醫院推動健康促進介入計劃之經營模式成效研究

A Study on the effectiveness of Hospital Health Improvement Intervention Program：A Business Case Prospective

劉娟娟(Chuan-Chuan Liu)

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/博士(2010年)

https://doi.org/10.6342/NTU.2010.10514

摘要

背景：醫療機構所實施的健康促進模式，是從疾病的觀點以降低罹病率和死亡率來增進健康的效果，多年來在醫療費用支出上升卻未見健康促進成效，學者指出是因為許多介入計劃主要研究方向著重在流程改善、顧客服務、品質提昇議題，並未從顧客角度去思考在健康促進上的需求，失去對健康促進的原意，建議對健康促進的推動需要有新思維與作法，將醫院角色與責任由後段醫療照護走向前端的「健康促進醫院」，其起源於「渥太華健康促進憲章」。對於一向以疾病治療的醫院來說，能支持醫院持續經營的財務來源是疾病照護與支付制度收入，現今醫院面臨DRGs實施，資訊快速發展帶來醫療環境變化，醫療品質的提升壓力，評鑑制度的要求等都影響醫院的經營與管理策略，在日益競爭的醫療產業，如何將健康促進與臨床醫學結合，使醫院管理者在財務面及供給面能取得平衡，認同健康促進也能帶來效益，進而積極推動達到健康促進醫院宗旨，學者建議需要將機構學習商業的經營模式，重新設計與規劃將之結合在醫療照護系統，建立一個以顧客為導向，以健康促進為目標的經營模式。
目的：本研究主要目的探討醫院建構健康促進介入計劃的經營模式，所提供之介入計劃對接受介入與未接受介入的受檢者，在健康狀態的影響以及在個人財務面有何正向回報；並從機構角度瞭解所提供之健康促進介入計劃經營模式對於機構的影響，是否會因此而帶來財務上的收益情形；如果沒有立即財務回報，對於機構能否提供非財務正向回報作為機構永續經營的價值。
方法：本研究利用回溯性資料分析，資料來源為台北市某醫學中心健康檢查部門，資料收集自2004年至2009年間連續做過兩次全身健康檢查且間隔三年資料，以接受介入計劃與未接受介入計劃進行在基期年至追蹤年的期間，所有健康檢查資料，內容包含健康問卷、健康檢查資料、健康風險指標、健康檢查費用、轉介門診次數、轉介門診費用、滿意度調查以及所提供之健康促進介入計劃在介入組與未介入組之間的差異變化進行分析，分析方法利用描述性統計、推論性統計、傾向分數、差異中之差異分析方法進行，在非財務面的健康狀態分析以及對機構之滿意度調查；在財務面則利用機構提供此介入計畫經營模式所產生轉介門診的人次及金額進行門診成本率及利潤率分析，經折現率調整後計算對於個人及提供介入計畫之機構所帶來之淨現值分析。
結果：本研究結果顯示，對於健康改善介入計劃在對於接受介入與未接受介入的受檢者健康狀態改善結果，在基期年至追蹤年的總體資料分析，在健康風險指標除了收縮壓、飯後血糖、高密度膽固醇外其餘變項皆呈現基期年與追蹤年有顯著差異，其p value<0.001；而在分組的差異檢定，在健康風險指標介入組與未介入組皆呈現顯著差異，p value<0.001；表示在健康改善介入計畫經過三年確實在介入組與未介入組的健康狀態產生改變。為避免在兩組在隨機分派的共變項導致對結果產生偏誤，利用傾向分數進行配對分析，結果在配對前的兩組所有具差異的變項經過配對後呈現不顯著，證明在在介入組與未介入組在基期年資料是同質分布，對於結果是不會產生偏誤。在進行介入組與未介入組配對後基期年至追蹤年差異檢定，結果在BMI p value <0.05、飯後血糖p value <0.01、膽固醇、高密度膽固醇、低密度膽固醇、ATP III其p value皆 <0.001、eGFR p value <0.01；為去除受檢者因自然生物因素或其他因素所產生對於健康狀態改變之影響，因此利用介入組與未介入組進行差異中之差異法分析，結果在DID分析其F值為266.39，Adj R2 0.6939；呈現在介入與未介入在基期年並沒有明顯差異，未介入組在基期年至追蹤年前後並無差異，介入組在追蹤期比起未介入組有顯著差異，在代謝症候群分數的呈現比起未介入組下降更多，表示此健康改善介入計劃是有效的介入計畫。
健康促進介入計畫對於介入組與未介入組在財務面成本效益分析，兩組長期觀察在費用支出，未接受介入者在未來的花費是遠比接受介入計畫者來的高；對於接受介入者比未接受介入者在成本花費總計算上，其淨現值為15661.63元，表示經過折現率調整後，介入組比未介入組所得到的淨現值為正，表示健康促進介入計畫由受檢者角度來看是一個好的經營模式。
健康促進介入計畫對於機構所提供之經營模式在非財務面對於機構評價，對於機構所提供之介入計畫經營模式利用滿意度問卷調查，結果以流程護理師92.85％最高，再次健檢的意願91.1％為次高，第三為對本次健檢滿意度90.05％，其餘各項滿意度皆達閾值85%以上，證明機構提供此健康促進介入計畫的經營模式是可以做為機構永續經營的服務模式。
健康促進介入計畫對於機構所提供之經營模式在財務面的經濟效益分析，以該機構在健保醫療費用門診收入佔44.28％，急診收入佔4.91％，住院收入佔50.81％，轉介門診金額是呈現上升趨勢，以高達700萬元至850萬元間，其中利潤也介於400萬元之間，為機構帶來直接經濟效益（淨流入）自2004年至2009年共計19,522,596.13元。
綜合以上結果，對於機構提供健康改善介入計畫對於受檢者在健康狀態的改善上確實有正向回報；在個人財務上確實可以減少支出情形產生；健康促進介入計畫的經營模式對機構在財務面的經濟效益，不論在轉介門診人次以及轉介門診在收入的利潤分析，確實可為機構帶來經濟效益；至於非財務面的觀察，由滿意度問卷結果確實得到好的口碑及顧客的忠誠度呈現，也證實可以做為機構永續經營的服務模式。

關鍵字

健康改善介入計劃 ； 經營模式 ； 傾項分數 ； 前後比較法 ； 正向回報

並列摘要

Background:From a disease standpoint, health promotion models are installed by medical facilities in order to reduce disease prevalence and mortality, effectively improving health quality. For many years, medical costs have increased without significant improvement in health promotion. Experts have pointed out that many intervention programs emphasize too much on service process improvement, customer service, quality improvement, yet failed to make a customer-based approach. New promotional concepts and methods have been suggested, letting the hospitals play an important role in health promotion, disease prevention and rehabilitation services, which shifts their responsibility from backstage caretaker to forefront promoter. This concept originated from the WHO Ottawa Charter for Health Promotion. For treatment-oriented medical facilities, their major financial resource comes from payment policies or pay-for-performance programs. As more hospitals enter the Diagnosis Related Group (DRG) system, changes in medical environment brought by the rapid development of information technology and the pressure on improving healthcare quality from evaluation systems have strongly affected hospital management policies. In the increasingly competitive medical business, the goal should be to combine healthcare service with clinical medicine and to achieve one’s best interests by maintaining the balance between finance and supply. The healthcare system should be re-designed to establish a customer-oriented business case for health promotion.
Goals:The main goal of this study is to compare the effects of the Health Improvement Intervention Program (HIIP) on recipients and non-recipients. Improvements in health status and reciprocal financial benefit will be evaluated. From an organizational viewpoint, a better understanding of its impact on healthcare management and financial return can be gained. If there’s no immediate financial return on investment (ROI), the ability to provide non-financial returns may be used to measure the value of organizational function and sustainable development.
Methods:In this retrospective cohort study, we collected the health examination data between 2004 and 2009 from one medical center in Taipei. All subjects underwent two complete exams with a time gap of three years. The baseline and follow-up data were compared between recipients and non-recipients of HIIP. These included laboratory data, risk scores, examination costs, outpatient clinic referrals, and satisfaction index. Differences between the two groups were analyzed with the before-and-after method using descriptive statistics, inferential statistics, propensity score (PS), and difference-in-difference (DID) methods. Non-financial aspects included health status analysis and satisfaction index. Financial returns gained from outpatient clinic referrals were analyzed from cost and profit rates, then calculated with risk-adjusted discount rates to produce the net present value (NPV) for individuals and the intervention program facility.
Conclusions:Both groups (intervention vs non-intervention) showed improvement in all risk factors except systolic blood pressure, postprandial glucose and HDL (p value<0.001). Difference tests between groups also showed significant improvement (p value<0.001), meaning that HIIP improved all recipients’ health status after three-year follow-up. To avoid errors caused by randomization between common variables, propensity score (PS) was used to perform matched analysis. All variables with significant difference before matching showed no significant difference after matching. This indicated that the baseline data of both groups were of homogenous distribution, which would minimize any errors. Difference tests between baseline and follow-up after matching showed improvement in BMI (p value<0.05), fasting glucose (p value<0.01), eGFR (p value<0.01), total cholesterol, HDL, LDL, ATP III (p value<0.001). DID analysis was used to remove any confounding effects caused by biological or other factors. The results (F=266.39, Adj R-Sq=0.6939) showed no significant difference between the two groups at baseline. While the non-intervention group showed no difference between baseline and follow-up, the intervention group showed significant improvement at follow-up, especially in metabolic syndrome scores. This suggests that the HIIP is an efficient intervention program.
In cost-benefit analysis, the long-term medical cost for non-recipients was much higher than recipients. After adjusting with discount rate, the calculated total NPV was 15661.63 dollars. In other words, this intervention program yielded a positive NPV, suggesting that it’s a good business case for the participants.
Non-financial evaluation based on customer satisfaction surveys yielded a top score for nursing service (92.85%), followed by the desire for repeat exam (91.1%) and overall satisfaction index (90.05%). All other indices also scored higher than the 85% threshold. This suggests the intervention program business case can be beneficial for sustainable development.
In organizational profit analysis, hospital income from outpatient clinic comprised of 44.28% total, emergency department 4.91%, hospitalizations 50.81%. Outpatient referral from HIIP increased by each year between 7 to 8.5 million; profit margin was also as high as 4 million. From 2004 to 2009, the direct economic benefit was 19,522,596.13 dollars.
In conclusion, the Health Improvement Intervention Program has a positive ROI on the participants’ health status promotion. It can also reduce individual medical costs. As for economic benefits on the medical facility, outpatient clinic referrals can bring significant profit. In non-financial observation, the high satisfaction scores yielded from customer surveys show that this program can be utilized for sustainable development.

並列關鍵字

Hospital Health Improvement Intervention Program ； business case ； before and after method ； return on investment

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