台灣常見手術市場集中與趨勢分析

研究背景：醫院與醫師服務量往往與病人之照護結果有正向的關係，因此國外開始提出集中化(Centralization)的概念，建議進行相關高風險手術之病人應前往較高醫院服務量的醫院，台灣實施全民健康保險至今已快二十年，過去也減少了許多醫院，國內雖有文獻在探討服務量與許多手術的照護結果，然而缺少文獻探討台灣長期手術市場的改變趨勢。研究目的：探討近十年台灣常見手術的市場集中趨勢與各手術照護結果之變化並分析市場集中程度對於台灣常見手術之照護結果是否有影響。研究方法：本研究研究期間為1999年至2010年，使用全民健康保險研究資料庫住院醫療費用清單明細檔，本研究分為兩部份，第一部分欲了解長時間下來台灣不同手術的手術集中化之趨勢與服務量集中趨勢及照護結果的變化等，照護結果本研究使用30日再入院率，選取手術為全髖(膝)關節置換術、闌尾切除術、結腸切除術、胃切除術、CABG與PTCA，第二部分選取全髖關節置換術與闌尾切除術以GEE來探討集中程度對於服務量集中與照護結果之關係。研究結果：在研究期間，癌症手術與常見的手術之醫院家數皆呈現下降的趨勢，然而除闌尾切除術外，其餘的市場集中程度皆下降，所以沒有「醫療市場集中」的情形。闌尾切除術市場集中程度些微上升可以認為是醫院數大幅的減少，且退出市場的醫院多為小醫院。而心血管手術則因為需求人數增加，進入市場的醫院增加，市場呈現更競爭的狀態。而本研究也認為，市場集中指標的趨勢會和民眾到市占率高的大醫院比例有相關性，所以除了手術的集中指標皆下降外，所有大醫院市佔率也都在下降。地區醫院年服務量和市場集中程度的相關性並不一致，市場集中程度與醫院之平均30日再入院率無顯著相關。未來建議在服務量-照護結果的立基下設立手術集中化政策。

關鍵字

服務量-照護結果；集中化；市場集中

並列摘要

Background: Studies reveal that hospitals or Surgeons with higher number of surgical procedures are associated with better patient outcomes. As a result, this volume-outcome relationship suggests that centralization of resources may further improve quality of surgery. It has been 20 years since Taiwan started the National Health Insurance. In the past years, the number of hospitals has been decreasing continuously. Although there have been studies investigated the volume-outcome relationship in Taiwan, there has been no study examine the trend of surgery centralization in a long-term perspective. . Objective: This thesis evaluated the distribution of surgery among hospitals, which is called “centralization”, in six common surgeries. Further, this thesis also analyzed the impact of market concentration on patient outcome. Methods: A secondary data analysis was performed using National Health Insurance Research Database (NHIRD) between 1999 and 2010. This study had two parts. The first part was to describe the trends in market concentration rates, hospital volume and 30-day readmission. The surgical procedures included Appendectomy, Total hip or knee replacement, Colectomy, Gastrectomy, CABG and PTCA. The second part used Appendicitis and Total hip or knee replacement as example to further analyze the relationship between market concentration rate and patient outcome by GEE models. Results and Conclusion: Between 1999 and 2010, the number of hospitals conducting cancer treatment and common surgeries were decreasing. Except for Appendectomy, HHI of the surgeries tended to be declining, which means becoming more competitive. Therefore, the phenomenon of “Surgery market concentration” didn’t occur in Taiwan. The increase of HHI of Appendectomy can be explained by the rapid decrease of small-sized hospitals during the observation period. Because of the increasing demands for Cardiovascular surgery, more and more hospitals entered the market. As a result, we observed the significantly decreasing HHI trend for PTCA. In this study, we concluded that HHI trends may have associated with the market share of big hospitals because of the simultaneous trend in HHI and the proportion of patients treated in big hospitals. In addition, this thesis found no significant impact of HHI on hospital’s average 30-day readmission in Appendicitis and Total hip or knee replacement. The results of the thesis suggest that government may introduce centralization policy or minimum volume standard based on volume-outcome relationship to improve surgery outcome.