發展台灣全民健康保險課責基礎支付模式

Developing An Accountability-Based Payment Model for Taiwan’s National Health Insurance

賴秋伶(Chiu-Ling Lai)

指導教授 ： 張睿詒

國立臺灣大學/公共衛生學院/健康政策與管理研究所/博士(2012年)

https://doi.org/10.6342/NTU.2012.01926

摘要

研究背景
為解決論量計酬醫療服務過度提供且缺乏照護協調性，以及論人計酬可能產生限制醫療服務與醫療服務提供者過度承擔財務風險等問題，發展課責式照護組織為給付單位的課責基礎支付模式，已成為各國最主要的支付制度改革政策之一。
研究目的
運用醫療費用申報資料建構課責式照護組織，並比較採用不同風險校正論人計酬設定目標預算，以及可避免醫療利用作為分享節餘機制對課責式照護組織財務風險影響，以評估發展全民健康保險課責基礎支付模式的可行性。
研究方法
本研究利用全民健康保險研究資料庫100萬人承保抽樣歸人檔，以2006年至2008年全年且2009年至少有1個月在保之保險對象為研究對象，並以其醫療利用之就醫型態資料發展課責式照護組織建構與病人歸屬方法。另亦比較採用性別年齡組成的人口模式與由人口模式及診斷資料組成的健康基礎模式作為風險校正論人計酬公式設定目標預算，以及運用可避免住院設算分享節餘，對課責式照護組織財務風險之影響。
結果
本研究建構88個課責式照護組織，共計847,811 (98%)研究樣本可以歸屬至門診主要照護提供者及課責式照護組織，研究樣本2008年醫療費用平均68%係來自於歸屬之課責式照護組織。運用風險校正論人計酬模式設定預算，課責式照護組織照護人數規模擴大，將提升風險校正模式醫療費用預測力並降低財務風險。運用健康基礎模式較人口模式平均財務風險可降低約2%醫療費用。採用可避免住院作為分享節餘機制平均財務收入可增加約4%醫療費用。
結論
本研究顯示全民健康保險對象就醫型態可作為建構課責式照護組織之基礎，發展課責基礎支付模式具有實務可行性。而採用較精確的健康基礎風險校正模式設定預算將增加預算分配公平性並降低財務風險，以可避免醫療利用作為分享節餘機制，將有助於獎勵照護成效改善並降低財務風險不確定性。

關鍵字

財務風險 ； 風險校正 ； 論人計酬 ； 可避免住院 ； 課責式照護組織

並列摘要

Background
The development of an accountability-based payment model to foster the creation of accountable care organizations (ACOs), which consist of providers who are held responsible for both the quality and cost of care, has become one of the most promising payment reform strategies.
Purpose
Our purpose is to develop a method for assigning National Health Insurance (NHI) enrollees and the providers who serve them to ACOs. Additionally, we will simulate the potential financial risk of the risk-adjusted capitation payment model used in setting budget targets and the potentially avoidable costs (PACs) used in the calculation of shared savings for ACOs.
Methods
We use a random sample of one million (5%) NHI enrollees from the National Health Insurance Research Database. Each NHI enrollee was assigned to a predominant ambulatory provider and an ACO based on the beneficiary's care pattern from 2006 to 2008. Demographic and health-based risk adjustment models were used to set capitation-based budgets and compare the financial risks. Financial risk is calculated as the likelihood that an ACO's actual medical costs exceed or fall short of its budget. Preventable hospitalizations were used to estimate the PACs and were calculated as potential savings for ACOs.
Results
A total of 88 ACOs were formed, and 847,811 (98%) enrollees were assigned to a specific provider and ACO. Two-thirds of health care services were billed by the assigned ACO in 2008. Enlarging the population size of ACOs will increase the accuracy of the risk adjustment model and reduce the financial risks to the ACOs. Using a health-based risk adjustment model to set capitation-based budgets, the average financial risk for each ACO will decrease by approximately 2% of the medical costs of the demographic model. Using preventable hospitalizations to calculate the potential savings, the average expected cost savings were approximately 4% of the medical costs for each ACO.
Conclusions
The development an accountability-based payment model for NHI is practical and feasible. This model would use claims data to assign virtually all enrollees to empirically defined ACOs that can be held accountable for their cost and quality of care. Adopting a health-based risk adjustment model for setting budgets and using PACs to calculate shared savings were critical to improving the equity of budget allocations and diminishing the financial risk among the ACOs.

並列關鍵字

financial risk ； risk adjustment ； capitation ； preventable hospitalization ； accountable care organization

參考文獻

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