全民健保下病患在各醫療層級間的就醫選擇－台北市小兒科病患為例

The Choice of Medical Institutions under NHI-An Example of Pediatric Patients in Taipei

劉彩卿(Tsai-Ching Liu) ； 吳佩璟(Pei-Ching Wu)

《醫務管理期刊》 2卷2期 (2001/06) Pp. 87-108

https://doi.org/10.6174/JHM2001.2(2).87

摘要

全民健保實施後，將醫療院所分為醫學中心、區域醫院、地區醫院、及基層醫療等四個層級。同時，試圖利用門診分級部分負擔，配合轉診制度，來達成分級醫療的目的。但由於病患在各層級醫療院所就醫，所需負擔的費用(out-of-pocket)差異不大，是否會影響病患就醫選擇，有待評估。除價格機制外，病患個人特徵及其他影響就醫層級選擇的因素，亦值得深入探討。因此，本研究利用台北市小兒科病患為樣本，採多重logit模型(multinomial logit)來研析全民健保實施下，影響病患就醫層級選擇的因素；俾期能對目前由於醫療層級的不當選擇，造成之醫療資源浪費的問題，給予相關單位一些政策建議。本研究結果發現，說醫價格對層級選擇如預期地呈顯著且負向影響。至於時間成本（交通時間及候診時間）的影響，不似就醫價格明顯，但亦產生部分預期效果。此外，隨著陪伴者自覺病兒病情越嚴重、居住於非北市、陪伴者年齡越大、接受醫療補助者、視領藥天數、醫院名氣及醫院設備為其就醫選擇的重要考量者，會偏好較高層級院所。本研究根據實證結果提出三個可行方案：第一，提高部份負擔額度，加大層級間的價格差距。第二，改善層級間不公平之藥品給付。第三，重新省視醫療補助政策的效果，是否扭曲醫療層級的選擇。

關鍵字

分級醫療 ； 就醫層級 ； 醫療選擇 ； 醫療院所 ； 小兒科

並列摘要

NHI divides the medical institutions into four groups: medical center, district hospital, regional hospital, and clinics and attempts to carry out this system by imposing the copayment system. However, there are little variations in out-of-pocket expenditures among medical institutions. Whether or not the choice of medical institutions will be affected by the copayment system need to be further examined. In addition to the price mechanism, the individual characteristics and other attributors to medical care use should also be investigated to find out the crucial factors that influence the patients' decisions to medical institutions, Therefore, this study applies a multinomial logit model to examine the determinants of medical institutions choice under NHI in order to provide the policy implication for improving the inefficiency of medical resource allocation resulted from the misusage of medical institutions. The data used are selected from the survey of pediatric patients in Taipei. The findings suggest that the medical price is expected to negatively affect the choice. Time cost is not found to play an important role. Those children who re in poor health status, non-Taipei resident, ken care by the elderly, receiving medical subsidies, care about the amount of medication, the reputation and equipment of institutions a mole likely to choose the upper level of medical institutions, such as a medical center. Three policy implications are: first, to increase the amount of medical copayments as well as to widen the price differences between the upper and lower level of institutions; second, to ameliorate the iniquity of medication payments among institutions; third, to reestimate the effectiveness of medical subsidies.

並列關鍵字

hierarchical medical care system ； medical care choice ； medical institutions ； Pediatrics