應用ABC於臨床路徑之成本計算模式─以口腔顎面外科為例

The Cost Calculating Pattern of Applying ABC on the Clinical Paths-- Case Study of Department of Oral and Maxillofacial Surgery

張淑清(Shwu-Ching Chang)

指導教授 ： 邱亨嘉

高雄醫學大學/健康科學院/公共衛生學研究所碩士在職專班/碩士(2003年)

摘要

研究目的：本研究欲以作業基礎成本制的主要精神與架構，建構個案醫院口腔顎面外科住院之作業與產品的分析模式。並以實例說明應用ABC制度於臨床路徑之成本計算模式，探討在DRGs / PPS支付制度下，同一DRG項下，三組不同主手術處置碼之病患所耗用之資源成本，並以該DRG為最終產品，做慧黠的成本分析，以提供個案醫院口腔顎面外科管理決策之參考。
研究方法：本研究採個案研究法進行，並選擇某醫學中心之口腔顎面外科住院部份為研究對象，分析該部門於民國91年2月1日至91年7月31日止(半年)之直接成本。並係依據其醫療服務的特性予以設計而成的。首先確認產品，再藉由產品流程之分析，訂定作業項目，將資源成本歸屬至各項作業，再將作業成本分配至成本標的，最後進行成本資料之分析。
研究結果：比較三組主手術處置碼之每住院人次成本，主手術處置碼244最低，計16,603元，其次為主手術處置碼2749，計31,884元，最高者為主手術處置碼251，計38,577元。可知診斷關聯群的設計有結構上的瑕疵，以致一個DRG內的病例，彼此費用相差可達倍數，因而平均價格是DRGs償付的特色，醫院須經由DRGs互補。再就人事成本資源耗用情形而言，評估作業，以主手術處置碼2749佔成本之比率最高為22.51%；檢查作業，以主手術處置碼244佔成本之比率最高為6.12%；照會作業，以主手術處置碼244佔成本之比率最高為7.19%；治療作業，以主手術處置碼2749佔成本之比率最高為37.43%；手術作業，以主手術處置碼251佔成本之比率最高為40.70%；照護作業，以主手術處置碼2749佔成本之比率最高為7.46%，能提供管理者進行成本控制與流程改善的參考。另就DRG169產品進行分析，具健保身份之病患，所須花費成本佔收入41.9%，其中人事成本佔15.66%，藥品成本佔12.59%，材料成本佔2.18%，設備成本佔0.71%，管理成本佔10.75%；以人事成本所佔百分比最高，其次為藥品成本及管理成本，設備成本最低。由於人事成本係屬固定成本，而藥品成本佔藥品收入71.7%，因而其成本之管控應著重於管理成本，可檢視是否有資源浪費情形。另，亦可加強投資項目或更新設備，以增加服務量，創造收益。
研究結論：(一)ABC制能協助該部門確認作業與產品，使成本的計算更為合理與精確；(二)ABC制透過作業與流程分析，能提供管理者進行成本控制與流程改善的參考；(三)ABC制可計算各項產品之損益，透過健保支付標準比較，能協助管理者做最佳產品組合之決策；(四)ABC制結合臨床路徑的實施與持續流程改善，可協助醫院在不降低醫療品質下，減少醫療成本，達到持續改善的目標；(五)ABC制可成功地推算出各項產品成本，在面對健保局即將實施之「包醫制」(DRGs)，能作出較為理性且具體的因應之道，提供策略發展之基礎。

關鍵字

作業基礎成本制度 ； 作業基礎管理制度 ； 診斷相關群 ； 臨床路徑

並列摘要

The Purpose of Research：The study, based on the structure of Activity Based Costing (ABC), was to establish an activity and process analysis pattern for the Department of Oral and Maxillofacial Surgery of the subject hospital. Cases were used to explain the cost calculating pattern of applying ABC on the clinical paths. This research thus discussed three different major surgery costs in the DRGs / PPS payment system, under the same DRG circumstance. With the DRG as the terminate product, this research also aimed to do the cost analysis to provide references for the management of Department of Maxillofacial Surgery.
Research Method：This research employed the case research method. It chose the Department of Maxillofacial Surgery of a medical center as the research subject. This research analyzed the direct cost of this department from Feb 1st to July 31st in 2002 and was designed according to the features of the medical care of this medical center. First of all, the product was confirmed, then the by analyzing the product process, the activity process would be set. The resource cost would be categorized into different activity, and then the activity cost would be distributed to the cost target. Finally, the cost data was analyzed.
Research Result：Among these three major surgery hospitalization cost, the Surgery 244 was the lowest as the cost was $16,603. Next was the Surgery 2749, with the cost of $31,884. The highest one was Surgery 251, with the cost of $38,577. Therefore, we have learned the structural defects of Diagnosis Related Groups (DRGs), which has made cost difference between cases in the same group multiple. As a result, despite the different cost of different surgery, the payment of DRGs will average the cost and give the average payment; the hospital therefore needs to make different surgery cost be complementary to one another. Furthermore, in the aspect of personnel cost, in terms of assessment, the Surgery 2749 is the highest as 22.51%; in terms of checking, the surgery 244 is the highest as 6.12%; in terms of conference, the Surgery 244 is the highest as 7.19%; in term of treatment, the Surgery 2749 is the highest as 37.43%; in term of operation, the Surgery 251 is the highest as 40.70 %, in term of care, the Surgery 2749 is the highest as 7.46%. These data can provide references to managers to control the cost and improve the procedures of medical care. In addition, according to the analysis of DRG 169 product, the NHI patients’ spending is 41.9% of the total income, in which the personnel cost is 15.66%, while the drug is cost 12.59, the materials cost 2.18%, equipment cost 0.71%, and management cost 10.75. The personnel cost has the highest percentage of cost, drug and management cost are the next, and the equipment is the lowest. Because the personnel cost is the fixed cost and the drug cost is 71.7% of drug income, the emphasis of cost control should be placed on the management cost. Therefore, whether there is resource waste could be investigated. Moreover, more emphasis should be placed on investments such as replacing old equipments in order to provide more services and increase income at the same time.
Conclusion：
1.ABC can assist the Department to confirm activity and products and thus make the calculation of cost more reasonable and accurate.
2.Through the activity and process analysis, ABC can provide references to the manager for controlling the cost and improving the process.
3.ABC can calculate the gain and loss of every product. Through the criteria of NHI payment, it can assist the manager to make the best policies for the best product combination.
4.ABC combines the enforcement of clinical paths and the continuous improvement of the process, so it can help the hospital to reduce medical cost and achieve continuous improvement without reducing medical cost.
5.ABC can successfully estimate the cost of every product. It can offer a more reasonable and concrete way to deal with DRGs which is to be enforced by Bureau of National Health Insurance, and at the same time provided a foundation for policy development.

並列關鍵字

Activity Based Costing (ABC) ； Activity-Based Management (ABM) ； Diagnosis Related Groups (DRGs) ； Clinical Paths

參考文獻

中文部份

1.中央健保局網站（網址：http://nhi.gov.tw/01intro.intro_5.htm），2002。

2.韓揆：土、洋DRGs--全民健保論病例計酬如何為繼。醫務管理期刊，2001。

3.劉志明、黎憲隆：作業基礎成本之決策支援系統的建立與應用。工業工程學刊，2001。

4.陳依蘋：臺積電與ABC。會計研究月刊，2001。