透析醫療市場結構對供給者行為及經營績效之影響

研究背景與目的?台灣醫療市場自實施全民健保以來，不僅影響台灣各層級醫療院所之市場板塊，改變各專科醫師之人力市場分佈，更因為重大疾病傷害納入健保給付範圍，為特定醫療市場提供一保險誘因，其中尤以透析(dialysis)醫療市場之消長轉變最為顯著。本研究擬針對全國透析醫療院所，瞭解近年來透析醫療市場結構之變化，並進一步探討市場結構對透析醫療院所經營行為及經營績效之影響。研究方法本研究架構採用市場結構、行為、績效理論（Structure -Conduct -Performance, SCP），其研究設計採用縱貫性研究設計研究(longitudinal study design)，利用回溯性之次級資料分析(retrospective secondary data analysis)，長期追蹤民國86年至88年間之透析醫療市場變遷與消長。並將透析醫療院所區分為長期存在之透析醫療院所、新加入之透析醫療院所及退出市場之透析醫療院所三組。統計分析方法主要為廣義估計方程式（GEE）用於分析長期影響透析醫療院所績效因子。研究結果一、在外部經濟環境下，透析醫療市場需求仍是日益增加，並且於透析醫療資源的投入亦是逐年增加，而在市場分佈中仍是以台北分局主要分佈，而相對高透析病患盛行率及發生率區域並未有相對較高的透析醫療分佈，反而傾向於人口數越多區域有較多的透析醫療院所分佈。二、在市場結構中，各縣市透析病患盛行率呈逐年成長趨勢，另外，在市場競爭程度中，研究發現約有4成區域為獨占市場，但大部分透析醫療院所仍處於競爭市場中。而在透析醫療市場中，每年新加入透析醫療院所在機構層級別上大部分為地區醫院及診所為主，在退出市場的透析醫療院所則以地區醫院佔居多。三、發現於民國86年市場結構中，透析病患盛行率和發生率越高區域則相對有較高的透析醫療設備及人力投入，而市場競爭程度並不影響透析醫療院所行為改變。四、研究中發現新加入組區域之原透析醫療院所，在新透析醫療院所設立後在民國88年間顯著在行為上有改變，相對的比前年有較多的醫療設備投入，而結果亦指出新院所加入該區域市場後，明顯在行為及績效表現上顯著低於原透析醫療院所。五、經由廣義估計方程式（GEE）長期分析，結果顯示為市場競爭程度越低區域、權屬別為法人及私立醫療機構之透析醫療院所、及投入越多醫療設備和醫師數的透析醫療院所經營績效越好，而針對退出市場組推測其本身市場結構及行為因素原因亦符合本研究預測模式的結果。討論與建議在透析醫療市場中，各層級透析醫療機構競爭已儼然存在，而面對市場的競爭下，對於公立醫療機構或新加入的透析院所在經營上面臨一大考驗，但相對地研究結果亦顯示出市場競爭程度越低區域經營績效越高，因此對於市場過度集中在競爭市場中的透析醫療院所，在台灣地區透析病患需求逐年增加下，是否往新的市場空間開拓，值得醫療供給者參考，另外，對於衛生主管機關者應著重於瞭解透析市場分佈狀況，以提供市場供需訊息，做為醫療供給者經營衡量參考，並為相對透析醫療資源較少區域能鼓勵透析醫療機構設立以維護民眾就醫權利。

關鍵字

SCP理論；經營績效；供給者；市場結構；透析

並列摘要

Background and Objectives After the implementation of the National Health Insurance Program in Taiwan, the market share of different levels of health care organizations, and the distributions of professional manpower have been changed. More important, the NHI payment for major illnesses has provided a strong financial incentive for specific service market, especially for dialysis market. The major purpose of this study is to understand the changes in dialysis market structures over time and its corresponding effects on dialysis providers’ production function and performance. Methods The research framework is based on Structure-Conduct-Performance (SCP) model .The research design was retrospective secondary analysis longitudinally .The study period was from 1997 to 1999.During the study period, all dialysis providers in Taiwan were included into study organizations, which were classified into three groups, long-term providers, new providers, and withdraw providers. Generalized estimating equation was used to identify the factors associated with the performance of dialysis facility over time. Results 1. From the perspective of external environment, the demand of dialysis was still growing and the inputs of medical resource increased correspondingly. A major proportion of dialysis facilities were located in Taipei areas. And higher prevalence and incidence of areas were not related to have higher aggregation of dialysis facility. Oppositely, more dialysis providers gathered in population centre. 2. In terms of market structure, the prevalence of dialysis in all counties increased year-by-year. Forty percent of dialysis market that were in a monopoly market, but most facilities were still under a competitive area. Among new providers, the majority of them were district hospitals and dialysis clinics. Most of withdraw dialysis providers were district hospitals. 3. At baseline (1999), the areas with higher prevalence and incidence had more inputs of medical equipments and medical staffs. However, market competition did not have significant influence on the change of dialysis providers’ inputs of medical resource. 4. Among the regions with new dialysis providers, the original dialysis providers had more inputs of medical equipment than the year before last. And the results also pointed out the new dialysis providers had the lower performance in comparison with original dialysis providers. 5. Using the generalized estimating equation(GEE) for predicting the determing factor, the results indicated that dialysis facilities in lower competition area、ownership for private and legal medical facility、with more medical equipments and physicians had the better performance in dialysis market. The prediction of GEE models also fitted on withdraw providers. Discussion and Suggestion In dialysis market, the competition already exists in different levels of health care organizations .Facing market competition, the public medical facilities or new providers have a challenge on operation of facility. Therefore, in a highly competitive market, developing a new market area may be a good strategy for long-term. In addition, for policy makers, they should focus on the distributions of dialysis market and provide related information to dialysis providers as a reference of operation. For the region of the insufficiency of medical care, the administration should encourage more providers to set a facility in order to maintain the right of patients accepting medical care.