形會愈來愈嚴重。有鑑於此，衛生主管單位開始進行所謂的「健康管理計劃」(Health management plan)的實驗。希望可以在健康管理計劃的運作下，使醫療資源能做更有效的利用，進而促成健保的改革。本研究的主要目的是以衛生署主導的「蘭陽糖尿病照護網」為例來評估健康管理計劃在國內實施之成效，希望能透過對此照護網的評估，提出衛生主管單位對這樣的健康管理計劃可能改善的方向。在以33家和中央健保局台北分局特約且參與蘭陽糖尿病照護網之醫療院所從民國86年至88年底照護的2,414位糖尿病病人其所有的醫療費用資料進行資料統計分析，並以CART方法將病人區分成10個資源耗用相似的群組後發現：1、蘭陽糖尿病照護網在形成的第二年（民國87年）醫療費用成長的很快，各項費用的成長率中最少的診查費也達29.80%。2、糖尿病病人的醫療資源耗用量透過CART法可以區分成10個病人分類組別（病例組合）且其平均的分組正確率還可達約40%。3、本研究中可以解釋糖尿病病患醫療資源利用差異的最佳因素除了就醫次數外，是基本人口學變項，性別和年齡。因此以目前所收集到的資料來看，本研究之結果並不支持蘭陽糖尿病照護網在健保的財務上具有成本效益之看法；但是由於本研究對糖尿病患分組方法正確預測率達40%的結果來看，健保局以論人計費的方式來管理和監控糖尿病病患的醫療資源耗用是否具有成本效益卻是值得試試的。

關鍵字

健康管理計劃 ； 迴歸與分類樹 ； 論人計費

並列摘要

The implementation of the National Health Insurance (NHI) since 1995 has encouraged the utilization of health resources. Rapid growth of health expenditure directly implies that health resources were abused and indirectly warns that NHI Bureau may pay too much to buy low quality health services. Therefore, Department of Health started a health management plan for diabetics patients in I Lan in 1997 and aims at promoting efficiency and quality of NHI services by the health management plan. The purpose of this study is to use this health management plan as an example to assess its results in terms of monetary efficiency.
Two thousand four hundred and fourteen diabetics patients cared by thirty-three health care institutions, which have contracted with the NHI Bureau Taipei Branch since 1994, were studied. Patients' utilization data were collected and analyzed by using Classification and Regression Tree(CART) method, Ten homogeneous resource utilization groups(case mix) were found and:
1. Health resources consumed by diabetics patients had growth rapidly in 1998, all expenses were increased at least at 29.8% rate.
2. These ten homogeneous groups can predict patients utilization behavior at about 40% correction rate.
3. Factors which can explain the variation of utilization of health resources among diabetics patients are demographic characteristics, such as age and gender, and frequency of utilization
Results of this study do not support the viewpoint that I Lan diabetics care network has achieved its goal of promoting cost-effectiveness. However, the success classification of ten homogeneous resource utilization groups suggests that capitation for diabetics patients may be a reasonable method to manage and monitor utilization of health resources by diabetics patients.

並列關鍵字

Health Management Plan ； Classification and Regression Tree ； Capitation