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評估總額預算下眼科醫師做為醫療供給者的行為變化-從競爭的公眾悲劇轉為合作的納許平衡

Changes of Providers' Behaviors upon Global Budgeting: An Example from Ophthalmologists' Experience, Evolving from Dysfunctional Tragedy of the Commons to a Cooperative Nash Equilibrium

Abstracts


背景:西元2002年起,台灣全面實施總額預算給付制度,同時採行支出上限制,分為牙醫、中醫、西醫基層與醫院四部分。本研究討論眼科醫師在總額預算實施後的醫療行為變化,是否會因此藉由增加高給付項目的服務量,來得到較高的收益(所謂的公眾悲劇),而當面對給付點值下降收入減少時,才逐步走向合作的納許平衡。 方法:我們使用國家衛生研究院發行的健保資料庫二級資料擷取西醫基層診所總額實施前(2000年)、實施後(2005與2007年)眼科醫師的申報資料進行分析。我們將西醫基層眼科診所資料,分為西醫一般案件(簡表)以及西醫其他專案案件(含檢查、處置等申報);我們也收取醫院總額實施前(2001年)、實施後(2005與2007年)的所有眼科醫師門診手術申報資料,而將醫院方面的資料分為論病例計酬類(白內障)以及其他門診手術(非論病例計酬)。我們的假設是預期總額實施初期,將產生公眾悲劇(點數增加點值下降),其中西醫基層診所將增加專案申報數量,而醫院則增加論病例計酬手術的數量;在總額實施後期(2007年),則因應各種調節因素,西醫基層診所將減少專案申報數量,而醫院也減少論病例計酬手術的數量,而達到納許平衡。 結果:我們原先預計總額實施初期會產生公眾悲劇,然而在所觀察的研究初期,考慮區域競爭的影響下,西醫基層診所一般案件(簡表)總申報點數減少,而專案總點數則為增加,符合本題假設。在醫院的部分,門診論病例計酬手術申報變化不明顯,而非論病例計酬手術則穩定增加,不符合本題假設。在實施總額後期,西醫基層診所一般案件(簡表)總申報點數減少,而專案總點數則為增加,不符合本題假設。在醫院的部分,門診論病例計酬手術申報減少,而非論病例計酬手術則穩定增加,符合本題假設。 結論:長遠來看,如果有足夠專業的自律機制,總額預算仍然可以控制醫療供給者不適當的誘導需求。

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Parallel abstracts


Background: In 1998, the National Health Insurance Bureau of Taiwan started to implement a phased global budgeting, which imposed a nation-wide expenditure capital on each sector of health care. The system was universally implemented for all categories of medical care institutions by July 2002. This study examined whether Taiwanese ophthalmologists responded to global budgeting by expanding the high-value care volumes to the capture greater revenue shares (Tragedy of the Commons) initially, and followed by adopting a cooperative Nash Equilibrium when faced with decrease in total revenues despite increasing care volumes. Methods: Secondary care data of ophthalmic claims for 2000, 2001 (pre-GB for clinic and hospital sectors, respectively), 2005 (post-GB for clinic and hospital sector) and 2007 (post-GB long-term response for clinic and hospital sectors) were analyzed. The data were extracted from simplified claim forms (SCF) (routine office visit, fixed low price) and special case claims (SCC)(complex clinical conditions with variable inputs) submitted by clinics as well as case payment (CP) claims for cataract surgery (fixed, though attractive reimbursement rate) and non-case payment claims (NCP, for cases with variable care inputs) submitted by hospitals. We expected the phenomenon of Tragedy of the Commons would cause ophthalmic clinics to expand high-value services (SCC) as well as the hospitals to increase CP volume. Results: Among ophthalmic clinics, SCC care increased with a concomitantly reduced SCF post-GB, and followed by a stabilization in the long-term post-GB phase. A moderating effect of market competition level (Herfindal-Hirschman Index) is observed. Among hospitals, the volume of CP claims reduced and stabilized while the volume of NCP claims increased steadily throughout the entire study period, which supported the notion of Tragedy of the Commons hypothesis but without attaining the Nash equilibrium. Conclusion: Global budgets may control supplier-induced demands in the long term of observation except an adequate professional self-regulatory mechanism is facilitated.

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