全民健保牙科總額支付制度在新竹市縣城鄉醫療服務差異性的探討

The Variation of Dental Medical service in Global Budget System under the National Health Insurance Scheme in city、country of Hsinchu City、Hsinchu Country

李俊德(Chun-Te Li)

指導教授 ： 黃純德

高雄醫學大學/口腔醫學院/口腔衛生科學研究所碩士在職專班/碩士(2003年)

摘要

本研究主要目的在探討全民健康保險牙科總額制度實施，對新竹市、縣的城、鄉醫療服務之影響。資料來源為86年7月1日至91年6月30日，中央健康保險局北區分局各特約院所申報之牙醫門診費用之40000筆資料、中央健康保險局北區分局牙保會87年10月至91年2月的會議記錄、中央健康保險局89-90年度，全民健康保險統計資料、醫療爭議審議委員會85-90年資料。
利用描述性統計來進行分析。研究結果發現，北區分局牙科保險委員會一直以單一指標方式來控管四縣市費用，導致：
一、費用申請分布曲線改變；牙科總額制度實施以來，北區牙醫師申請費用點數分布，原來呈常態曲線，89年7月起申報費用25萬以下、50萬以上的醫師，申請費用點數向25-50萬點區間集中，而呈中間長柱形曲線，依照比率顯示，新竹市集中較明顯，意指原來低申報費用的醫師，有誘發醫療需求趨向。
二、醫療模式改變；新竹縣牙醫師申報診療項目走向低點數價位；新竹市牙醫師申報診療項目走向高點數價位。
三、新竹縣牙醫師人數幾乎沒有成長；北區牙醫師新開業或服務的選擇地點，仍以人口密集、交通方便的桃園、新竹市為優先。
四、新竹縣牙醫門診數下降；民眾預約掛號或臨時候診不容易，就醫方便性不佳，減少牙齒治療次數，使得牙病症狀惡化。全年增加了5000顆拔牙數；而新竹縣牙醫師消極的不願作國小學童口腔健檢，避免大量學生同時來診所補牙等牙科治療，增加門診量；新竹縣牙醫預防保健工作推行不理想。
五、新竹縣爭議審議案件增加；牙醫師被核刪的申報案件，必須藉由衛生署爭議審議的機制，來回覆北區牙保會審查醫師不適當的案件核刪，這也是對控管方式的不信任、不滿意。
六、新竹縣牙醫健保申請件數下降；90年度新竹縣牙醫門診時數減少致使門診件數比89年度下降5006件（北區分局90年度牙醫健保申請件數增加152068件），也代表新竹縣民眾利用率下降。口腔疾病具有累積性，拖延治療，會致使疾病惡化，傷害健康與生活品質。
依據研究結果建議衛生主管機關，除監控醫療費用的成長外，應顧及費用支付的公平及合理性，進一步瞭解醫療費用改變的原因，並應縮小城鄉醫療利用的差異性，滿足被保險人就醫的方便，以作為政策修訂參考。

關鍵字

總額支付制度 ； 民眾使用率

並列摘要

This research is mainly in exploring the influences of implementation
of Dental Medical Service in Global Budget System under the National
Health Insurance Scheme to the medical services in city and countryside
of Hsinchu City and Hsinchu County.
The source of information is from the 40,000 copies of the filing of
dental charges of special contracted hospitals of northern branch of the
Bureau of National Health Insurance during the period from July 1st, 1997
to June 30th, 2002; the meeting minutes of dental insurance committee of
northern branch of the Bureau of National Health Insurance from October
1998 to February 2002; 2000-2001 annual national health insurance
analysis dada of the Bureau of National Health Insurance; and the data of
Medical Treatment Dispute and Deliberation Committee of year
1996-2001. The paper uses descriptive statistics to analyze the data.
The result of the research is found that the dental insurance committee of
the northern branch has been using a single indicator to control the
expenses of the four cities and counties leading to:
(1) Change of distribution curve in filing for charges have changed.
Since the implementation of Dental Medical Service in Global
Budget System, the curve of points of filing for insurance claim by
northern area dentists showed the constant cure originally, however,
those dentists whose filing for insurance claim were under 25
thousands points or above 50 thousands points now is started to
concentrate in the band between 250-500 thousands points from July
2000, and as the result, the mid-long-column distribution cure
occurred. According to the display ratio, the trend of concentration is
more prominent for Hsinchu City, indicating the originally low
insurance claim dentists tend to induce medical needs.
(2) Changes in mode of medical treatment. Dentists in Hsinchu
County move towards low point price level in filing of medical
treatment items, while Hsinchu City move towards high point price
level.
(3) There is almost no growth in the number of dentists in Hsinchu
County. Newly opened dental clinics or service points in northern
area are still mainly concentrated in the populated and convenient
Taoyuan and Hsinchu City.
(4) Number of dental visits is on the decline. Difficulty in making reservation or urgent registration for civilians, inconvenience in
visiting dental clinic, and reduced number of dental treatments
attributed to the increase in worsening dental symptoms. Number
cases of tooth extractions increased by 5000 for the year. Dentists
in Hsinchu County are negative about dental check for school
children and avoid large number of school children visiting the
clinics for treatments such as filling of cavity have increased the
number of clinic visits. The implementation of preventive health
care in Hsinchu County is not as expected.
(5) Number of complaint cases appealing has increased. The filing
cases being disapproved have to go through the mechanism of
reviewing by Department of Health to determine whether dental
treatments have been properly carried out also resulted in the distrust
and dissatisfaction of the controlling mechanism.
(6) Number of filing cases for dental health insurance has decreased in
Hsinchu County, and the number of clinical visiting hours has also
decreased, that caused the filing cases reduced by 5006 in 2001 as
compared to 2000 in Hsinchu County (Number of filing cases
increased by 152068 cases for northern branch in 2001). This also
indicates the utilization of health insurance for Hsinchu civilians are
declining. Oral illness is cumulative. Delay in treatment tends to
worsen the illness, resulting in damage to future health and burden in
living quality.
Based on the result of this research, it is recommended that, except for
monitoring the growth of medical expenses, the Health Department
Authority should also looking into the fairness and soundness of expenses
and further understand the reason of change in medical expenditure as
well as narrowing the gaps between city and countryside in using medical
resources so as to satisfy the convenience of the insurer in visiting dental
clinics and as a reference for future modifications of policies.
IV

並列關鍵字

Global Budget System

參考文獻

1.全民健康保險法。2001.7。17-19。

2.中華民國牙醫師公會全國聯合會第七屆第二次理事會決議修訂全民健保牙醫門診總額委員會，組織簡則2000.9.19。

3.行政衛生署，全民健康保險醫療費用支付標準1997.5至2000.7例次公告。

4.中華民國牙醫師公會全國聯合會。第七屆第四次總額委員會制定。全民健保牙醫門診總額北區分區委員會組織簡則2001.1.14。

5.中央健康保險局北區分區牙科保險委員會第一屆二屆會議記錄1998.7-2002.2。