全民健保部分負擔調漲對門診醫療利用影響之長期追蹤分析

The Longitudinal Analysis of the Effects of NHI Cost-sharing Increase on the Utilization of Out-patient Services

張迺榮(Nai-Jung Chang)

指導教授 ： 鄭守夏

國立臺灣大學/公共衛生學院/衛生政策與管理研究所/碩士(2009年)

https://doi.org/10.6342/NTU.2009.02804

摘要

台灣自1995年實施全民健保以來，數次採取部分負擔調漲的方式，試圖從需求面來抑制民眾的門診利用，並引導民眾減少越級就醫。目前關於部分負擔制度的成效已得到廣泛評估；然而，以往的研究多數為橫斷性的研究，較少長期追蹤資料的研究。本研究試圖以健保資料庫的固定樣本進行長期追蹤分析，以釐清部分負擔政策介入對於民眾門診利用及越級就醫的相關影響，並且探討某些特定民眾是否受到影響。本研究分為以下三個主題：(1)主題一：檢視部分負擔調漲對較低所得民眾醫療利用的影響。(2)主題二：檢視部分負擔調漲對醫療利用的長期影響。(3)主題三：檢視部分負擔調漲對民眾越級就醫及降級就醫的影響。
　　選擇性的衝擊。此外，部分負擔調漲對於需部份負擔身份者的越級或降級就醫比例未產生明顯的影響。因此，在抑制民眾越級就醫的政策目標上，部分負擔調漲並非適切有效的措施。根據研究結果，我們建議政府除了部分負擔之外，應制定新的政策，以發展較完善的分級醫療轉診制度。

本研究使用1997至2006年健保資料庫的「承保抽樣歸人檔」，進行跨越三次部分負擔調漲的長期追蹤分析。研究方法主要為：(1)主題一：以邏輯斯迴歸分析影響民眾就醫次數持續減少的因素；(2)主題二：採用間斷時間數列設計配合間斷時間數列迴歸，以及準實驗設計配合差異中的差異和廣義估計模型，來探討三次部份負擔調漲對醫療利用的長期影響；(3)主題三：採用準實驗設計配合差異中的差異和廣義估計模型，探討影響部分負擔前後越級及降級就醫比例的因素。

研究結果呈現出：(1)主題一：部分負擔實施並未對較低所得民眾產生明顯抑制就醫的衝擊。(2)主題二：從整體醫療利用來看，對於男性需付部分負擔身分者，1999年部分負擔調漲後對醫療利用產生抑制的作用；從個人就醫利用來看，三次部分負擔調漲皆對於民眾醫療利用有顯著抑制的作用。(3)主題三：2002年及2005年兩次部分負擔調漲介入，對於需部份負擔身份者的越級或降級就醫比例並未呈現顯著的影響。

關鍵字

部分負擔 ； 分級醫療 ； 全民健保

並列摘要

Since the implementation of National Health Insurance (NHI) in Taiwan in 1995, the NHI has raised the cost-sharing requirement several times to restrain the increasing number of physician visits and to promote the referral system. The effect of NHI cost-sharing policy has been widely assessed; however, most of previous studies only examined the short-term effect using cross-sectional study design. The aim of this study was to examine the 3-times cost-sharing increases on the health services utilization using longitudinal techniques. This study comprises three research topics: (1) Examining the effect of increased cost-sharing on physician visits of relatively low-income people; (2) Investigating the long-term effect of cost-sharing policies on health services utilization; and (3) Examining the long-term effect of cost-sharing policies on up-grade or down-grade outpatient visit.
This study conducted analysis with a longitudinal study design. The main data source was the Longitudinal Health Insurance Database compiled in the year 2005 (LHID2005). This study selected the five subsets of the LHID2005 to form a sample of 200,000 subjects. (1) A logistic regression was applied to examine the factors associated with continuous decreasing number of physician visits; (2) An interrupted time series design with the segmented regression analysis and difference-in-difference analysis with Generalized Estimating Equation (GEE) were performed to test the impact of various cost-sharing increases on the number of physician visits; (3) A difference-in-difference design with Generalized Estimating Equation (GEE) was conducted to examine the impact of various cost-sharing increases on the skipping grades in seeking outpatient service.
Major results are as follows: (1) The increases of cost-sharing requirement did not significantly restrain the number of physician visit among low-income population. (2) The cost-sharing increase in 1999 had significantly reduced the number of physician visit especially for male subjects who need to pay cost-sharing. In addition, from individual perspective, the three-times cost-sharing increases had significantly reduced the number of physician visit. (3) The cost-sharing increases in 2002 and 2005 were not significantly associated with the rate of the up- or down- grades in seeking outpatient service.
We concluded that the increases of cost-sharing requirement had long-term impact on the health services utilization. No significant variation was observed among different income groups. The cost sharing policy has no significant effects on the skipping grades in seeking outpatient service. According to the findings, we suggest that the government should develop new strategies to promote the referral system in addition to the cost-sharing policy.

並列關鍵字

Cost-sharing policy ； Hierarchy of medical service ； National health insurance

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