2000至2002年各層級醫療院所藥品利用 趨勢與藥價調整政策影響之分析

The Influence of NHI Drug Reimbursement Adjustment for Drug Utilization and Expenditure on Different Levels of Health Care Organizations from 2000 to 2002

陳志麟(Chih-Lin Chen)

指導教授 ： 王俊文

中山醫學大學/醫學院/醫學研究所/碩士(2005年)

摘要

研究背景：
台灣的全民健保實施從1995年起已超過十個年頭，健保藥費支出所佔之比率一直高居不下，從中央健康保險局健保資料庫的統計數據中，可得知在1996年為621.8億元，1997年為640億元，成長率為2.9%；1998年的藥費急速攀升到722億元，成長率為12.9%；1999年藥費高達804億元，成長率亦高達百分之11.3%；而在1999年公告實施之「全民健康保險藥品支付價格調整作業要點」進行藥價調查之後，自2000年開始的藥費成長率都維持在7%以下，尤其是2000年及2001年成長率僅為3.1%及2.2%。　
本研究係針對目前醫療費用的結構已失衡，並已嚴重影響醫療生態之平衡發展，健保之財政壓力，政府希望加重醫療院所之財政責任，推動總額支付除了藉由資源重新分配，有效改善財政分配不公的問題，期望全民健保政策更趨健全。而在失衡的醫療費用中佔有舉足輕重地位的藥費耗用增長趨勢？1999年實施藥價調整政策將對各層級醫療院所在門診及住診之藥費耗用上產生之影響？成為本研究之重點。
材料與方法：
本研究所採行之分析方法主要為次級資料處理分析，在次級資料處理中藥理名稱分類及藥費分析部分，係採用SPSS（11.0版）for Windows以及Microsoft Excel兩種軟體程式為統計工具，用以篩選、分類及分析資料庫之資料。主要將2000年1月起至2002年12月止各層級醫療院所向健保局申報之總藥品費用依據資料之特性（年度別、層級別及門住診別）等方式，以呈現藥品申報總金額排名前一千品項佔當年度、各層級整體及門住診藥品申報金額之比率，再利用多變項分析中之變異數分析（One-Way ANOVA）對在不同層級間，各個藥理分類藥品於門、住診藥品申報費用檔中之趨勢分析，並進一步進行相關藥品政策之影響進行探討及分析，作為本研究對藥價政策之未來走向之政策建議基礎。
研究結果：
一、本研究發現2000年至2002年之間依AHFS藥理分類架構下，我國健保藥品費用整體成長趨勢，其佔率最高為心臟血管用藥；二、本研究發現依AHFS藥理分類架構下，四層級醫療院所及其門住診藥品成長趨勢，其佔率最高為心臟血管用藥；三、不同藥品分類其於四層級醫療院所間的耗用差異，在門診部分以腸胃道藥物在醫學中心/區域醫院與地區醫院/基層診所有明顯差異；在住院部分以心臟血管藥物在醫學中心影響最大，基層診所影響最小。
討論：
一、維生素類之藥費衰退之原因係因藥價調查後，藥價調整之影響對藥品管控有正面意義。二、抗感染劑之市場分佈主要在醫學中心、區域醫院、地區醫院之住院病人，如何加強醫院感染管控是一重要課題。三、心臟血管藥物在四層級皆呈成長趨勢，對國人之健康是一大警訊。四、未分類治療藥物所佔比例偏高，藥理分類有必要重新定義。五、藥費成長趨緩與2000年實施藥價調查及分類分組定價、2001年西醫基層總額制度開辦及2002年調降西醫基層診所日劑藥費有明顯關係。六、門診部分－腸胃道藥物在醫學中心/區域醫院與地區醫院/基層診所有明顯差異。七、住院部分－心臟血管藥物在醫學中心影響最大，基層診所影響最小。

關鍵字

醫療院所 ； 藥品利用 ； 藥價調整政策 ； 藥品費用 ； 全民健保 ； 藥品價格 ； 藥價差

並列摘要

Background:
National Health Insurance (NHI) Program has been launching for more than a decade, in which the drug expenditure has always been a large financial burden to Bureau of National Health Insurance (BNHI), from 62.1 billion in 1996 up to 80.4 billion in 1999. The growth rates at 1998 and 1999 even reached to 12.9% and 11.3% respectively. In view of the drastic increase in drug expenditure and its growth rate, BNHI in 1999 announced a drug reimbursement adjustment policy for drug utilization and expenditure aiming at controlling the drug expenditure to a reasonable level. Eventually, the expenditure on drug utilization has been decreasing from around 7% in 2000 to 3.1% in 2001, and then to 2.2% in 2002.
Although the drug expenditure has been dropped to below 3%, the underlying factors controlling the growth are still unknown. The influence of the reimbursement adjustment policy on different levels of health care organizations has yet been studied. Therefore, the primary objective of this thesis is to analyze in-depth the utilization and expenditure of drug in between January 2000 to December 2002, three years of time when the new policy has been launched. Then, recommendations are inferred from the findings to improve the monitoring of the drug expenditure and medical care.
Materials and methods:
Data being analyzed is obtained from the BNHI, starting from January 2000 to December 2002. The data is basically the detail break-down expenditures the health organization units submitted to BNHI for reimbursement. In which, the data not only provides the information about the total amount of drug expenditure within the organization, but also provide detail information regarding the expenditures in different period of time, different levels and different departments, such as in-patient departments (IPD) and out-patient departments (OPD). Not all kinds of drug are studied in the thesis. Only the top 1000 drugs out of about 4000 drugs ranked by their total expenditures within the period of study will be selected, which have already constituted over 70% of the total amount on drug expenditure. Their trends are thus analyzed by using one-way ANOVA in different dimensions including by different levels, by AHFS and by in/out-patient departments.
Results:
Within the period of study, it is found that (1) the expenditures of all 19 categories of drugs in accordance with AHFS categorization are increasing. The expenditure in curing heart blood vessel is the largest. (2) By analysis the expenditure in different levels, it is also found that the drug expenditure in curing blood vessel is the largest in all 4 levels. (3) By different levels of health care organizations, the drug expenditure in curing heart blood vessel is the top in medical centers & regional hospitals while the drug expenditure in curing intestine is the top in district hospitals & clinics.
Conclusions:
(1) The drop of the expenditure in Vitamin should be due to the imposing of the reimbursement adjustment policy.
(2) Observe a large amount of expenditure in anti-infection medicine in medical center, regional & district hospitals, it seems that infection has been an inevitable problem in hospital. A better monitoring system for infection control seems to be a topic to be concerned.
(3) It is an alarm to our citizen that the expenditure of drugs for curing blood vessel is increasing. It seems necessary to have a campaign to promote the health care on heart diseases.
(4) The proportional of the unclassified drugs is persistently in high level. Re-categorization should be done in the future.

並列關鍵字

Health Care Organizations ； Drug Utilization ； NHI Drug Expenditure ； Reimbursement Adjust

參考文獻

黃文鴻(2002)。藥品支付價格調整對藥品利用型態之影響。國立陽明大學衛生福利研究所，行政院衛生署九十一年度委託研究計畫。

許俊卿、李志翰(1998)。臺灣地區十年來阿片類止痛藥使用趨勢之探討。中華公共衛生雜誌，17(6)，495-503。

黃文鴻、羅孔伶、陳柳文(1998)。我國健保藥價與國際藥價比較分析之探究。中華公共衛生雜誌，17(3)，265-272。

譚延輝(2001)。健保局目前面臨的藥物問題。臺北市藥師公會會刊。17(3)，26-33。

鄭淑妃等(2001)。全民健康保險藥物爭議審議案件研究。醫院藥學，18(3)，138-145。