醫療給付效益提昇計劃前後馬祖地區民眾醫療利用與費用之分析

An Analysis of Medical Utilization and Expenditure before and after the Intervention of Integrated Delivery System in Matsu

謝春福(Chun-Fu Shieh)

指導教授 ： 楊銘欽

國立臺灣大學/公共衛生學院/醫療機構管理研究所/碩士(2004年)

https://doi.org/10.6342/NTU.2004.01932

摘要

連江縣通稱為馬祖地區。全民健康保險局於民國89年3月1日委由連江縣立醫院辦理馬祖地區醫療給付效益提昇計畫，初期協調台北市醫師公會調派醫師支援馬祖地區專科醫療，但由於專科醫師人數與品質難以掌握，遂連繫台北市衛生局，由所屬各市立醫院於民國89年6月1日起輪流派遣專科醫師支援馬祖地區專科醫療。因此，本研究目的在於探討全民健康保險局實施馬祖地區醫療給付效益提昇計畫對馬祖地區民眾門診、住院與預防保健利用與費用之影響，並了解民眾於縣內與縣外就醫之比率是否有差異。
本研究為一自然實驗，觀察馬祖地區民眾在實施馬祖地區醫療給付效益提昇計畫前後四年之時間，為排除外在環境影響，採用實驗年度與對照年度方式進行研究；將穩定實施馬祖地區醫療給付效益提昇計畫之年度為實驗年度，沒有穩定實施馬祖地區醫療給付效益提昇計畫之年度為對照年度。本研究使用次級資料進行分析，運用全民健康保險局資料庫民國93年1月設籍於馬祖地區(連江縣)之民眾，勾稽其於民國88年至91年之健保就醫申報資料進行探討，以差異中之差異法與Chi-square test進行統計分析。
本研究主要結果如下：
1. 馬祖地區居民縣內外之整體門診利用方面，在醫療給付效益提昇計畫介入前每年平均門診次數為9.5(民88)、10.1(民89)次，介入後為10.7(民90)、10.7(民91)次(表4-6)，有增加的趨勢。
2. 馬祖地區實施醫療給付效益提昇計畫後全縣每人門診醫療費用支出呈成長的趨勢，平均每人費用由介入前6557.4元增加至7055.0元，成長了7.6%。縣內費用由介入前之3007.4元增加至介入後之3345.8元，成長率為11.3%，平均每人次縣內費用成長率為-1.5%。此可能因醫療給付效益提昇計畫後門診量增加，但高費用的醫療處置並未增加之故。
3. 醫療給付效益提昇計畫介入後，全縣住院次數由介入前之670次增加至介入後之766次，成長率為14.3%。其中縣內住院次數比率由介入前之18.4%(民89)增加至介入後之23.2%(民90)(表4-19)，成長率僅4.8%。比例雖有增加，但仍顯示居民對馬祖地區醫院的醫療水準尚未建立足夠的信心。
4. 各類預防保健中，成人健檢的人次最不穩定，同時影響統計分析的結果。由於小於5歲兒童之健兒門診人數與人次不受成人健檢之影響，應可做為很好的指標。由健兒門診人次分析，由民國89年之67人次，增加至民國90年之190人次，增幅達183.6%，且縣內外比率也呈現有意義之增加(表4-28)。
5. 縣外之門診或住院所佔全縣之利用比率，在計劃介入後都呈下降的趨勢，顯示提昇醫療供給資源，可以減少馬祖居民因病需舟車勞頓遠赴台灣本島就醫的比例。
6. 縣內原有醫療機構之服務量在醫療給付效益提昇計畫介入後仍有成長。但至民國91年支援計畫就醫量已呈穩定狀態，此時除非引進新的診療服務項目，才有可能有正向之成長率。
7. 馬祖地區醫療給付效益提昇計劃實施後，雖然可預防性住院部份之全縣住院次數由介入前的68人次(民89)減少到介入後的65人次，減少-4.4%，但長期來看並未減少。

整體而言，本研究發現馬祖地區醫療給付效益提昇計劃實施後，馬祖地區居民縣內外之整體門診利用、住院次數與各類預防保健皆有增加的趨勢。全縣每人門診醫療費用支出呈成長的趨勢，縣內門診每人次費用為負成長。縣外之門診或住院所佔全縣之利用比率，在計劃介入後都已下降；但可預防性住院部份長期來看並未減少。縣內原有醫療機構之服務量在醫療給付效益提昇計畫介入後仍有成長。
因此本研究建議，須持續加強馬祖地區原有醫療機構之醫療人力與設施，已訓練完專科之公費醫師仍為最佳支援醫師人選，應努力爭取；馬祖地區島際交通仍須持續改善；並須加強內科與外科系統醫師之支援，而且計劃支援醫院需考慮其支援持續性。

關鍵字

差異中之差異 ； 就醫公平性 ； 醫療利用 ； 醫療費用 ； 整合性醫療照護

並列摘要

Lien-Chian County was commonly called Matsu Island. Integrated Delivery System (IDS) of Matsu was entrusted to Lien-Chian County Hospital by the Bureau of National Health Insurance on March 1st 2000. Initially we coordinated with Taipei Medical Association to sent medical doctors in support of specialist therapy in Matsu. Because the support was instable, we changed to seek support from Taipei Municipal Hospitals on June 1st 2000. The Purpose of this research was to discuss the effect of IDS on the utilization and expenditure of out- patient, admission and preventive services in Matsu, and to understand the ratio of going to a doctor inside and outside the county.
This research was a natural experiment, we observed 4 years of IDS program. In order to excluding the effect of external environment, we used the method of experimental year and control year. Experimental year was defined as the year of carrying out stable IDS, and control year was defined as the year of carrying out unstable IDS. This research used secondary data from the database of the Bureau of National Health Insurance, to analyze the declaration data of the population of family registration in Lien-Chian County from 1999 to 2002. We used difference in difference and Chi-square test to examine the effect of the IDS program..
The major findings of this research are listed as follow:
1. The overall utilization of out-patient-department (OPD) revealed the annual average OPD utilization before the intervention of IDS was 9.5(1999), 10.1(2000), and 10.7(2001), 10.7(2002) after the IDS. There was an increasing tendency.
2. The medical expenditure of OPD of each person also shows an increasing tendency, which was NT$ 6,557.4 before IDS intervention and 7,055.0 after, the growth rate was 7.6%. The expenditure inside the county increased before IDS intervention from NT$ 3007.4 to NT$ 3345.8 after, the growth rate was 11.3%. The growth rate of average utilization per person was –1.5%. It is possible because there are no high price of medical procedure and medicines in spite of the increase of OPD volume.
3. After the intervention of IDS, the annual admission utilization increased from 670 to 766, the growth rate was 14.3%. Admission utilization ratio increased from 18.4% (2000) to 23.2% (2001) inside the county. Although the ratio was increased, but it also suggests that the residents did not have confidence toward the medical quality inside the county.
4. Among the preventive services, the volume of the adult health examination was unstable, and it will change the result of the statistics and analysis. Because the volume of the healthy baby clinic was not related directly to the volume of adult health examination, so it was a good indicator. In the analysis of volume of healthy baby clinic, the volume increased from 67 persons (2000) to 190 persons (2001), the growth ratio was 183.6%, and the ratio of the volume of inside county and outside county was increased.
5.The utilization ratio of OPD and admission outside the county decreased after IDS intervention. It revealed that if we increased medical resource supply, the ratio of long way trip due to going to a doctor from Matsu to Taiwan would be decreased.
6. The service volume of the existing medical organization in the county increased after intervention of IDS. Because of the volume of medical service was stable in 2002, except for adding new items of health services, it will not be possible to have positive growth rate.
7. After intervention of IDS, although the volume of avoidable admission of the whole county changed from 68 persons to 65 persons, and the decreased rate was –4.4%, but there was no decreasing tendency.
Finally, this research discovered that there were increased tendency of the overall volume of OPD utilization, admission and preventive service after IDS intervention. Overall OPD expenditure of each person had growth tendency, each person’s OPD expenditure in the county had negative growth. The overall OPD or admission utilization outside the county decreased after IDS intervention; but avoidable admission had no decrease for a long time period. The OPD volume of existing medical organizations had positive growth after IDS intervention.
This research suggest that we should continue to strengthen the human resources and facility of existing medical organization in the county, well trained public financed doctors are the first choice when recruiting new staff; the transportation among Matsu islands should be improved; the number of internal medicine and surgical doctors should be increase to strengthen the support; and the consistency of support of IDS program must be taken into consideration.

並列關鍵字

difference in difference analysis ； medical care expenditure ； health care utilization ； Integrated Delivery System (IDS) ； health care equity

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