建立西醫基層診所之效率檔案

Efficiency profiling of primary care providers based on ACG case mix system

陳筱函(Hsiao Han Chen)

指導教授 ： 林文德

長榮大學/健康科學學院/醫務管理學研究所/碩士(2008年)

摘要

目的：
建立家醫整合計畫B型支付方案下各診所之效率檔案，以評估計畫之成效。
方法：
利用某一健保分區94及95年之家醫整合性計畫會員申報資料，扣除未就診及門診費用最高1%的會員，以及3間特殊次專科(眼科、皮膚科、精神科)診所，最終樣本為78間診所、71072位會員。採用校正臨床群組(Adjusted Clinical Groups，ACGs) 歸類病患疾病嚴重度，並利用配對t檢定檢驗病患嚴重度兩年間的差異。診所的效率以所有會員的實際費用除以ACGs預測的會員費用而得，比值愈低代表診所較具效率；信度分析以皮爾森檢定診所兩年效率值之相關性，效率排名則以斯皮爾曼檢定兩年之相關性，效度分析以會員固定就診率做為效標。
結果：
同一會員兩年間的嚴重度並無顯著變化；78間診所的效率值分佈在0.7-1.5之間，且兩年的效率值相關係數為0.93，效率排名的相關係數為0.91，均達顯著程度。診所的效率值和住院率及會員固定就診率皆無顯著相關。
結論：
ACGs風險校正工具應用在家庭醫師整合性照護計畫之家戶會員疾病嚴重度的分類以及預測醫療費用，初步使用即有不錯的結果，根據ACGs預測的費用計算診所的效率，信效度的檢測可再利用其他指標更進一步確認ACGs風險校正工具的穩定性及適用性，未來也可考慮以此工具做為比較西醫基層診所效率的參考，以提升診所之效率。

關鍵字

效率檔案 ； B型支付方案

並列摘要

Purpose:
To analyze the efficiency of the clinics under Family Medicine Integration Project Payment B to increase the effect of this project.
Material and Method:
According to the application data of Family Medicine Integration Project members from Bureau of the one of the National Health Insurance Region Branch from 2005 to 2006, eliminating the top 1% members for their high policlinic charge or not visiting and 3 special division clinics on ophthalmology, dermatology and psychiatric, there are 78 clinics and 71072 members for the final samples. Adjusted Clinical Groups is adopted to classify the levels of how serious the patients are and use paired t testing to check the range in two years. The members in the family physician clinic visit times be a external validity. To use Pearson correlation coefficients test the correlation of efficiency between 2005 and 2006 for reliability. Use Spearman correlation coefficients test the correlation of efficiency position between 2005 and 2006. The positive cost paid by all members divided by the member cost expected by ACGs equals the efficiency of the clinic. Lower the ratio is, higher the efficiency is.
Result:
There isn’t a big change on one member in two years. The efficiency rates of 78 clinics are from 0.7 to 1.5. Besides, the correlation of efficiency in two years is 0.93 and the correlation of efficiency position is 0.91, both reach the obvious level. The correlation of the efficiency of the clinic and the times that the member goes to this clinic is 0.41, which also reaches the obvious level.

Conclusion:
Classify with ACGs is stable and the clinic’s efficiency according to cost expected by ACG also gets good reliability and validity. We could use it to compare clinics’ efficiency in the future to raise the efficiency of the clinics.

並列關鍵字

ACGs ； physician profiling ； Payment B

參考文獻

李偉強、楊昭恂、洪世欣和黃東波(2007)。應用ACG病例組合系統評量榮民疾

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