醫院總額和醫院藥品總額對醫院用藥之影響－
以Sulfonylureas降血糖藥為例

研究目的健保局自2002年7月1日起全面性實施醫院總額制度，希望藉由醫院總額使醫院改變醫療行為，抑制不斷上漲的醫療費用，防止健保赤字持續擴大。醫療費用逐年上漲是多年來的趨勢，其中藥品費用支出約佔全醫療費用支出的三分之ㄧ左右，如何有效降低藥品費用，本研究將探討醫院總額和醫院藥品總額對醫院用藥之影響。研究方法本研究資料為國家衛生研究院所提供的全民健康保險資料，採取前測、後測等設計分為二部份進行探討，第一部份：以2000年1月至2002年12月實施醫院總額前、2003年1月至2005年12月醫院總額實施後探討進口藥品、國產藥品在醫院使用量及耗用金額之影響；第二部份：以2000年1月至2004年12月實施醫院藥品總額前、2005年1月至2005年12月實施醫院藥品總額後探討進口藥品、國產藥品在醫院使用量及耗用金額之變化，再分析探討醫院特質、病人特質和使用量及金額之關係。研究結果一、醫院總額制度實施前後對進口藥品使用量和金額之影響 1.醫院總額實施後進口藥品使用量增加，國產藥品使用量增加 2.醫院總額實施後進口藥品耗用金額增加，國產藥品耗用金額增加二、健保局實施醫院藥品總額對醫院用藥之影響 1.醫院藥品總額實施後進口藥品使用量減少，國產藥品使用量增加 2.醫院藥品總額實施後進口藥品耗用金額增加，國產藥品耗用金額增加三、醫院總額制度實施前後病患特質用藥之影響醫院總額實施後44歲以下這組使用量增加，45歲到64歲、65歲以上這兩組使用量呈減少現象，總額後耗用金額這三組皆呈現成長。四、醫院特質和使用量及金額之關係 1.層級別醫院總額前2000年~2002年三年平均申報數量以醫學中心最高35.01%；區域醫院33.03%；地區醫院17.71%；基層診所14.25%，總額實施後2003年~2005年平均申報數量以區域醫院最高33.80%；醫學中心33.60%；地區醫院18.18%；基層診所14.42%，實施醫院總額後醫學中心、基層診所平均申報總數量是呈下降的，區域醫院、地區醫院平均申報總數量是呈成長現象。醫院總額實施前平均申報金額以醫學中心41.71%最高，實施後平均申報金額39.81%亦為最高，實施醫院總額後進口用藥平均申報總金額四個層級醫療院所皆呈成長趨勢。 2.分局別：醫院總額實施前平均申報數量以台北分局最高33.16%；東區分局最低2.28%，實施後以台北分局35.85%最高；東區分局2.56%最低。醫院總額實施前平均申報金額以台北分局35.59%最高，實施後台北分局39.93%最高。 3.權屬別醫院總額實施前平均申報數量以財團法人醫院最高41.18%，實施後財團法人醫院41.61%也為最高，實施醫院總額後公立醫院、財團法人醫院平均申報總數量呈下降趨勢，私立醫院則呈現成長情形。實施總額前平均申報金額以財團法人最高48.19%，實施後以財團法人醫院49.08%平均申報金額最高，實施醫院總額後三個權屬別醫院平均申報總金額皆呈成長現象。五、使用數量及金額之影響因子性別、年齡、醫院層級別、健保局分局別、藥品總額會影響進口藥使用數量和金額。結論與建議實施醫院總額進口藥品申報數量成長率逐年下降，相對國產藥品成長率逐年攀升，對國產藥品而言實施醫院總額以後成長更快，實施醫院總額後進口藥品、國產藥品申報金額皆比實施前呈現成長現象，2005年健保局實施醫院藥品總額訂定門、住診藥費目標值，進口藥品申報總數量大幅度下降，申報總費用也趨於下降，真正對於進口藥品影響的是醫院總額內的藥品總額，國產藥品也因醫院總額的實施及藥品總額的限制用藥上限取代了一部份的進口藥品市場空間，也改變醫院的用藥行為。由本研究研究結果發現醫院總額制度全面實施後，醫學中心、區域醫院使用進口用藥數量平均比率佔67.87%，進口藥品成本較高，比學名藥貴三分之ㄧ以上，為了開源節流遏止虧損促使醫院提升採用學名藥比率以降低醫院用藥成本，建議主管機關應予重視。

關鍵字

糖尿病；原廠藥；磺醯尿素類

並列摘要

Purpose Since July 1, 2002, the Bureau of National Health Insurance implement the hospital total cost amount system to control the medical expenses and prevent health insurance deficit expanded continually. The medical expense has been risen year by year, the medication cost is the largest expenses of total medication cost. This paper will discuss how to reduce the medication cost, also the hospital total cost amount and medication total cost amount influence hospital medication. Method By using the material of people health insurance from National Health Research Institutes, we apply pre-test and per-test on the discussion. The first part：before implement hospital total cost amount system which from January, 2000 to December,2002; also after implement hospital total cost amount system from January,2003 to December,2005, in which we discuss about the use amount and expense cost influence of import drugs and the domestically produced drugs in the hospital. The second part: before implement hospital total cost amount system which from January, 2000 to December,2004; also after implement hospital total cost amount system from January,2005 to December,2005, in which we discuss about the use amount and expense cost influence of import drugs and the domestically produced drugs in the hospital; later we analyze and discuss the hospital particular; patient character and the relation between use amount and cost. Result A.The influence of before and after the hospital total amount system implementation to import drugs use amount and expense cost 1. After the hospital total amount implementation, both the import drugs and the domestically produced drugs use amount increase. 2. After the hospital total amount implementation, both the imports drugs and the domestically produced drugs expense cost increase. B.The influence of after the hospital drugs use total amount implement to the hospital medication 1. The import drugs use amount reduce but the domestically produced drugs amount of use increased after the hospital drugs use total amount implementation. 2. Both the imports drugs and the domestically produced drugs expense cost increase after the hospital drugs use total amount implementation. C.The influence of patient medication distribution between before and after the hospital total amount system implementation After the hospital total amount implementation, the use amount increase of ages under 44 group, but reduce of both age 45 to 64 years group and age above 65 years group. Three groups show increase of expense cost. D.The relation between hospital particular and both use amount and expense cost 1. The Class： From year 2000 to 2002 and before the hospital total amount implementation, the medical center shows the highest 35.01% annual average declaration quantity; the region hospital shows 33.03%; the local hospital shows 17.71%; and the local clinic shows 14.25%. From year 2003 to 2005, after the hospital total amount implementation, the region hospital shows the highest 33.80% annual average declaration quantity; the medical center shows 33.60%; the local hospital shows 18.18%; and the local clinic shows 14.42%. By above statistics, we find out after hospital total amount system implementation, the annual average declaration quantity of both medical center and the local clinic show reduce; but of both region hospital and local hospital show increase. Also by both while before and after the hospital total amount implementation, the medical center shows the highest 41.71% and 39.81% of average declaration cost. Above four different level medical institutes show increase of the average import drugs use cost the implementation, 2. The District： Before the hospital total amount implementation, the Taipei Branch of Bureau of National Health Insurance with the highest 33.16% average declaration quantity; the Eastern Region Branch of the Bureau of National Health Insurance with the lowest 2.28%. After the hospital total amount implementation, the Taipei Branch of Bureau of National Health Insurance with the highest 35.85% average declaration quantity; the Eastern Region Branch of the Bureau of National Health Insurance with the lowest 2.56%. Before the hospital total amount implementation, the Taipei Branch of Bureau of National Health Insurance with the highest average declaration cost 35.59%; and 39.93% after the implementation. 3. The Authority： Before the hospital total amount implementation, the legal foundation hospital shows the highest 41.18% average declaration quantity, also 41.61% after the implementation. Both public hospital and legal foundation hospital show the average declaration quantity reduce after the implementation, but private hospital shows increase. Before the implementing, the legal foundation hospital show the highest average declaration cost amount 48.19%, and 49.08% after the implementation. All three different authority hospitals show increase of the average declaration cost amount. E.Influence factor of use amount and total cost Include gender、age、hospital level、the sub-bureau of health insurance bureau and the drugs total amount all affect the import medicine use quantity and the cost amount Conclusion and Suggestion After the hospital total amount implementation, the import drugs quantity report drop year by year, but the domestically produced drugs amount grow rapidly. Also after the implementation, the declaration cost amount shows grow of both import and the domestically produced drugs. Year 2005, the National Health Insurance implement the total drug use amount, both the import drug amount declaration and total cost declaration drop down substantially. Which import drug effect the total drug amount of hospital total amount. Cause of the implementation, the domestically produced drugs also substituted for a partial import drugs. From this result, we find out that after the hospital total amount system implementation comprehensively, the average import drug use rate is about 67.87% in both medical center and region hospital. Compare to the scientific medicine, the import drug is more expensive and higher cost. For save medicine resources and prevent expenses lose therefore we suggest the chief organizations should seriously care about the hospital medication use and promote the scientific medicine use.