健保部分負擔調整對糖尿病人門診醫療利用
之影響

中文摘要研究目的健保局自94年7月15日起調整醫院門診基本部分負擔，希望藉由提高部分負擔，使民眾逐步改變就醫行為，盡量於社區內醫療院所就醫，降低大醫院門診量。依衛生署調查資料顯示，各地區高血糖盛行率在6%-10%之間，以南部及東部地區較高。糖尿病為重大慢性病，需持續治療以控制病情，本研究將探討部分負擔調整對於糖尿病人門診醫療利用及就醫行為之影響。研究方法本研究資料為健保局南區分局所提供之次級資料，採取前測、後測等設計，以93年8-12月、94年8-12月之5個月資料，分為二部分進行探討。第一部分篩選雲嘉南地區17家區域級以上醫院，在研究期間皆有就醫之糖尿病人為研究對象，依受部分負擔影響程度分為三組『部分負擔組』、『重病殘障組』、『榮民低收入組』，觀察部分負擔調整對於門診醫療利用之影響。第二部分選取2家醫學中心93年8-12月期間，就醫次數≧3次之糖尿病人為研究對象，追蹤同一群個案在部分負擔調整前後，醫療利用及就醫行為之變化。研究結果一、糖尿病人在區域級以上醫院門診醫療利用之影響： 1.部分負擔調整後，就醫人次下降幅度以『部分負擔組』最高（-9.4%）、『重病殘障組』次之（-5.1%）、『榮民低收入組』不明顯（-0.5%）；醫學中心就醫人次明顯下降，以『部分負擔組』最高（-19.9%），區域醫院則不明顯。 2.平均每次給藥天數在部分負擔調整後有明顯增加，增加幅度以『部分負擔組』最多、『榮民低收入組』最少。平均每次門診總醫療費用，『部分負擔組』增加幅度大於『重病殘障組』，而『榮民低收入組』僅在醫學中心呈現增加的趨勢。二、醫學中心糖尿病人醫療利用及就醫行為之影響： 1.部分負擔調整前，在醫學中心就醫次數≧3次者有5,070人，部分負擔調整後，有45.4%的人就醫次數≦2次；在醫學中心總就醫人次下降（-26.7%），區域醫院、地區醫院及基層診所分別增加114.4%、89.1%、110.8%。 2.病患特質性別、年齡、殘障程度與糖尿病人選擇醫院層級有明顯相關，影響就醫行為改變之因素以「年齡」有顯著影響力，「殘障程度」達統計學上邊際顯著。討論與建議部分負擔調整後，糖尿病人在區域級以上醫院就醫次數減少，平均每次給藥天數與門診總醫療費用均增加。醫學中心偏好者之糖尿病人至各層級院所就醫次數平均比例，醫學中心由部分負擔調整前的94.49%下降至77.15%、基層診所由4.18%上升至11.89%，顯示部分負擔調整對於慢性糖尿病人，已產生影響，減少就醫次數或轉移至其他層級院所就醫，並以基層診所最多。部分負擔的調整及大醫院陸續調漲掛號費用的加成效應，致慢性糖尿病人就醫成本提高，減少就醫次數是否會影響到必要的醫療需求，建議主管機關應予以重視；另對於部分負擔制度評估，除考慮需求面的效應外，亦應評估醫療院所提供醫療服務的適當性。關鍵詞：部分負擔、糖尿病、醫療利用、病人行為

關鍵字

部分負擔；糖尿病；醫療利用；病人行為

並列摘要

Abstract Purpose: The Bureau of National Health Insurance had raised outpatient co-payment since July 15th, 2005, in an attempt to correct patient’s attitude in medical utilization. They wish to shift the patients from large hospital to local hospital or clinic, and thus leading to reduced outpatient number in medical center. According to the data of the Department of Health, Executive Yuan, ROC, the prevalence of Diabetes is 6 to 10%, and higher in south and eastern Taiwan. Because Diabetes is an known chronic disease, that need long term medical care, we choose to research the influence of medical utility and attitude of Diabetic patients after the adjustment of outpatient co-payment. Method: Our samples were secondary data, obtained from 2 periods of time; from August to December during 2004 and 2005. The data were supplied from the Southern Region Branch of the Bureau of National Health Insurance, and designed as a pre- and post-test. In addition, the data was broken into two parts. Part 1 data includes information from the outpatient diabetes at 17 district hospitals and medical centers in Yunlin , Chiayi and Tainan area. We separated them into three group, and study the influence of higher co-payment on their medical utilization. The Part 2 data includes outpatient diabetes, who had visited medial center more than 3 times during the period from August to December, 2004. We study the influence of higher co-payment, on their medical utilization. Result: 1. The effect on medical utilization of diabetic patient in district hospital or medical center: A. After the adjustment of co-payment, the number of hospital visits decreased most in the group with the highest co-payment (-9.4%). The major disease and handicap group is second (-5.1%) and the low income veterans had little change (-0.5%); Medical center showed the most significant decrease in medical visits since they are the group with the greatest increase in cop-ayment (-19.9%). While district hospital showed little changes. B. Average day of medication prescribed at each visit have increased since the rise in cop-ayment. The increase amount is most evident in the group with the highest increase in co-payment and least in the minimal effected group (low income veterans). The average total medical cost of each visit increase markedly in the increase copayment group oppose to the major disease and handicap group. And the veteran group’s total medical cost only increased in the medical center visits. 2. The effect on medical utilization of medical center diabetic patients. A. Prior to the adjustment of co-payment, there are 5070 patients who had visited the medical center >= 3 times during the study period. After the adjustment of the copayment 45.4% of these patients decreased to only <=2 times; There is a decrease of 26.7% in the total patient visit of medical center. District and regional hospital plus local clinic showed an increase in patient visits of 114.4%, 89.1% and 110.8% respectively. B. There is significant relationship between the sex, age and level of severity of handicap in the change of medical utility of this diabetic patient. Age and level of handicap have statistical significant difference. Discussion and Suggestion: After the adjustment of the co-payment, diabetic patient visited large hospital less but the average days of medication given and the total medical cost increased. The prior medical center diabetic patients shifted from visiting medical centers to other less costly clinic after the adjustment of co-payment. There is a drop of visits from 94.49% to 77.15% after the raise of copayment in medical center. While local clinic visits raised from 4.18% to 11.89%. This clearly showed that there is a significant change in medical utility in diabetic patients after the adjustment of co-payments, with less visits and shift of treatment to local clinics. The adjustment of co-payment and the raise of registration fee in large hospital, cause chronic diabetic patient’s medical cost to rise. Dose the subsequent decrease in medical visit affect the necessary medical need of the patient? We suggest the Bureau of National Health Insurance should further investigate the co-payment system considering the effects on medical need and the appropriateness of the medical service provided by the hospital. Keywords: copayment、diabetes、 medical utilization、patient behavior