就醫自付額對醫療利用和病患選擇就醫處所的影響-以高高屏地區門診氣喘病患為例

Impact of Out-of-pocket Payment on Medical Utilization and Accessibility of Different Medical Facilities- A Case Study of Asthmatic Outpatients in Taiwan

林佩姿(Pei-Tzu Lin)

指導教授 ： 陳立佳

高雄醫學大學/藥學院/臨床藥學研究所/碩士(2009年)

https://doi.org/10.6832/KMU.2009.00054

摘要

研究背景 氣喘是需要長期控制的慢性疾病，適當的藥物治療可預防氣喘的急性發作和改善生活品質。部分負擔制度是常用來控制醫療需求、節約醫療資源的策略，但也可能影響病人的藥品使用及醫療成效；特別是對患有慢性疾病的病人而言。國內目前尚無針對慢性病患者醫療負擔能力、就醫選擇及服藥行為的研究，故本研究探討自付額對氣喘病患的醫療利用、就醫處所選擇及用藥之影響。
研究方法 本研究分成量化及質性研究兩部份。量化研究分析部分負擔是否真能影響醫療利用及花費，以ICD-9CM（493）篩選中央健康保險局高屏分局2004年1月至2007年12月各醫療院所每月申報的資料進行間斷時間序列分析，檢測2005年7月15日門診加重未轉診部分負擔制度實施對醫療利用及花費的影響；再根據醫療院所層級（醫學中心、區域醫院、地區醫院及基層院所）、是否需要部分負擔及處方箋種類（一般處方箋及慢性病連續性處方箋）進行分層分析。分析變項包含：醫療利用（每月申報人數及件數）、醫療花費（每月申報藥費、部分負擔及申請金額）及處方型態（每月開立的處方筆數、經計算後平均每一筆處方箋的給藥天數、平均每一筆處方箋的給藥品項、平均每一筆處方箋的藥費）。
質性研究採用焦點團體座談方式，於高屏地區各不同醫療層級舉辦座談會，深入探討影響氣喘病患就醫處所選擇的因素，以推演印證量化研究中的發現。每場邀請4至5位氣喘病患參與40至60分鐘的討論，以錄音方式蒐集資料，並於會後採逐字稿方式翻譯，再進行分析。
結果 量化研究發現於政策實施後，醫療院所每月氣喘病患的門診總申報人數（-7.15%，p= 0.004）、總申報件數（-9.29%，p< 0.001）及總申報金額（-11.17%，p= 0.008）均呈顯著減少；而依醫療層級分層後，在地區醫院及基層院所也可發現上述變化。部分負擔總申報費用（+11.31%，p< 0.001）顯著增加、但分層後發現醫學中心（+30.83%，p< 0.001）、區域醫院（+23.71%，p< 0.001）為顯著增加，而基層院所則為顯著減少（-13.62%，p= 0.001）。一般處方箋總申報筆數於政策實施後顯著減少（-8.92%，p= 0.001），且在地區醫院（-11.90%，p< 0.001）及基層院所（-8.93%，p= 0.007）也呈顯著減少；而慢性病連續性處方箋申報筆數則沒有顯著改變。
本研究於不同層級醫療院所共舉辦四場焦點團體座談會，共14名參與者。結果發現影響氣喘病人選擇就醫處所的因素有：醫院名氣及醫療設備、醫生名氣及專業度、服務態度、就醫方便性、治療效果、資訊來源、藥品差異及就醫習慣；僅有一位參與者考慮價錢因素。即使在充分告知各醫療層級收費標準後，大部分參與者皆表示醫療花費仍不是就醫的主要考量因素。
結論 門診加重未轉診部分負擔可以明顯抑制醫療利用、節約醫療花費，特別是對地區醫院和基層診所的影響最明顯，但對於較高層級的醫療院所則沒有影響，故部分負擔制度並沒有促進轉診回流的效果。對目前仍在接受治療的氣喘病患而言，自付額仍在可負擔的範圍內，就醫自付額並非選擇就醫處所之主要考量，醫院或醫師的名氣才是就診主要考量的因素。欲促使醫療資源合理利用及轉診回流，單純以加重部分負擔的節約成效有限，尚需制定其他相關配套制度以改善現況。

關鍵字

氣喘 ； 自付額 ； 焦點團體

並列摘要

Background: Asthma is a long-term, chronic condition, which requires routine and appropriate medications to prevent acute attacks and improve quality of life. Co-payment is a common strategy to control medical demands and rational use of resources, but it may also cause a negative treatment effect according to previous research. In Taiwan, there is a lack of study to explore affordability of patients with chronic diseases to access different tiers of medical facilities. Therefore, this study explored the influences of out-of-pocket payment on asthmatic patients’ medical utilizations and chooses to access different tiers of medical facilities.
Methods: This study obtained both quantitative and qualitative approaches. Quantitative research aims to explore whether the co-payment do impact on medical utilisation. A segmented time series analysis was conducted on a monthly outpatient medical claim data retrived from the Kao-Ping Branch of National Health Insurance during January 2004 to December 2007, to explore the impacts of the increase Non-referral Co-payment Policy implemented on 15th July 2005. Asthmatic patients were identified by ICD-9 code and their corresponding outcome variables including medical utilization (numbers of patients, number of visits), medical cost (treatment cost, drug cost, co-payment) and prescribing pattern (number of prescriptions, number of items per prescription, duration per prescription, drug cost per prescription) were also retrieved. Outcomes were stratified by different tiers of medical facilities (medical centers, regional hospitals, local hospitals and clinics), co-payment groups and types of prescriptions (general and continuous prescriptions). The qualitative research aims to explore the factors which influence onpatients’ choices of accessing different medical facilities. Participants were recruited from different tiers of medical facilities, and the number of each group was above five and the discussion time was 40 to 60 minutes. Data were collected by tape-recoding andtranslated word by word for analysis.
Result: After the policy intervention, total numbers of outpatients (-7.15%, p= 0.004), total numbers of visits (-9.29%, p < 0 .001) and total treatment cost (-11.17%, p= 0.008) significantly decreased; and the changes were also observed at local hospitals clinics. Total co-payment significantly increased (+11.31%, p< 0.001), and this was also found at medical centers (+30.83%, p< 0.001) and regional hospitals (+23.71%, p < 0.001), but it significantly decreased at clinics (-13.62%, p= 0.001). Total numbers of asthmatics outpatients’ general prescriptions (-8.92%, p= 0.001) significantly decreased, which was also found at local hospitals (-11.90%, p< 0.001) and clinics (-8.93%, p= 0.007). However, there was no change for continuous prescriptions.
Four focus groups were conducted at local community (n= 1), regional hospital (n= 1) and medical centers (n= 2), which included 14 participants. The saturated opinions indicated that patients’ perceptions on the reputation of physicians and hospitals, physicians’ professionalism, convenience of transportation, time-saving, source of information, treatment efficacy of medicines, hospital equipments, quality of services and differences in drugs’ brands and appearances were the influencing factors to patients’ choices on medical facilities. However, only one participant ever mentioned the medical cost is a concern. After being properly informed about the differences of medical costs at different tiers of medical facilities, most participants’ perceptions consisted with the previous finding that medical cost is not the most important considerations for accessing medical facilities.
Conclusions: Reputation of physicians and hospitals were patients’ main considerations to assess different hospitals. Out-of-pocket payment has limited efficacy to ameliorate referral system and does not create burden problems after the intervention of policy. If governments want to cut unnecessary medical utilization and improve the referral system, they should make other related policies.

並列關鍵字

asthama ； out-of-pocket payment ； focus group

參考文獻

1. Muszbek N, Brixner D, Benedict A, et al. The economic consequences of noncompliance in cardiovascular disease and related conditions: a literature review. International Journal of Clinical Practice 2008;62(2):338-51.

2. Janson SL, McGrath KW, Covington JK, et al. Individualized asthma self-management improves medication adherence and markers of asthma control. Journal of Allergy and Clinical Immunology 2009;123(4):840-6.

3. 陳皇仲、張斐綾、盧瑞芬等人。全民健保部分負擔政策對醫院復健科門診醫療使用的影響。臺灣復健醫誌 2005;34(2):73-80.

4. 洪明皇。全民健保新制部分負擔對不同社會群體影響之探討。國立政治大學 財政學系 碩士論文 2001年。

5. 中央健康保險局。2009全民健康保險簡介。http://www.nhi.gov.tw/webdata/webdata.asp?menu=3&menu_id=54&webdata_id=2891&WD_ID=65 (accessed on 10th June 2009). 2009.