- 學位論文
影響就醫層級選擇的因素-以停復保人員為例
Factors That Influence Medical Hierarchy Selection - A Case Study of Patients That Had Ever Suspended and Resumed NHI Coverage
摘要
健保自開辦以來，藉由部分負擔及各種制度來抑制民眾越級就醫情形，本研究旨在探討除了價格機制以外，是否有其他因素影響民眾就醫層級的選擇。 本研究以2010年至2015年的台灣停復保族群為樣本，並藉由Probit等機率模型與其邊際效果分析影響民眾就醫選擇之因素，以及二代健保政策施行前後對於病患的就醫層級選擇影響，並進一步探討有無職業者就醫層級選擇差異。 研究發現，地區醫院的就醫機率，在二代健保實施後，顯著減少。區域醫院和診所則是顯著增加。 女性有較高醫療使用機率，但男性比女性會選擇較高層級就醫，二代健保實施後，男性至高層級院所就醫的機率下降。 離北部地區愈遠，民眾至各醫療層級就醫機率愈低，但是至高層級醫療院所就醫機率比基層院所機率更低。而軍公教人員，相較於非軍公教人員，離北部愈遠，仍選擇醫學中心就醫。軍公教或民營機構投保愈久，至基層醫療院所就醫機率愈高，無職業的地區人口身分投保月數愈長，至高層級醫療院所就醫機率愈高。 有職業者，當年最高累積欠費金額愈多，至醫學中心、區域醫院和診所就醫機率顯著降低。無職業者，當年最高累積欠費金額愈多，至醫學中心、區域醫院就醫機率顯著增加。 泌尿科、急診醫學科、消化內科和心臟血管內科在區域醫院就醫機率高於醫學中心。二代健保實施後，泌尿科、急診醫學科、消化內科在區域醫院的就醫機率有降低，顯示區域醫院為急重症或慢性病醫療主力的情形有稍微緩和。 慢性病和急重症門診在地區醫院以上層級醫療利用率較高。而基層醫療院所以輕症疾病，如耳鼻喉科、皮膚科、牙科和中醫的治療為主。不同層級醫院，其疾病類別分佈明顯不同，顯示多數民眾有一定程度的就醫素養，惟有無職業者仍有不同就醫選擇行為，無職業者高層級醫療利用率高，因為其時間等機會成本較低，可以至大醫院久候。而二代健保的實施也造成民眾就醫層級選擇的改變。 建議加強醫療資源重複不當利用的查核，同時宣導國民健康和預防保健，以減少各醫療層級的資源耗用，才能維護真正有醫療需求者的權益。
並列摘要
Since National Health Insurance (NHI) implement, the government curb people upgrading in seeking outpatient service by co-payment and a variety of systems. This study aims to explore whether there are other factors that affect people's choice of medical hierarchy besides the price mechanism. We use the group of Taiwan beneficiary that had ever suspended coverage from 2010 to 2015 as samples of the research in order to analyze the factors that affect people how to choose a doctor, and the research variables how to affect the choice of the medical hierarchy before and after the implementation of “second-generation NHI” by Probit probability model and so on and its marginal effect analysis. Further, we explore the considerations of the medical hierarchy selection between the working and non-working people. The study found that after the implementation of the “second-generation NHI”, the probability of district hospitals for medical treatment significantly reduces. Area hospitals and clinics for medical treatment significantly increases. Women have higher probability of medical use, but men choose a higher level of healthcare than women do. After the implementation of “second-generation NHI”, the probability of male patients seeking to higher levels of hospital treatment declines. The farther away from the northern region, the lower the probability of medical treatment in each of medical hierarchy; and further, the probability of higher levels of medical institutions for medical treatment is lower than the probability of basic level medical institutions. The government employees compared to non-government employees, farther away from the north, still choose medical research center for medical treatment. Government officials or employees in private sectors subscribe to this insurance longer, the probability of the medical treatment in the basic level medical institutions is higher; non-working people subscribe to this insurance with the Township (City) Office longer, the probability of the medical treatment in the higher level medical institutions is higher. The probability of the patients of urology, emergency medicine, gastroenterology and cardiovascular seeking healthcare in area hospitals is higher than the probability in medical research center. After the implementation of “second-generation NHI”, the situation has eased slightly. The more premium arrears working people owe in a year, the more significantly the probability of them seeking healthcare in medical research center, area hospitals, and clinics reduces. The more premium arrears non-working people owe in a year, the more significantly the probability of them seeking healthcare in medical research center and area hospitals increases. The medical utilization rate of chronic disease and acute severe outpatient in the district level and above hospitals is higher. The primary care hospitals mainly treat mild disease, such as ENT (ears, nose, and throat), dermatology, dentistry, and Chinese medicine. The distribution of disease categories varies among different levels of medical care facilities. It shows that most people have some degree of medical treatment literacy. Nevertheless, there are still significantly different choice behavior between working and non-working people. Non-working people seek healthcare in the high-level medical institutions with higher medical utilization, because of their lower opportunity cost (they are willing to wait for a long time in large hospitals). Besides, the implementation of “second-generation NHI” is also contributed to the change of the public's choice behavior of medical treatment. We should strengthen the examination of repeated and improper use of medical resources; simultaneously, advocate national health and preventive care to reduce the medical resource consumption in each of the medical hierarchy. Only in this way can we defend the rights of people who really need medical care.