支付制度對醫療資源耗用的探討－以闌尾切除術為例

Comparing Medical Utilization among Different Payment Systems-an Example of Appendectomy

林美珠(Men-Chu Lin) ； 沈昱名(Yu-Ming Shen) ； 文羽苹(Yu-Ping Wen) ； 史麗珠(Lai-Chu See)

《醫務管理期刊》 7卷3期 (2006/09) Pp. 306-322

https://doi.org/10.6174/JHM2006.7(3).306

摘要

本研究是以闌尾切除術為例，比較論量計酬(Fee for Service, FFS)、論病例計酬(Case Payment, CP)、總額預算(Globe Budget, GB)及醫院層級對醫療資源使用的影響，故分別選取FFS（民85年11月至86年2月）、CP（86年11月至87年2月）及GB（91年11月至92年2月）之三種不同時期，在桃竹苗地區之闌尾切除術的健保局申報資料作二手統計分析。
結果發現(1) CP後疾病嚴重度提升。(2)住院天數自FFS的5.4天，降為CP的5.1天，再下降為GB的4.7天；醫療總費用(total fee, tfee)卻自FFS的26,072元，上升為CP的27,192元，再上升為GB的29,614元。(3)將疾病嚴重度分層及調整病患年齡，醫學中心的tfee仍較區域及地區醫院高，住院天數也較長。(4)依CP將tfee轉換成ABC段，A段為tfee低於支付標準，B段為高於支付標準但低於核實上限，C段則是高於核實上限。醫學中心從FFS到CP, A段%減少，BC段%增加，達顯著差異；GB後的ABC段%，與FFS時期比例相近。
由此可見(1)支付標準對醫療資源耗用有顯著影響，(2)醫療院所能有效控制醫療成本，(3)控制嚴重度後，醫院不同層級的差異仍然存在，(4)嚴重病患有傾倒至醫學中心之嫌。

關鍵字

論量計酬 ； 論病例計酬 ； 總額預算 ； 闌尾切除術 ； 醫療資源

並列摘要

The National Health Institute (NHI) reimbursement database of appendectomy was used to examine how varied payment systems (fee for service (FFS), case payment (CP), global budgeting (GB)) and hospital level affect medical utilization. Secondary data analysis was performed on the North Branch of NHI from Nov. 1996 to Feb. 1997 (FFS), Nov. 1997 to Feb. 1998 (CP), and Nov. 2002 to Feb. 2003 (GB).
We found: (1) After CP, disease severity increased. (2) Mean length of stay (LOS) started from 5.4 days at FFS, decreased to 5.1 days at CP and 4.7 days at GB. Mean total medical fee (total fee, tfee) was NT$ 26,072 at FFS, increased to NT$ 27,192 at CP and NT$ 29,614 at GB. (3) When data was stratified by disease severity and adjusted for age, tfee was still higher in medical centers than that in regional or local hospitals, so was LOS. (4) Tfee was transformed into segment ABC based on CP. Segment A were records with tfee＜reimbursement ceiling; segment B were those with tfee＞reimbursement ceiling but ＜ FFS floor; segment C were those with tfee＞FFS floor. In medical centers, segment A % decreased, and segment BC% increased after CP, a significant difference from those at FFS (p=0.0056). Segment ABC proportions at GB were similar to that at FFS.
We concluded that payment system has a significant impact on medical utilization. Control of the cost of medical utilization by hospitals was seen. After stratified for disease severity, medical fee and LOS were different among various levels of hospitals. Case dumping from low level of hospitals to medical centers seems to be common.

並列關鍵字

Fee for Service ； Case Payment ； Global Budgeting ； Appendectomy ； Health Utilization

參考文獻

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