全民健康保險強制門診減量的因應策略：分析臺大醫院的作法

The Strategies to the Mandatory Reduction of Outpatient Clinic Services by National Health Insurance: A Case Study of National Taiwan University Hospital

賴逸儒(I-Rue Lai)

指導教授 ： 余峻瑜

國立臺灣大學/管理學院/商學組/碩士(2021年)

https://doi.org/10.6342/NTU202101455

摘要

背景 門診減量是台灣健保署在民國107年為了落實分級醫療與轉診制度所實施的一項強制政策，要求醫學中心與區域醫院(簡稱醫中與區醫)以106年的門診件數為基準，每年需減少2%門診數量，超出額度的門診服務均不予給付，醫院須自行吸收成本。預期在5年後達成醫中與區醫門診減量10%的目標。
臺大醫院係台灣歷史最悠久的大型公立醫學中心，門診營收占其總業務收入的55%。在107年第四季因門診減量未達標準而被健保核扣40,248,573點。若減量措施不當，影響所及包括(1)營收與績效損失; (2)市場占率變動; (3)社會責任壓力等。本研究係針對臺大醫院因應強制門診減量的策略，進行回溯性的資料收集，策略分析與結果討論。
方法 臺大醫院成立門診減量小組，規劃以(1)成立雙向轉診平台，優化分級醫療轉診效能；(2)爭取有利的減量計算方式兩大主軸因應。實際的做法包括(1)優化星月計畫轉診平台，提升轉診便利與資訊共享；(2)溝通與獎勵轉出輕症病患到基層；(3)爭取按年度而非按季計算減量結果；(4)爭取增加可排除於減量計算的項目等。
結果 經過上述努力，轉出至基層院所與體系分院的輕症患者明顯增加，臺大醫院在108年達成門診輕症減量4.21%的目標，並且維持門診營運成長。
結論 臺大醫院以優化轉診、爭取有利政策的策略達成民國108年的門診減量4%目標。然而，面對未來更高的減量要求，除強化與基層院所合作、善用體系分院外，仍需提升保險者(病患)的健康識能，爭取健保署的政策配套與獎勵，方能實現分級醫療理想並追求醫療體系的成長。

關鍵字

門診減量 ； 分級醫療 ； 星月計畫

並列摘要

Background:
Reduction in outpatient services is a mandatory policy established by the National Health Insurance Administration in 2018 as a measure to implement medical triage and referral. Under this policy, medical centers and regional hospitals are required to reduce the number of outpatients by 2% per year based on the total number of outpatients in 2017, targeting to reach a total of 10% reduction in 5 years. Moreover, costs for outpatient services provided beyond the reduction target will not be reimbursed by the National Health Insurance that they are to be borne by the medical centers and the regional hospitals.

National Taiwan University Hospital (NTUH) is Taiwan's oldest large-scale public medical center, revenues generated from outpatient services account for 55% of its gross revenue. In the fourth quarter of 2018, 40,248,573 points were deducted from the National Health Insurance due to NTUH not meeting its reduction target. When reduction measures are implemented inappropriately, impacts may range from revenue loss and performance deterioration to decrease in market shares, and pressures from not fulfilling social responsibilities, etc. This study analyzed historical data and strategies implemented and discussed the results and conclusions on NTUH’s approach to reduction of outpatient services.
Approach:
NTUH established an outpatient reduction team that leverages on two parts: first, the set-up of a two-way referral platform to optimize the efficiency of triaged medical referrals; second, to apply an alternative reduction calculation method. Practices adopted include (1) optimizing the Star-Moon Project referral platform to enhance information sharing among referral network facilities, (2) communicating and rewarding for transferring patients with mild illness to general practice clinics, (3) measuring annual rather than quarterly reduction results, and (4) increasing exemption items from the reduction calculation.
Results:
As a result of efforts mentioned above, there has been a noticeable increase in the number of mild-illness patients transferred to general practice clinics or branch hospitals. NTUH has therefore reached its outpatients reduction target with 4.21% in 2019 and has since then maintained its operational growth in outpatient services.
Conclusion:
By optimizing referrals and pursuing favorable policies, NTUH has achieved the 4% reduction target for outpatient visits in 2019. However, in the face of higher reduction requirements in the future, in order to achieve the ideal triage medical care and growth and development of the medical system, in addition to strengthening cooperation with local clinics and making good use of branch hospitals, it is necessary to enhance knowledge of insurers (patients), and seek support and incentives from National Health Insurance Administration.

並列關鍵字

Reduction in outpatient services ； medical triage ； Star-Moon Project

參考文獻

參考文獻

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