全民健保實施陰道分娩論病例計酬制對醫療資源使用方式的影響－以某財團法人醫學中心為例

The Impact of Case Payment System on the Utilization of Vaginal Delivery under National Health Insurance in Taiwan-using Data in a non-for-profit Medical Center

莊逸洲(Yi-Chou Chuang) ； 陳怡如(Jennifer I-Ru Chen) ； 史麗珠(Lai-Chu See) ； 陳理(Lee Chen)

《中華公共衛生雜誌》 18卷3期 (1999/06) Pp. 181-188

https://doi.org/10.6288/CJPH1999-18-03-02

摘要

目標：文獻指出，將醫療支付制度由論量計酬(Fee-for-Service)改為論病例計酬(Case Payment)可有效控制醫療費用上漲。台灣於1995年3月實施全民健保，同年即對陰道分娩及剖腹産採行論病例計酬制度。本研究希望藉由分析費用消長，了解台灣實施此制度後是否真能節省醫療資源。方法：本研究以某醫學中心為例，採用健保實施前4,234個論量計酬之陰道分娩案例及健保實施論病例計酬制後共4,480個案例為研究對象，分析探討健保實施此制度前後一年醫療資源使用方式的變化。結果：論病例計酬制度實施後，陰道分娩平均總醫療費用和住院日均分別顯著降低，且可能由於中央健康保險局明確規範標準住院日數為三天，促使論病例計酬制產婦之平均住院日比前者更趨近三天。另外，我們懷疑這個新制度可能鼓勵醫師，為了讓產婦儘早出院而更改開藥行為，致藥品費增加約21%。檢驗、檢查費用的下降則似乎是趨向門診化的結果。結論：1論病例計酬付費制度可能有效抑制醫療費用上漲；2制度中明確訂定合理的規範，可以誘導醫療提供者改變其行為，達到制度預期之目標；3設定基本診療程序項目，可促使醫療照護維持一定品質，不致因支付制度的改變而受影響。

關鍵字

陰道分娩 ； 論病例計酬制 ； 全民健保

並列摘要

Objectives: It has been demonstrated in literature that Case Payment System (CPS) could control the growth of health expenditures effectively in comparing with Fee-for-service (FFS). Taiwan National Health Insurance (NHI), implemented in March 1995; therefore soon dedicated the adaptation of CPS for vaginal delivery and cesarean section reimbursement in the same year. We want to investigate if it was indeed the case in Taiwan Methods: This study compared the changes in resource utilization at a medical center hospital from January to December 1994 and from May 1995 to April 1996. There were 4, 234 vaginal deliveries categorized as the FFS group, prior to the NHI implementation, and 4, 480 deliveries as the CPS group after the CPS implementation. Results: In the CPS group, the average medical expenditure and average length of maternal postpartum stay (MPS) decreased 6.4% and 12%, respectively compared to the FFS group. A reduction of MPS from 3.4 days to slightly over 3 days was possibly in response to MPS standards set by the NHI CPS program. However, there was a 21% increase in medication expenditures during maternal stay in the hospital. We suspect that this new system modified obstetricians' prescribing patterns in order to discharge patients early. Clinical exam and lab test expenditures also decreased; these expenses seemed to be shifted to outpatient care prior to admission. Conclusions: CPS may indeed contain medical expenditure. Furthermore, it is possible to induce physicians' practice behavior if the policy is precise and reasonable. However, we believe that the NHI CPS program has to establish minimum requirements standard for ensuring service quality and avoiding the possible behavior deviation of physicians in response to the new reimbursement scheme.

並列關鍵字

Vaginal Delivery ； Case Payment ； National Health Insurance