牙醫門診總額實施後財務控管成效之分析

全民健保自八十四年三月一日實施後，醫療費用大幅成長，健保財務平衡受到很大的衝擊，因此很多學者建議支付制度必須做改革，以便平衡健保的財務，讓健保能永續經營。自民國八十四年十二月牙醫界即參與衛生署牙醫總額支付制度之推動，共同規劃牙醫總額支付制度試辦計劃，於八十七年七月開始實施，每年對於健保牙醫門診服務的總支出，有預算的限制，牙醫師公會必須承擔財務的責任。牙醫全聯會在全民健保牙醫門診總額委員會的架構下依健保局各分區來劃分為六個分區委員會，在各區獨立自主的精神下，各區有不同的費用控管辦法。本研究之目的為藉由牙醫門診總額支付制度實施後，研究不同之控管方法對於平衡醫療費用的成效，提供各分區參考，使總額能順利推行，讓全民健保能永續經營。本研究以民國87年7月至89年12月健保特約醫療院所申報之牙醫門診費用申請表、門診處方及治療明細為資料庫。並以描述性分析、相關性分析（correlation）及One-way anova來檢定不同分區不同財務控管方法與每點支付金額、爭議審議案件多寡及牙醫師職業滿意度之相關性，且並與此作為評估不同控管方法對費用控管的成效。研究結果顯示，從87年7月到89年12月，其中有六季的點值低於1，其間變異係數僅有2.5%，可見醫療費用的控管成效不錯。以各分區來看十季平均數以南區最接近1，中區最低，花東區最高。全局的爭審後核減率除了87年10月至88年3月二季高於1%以外，大都低於1%。各分區比較發現北區的爭審後核減率為最高，南區點值及核減率最為穩定，東區乃因醫師可服務的人口比率較高，所以點值相對較高其次是高屏區、台北區、中區、南區、東區。台北分區受到醫師與投保人口比率較低及該區民眾高使用率而使點值下降。北區幹部負責合作，人為有效控管助益很多。中區每位醫師可服務的病人數較少人口比率低，民眾高使用率及實施初期高額無法有效抑制，部分幹部責任感不足，以及財務控管模式欠缺公平性，更是雪上加霜。高屏區實施初期高額未能控制，縣市間幹部欠缺溝通與合作，紛爭不斷，更使點值加速惡化。高屏地區審查醫師未能遵行全聯會所訂定之審查注意事項，自行以不當的核減原因核刪費用造成爭審增加的主因。由本研究發現，不同控管方式確實會影響財務控管成效，建議可參考財務控管成效良好之分局的控管方式，藉由公平合理之機制，以使醫療院所共同接受同儕制約的精神，並促成醫療費用合理化之目標，南區電腦審利用檔案分析方式對異常申報之院所，提供其申報異常的情形，與醫療院所進行溝通，藉此做為財務的控管方法應屬六分區當中最佳的模式。

關鍵字

總額預算；全民健保

並列摘要

National health insurance was implemented on 1st of March 1995 in Taiwan. However, substantial increases in medical expenses have caused great impact on the balance of the financial situation in the new health insurance system. Several plans of reform on payment schemes have been proposed. Since the very beginning, dental associations have participated in the planning of the implementing the global budget scheme into dental care service proposed by Ministry of Health. Then, Dental global budget was first implemented in July of 1998. The upper limit of total budget in oral care was set up annually by mutual negotiation between bureau of the national health insurance and the dental associations, and the latter are responsible for financial control in the dental care service. Committee on dental global budget in the national dental association is composed of six-district committees correspondent to six divisions of Bureau of national health insurance. Each district committee works autonomously and independently, and therefore has its way of financial control. The aim of this study is to investigate the efficacy of financial control in six-district committees under different methods over the period of 1998 to 2000. Moreover, this study also focuses on identifications of the factors, which might potentially affect the efficiency of the financial control. The material used in this study is based on the data provided by Bureau of national health insurance. Descriptive statistics, Pearson correlation, analysis of variance and multiple regression were used to investigate the relationship between the variables investigated in this study. The results show that from July 1998 to December 2000, the average credit in six out of ten seasons was below unity with coefficient of variation being 2.5%. That indicated the financial control during this period was at the acceptable level. In the individual division, the southern district had the mean credit value closest to one. The mean credit value in the central district was the lowest, and that of the eastern was the highest one. The average deduction rate in this period of time was almost below 1% except the two seasons between October 1998 and March 1999. The between-districts comparisons found that the credit values and deduction rates were relatively stable in the Southern district as compared to the others. The deduction rate in the Northern district was the highest among the six districts. The district with the highest mean credit values was the Eastern district, and then the Kao-ping district, Taipei district, and Central district. The population to dentist ratio was low in the Eastern district, and this might contribute to the high credit value in this district. The self-discipline and efficiency of financial monitoring in the members of the Northern district led to the above average credit values in this district. On the contrary, in the Central district, the lack of self-discipline, low ratio of population to dentists, and high frequency of dental visits gave rise to the poor financial control. In the Kao-Ping district, the lack of efficient monitoring of the dentists with large amounts of payments, and the short of communications between the members in the committee resulted in the poor control of the credit values. In summary, different ways of financial control actually affected the stability and changeability of financial status in the six districts. To adopt the means of financial control in the well-performed districts with peer-reviewed and explicit monitoring schemes is the better way to rationalize the distribution of the resources in national dental health care. Cross-validation, detection of anomalies in the payment applications, and open communications with the dentists in the Southern district should be the better model of financial control among the six districts.