- 學位論文
醫療服務市場競爭程度與醫院收費及照護結果之相關性研究
The Association between Market Competition,Out-of-pocket Charges and Healthcare Outcomes
摘要
研究背景與目的:在總額預算制度的實施下，全民健保的支出受到節制，但醫療服務成本的控制責任卻轉移到醫療服務提供者身上，此時醫院既要控制成本，又要面臨醫療服務市場的高度競爭，如此可能對醫院造成營運上的壓力。近年來有學者發現醫院提供的自費醫療服務項目有增加的趨勢，且醫院開始會將多收取自付費用作為因應策略；另一方面，根據Gaynor的理論，在醫療服務價格受到管制下，醫院之間會進行品質競爭。於此，瞭解醫院面對競爭時所採取之策略是當前極需探討之議題，但過去十年來，國內有關醫院向民眾收取之醫療費用資料仍舊不足。本研究主要目的在於分析在醫療服務價格受到健保署管制下，面臨競爭的醫院是否會以多收取醫療費用作為其求生存之手段，以及競爭是否會帶來醫療品質的提升。 研究方法:本研究以利用2018年「全民健保病人住院經驗調查問卷」作為研究調查工具，收案對象為年齡20歲以上，過去一年有住院經驗的病患。自變項「市場競爭程度」是依照衛生福利部醫療網計劃所規畫之16個醫療區(扣除澎湖醫療區)劃分市場範圍，再以賀芬達指數(HHI)計算各醫療區之競爭程度。依變項則是使用病人填答之問卷，測量住院期間的醫院收費及照護結果(包含對醫院照護的整體評分及推薦意願)。考慮到資料結構具有鑲嵌(nested)的特性；因此，將研究資料結構分成「病患」(解釋變項包含人口學特徵及住院情形)及「醫院」(解釋變項包含醫院特質)兩個層級後，若依變項為「連續」屬性之資料，例如:醫院收費，在多變項分析時將採用階層線性模式(HLM)進行分析；而依變項為「類別」屬性之資料，例如: 醫院整體評分及推薦意願，則採用階層廣義線性模式(HGLM)進行分析。 研究結果: 研究結果發現，醫院收費平均為2.67萬元，標準差為3.33萬元；在照護結果方面，病患對醫院整體評分，高評分( 9-10分)佔45.74%，低評分( 0-8分)佔54.26%，而推薦意願則以「願意推薦」為主，佔85.94%。多變項分析的結果發現，在控制其他變項下，相較於市場競爭程度低之醫療區，市場競爭程度高的醫療區醫院收費較高，高出1.2%，但並無達到統計上的顯著差異(p=0.844)；在照護結果方面，經由控制其他變項後，市場競爭程度與對醫院整體評分及推薦意願無關。此外，病患階層的「年齡」、「教育程度」、「住院管道」、「病房類型」、「住院天數」，醫院階層的「醫院評鑑等級」、「醫院權屬別」及區域階層的「區域付費能力」是影響醫院收費的相關因素；而病患階層的「教育程度」、「家戶所得」、「住院管道」及「病房類型」是影響對醫院整體評分的相關因素，至於「教育程度」、「住院管道」、「病房類型」及醫院階層的「醫院評鑑等級」則是影響對醫院推薦意願的相關因素。 結論與建議: 在我國住院服務市場並沒有發現市場競爭會影響醫院的收費，也沒有發現各醫療區競爭會影響醫療服務品質，表示在價格管制之下，表示醫院不會以「價格」作為競爭的手段；同時，研究結果也說明醫院的表現並不會因為競爭程度高低而有所不同，象徵著病患無論在何處就醫都能享有公平合理的價格及獲得良好的醫療照護，建議衛生主管機關應持續關注市場競爭之下醫療服務提供者所採取的相關策略，以及注重於瞭解病患之就醫經驗，對此改善整體醫療品質，本研究結果可供相關政策及醫院管理之參考。
並列摘要
Background Objectives: Under the implementation of a global budget payment system for hospital reimbursement, the expenditure of National Health Insurance (NHI) is restrained, but the responsibility for controlling the cost of medical services is transferred to the medical service providers. At this time, the hospital not only needs to control the cost, but also needs to face higher competition in the medical service market, which may cause operational pressure on the hospital. In recent years, some researchers have found that the number of “out-of-pocket” services provided by hospitals has increased, and hospitals have begun to charge more out-of-pocket payments as a coping strategy. On the other hand, according to Gaynor's theory, if medical service prices are regulated, hospitals will compete for quality. Therefore, understanding the strategies adopted by hospitals in the face of competition is a topic that needs to be discussed at present. However, in the past ten years, there is still insufficient information about the out-of-pocket payments charged by hospitals in Taiwan. Therefore, the main purpose of this study is to analyze when medical service prices are regulated, whether hospitals facing competition will charge more out-of-pocket payments, and whether competition will improve the quality of medical care. Methods: This study used the National Health Insurance Patient Hospitalization Experience Questionnaire in 2018 as a research tool, and the subjects were patients older than 20 years old and had hospitalization experience in the past year. The independent variable “market competition degree” is based on the 16 medical districts (excluding the Penghu medical district) planned by the Ministry of Health and Welfare's medical network plan to divide the market scope, and then calculates the competition level of each medical district by using the Herfindahl-Hirschman Index (HHI). The dependent variables were questionnaires filled out by patients to measure out-of-pocket charges(including NHI copayment) and healthcare outcomes (including global ratings and willingness to recommend of hospital care) during hospitalization. Considering that the data structure is nested, the research data structure is divided into two levels including “patients” (explaining variables including demographic characteristics and medical uses) and “hospitals” (explaining variables including hospital characteristics). Then, if the dependent variable is continuous, such as hospital charges, the hierarchical linear model (HLM) will be used in the multivariate analysis; and if the dependent variable is category, such as the global ratings and willingness to recommend of hospital care were analyzed using Hierarchical Generalized Linear Model (HGLM). Results: The results of the study found that the hospital charges an average of NT26,700 Yuan, with a standard deviation of NT33,300 Yuan. In terms of healthcare outcomes, patients’ global ratings of hospital care with higher scores (9-10 points) accounting for 45.74%, and lower scores (0-8 points) accounting for 54.26%, while the willingness to recommend was dominated by “willing to recommend”, accounting for 85.94%. The results of the multivariate analysis found that, compared with the medical districts with lower market competition, the hospital charges in the medical districts with higher market competition were higher by 1.2%, but the association was not significance(p=0.844). On the other hand, it was also found that the association between the degree of market competition has nothing to do with the global ratings of the hospital and the willingness to recommend. In addition, the results revealed that hospital charges were associated with age, education level, admission route, types of wards, lenth of stay of the patient level, hospital accreditation level, hospital ownership of the hospital level and ability to pay of the regional level. Finally, the global ratings of the hospital were associated with educational level, household income, admission route and types of wards. The willingness to recommend were associated with admission route, types of wards and hospital accreditation level. Conclutions: In Taiwan, it has not been found that market competition will be associated with out-of pocket charges, nor has it been found that market competition will be associated with the quality of medical care. Therefore, when medical service prices are regulated, hospitals will not use “price” as a means of competition. At the same time, the study results also show that the performance of hospitals will not be different due to the level of competition, which symbolizes that patients can enjoy fair and reasonable prices and high quality of medical care no matter where they go to see a doctor. It is suggested that policy makers should continue to pay attention to the relevant strategies adopted by medical service providers under market competition, as well as pay attention to understanding the patient hospitalization experience, so as to improve the overall medical quality. The results of this study can be used as a reference for relevant policies and hospital management.
參考文獻
延伸閱讀
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