台灣全民健康保險藥價給付費率調降政策在價格管控之影響的探討--- 以降血壓藥為例之實證研究

Exploration of the Influences on Price Control of Drug Reimbursement Rate Reduction Policy in Taiwan’s National Health Insurance System--- An Empirical Study on Hypotensive Agents

陳計良(Chi-Liang Chen)

指導教授 ： 劉順仁

國立臺灣大學/管理學院/會計學研究所/博士(2008年)

https://doi.org/10.6342/NTU.2008.02352

摘要

逐年上漲的醫療支出已經成為各國政府所面臨的嚴重問題，而且急需尋求解決的對策。其中藥品費用上漲的速度更超過整體醫療支出上升的速度，這促使許多控制藥品費用的政策被制訂以抑制藥品費用的上漲。台灣實施「全民健康保險」制度已超過十年，在控制藥品費用上也實施了許多政策，其中藥價給付費率調降政策在2000年至2003年更是執行了三次，每一次藥價調降的幅度及種類項目均不相同，究竟其成效如何以及對藥品使用療效之潛在影響，還有不同醫院對此政策之反應，實是值得加以進行系統性之研究。
本文擷取全民健康保險研究資料庫之歸人檔承保資料，去除藥價給付費率調降政策以外的其他政策影響以及考慮季節效果之後，挑選出40歲以上之高血壓病人樣本族群，三次調降政策分別為5698人、5862人以及6432人，另外，依照世界衛生組織之「藥品解剖學治療學化學分類系統」，再從這些樣本族群的門診資料彙整出最常用的兩類高血壓藥物，採用階層線性模型來分析醫療服務供給者在面臨藥價給付費率調降政策的負面財務誘因時，其醫療行為的改變對此政策控制藥品價格的效果以及對藥品使用療效之影響。
本文研究結果發現，在2000年至2003年執行的三次藥價調降政策，對於兩類最常用的高血壓藥物並不具有價格控制效果，亦即想藉由控制藥品價格來降低藥品支出的政策目標並無法達成；另外，在相同的藥品成本下，也無法增進藥品使用的療效。根據階層線性模型的分析結果，發現不同特質及屬性的醫院對藥價調降政策確實具有不同的反應。

關鍵字

成本控制政策 ； 藥品支出 ； 財務誘因 ； 醫療提供者行為 ； 全民健康保險

並列摘要

Rapidly rising pharmaceutical costs have been a worldwide problem. Under such pressure, governments in many countries have launched various programs in order to curtail the growth of drug expenditure; among them, drug price control is frequently used. Extant research, however, has used macro-level (aggregate) data and can only provide very limited insights into the effect of the drug price control policy on health care providers’ prescription behaviors. Consequently, these works fall short in examining whether the pharmaceutical price control policy can improve the cost-curative effect of pharmaceutical use, and whether the drug price control policy may have different influences on health care providers with different characteristics.
This study investigates influences of Taiwan’s drug reimbursement rate reduction policy in its National Health Insurance system on the price level and the cost-curative effect of pharmaceutical use, using hypertension patients’ usage of hypotensive agents as the example for such analysis. Specifically, we take advantage of the rich content of data in the National Health Insurance Research Database to construct a micro-level database that enables us to examine the following additional two issues: (1) whether the pharmaceutical price control policy has helped improve the cost-curative effect of usage of hypotensive agents, and (2) whether this policy has different effects on health care providers with different characteristics.
We used Taiwanese hypertension patients aged 40 or over as our study population. This population accounts for almost the entire population of hypertension patients who take prescription drugs. We selected the two most used narrow classes of hypotensive agents based on the first four digits of the coding system of Anatomical Therapeutic Classification (ATC). They are peripherally acting antiadrenergic agents (ATC code=C02C) and plain angiotensin II antagonists (ATC code=C09C).To provide insights into whether the reimbursement rate reduction policy has had different effects for hospitals with different characteristics, we apply the hierarchical linear modeling (HLM) technique.
Findings from this study indicate that the price control initiatives between 2000 and 2003 were not helpful for improving the cost-curative effect of using the C02C and the C09C drugs, since the daily expense was not reduced for these two drug classes because of the initiatives. As the magnitude of price reduction level was small for each of the two drug classes, such findings reflect the uselessness of the small price reduction.
While the drug price control policy had insignificant effects on the daily expense for the C02C drugs and the C09C drugs, variations in the influence existed among health care providers with different characteristics. Physicians in public hospitals appeared to prescribe cheaper C09C drugs after the 2000 price reduction. In contrast, physicians in medical centers tended to prescribe more expensive drugs in the two classes after a reimbursement rate reduction action. The percentage of the specialist group comprising cardiologists, nephrologists, and internal medicine physicians in a hospital was associated with a tendency to prescribe more expensive C09C drugs after the 2001 and the 2003 reductions.
The different changes in the daily expense after the drug price reductions for hospitals suggest that hospitals with different characteristics might have different patterns of switching drug types in their prescriptions or some patients might switch hospitals after an action of reimbursement rate reduction. Such results suggest a need for the government to better monitor health providers’ behavior of switching prescription drugs and patients’ behavior of switching hospitals so as to have a better understanding with respect to how drug price control actions could affect pharmaceutical expenditures and health care quality.

並列關鍵字

Cost control policy ； Drug expenditure ； Financial incentive ； Health care providers’ behavior ； National Health Insurance system

參考文獻

Abbott, T. A., and Vernon, J. A. (2005). The cost of US pharmaceutical price reductions: A financial simulation model of R&D decisions: National Bureau of Economic Research, Inc.

Andersson, K., Bergström, G., Petzold, M..G., and Carlsten, A. (2007). Impact of a generic substitution reform on patients' and society's expenditure for pharmaceuticals. Health Policy, 81, 376-384.

Bloor, K., and Freemantle, N. (1996). Lessons from international experience in controlling pharmaceutical expenditure. II: Influencing doctors. British Medical Journal, 312(7048), 1525-1527.

Bloor, K., Maynard, A., and Freemantle, N. (1996). Lessons from international experience in controlling pharmaceutical expenditure. III: Regulating industry. British Medical Journal, 313(7048), 33-35.

Bureau of National Health Insurance. (2007c). Guidelines of price adjustment for National Health Insurance reimbursed drugs. [http://www.nhi.gov.tw/webdata/AttachFiles/Attach_8559_2_chi65-4.pdf]