加重部分負擔與家庭醫師制度對轉診病患醫療資源耗用差異之研究

The Effects of Co-Payment Increment and Family Doctor System on Utilization of Medical Resources with Patient Referring System

劉美君(Liu Mei Chun)

指導教授 ： 李弘暉

元智大學/管理學院/管理研究所/碩士(2006年)

摘要

我國於民國八十四年三月開始實施全民健康保險，迄今已屆十年。醫療費用快速上漲及醫療資源不當使用是我國面臨一大問題，同樣為實施健康保險國家所面臨的共同挑戰。目前全球實施全民健康保險的國家，大都採取部分負擔用以抑制過度醫療花費。實施家庭醫師制度，避免醫療資源重覆浪費，使民眾獲得最具成本效益的醫療照護，讓健康保險得以永續經營。
健保局自2003年起即已開始推動「家庭醫師整合性照護制度試辦計劃」，並於2005年7月15日調整健保部分負擔政策，落實轉診制度以推動本土化的家庭醫師制度。本研究以北區某區域醫院2005年4~10月之轉診與非轉診病患為例，探討加重部分負擔制度之採行，其轉診之成效及醫療資源耗差異；並進一步探討個案醫院配合衛生政策投入專責單位負責運作於調整部分負擔後，其轉診家戶病患之比率及其病歷組合差異性。
研究結果發現：
一、加重部分負擔前後，轉診與否對於疾病分佈及資源耗用上並無顯著影響。
二、同一主要診斷之下，經控制次要診斷與年齡分佈後，轉診與非轉診病患於醫療資源耗用上皆無顯著差異。
三、加重部分負擔實施前後，家戶病患轉診率並無成長且其醫療資源耗用統計分析結果為無顯著差異。整體而言，短期內尚無法看出轉診制度實行成效。
四、未透過轉診而逕自醫院就醫病患其所屬科別以兒科為最多，一般科次之。該結果與家庭醫師本身所屬科別有關連性。
五、民眾對個案醫院轉診服務人員之服務及專業能力表現給予較高滿意度；而於轉診流程及轉診時間方面則低於整體平均滿意度。

關鍵字

轉診制度 ； 家庭醫師 ； 部分負擔 ； 醫療資源耗用

並列摘要

The problems of inappropriate utilization of medical resources and rapid expansion of medical expenditure still exist since the implementing National Health Insurance System in 1995. Most countries carry out the co-payment system as their own strategy to suppress the rapid expanding medical expenditure. In order to achieve the most efficient medical care utilization, family doctor system plays important role in reducing unnecessary utilization of medical resources.
Since 2003, Bureau of National Health Insurance implements 「Family Doctor Integrated Delivery System」，and later in 2005, increases the co-payment in order to integrate the referring system and family doctor system. We study the utilization of medical resources and the satisfactory degree between referred and self-referred patients after implementing those two plans described above. Since April 2005 to October 2005, both referred and self-referred patients in one community hospital are included. We study the efficiency of referring system and the different utilization of medical resources in order to see the effect of increment of co-payment. With a specialized group organizing the policy of co-payment adjustment, the percentage of referred patients and their combinatory differences in medical charts in the studying hospital are also evaluated.
Results:
1. Disease distribution and medical resources utilization are not affected with implementing referring system and the increment of co-payment.
2. After adjusting the second diagnosis and age distribution, there is no difference in utilization of medical resources between referred and self-referred patients with the same first disease diagnosis.
3. The patient number rate of referred patients from family doctors is similar before and after adjustment of co-payment.
4. Most of the self-referring patients are seeking for pediatric and general medical help, which might relate with the subspecialty of their family doctors.
5. The satisfactory degree of referred patients is higher in the performance and professional ability of hospital staffs and lower in the time needed for referral and its process.

並列關鍵字

Referring system ； family doctor ； co-payment ； utilization of medical resource