全民健康保險呼吸器依賴患者整合性照護試辦計劃實施成效與對臺灣醫療市場影響之研究

Assessment of the Effectiveness and Influence of “the National Health Insurance Managed Care Demonstration Program for Ventilator Dependent Patients” in Taiwan’s Medical Market

陶啟偉(Chi-Wei Tao)

指導教授 ： 黃恆獎

國立臺灣大學/管理學院/國際企業學研究所/碩士(2005年)

https://doi.org/10.6342/NTU.2005.02967

摘要

本實驗的設計為自然實驗（natural experiment），分析與探討「全民健康保險呼吸器依賴患者整合性照護前瞻性支付方式」試辦計劃(以下簡稱試辦計劃)實施前後（民國85年至91年），依據中央健康保險局全國資料分析，是否有效疏減與抑制加護病房（ICU）床位數的增加？同時藉由呼吸照護病房（RCW）床位數增長率、與核發長期使用呼吸器重大傷病卡成長之合理性，與台灣地區的疾病盛行率，檢討此計畫之實施是否有效地達到計畫原先設計的目的？及試辦計劃導入後，醫療院所RCW照護品質是否有因而提升？
依研究結果顯示，全國呼吸照護病房床位數與長期使用呼吸器重大傷病卡數快速增加。顯示本試辦計劃的支付制度改革對醫療提供者產生誘因，醫療機構認同本試辦計劃具體可行，故提供RCW快速成長動能。唯經分析，ICU病床成長數並未因此有效抑制，與當初構想不符。顯係ICU床位數增長的因素甚多，此計劃是否能有效遏制，惟需視人口因素、市場供需曲線與健保對醫院之誘因，有賴更長期追蹤研究與分析。
RCW的病床數與長期使用呼吸器重大傷病有效卡數成長快速增加，遠高於實施試辦計畫前之預估成長數與台灣老年人口成長比率，且其長期呼吸器依賴之疾病盛行率也遠較於過往與歐美諸國為高，顯然市場上有不正常的需求誘發現象。
且目前試辦計畫並未全面強制實施與考核，導致試辦計畫內或計畫外之RCW品質審查結果分析，無論過程面，與結果面品質皆不佳；明顯於醫療品質層面未能加強把關，導致效果不彰，醫療品質未同步提昇。
建議健保局應全面導入、強制實施，且從供給面控制著手，降低誘發需求與資訊不透明之問題的產生。嚴格實施本試辦計劃，落實試辦計劃下轉機制，使RCC確實發揮守門員角色，嚴控RCW病患來源。如此可避免供給面誘發需求，避免慢性心肺功能不佳患者回流與長期異常的滯留於醫療體系。同時考慮新增護理之家為”長期使用呼吸器中途機構” (Respiratory Treatment Unit, RTU)介於RCW與Home care之間，其費用採論人計費並可提升護理之家效用，且讓醫療治療需求與長期醫療照護明確區隔。

關鍵字

呼吸照護病房 ； 臺灣 ； 全民健康保險 ； 呼吸器依賴患者整合性照護試辦計劃

並列摘要

In this observational study, we analyzed the effectiveness and market change two years before and after the introduction of the “National Health Insurance Managed Care Demonstration Program for Ventilator Dependent Patients”(1999~2000 vs. 2001~2002）. The demonstration program offered good incentive to the medical market and local hospitals. The respiratory care ward (RCW) and the number of issued cards of the ventilator-dependent patients increased dramatically. We cannot exclude the possibility that there were supplier-induced demands and the economic incentives for the patients’ family. Compared to non-enrolled hospitals, quality indices of enrolled hospitals showed no difference in “process face” and “result face”, they were only superior in “structure face”.
We recommend that the demonstration program be generalized, with more efficient monitoring and control. In addition, establishment of Respiratory Treatment Unit (RTU) should be considered as a step-down nursing care unit for the patients, to lower medical expenditure and segregate the demands for long-term medical treatment and long-term nursing care.

並列關鍵字

Integrated Delivery System (IDS) ； Taiwan ； National Health Insurance Managed Care Demonstration Program, ventilator dependent patients, respiratory care ward (RCW)

參考文獻

1. Aharony L and Strasser S. Patient satisfaction: what we know about and what we still need to explore. Medical Care review 1993, 50(1): 49-79.

4. Gaynor, M., 1994. “Issues in the Industrial Organization of the Market for Physician Services,” Journal of Economics and Management Strategy, 3(1), 211-255.

5. Gaynor, M., Deborah, H.W., 1999. “Change, Consolidation, and Competition in Health Care Markets,” Journal of Economic Perspectives, 13(1), 141-164.

7. Gray JAM: Evidence-based Health Care- How to Make Health Policy and Management Decisions. P209-218, 1997

8. Gruber, J., Owings, M., 1996. “Physician Financial Incentives and Cesarean Section Delivery,” Rand Journal of Economics, 27(1), 99-123