血液透析與腹膜透析之成本分析與管理：作業基礎方法之應用

Cost Analysis and Management of Hemodialysis and Peritoneal Dialysis Treatments: An Activity-Based Approach

游麗穎(Li-Ying Yu)

指導教授 ： 張睿詒

國立臺灣大學/公共衛生學院/醫療機構管理研究所/碩士(2010年)

https://doi.org/10.6342/NTU.2010.02321

摘要

台灣全民健康保險制度自開辦以來，一直受到民眾高度的肯定與信賴，受惠最多者即是重大傷病的患者，而各總額部門中又以門診透析之整體醫療服務品質滿意度為最高，可見透析服務深受國人的肯定。根據行政院衛生署的統計，2008年於醫院中進行透析的人次，相較於1998年，十年間成長了74.1%，因此在民眾對透析高度滿意、透析病人激增及醫療支出高漲的情形下，已成為健保沉重的財務負擔。

台灣末期腎臟病(ESRD)的發生率(Incidence)與盛行率(Prevalent)皆高居世界第一，而透析的病人當中，有91.5%的透析患者選擇血液透析，僅有8.5%選擇腹膜透析。影響民眾透析模式選擇的因素中，償付政策(Reimbursement)佔重要的角色，許多研究認為腹膜透析的醫療支出低於血液透析，因此，有些國家以較高的償付政策來獎勵腹膜透析，腹膜透析的利用率相對較高，但台灣腹膜透析推行多年來，比率仍然偏低。

透析的醫療支出為付費者最關心的議題，唯許多文獻是以付費者的觀點來比較血液透析與腹膜透析的醫療支出，但對醫療提供者而言，獲利才是他們所關心的議題，醫療機構與醫師的行為又直接影響病人透析模式的選擇，又有研究者認為在比較治療模式的成本時，作業基礎成本分析(Activity-based cost analysis, ABC)是最適當的成本應用方法，因此本研究的主要目的是希望從醫療機構的觀點出發，以作業基礎成本法來探討血液透析與腹膜透析的成本及機構獲利狀況，作為醫療機構內部成本管理及健保支付制度之參考。

本研究採個案研究法(Case study)，以某財團法人醫院之血液透析室與腹膜透析室為研究對象，選取2009年12月1日~2009年12月31日，1個月期間之資料進行分析。研究結果發現，從付費者的觀點來看，血液透析的成本高於腹膜透析，血液透析每人每年申報的醫療費用大約是腹膜透析病人的1.39倍；從醫療服務提供者的觀點來看，血液透析的成本主要為人力、設備等固定成本，而腹膜透析的成本主要為藥品、材料費等變動成本，血液透析與腹膜透析的總成本無明顯差異；在現有健保支付制度下，醫療機構提供血液透析的利潤高於腹膜透析。作業基礎成本制是精確的成本分析方法，有助於醫療機構了解各產品線及各作業成本的結構，及有助於資源有效的運用及合理的分配。

由於政府對腹膜透析政策上的鼓勵，近年來國內腹膜透析的比率已略有成長，健保在支付腹膜透析的鼓勵，對於腹膜透析選擇比率的提升，已見些許成效，在增加對機構成本的了解，應可制定更加完善的透析支付制度，以達成其政策目標。

關鍵字

透析 ； 血液透析 ； 腹膜透析 ； 透析模式 ； 作業基礎成本 ； 醫療成本 ； 成本分析

並列摘要

Taiwan National Health Insurance has been highly affirmative and trust by Taiwan people. The most beneficial group is patients with catastrophic illness. The satisfaction rate on the outpatient dialysis service is the highest at all services, that is, the dialysis services are extremely affirmative by the people in Taiwan. According to Department of Health, Executive Yuan, the number of people received dialysis treatment in hospitals in 2008 was growing 74.1% since 1998. Therefore, the medical costs on dialysis become financial burdens of Taiwan National Health Insurance because of the increasing number of dialysis patients and high costs on dialysis services.

The incidence and prevalent on End-Stage Renal Disease (ERSD) in Taiwan are in the first place of the world. Among the patients who received dialysis treatment, 91.5% of them chose hemodiaysis and the other 8.5% chose peritoneal dialysis treatment. Reimbursement plays an important role to affect people’s choices. Many studies believe the cost of peritoneal dialysis treatment is lower than the cost of hemodialysis treatment. As a result, some countries use reimbursement policy to encourage people to accept peritoneal dialysis treatment, accordingly the usage of peritoneal dialysis is better. Even though the Taiwan Government officials tried to encourage people to use peritoneal dialysis instead, the usage rate is still low.

Payers concern about the medical cost on dialysis. Several studies were done from payers’ perspectives to compare the medical costs between hemodialysis and peritoneal dialysis. For most medical providers, they care about the issue of profits. The managers from healthcare organizations and physicians are most likely to affect practice patterns such as modality selections. Besides, some researchers believe that activity-based cost analysis (ABC) is the most appropriate cost approach to apply when comparing modality expenses between different therapies. Therefore, the main purpose of this study is to use activity-based cost approach to learn the cost and profit of hemodialysis and peritoneal dialysis, the cost analysis is performed from the perspectives of the service providers; in addition, the results are used as references of internal cost management and National Health Insurance payment system.

The case study method is used to study the hemodialysis and peritoneal dialysis patients in one non-profit hospital in Taiwan. The data is collected from December 1 to December 31, 2009. From the data analysis, it found the cost of hemodialysis is higher than the cost of peritoneal dialysis from payers’ perspectives. The cost of hemodialysis is 1.39 times (per person per year) higher than the cost of peritoneal dialysis. From the healthcare providers’ perspectives, hemodialysis cost is driven largely by the fixed costs, such as staff and equipment, etc. and peritoneal dialysis cost is driven primarily by variable costs, such as medications and medical supplies, etc. The total cost between hemodialysis and peritoneal dialysis show no differences. Under current National Health Insurance payment system, the profit of hemodialysis is higher than peritoneal dialysis. Activity-based cost approach will help the facilities understand the cost of product lines and activities; furthermore, it helps to plan better resources utilization and distribution.

Because the government officials’ policy encourages the people to utilize peritoneal dialysis and National Health Insurance supports the use of peritoneal dialysis treatment, the usage of peritoneal dialysis is increasing. Better understanding about the cost of the facilities can help the government officials to make better reimbursement policy to achieve the policy goal.

並列關鍵字

Dialysis ； Hemodialysis ； Peritoneal dialysis ； Dialysis modality ； Activity-based cost analysis ； ABC ； Medical cost ； Cost analysis

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