- 學位論文
就醫自付額對醫療利用及就醫處所選擇之影響 – 以高高屏地區胃食道逆流患者為例
The Impact of Out-of-pocket payment on Medical Utilization and Accessibility to Different Medical Facilities – A case study of GERD Patients in Kao Kao-Ping Area of Taiwan
摘要
背景：部分負擔制度是各國健康照顧付費者用來控制醫療花費的方法之一，但亦可能因抑制必需醫療利用，而惡化健康照顧品質，負面地增加醫療花費支出。台灣中央健康保險局（健保局）提供民眾就醫之給付幾乎囊括各類疾病，且賦予民眾自由選擇就醫處所的權利。面臨財政困境，健保局於2005年7月15日實施加重門診未轉診部分負擔制度，增加民眾於醫院層級醫療院所之就醫自付額，以試圖促使民眾轉診回流至基層醫療院所，而此制度已被證實對於整體疾病之轉診回流成效有限。未發掘就醫自付額如何影響特定疾病族群之就醫處所選擇，及了解其就醫處所考量之因素，本研究選擇一種不需積極治療之疾病-胃食道逆流，採取量化及質性兩種不同方法探討。 方法：量化分析部份採用間斷時間序列分析，分析地區域性健保申報資料，採用以月為單位之醫療利用及花費申報資料為時間序列資料，以套裝統計軟體STATA 10.0進行分析。分析內容包括：醫療利用（申報件數、申報人數）、花費（申請金額、部分負擔金額）及處方型態。質性研究則採用焦點團體討論，徵求高高屏地區於不同醫療層級就醫之胃食道逆流病患參與焦點團體討論。 結果：胃食道逆流整體就診人數在政策實施時顯著增加，且政策後仍持續上升。政策對胃食道逆流病患於醫學中心、地區醫院之醫療利用有抑制作用；而對於基層醫療院所之醫療利用有增加作用。在較高層級的醫療院所，政策對於需部分負擔族群及領一般處方箋之病患影響大於免部分負擔族群及領慢性病連續性處方箋之病患。質性研究於不同醫療層級及地區（包含城市及離島）收入46位參與者，共舉行九場焦點團體。所有參與者選擇就醫處所時，一致都優先考量醫師的名氣及醫院的規模。另外，地緣及醫師的建議也是參與者選擇就醫處所時重要考量因素之一。幾乎所有參與者都可接受目前四層級醫療院所之就醫自付額，但認為高層級醫療院所之就醫自付額是貴的，尤其是醫學中心；但由於大多數參與者普遍信任較高層級醫療院所有較好的儀器、設備及醫療照護，因此偏好選擇高層級醫療院所就醫。另外，醫師也會用某些策略，例如：開立慢性病連續性處方箋，以節省病患花費，以留住病患繼續就醫。 結論：自付額對台灣胃食道逆流的醫療利用確有影響，增加就醫自付額會促進胃食道逆流病患回流至基層醫療院所。然而，就醫自付額未造成目前正接受治療的胃食道逆流病患之醫療負擔問題，也不影響其就醫處所的選擇。建議未來可進一步研究在不同就醫自付額下，探究胃食道逆流患者如何權衡各個就醫處所選擇的考量因素，及探討不同就醫自付額將如何影響此族群病患就醫處所的選擇，以期制定節約醫療利用且不損害民眾就醫權利的費用管控政策。
並列摘要
BACKGROUND: Co-payment is commonly used by health care payer to control unnecessary medical utilisation. Taiwan’s national health insurance (NHI) provides generous coverage and patients’ full freedom to access different tiers of medical facilities. NHI’s attempt to divert outpatient care utilisation into primary care by the policy that largely increased co-payment on 15th July 2005 only showed limited effects on overall diseases’ medical utilisation. To explore how out-of-pocket payment (OPP) affects the choices of accessing different tiers of medical facilities in a specific disease group, and to determine the relative importance of factors (attributes) associated with patients’ choices, we choosed gastroesophageal reflux disease (GERD), which generally does not need aggressive treatment, by using both quantitative and qualitative approaches. METHODS: Interrupted time-series analysis on regional monthly outpatient medical claims was used as quantitative approach and conducted in STATA 10.0. Number of visits and outpatients, total cost of outpatient care, and prescribing patterns were evaluated. Focus groups which recruited GERD outpatients from different tiers of medical facilities in southern Taiwan were used as qualitative approach. RESULTS: The overall numbers of outpatients were significantly increased after the policy implementation, and the trend after policy also significantly increased. The policy discouraged contacts in local hospitals and medical centers, and encouraged contacts in primary care (physicians’ clinics). Comparing against the policy’s effects on exempted group, and patients with continuous prescriptions, the policy had greater inhibiting effects on co-payment group and patients with general precriptions. Night focus groups were held in different tiers of medical facilities, recruiting 46 participants from cities and an off-shore island. Reputation of doctors and size of medical facilities are the highest priorities and unanimous considerations of all participants. Distance (transportation convenience) and advises from doctors were also important attributes for accessing medical care. Participants generally thought the current OPP is acceptable, yet expensive when go to higher tiers, especially medical centers. Despite that, they still preferred and felt worthy to visit higher tiers of medical facilities due to their trust on quality (better medical cares, drugs and equipments), and also doctors may use cost-saving strategies such as continuous prescriptions to help patients minimize OPP. CONCLUSION: Increasing OPP had shown to divert GERD outpatients from higher tier to lower tier medical facilities at the time of policy implementation. However, current OPP does not seem to impact on participants’ affordability and accessibility of treatment. Future study is suggested to determine the relative importance of attributes and how different OPP influence on decision making to help develop optimal policy.