Tw-DRGs支付制度架構合適性及醫療資源配置合理性探討－ 以高屏地區腎及泌尿道感染（DRG320、321）二組群為例

研究背景健保局在總額支付制度下原2008年實施Tw-DRGs支付制度，惟醫界反彈加上各界質疑，造成二極化聲浪，不得不於2007年12月公告廢止實施，並宣稱會再持續與醫界協商。基於此發展需有實證研究去證明Tw-DRGs支付制度是合理的，以及未來健保局在醫療費用與醫療品質管理上須注意的重點，故本研究選擇原第一階段6個MDC中件數（49％）、費用（38％）占率最高的MDC11〈泌尿道系統〉之DRG320與DRG321二組做為研究對象，探討Tw-DRGs支付制度架構合適性、醫療資源配置與耗用合理性，及找出影響醫療資源耗用因子。研究方法利用2005~2007年健保局高屏分局住院費用資料庫，試行以Tw-DRGs支付制度導入後本研究DRG項目，其醫療費用在不同層級間的變化，並探討例外案件（outlier）的處理等作為支付架構合適性的研究。以平均醫療費用、3日內再急診、14日內再住院等指標探討未來醫療院所可能面臨的挑戰。再以病患人口學、臨床特質、醫院特質等變項，探討未來健保局醫療費用監控與審查重點。研究結果一、Tw-DRGs支付制度架構合適性：1. 疾病分類週延性：導入後平均醫療費用的CV值DRG320 CV值38.1％、DRG321 CV值＜22.7％。2.導入後醫療費用案件數落入定額支付區DRG320為91％、DRG320為96％。3.因疾病嚴重度不同而有不同給付：導入後平均醫療費用DRG320有增加、DRG321微降，DRG320、321幾何平均住院天數均低於公告參考值，但其平均住院天數均高於公告參考值，轉院案件占率6.5%，以住院0-2天轉院及地區醫院占率最高。二、醫療資源配置與耗用合理性：DRG320、321導入後平均醫療費用與年齡層、醫院層級皆達顯著差異。3日內再急診占率均＜1.8%，14日內再住院（本次疾病相關）均＜0.4%，14日內再住院（全疾病）DRG320為6.0％、DRG320 2.8％。三、影響醫療費用之因子：DRG320、 DRG321皆以住院天數、出院狀況、醫院層級別、Base Rate、次診斷編碼數等為其醫療費用重要影響因子。結論和建議一、CV值小對疾病分類是好的，整體支付系統尚屬穩定，導入後有把較多的錢放在嚴重度高的DRG320是適當的，支付計算基礎採中平原則，未影響整體國家醫療支出，故Tw-DRGs支付制度架構仍屬合適的，對有虧損的醫院，應從提升效率著手落實標準化作業流程，對多給錢的醫院更應再加強醫療品質。平均住院天數均高於參考值將可促使醫院加強管理。二、導入後平均醫療費用與年齡層雖有差異，然DRG是屬於包裹式給付本有互補之效，醫院不能因每位病人花費不一而有差別待遇，須做好臨床路徑管理、提升醫院照護品質。平均醫療費用在層級上有差異，顯示醫學中心應釋放DRG320、321等相對權值低的病人，導向以社區型醫院為主，避免資源浪費，落實分級醫療。地區醫院須加強收治是類病人能力，區域醫院介於二者間更須加強效率，整體而言醫療資源配置與耗用亦屬合理。三、影響醫療費用最重要因子為平均住院天數，應為醫院管理首要目標，也是健保局審查重點；建議先運用於品質管理與資源分配，對平均住院天數須加強審查及研擬相關配套措施。醫療提供者可運用加強臨床路徑、成本概念等，並用心提供建言，在可行方案締造三贏局面。

關鍵字

台灣版的診斷關聯群；支付制度；疾病分類；主要疾病類別；相對權值

並列摘要

Background: The Bureau of National Health Insurance（BNHI） had planed to implement theTw-DRGs ( Taiwan Diagnosis Related Groups) payment system under the global budget system in 2008. However, under the objection of the medical group and other aspects, the plans was abolished on December, 2007, and declared to continue negotiation with the medical group. Under this development, it’s important to perform an evidence-base research to prove the feasibility of the system, then providing a good strategy of medical quality control for Bureau of National Health Insurance . Therefore, Our study chose one of the original first stage’s 6 MDC( Maior diagnosis categry) , MDC11（urogenital system） including the two groups of DRG320 and DRG321, as the research’s object .The characteristics of MDC11 including the the commonest medical payment claims of the 6 MDCs(49%), the highest proportions of healthcare expenses (38%). We aimed to explore the Tw-DRGs payment system’s structure applicability, medical resource distribution, rationality of expense and explored the factors that affect the medical resource expense. Methods：Using the inpations medical payment claimed data of the bureau of national health insurance, Kao-Ping branch, we tried to introduce the Tw-DRGs payment system into the DRG with the variations between different healthcare stratums, and analyzed how to deal the outlier of our study to validation structure of payment. Using the average of medical cost, rates of returning to emergency department (ED) within three days and readmission within fourteen days as indicators, we analyzed the challenges that the medical providers may face in the future. Moreover, using the variants of the popularity, clinical specialty, hospital peculiarity, we explored the aspects of future monitor and inspection. Results：First, the application of the Tw-DRG paymentstructure: 1. The comprehensiveness of disease’s category: The CV value of DRG320 was 38.1% with DRG321 value <22.7% after introducing the system. 2. After introducing the system, the case falling into the area of fixed payment in DRG320 was 91% with DRG320 96%. 3. Different severity of diseases with different payment: After introducing, the average of medical cost was increasing in DRG320 and decreasing in DRG321. The statistic average inpatient days were lower than public announcement in DRG 320 and 321, but both of the average inpatient days were higher than the reference value of announcement. The rate of transfer was 6.5%, with the higher rate in the regional hospital and the patients admitted within 0-2 days. Second, the reasonableness of medical resource distribution and expense: There was a significant difference of average medical cost in the age and stratums of hospital. Rate of returning to ED within 3 days was <1.8%, and readmission with the same disease was <0.4%. Readmission rate of whole diseases within 14 days was 6.0% in DRG 320 and 2.8% in DRG 321. Third, the impact factors of medical cost: Both the important factors of DRG 320 and 321 were including days of inpatient, the status of discharge, the stratum of hospital, base rate and numbers of secondary coding. Discussion and Suggestions：First, it’s positive of lower CV value in the category of diseases. With the stable payment system, after being introduced, it’s proper because more money was deposited into the more severity patients of DRG 320 group. The principle of payment system was equalization; the whole expense of medicine was not increasing. Therefore, the Tw-DRG payment system was applicable. For the negative revenue hospitals, they should start to increase the efficiency and use standardized procedures. Hospitals with more budget should be monitored the quality of care. The hospitals having higher length of inpatient should be enforced to be supervised. Second, although there was a difference between age in the average medical cost, the package payment of DRG could complement each others that the hospital could not have difference treatment of patients with different payment. The clinical pathways should be established and increasing the quality of care. There was a difference in the average medical cost of different stratum of hospital, which revealed that the medical centers should release the lower CV value patients of DRG 320 and 321, and transferred to community hospital to decrease wasting of medical resource and establishing the diversion. Community hospital should increase the ability of care and the regional hospitals should increase its efficiency. Overall, the distribution of medical resource was reasonable. Third, the most important factors affected the medical cost was average days of inpatient and it should be the first priority of hospital management and the key point of investigation by bureau. We suggest using the quality control and resource redistribution to investigate the length of inpatient and develop associated strategy. Medical providers could using the clinical pathways and concept of prime of cost with proving suggestion to government and create a triple-wining situation.