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全民健康保險論病例計酬制審核模式之研究

Establishment of Case Payment Review Model under NHI

摘要


全民健康保險已於民國八十四年三月一日實施,依據過去勞工保險醫療給付所須審查之資料量來推估,全民健保之資料量門診每年至少有九億三仟多萬項,而住院每年亦有二千六百多萬項。面對如此龐大之資料量,將來審查工作勢必要透過資訊電腦化,建立審查標準,利用媒體申報向電腦自動核對,符合標準者即予核付,超出標準異常案例,再以人工審核,利用差異分析及異常管理之理念、工作簡化之制度設計,達到低成本高效率、確保醫療品質、簡化行政手續及提高給付時效等目標。 全民健康保險住院支付制度未來將採用DRGs,在國內版DRGs尚未建立前,為長遠之計,而有初期採用論量計酬(FFS)及論病例計酬(Case Payment)之混合制,再過渡至國內版DRGS。 DRGs之推動最被垢病的就是醫療品質無法確保,因此建立一套公平、公正、及公開之合理審查制度,以確保醫療品質,同時簡化行政手續、迅速合理支付醫療費用及節省行政成本,實為當務之急。 本研究針對住院部份即將實施論病例計酬,為確保醫療品質及不影響病人醫療的個別性下,由長庚紀念醫院各相關專科概訂並經各專科醫學會審查,已完成一般外科等十專科之腹股溝疝氣等廿八項疾病中英文對照之『基本治療程序要求』,以建立一套PPS制度下之醫療審查標準模式,可據以參考推廣至未來全部DRGs標準。茲建議全民健保優先由這廿八種疾病試辦並繼續向其他醫學中心及各專科醫學會合作,擴大論病例計酬之實施範圍。但在訂定論病例計酬標準時,必須考慮各不同等級醫院之平均疾病嚴重度差異,以建立人平合理之醫療給付制度。最後本研究針對相關審核模式及電腦流程提出建議。

並列摘要


National Health Insurance (NHI) will be implemented on March 1, 1995. The estimate annual number of claim items reviewed under NHI will amount to at least 930 million for outpatient and 26 million for inpatient respectively. The only way to process those data efficiently is to set up standards for review, and to identify abnormal cases for manual review throughout the computer analysis. Finally, the objectives of NHI claim review system are quality assurance, process simplification, shortened reimbursement time by the design of simplification & the management of outliners. With respect to the case payment which will be adopted in inpatient reimbursement, 28 minimum requirements which are written in English & Chinese, based on diagnosis, have been completed. These minimum requirements were spelled out by the related departments of Chang Gung Memorial Hospital and reviewed by different associations of specialties in an effort to establish a peer review model under PPS or under DRGs in the future. These 28 cases are highly recommended to be implemented under Case Payment, and more minimum requirements should be completed by the cooperation of medical centers and specialty associations. In addition, the average variation of severity of illness in different levels of hospitals must be taken into consideration when setting up the reimbursement for case payment in order to pursue a fair & reasonable payment system. Finally, the related models of peer review and computerization process are also presented here.

被引用紀錄


宋霖霏(2002)。全民健保論病例計酬制實施對醫療資源耗用情形之影響評估-以鼻中膈鼻道成形術為例〔碩士論文,臺北醫學大學〕。華藝線上圖書館。https://www.airitilibrary.com/Article/Detail?DocID=U0007-1704200714495066
張文麗(2002)。探討適合台灣醫院醫療品質審查組織模式〔碩士論文,臺北醫學大學〕。華藝線上圖書館。https://www.airitilibrary.com/Article/Detail?DocID=U0007-1704200714495067
陳怡蒼(2003)。醫師對論病例計酬醫療品質認知之探討〔碩士論文,臺北醫學大學〕。華藝線上圖書館。https://www.airitilibrary.com/Article/Detail?DocID=U0007-1704200714513283
黃啟聰(2004)。地區醫院轉型長期照護機構經營策略之研究〔碩士論文,亞洲大學〕。華藝線上圖書館。https://www.airitilibrary.com/Article/Detail?DocID=U0118-0807200916281550
黃郁蓁(2010)。跨組織學習與知識移轉之研究-以S區域醫院微創中心為例〔碩士論文,亞洲大學〕。華藝線上圖書館。https://www.airitilibrary.com/Article/Detail?DocID=U0118-1511201215465039

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