全民健康保險實施醫院門診合理量對醫療服務之影響評估

自民國九十年元旦起全民健保實施醫院門診合理量制度，推行期間引發諸多爭議，包括對醫院門診服務之衝擊，限制門診量危及民眾就醫權益的顧慮，及制度的誘因下所帶來的負面效應，使醫院有擴充門診量，以補足診察費折扣後之差額的可能等。無論如何，醫院門診合理量制度仍背負「提升醫療品質」及「改革扭曲的醫療生態」之重任，在醫學中心及區域醫院間推行。本研究以制度實施後半年及前年同期之健保資料，探討制度對不同層級醫院及地區之門診量及醫療費用的影響。根據本研究之結果：(1)制度實施後半年，醫學中心的門診量較去年同期增加6.5%，區域醫院增加8.3%，除南區分局之醫學中心及東區之區域醫院門診量較去年同期減少，其他醫院的門診量皆顯著增加，成長率介於4.3-19.7%之間，具統計上顯著意義。(2)門診合理量制度實施後，醫學中心的主要就醫科別中，心臟血管內科、腸胃內科、內分泌科的門診量明顯增加，增加比例介於8.2-19.4%之間；區域醫院以腸胃內科、心臟血管內科、骨科、神經科的增加較顯著，增加比例為12.1-19.0%。(3)門診合理量制度對總醫療費用的影響並不顯著。(4)根據複迴歸模式分析年齡層別、醫院層級別、制度別與各項費用的關係，得到以下的結果：(a)診察費與年齡層間呈負相關，可能與高年齡層病忠的醫療需求較高及複診次數較多有關；(b)區域醫院的診察費較醫學中心為高，可能與醫學中心的醫師門診量較區域醫院高，診察費經折扣後，取得點數較低所致。(c)明顯受到影響的費用僅診察費及藥事服務費，其中醫學中心的平均診察費減少4.6%，區域醫院減少3.7%，在節制醫療資源的浪費上，是唯一被控制的醫療費用，這是由醫療供給面限制醫療費用成長可收成效的部份。因此門診合理量的實施，短期並未能降低醫院的門診量於合理範圍內。

關鍵字

醫院門診合理量；診察費；總額預算制度

並列摘要

Hospital Outpatient Services Containment Policy of Visits of National Health Insurance was implemented since January 2001. There were many controversies including influence on hospital outpatient services, patient accessibility of outpatient services and negative effect of economic incentive, such factors inversely expand outpatient services volume to compensate the reduction of diagnostic fee. However, NHI still implemented this payment system try to improve both medical quality and the distorted medical ecology. This study collected National Health Insurance Database within half year before and after the hospital outpatient volume control payment system to analyze the impacts on outpatient visit volume and medical expenses of different level of hospitals and different NHI branch bureau. The results reveal (1) After half year of this payment system, outpatient visit volume increased 6.5% and 8.3% in medical centers and regional hospitals respectively comparing to same period of previous year. The outpatient visit volume of all hospitals except medical centers in southern branch bureau and regional hospitals in eastern branch bureau significantly increased, the growth rate range is 4.3%~19.7%. (2)After implementation of this payment system, significant increase of outpatient volume in medical centers was seen in cardiovascular, gastroenterology, endocrinology sections, the growth rate was around 8.2%~19.4%; while in regional hospitals, gastroenterology, cardiovascular, orthopedics and neurology sections increased significantly and the growth rate is 12.1% to 19.0%. (3) Outpatient volume control has no effect on total medical expenses (4) By using multiple regressive analysis of the age group hospital level. payment system and individual fee, we find (a) negative inter relationship between diagnostic fee and age group, this probably due to medical demand and multiple outpatient visits for the elderly (b) Diagnostic fee in regional hospitals is higher than that of in medical centers, this might due to higher outpatient visit volume in medical centers, but average fee was lowered after deduction (c) Significant effect was seen only in diagnostic fee and drug service fee, average diagnostic fee decreased 4.6% and 3.7% in medical centers and regional hospitals respectively, and such decrease was the only one under controlled medical expense to reduce medical resources consumption, and thence limit medical expenses growth from medical providers. So it is not effective that the policy can really lower the outpatient volumes to reasonable range and lead physicians provide longer diagnostic time and bettor medical services.