西醫基層總額對透析診所之服務提供影響-以高屏地區為例

研究背景與目的：西醫基層總額支付制度於90年7月實施，由於支付方式設定為支出上限制，對於高費用成長與高產值之門診血液透析診所可能造成何種影響與衝擊，在點值不確定因素下，透析診所又將如何因應。本研究目的係在探討總額支付制度對透析診所在醫療投入與產出的影響，並評估透析診所在總額後是否產生風險篩選行為，及瞭解基層總額實施後對整體透析醫療市場之影響。研究方法：本研究採類實驗（Quasi-experiment）研究設計，研究對象為高屏地區基層提供血液透析業務之診所，以中央健康保險局高屏分局提供之次級資料（secondary data）進行回溯性分析，依研究架構分透析診所特質、人力設備投入、醫療服務產出三種類別，探討透析診所在總額前後投入與產出是否有差異，以新透析病患特質及跨院所透析治療人數比率評估風險篩選行為是否產生。研究結果：（一）總額實施後透析診所在服務家數成長46.15%、腎臟專科醫師成長37.50%，其中透析治療床成長率48.12%高居全國之冠，顯示在總額後透析診所在人力設備擴充，有規模大型化之趨勢。（二）透析診所在總額後整體產出服務量較總額實施前成長率大於20%，惟總額實施前已設立之透析診所（13家）醫療產出服務在總額前後未有顯著成長。（三）透析診所在總額實施後新透析病患平均年齡58.5歲，性別分布女性占55.3%與總額前無顯著差異，而且病患在平均透析次數（12.19次/月）與跨院所透析治療人數比率（1.10%）在總額前後並無明顯變化，推論透析診所在總額預算實施後無風險篩選行為產生。（四）西醫基層總額實施後基層透析診所在透析市場占率由18.52%提高至20.65%呈現成長趨勢。討論與建議：第一期西醫基層總額協定每人年成長率為3.727%，然而整體洗腎透析部門成長高達20%，遠超過協定成長率致使季點值偏低，已對透析診所之營運與發展產生不利影響。再者目前透析提供服務家數已趨於飽和，未來新設立時應考量透析醫療社區化，避免集中都會區。本研究僅就單一地區與層級進行研究，建議後續可針對各層級透析醫療服務與利用進行探討，作為全國單一血液透析總額支付制度參考。

關鍵字

總額預算；血液透析；風險篩選

並列摘要

Since National Health Insurance was implemented, the medical expenditure on hemodialysis, as a high-priced therapy, has maintained a high growth-rate. This study focuses on special clinics that provide hemodialysis therapy and are contracted with Bureau of National Health Insurance Kao-ping Branch (NHIKP). According to the quality of clinics, the investment in the medical faulty, and the quantity of medical service, it is explored whether clinics of hemodialysis specialty are under the influence that Bureau of National Health Insurance implemented the global budget for clinics’ physicians. It is also evaluated if the risk selection of those clinics happens and clinics’ percentage of medical expense of hemodialysis chenges after the implementation of the global budget. The research shows that, after implementing the global budget for clinics’ physicians, not only the numbers of clinics, special doctors, and beds for therapy grow, but also the growth-rate of quantity of medical service beocmes 20% more than before. Moreover, the clinics’ percentage in the NHIKP medical expense of hemodialysis therapy has increased from 18.52% to 20.65%. It is deduced that the clinics’ risk selection did not occur from the analysis of patients’ age, sex, frequency of hemodialysis, and shift from clinics to hospitals. To sum up, the high groth-rate of quantity of medical service does no good for the development of clinics of hemodialysis specialty in the global budget scheme.