醫療保險支付制度對醫師決策之影響－以裝置血管支架為例

The Effect of Changing Reimbursement on Physicians' Clinical Decision-A Study of Primary Stenting

張樹棠(Su-Tang Chang) ； 童瑞龍(Jui-Long Tung) ； 錢慶文(Ching-Wen Chien)

《醫務管理期刊》 5卷1期 (2004/03) Pp. 19-33

https://doi.org/10.6174/JHM2004.5(1).19

摘要

全民健康保險開辦迄今，為考慮健保財務收支能夠平衡以達永續經營的目的，自民國91年9月健保局一方面提高保費和部份負擔以符合社會分攤和使用者付費的精神，另一方改革健保醫療支出，將傳統論量計酬制度轉換為總額支付制度。但因論量計酬制度在我國已實施多年，一時之間無法將此制度完全推翻，因此總額預算在實施之初尚沿襲過去論量計酬的方式來做總額預算，但在住院卻擴大全面實施論病例計酬(Case Payment System)制度。
然而根據國外的經驗顯示－醫療費用的控管最重要的是要能找出並改變影響醫師臨床上的決策，以抑制醫療費用的成長。本研究以某醫學中心缺血性心臟病人為例，探討醫師治療缺血性心臟病之臨床決策是否受到論病例計酬制度實施的影響？若有影響則影響力如何。在經過以CHAID法分析樣本資料後發現：
1．論病例計酬制度的實施卻對醫師臨床醫療行為具有影響力，且對不同年資背景之醫師影響有所差異。
2．論病例計酬制度對於年資較淺醫師比年資較長的醫師在治療缺血性心臟病決策上較有顯著之影響。
本研究結果顯示論病例計酬制度對醫師之臨床醫療行為確有顯著之影響，所以醫務管理者必須關心這個現象並提出因應之道，以保障病患之就醫權利。

關鍵字

論病例計酬 ； 醫師決策 ； 血管支架

並列摘要

The National Health Insurance Bureau (NHIB) has raised premiums and co-payments for balancing its financial safety on September 2002. The NHIB also has adopted a global budget payment system in replacing traditional fee-for-service payment system to contain health expenditure. However, because fee-for-service payment system has been used in Taiwan for a long time, it can not be replaced completely and rapidly. Therefore, the global budget payment system which the NHIB adapts is a fee-for-service version of global budget. But all inpatient services including in the National Health Insurance will be reimbursed by a case payment system.
According to the experience of other countries, controlling physicians' clinical decision-making behaviors is the best remedy for containing health care expenditure. Factors associated with physicians' clinical decisions should be carefully examined. The purpose of this study is to find clinical factors that influence physicians' clinical decisions of primary stenting. Claim and personnel data collected from 2,351 Patient with Ischemic Heart Disease (IHD) and their attending doctors were analyzed by a CHAID. Results of statistical analysis indicate:
1. Case payment system can influence physicians' clinical decision making but its influence varied by years of attending doctors experiences.
2. Attending doctors having less experience receive more influence of case payment system on their clinical decision making than those more-experienced colleagues.
Results of this study suggest hospital managers should attend more about this phenomenon so that patients' right can be protected.

並列關鍵字

Case Payment ； Physicians' Decision-making Behavior ； Primary Stenting

參考文獻

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全民健康保險統計

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朱澤民(2001)。全民健康保險財務收支發展及因應改革方案芻議。中央健康保險局。

李明亮(2001)。台灣未來的衛生醫療政策。行政院衛生署。