實施TW-DRGS前影響醫院住院資源利用之因素及年度變化－以婦產科為例

Affecting Factors and time changes of hospital utilization before implementing Tw-DRGs ─Example of Obstetrics and Gynecology items

黃雅姿(Ya-Tzu Huang)

指導教授 ： 溫信財

臺北醫學大學/公共衛生暨營養學院/醫務管理學研究所/碩士(2010年)

https://doi.org/10.6831/TMU.2010.00147

摘要

美國1983年實施DRGs至今二十多年，該經驗顯示可減少醫院非必要之住院日數、住院醫療費用及強化醫療資源利用。健保局為提昇國內醫療服務，已於2010年1月1日實施台灣版DRGs (Tw-DRGs)，期望利用支付制度的改變，促使醫院資源使用更有效率。因此Tw-DRGs之實施成為當前社會關注的議題。本研究目的即在探討瞭解Tw-DRGs實施前，醫院婦產科醫療資源耗用變化之相關因素及年度變化，並比較不同醫院特性在醫療資源耗用之差異。
本研究資料來自國家衛生研究院2001-2007年之住院費用清單，先將「醫事機構基本資料檔」 (HOSB)與「住院費用清單明細檔」(DD)進行串檔後，加上醫事機構診療科別名細檔(DETA)，再利用健保局提供之網路資訊服務系統，轉出第一階段首先導入之155項Tw-DRGs代碼，依據健保局第7.3.7版權值表，取得本研究所需之Tw-DRGs 21項婦產科DRG碼後，再以SAS9.1統計軟體分析資料，以描述及推論性統計分析年度別、醫院地區、權屬、評鑑別等特性及論病例計酬案件比率對住院天數及醫療費用的影響，並進一步以論病例計酬定額減去醫院總平均住院醫療費用，由其醫療費用差額了解醫院因應支付制度改變之成效。
研究結果顯示：影響醫院婦產科21項Tw-DRGs之資源耗用因素中，年度別變項之平均住院天數約在3.64-3.9天間，2001-2007年間並無明顯變化；平均醫療費用約在20813-28267間，若以2001年為參考組，複迴歸顯示，除2003年外，其他年度分別較2001年上升91、74、2,310、4,442及4,963元，統計上皆有顯著差異(p<0.001)；醫療費用差額約在2,939-9,169間，複迴歸顯示，除2004年外，其他年度分別較2001年多110、135、36、6,667及6,133元，統計上皆有顯著差異(p<0.001)；論病例計酬案件比率部份，論病例計酬案件比率越高，住院天數越低(p<0.001)、醫療費用越低(p<0.001)，而醫療費用差額越高(p<0.001)；病例組合指標(Case Mix Index, CMI)為影響資源耗用最顯著之因素，複迴歸顯示， CMI值每上升1，住院天數上升1.64天，醫療費用上升44,466元，醫療費用差額少1,766元(p<0.001)；合併症與併發症(Comorbidity & Complication, CC)，個案比率越高住院天數越長(p<0.001)，醫療費用越多(p<0.053)，醫療費用差額越低(p<0.001)；在醫院特性方面，醫院權屬別以公立醫院住院天數4.10天較長，財團法人醫療費用26,132元較高，醫療費用差額則以私立醫院7,470元較高；層級別方面以醫學中心住院天數3.89天及醫療費用28,049元較高，但療費用差額則以地區教學醫院醫6,406元最高；醫院地區別以高屏地區住院天數3.84天最長，南區醫療費用24,806元最高，東區醫療費用差額6,577元最高 ；最後，本研究也從婦產科CMI看出醫學中心病人之疾病嚴重度較高，合併症與併發症較多。
由以上結果可知，各層級醫院對健保局實施多年之論病例計酬，已有相當之因應經驗，而面對Tw-DRGs時代之來臨，本研究建議醫院除充分了解自身之住院費用結構外，應定期監控醫療費用之變化，並針對健保局Tw-DRGs之各項規範及要來分析與改進；由於合併症與併發症可增加醫院之醫療給付，所以應加強醫師在病歷書寫完整性，提升疾病分類人員編碼的正確性；並利用DRG分析軟體加強院內審查，對於病情複雜或超出上限之個案，應藉由個案管理師加強管理並提升照護品質。

關鍵字

台灣版疾病診斷關聯群(Tw-DRGs) ； 醫療費用 ； 資源利用 ； 婦產科

並列摘要

Background:
According to the experience of US Diagnosis Related Groups (DRGs) started in 1983 and has implemented more than 20 years, it had successfully reduced unnecessary length of stay(LOS), medical cost and enhanced medical service resources. Under the same reason, the Bureau of National Health Insurance (BNHI) of Taiwan also initiated Tw-DRGs in January 1, 2010, expecting the hospital utilizations would be more effectively by change of payment system. The purposes of this study are to explore the factors and trend of utilization changes of Obstetrics and Gynecology inpatients before Tw-DRGs implementation, and also compare the utilization differences among the various hospital characteristics.
Methods:
The inpatient claim data were abstracted from National Health Research Institute from 2001-2007. After connecting the hospital basic file (HOSB) with the hospital inpatient expenses file (DD), the 21 Obstetrics and Gynecology DRGs were extracted by BNHI software (version7.3.7), then the descriptive and inferential statistics was used by SAS9.1. The affecting factors of hospital average LOS and cost include year effect, hospital characteristics, casepayment rate, CMI (case mix index) and CC (comorbidity and complication) were tested, and the balance of NHI casepayment reimbursement and hospital cost were also simulated to predict hospitals’ efficiency when BNHI had announced the Tw-DRGs implementation plan.
Result:
We found the lengths of stay were 3.64-3.9 days and the average cost is NT$20,813-NT$28,267 dollars in 2001-2007. Multiple regression showed besides 2003, if the reference was year 2001, the average cost 2001-2007 increased NT$91, NT$74, NT$2,310, NT$4,442 and NT$4,963 dollars respectively (p<0.001). Multiple regression also showed besides 2004, the balance of NHI casepayment reimbursement and hospital cost increased NT$110, NT$135, NT$36, NT$3,623 and NT$6,133 dollars respectively (p<0.001). The result also showed when the casepayment rate went up then the length of stay decreased, but as CMI went up then the length of stay increased. CMI was the most significant factor to predict utilization, if the CMI raised 1 then utilization increased 1.64 days and NT$44,666 dollars (p<0.001). The CC rate was positive correlated with hospital utilization, so when CC rate went higher then length of stay and cost increased, too (p<0.001). Finally, we found that the length of stay of public hospital and medical center are longer (p<0.001), and the CMI and CC is the highest in medical center as well.
Conclusion:
Since casepayment has implemented in Taiwan for many years, from the results, we believed that hospitals had well experience to cope with the Tw-DRGs. So hospitals faced the Tw-DRGs new payment system, they had to monitor and control their own cost structure. Due to CC is a significant factor of Tw-DRGs reimbursement, accuracy and completeness of medical record should be promoted in physicians and certified coders, also case manager and DRGs software should be used to enhance the quality of care.

並列關鍵字

Taiwan Diagnosis Related Groups (Tw-DRGs) ； Medical cost ； utilization ； Obstetrics and Gynecology

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