- 期刊
Tw-DRGs導入前後醫院經營績效評估－以某國軍醫院骨科為例
Evaluating Hospital Performance for Implementation of the Tw-DRGs on Orthopedics in an Armed Force Hospital
摘要
我國中央健康保險局自2010年1月1日起逐年分階段導入臺灣版診斷關聯群（Taiwan-Diagnosis Related Groups, Tw-DRGs）支付制度，預期會對醫院經營管理及醫療照護品質產生深遠的影響。某國軍醫院，在第一階段導入164項目中，以骨科對該院的營運衝擊最大，因此本研究即以某國軍醫院骨科為對象，分析比較其導入Tw-DRGs前後兩年半的經營效率及醫療照護品質並提出因應策略建議。本研究以資料包絡分析法（Data Envelopment Analysis, DEA）為方法，比較某國軍醫院骨科住院病患，自2007年第三季至2012年第二季即Tw-DRGs導入前後兩年半間，以每一季為一個決策單位（decision making unit, DMU）共計20個，選定3個投入變項（醫師數、護理人員數及住院醫療成本）與3個產出變項（醫療收入、住院手術人次及住院人日數）的資料進行分析比較。研究發現，在推論性統計方面，投入項與產出項間無顯著相關，Tw-DRGs導入前後投入項間無顯著差異，產出項中的骨科住院人日數有顯著差異。至於醫療照護品質方面，平均住院日及術後感染率則有顯著減少。而經營效率DEA法的CCR模式顯現，每年度第一季的效率值皆為該年度最低，平均效率值為89.03%，有6個有效率決策單位（DMU），以2007年第四季為最有效率之參考集合（reference set）。以Bilateral模式比較，Tw-DRGs實施前的平均效率分數1.26與實施後的平均效率分數0.90有顯著差異。進一步分析研究結果發現每年度第一季效率值皆較低，可能與民眾就醫習慣（遇農曆春節）有關。2007年第四季的產出變項相對較高，故可當為提升經營效率的參考。而Tw-DRGs實施前平均效率分數較高，應與醫療總額有關，分配的醫療總額愈高，達成的醫療收入相對也會提高。Tw-DRGs實施後，醫療總額減少，也降低平均效率分數。總之，Tw-DRGs是健保局推動的重要支付方式，雖然目前沒有如期分階段導入，但未來勢必會繼續推行，醫院經營者必須要同時提升經營效率及整體醫療照護品質，合理縮短平均住院日，降低術後感染率及3日內再急診率，以創造醫院經營者、病患及健保局全贏的醫療服務。
並列摘要
The Bureau of National Health Insurance has imported Taiwan-Diagnosis Related Groups (Tw-DRGs) payment system every year in phases since January 1, 2010, expected to have a profound impact in the hospital management and medical care quality. The orthopedics would have the largest impact on hospital's operations in the first phase of the 164 items of Tw-DRGs in an armed forces hospital. This study compares the operational efficiency and medical care quality between the two-and-a-half years before and after the import of Tw-DRGs, and proposes coping strategies recommended for the target hospital. We employ the data envelopment analysis (DEA) method using 20 decision making units (DMU) to compare the operational efficiency with the three input variables (including the number of doctors, number of nurses, and hospital medical costs) and three output variables (including medical income, the numbers of surgical operations and the number of patient-days) between the import of Tw-DRGs (from the third quarter of 2007 to the second quarter of 2012). Previous studies found that between input and output variables have no significant relation in inference statistics. The input variables before and after Tw-DRGs is imported also have no significant difference, however, the output variables, the number of orthopedic inpatients, have significant difference before and after Tw-DRGs. As for the quality of medical care, the average length of stay and postoperative infection rates have significantly reduction. Moreover, the operational efficiency in DEA metdod's CCR model shows that the degree of efficiency value in the first quarter of each year is the lowest of the year, the average efficiency value is 89.03%, six efficient DMU, and the most efficient reference set in the fourth quarter of 2007. Using Bilateral model, the average efficiency scores before the implementation of Tw-DRGs is 1.26, it has significant difference on the average efficiency scores 0.90 after the implementation of Tw-DRGs. Further research results found that efficiency values of 1st quarter are lower, it may be related to people's medical treatment habits (the case of the Chinese New Year). Output variables were relatively high in the fourth quarter of 2007, therefore, it can be used as reference set for improving management efficiency. However, the average efficiency score before the implementation of Tw-DRGs is higher, it is related to the medical total amount. The higher the medical total amount allocated, the medical income reached relatively would also improve. After the implementation of Tw-DRGs, the medical total amount decreased and also reduced the average efficiency scores. In short, Tw-DRGs is the important payment system driven by the Bureau of National Health Insurance. Although it is not scheduled to import in phases currently, it is bound to be continued in the future. Therefore, Hospital operators must improve operational efficiency and overall quality of medical care, shorten the average length of stay, and reduce the incidence of postoperative infections and 3-days re-emergency rate simultaneously, in order to create a all-win medical services of the hospital operators, patients and the Bureau of National Health Insurance.