乳癌論質計酬之成本效性分析

A Cost-Effectiveness Analysis of the Pay-for-Performance Program for Breast Cancer

董淑萍(Shun-Ping Dung)

指導教授 ： 陳美美副教授

長榮大學/健康科學學院/醫務管理學系(所)/碩士(2012年)

https://doi.org/10.6833/CJCU.2012.00159

摘要

背景 乳癌是台灣女性癌症中發生率排名第一，而死亡率排名第四的重要疾病，是婦女健康的重大威脅。加上女性發現罹患乳癌時，疾病大多已進展至第二期以上，增加治療的困難度。若能早期發現並給予正確治療，將能有效減少乳癌復發和降低死亡率。因此健保局在2001年推行乳癌論質計酬方案，希望能透過團隊方式，提供病人最適切的醫療服務，有效率的使用醫療資源。但是方案推行後，只有7間醫院加入。且針對此方案的成效研究僅有單年的觀察結果，未有長期的成效分析。

目的 探討參加乳癌論質計酬與未參加乳癌論質計酬的病人在短、中期的醫療資源使用的差異與照護結果，並進行成本效性分析。

研究方法 以Aday的醫療服務行為模型為研究架構，採準實驗研究設計，實驗組為參加乳癌論質計酬之病人，對照組為未參加乳癌論質計酬之病人。資料來源為國衛院全民健保研究資料庫2005年抽樣承保歸人檔13組資料。擇取2005-2008年間，在區域醫院或醫學中心就醫，所有療程都在同一支付制度下的新發病乳癌病人為研究對象，計得實驗組109人，對照組413人。統計分析採t檢定、卡方檢定、複迴歸分析、存活分析、Cox迴歸分析和成本效性分析。

研究結果
一、在醫療資源利用方面，乳癌病人的絕大多數醫療資源使用是在發病的第一年。分年的t檢定與卡方檢定發現，在第一年，乳癌論質計酬參加者的手術次數、總檢查費用與追蹤費用皆顯著高於未參加者，而平均每次住院天數、總住院天數、化學治療次數、放射治療次數皆顯著低於未參加者。在第二年，乳癌論質計酬參加者的門診次數與總其他治療費用顯著低於未參加者。在第三年，乳癌論質計酬參加者僅總檢查費用顯著低於未參加者。其他醫療資源的使用無顯著差異。
二、在總醫療費用方面，當控制其他影響因素後，乳癌論質計酬參加者的第一年和全三年的總門診費用、總住院費用和總醫療費用皆顯著高於未參加者。
三、在照護成果方面，乳癌論質計酬參加者在乳癌復發與死亡的機率雖略低於未參加者，而發生復發與死亡的時間雖也較晚，但皆未達顯著性差異。在控制其他影響因素後，結果也未改變。
四、在成本效性分析方面，因衡量效性的照護成果無顯著性差異，故轉為最小成本分析法。參加論質計酬的乳癌病人比未參加者有較高的總醫療費用。

結論 乳癌論質計酬參加者在短期(第一年)或中期(全三年)的總門診費用、總住院費用和總醫療費用皆高於未參加者。在以復發與死亡衡量的成效上，兩組無顯著性差異。因此在成本效性分析上，乳癌論質計酬並未優於傳統方式。

關鍵字

論質計酬 ； 乳癌

並列摘要

Background: Breast cancer is the most common cancer and the fourth leading cause of cancer death among women in Taiwan, imposing a great threat on women’ health. Meanwhile, as breast cancers among most women are often diagnosed at the second or a later stage, they are more difficult to be cured. If breast cancers can be diagnosed and treated properly at an earlier stage, the recurrence rate and mortality can be reduced effectively. As a result, the Bureau of National Health Insurance (NHI) launched the pay-for-performance program for breast cancer in 2001, in hopes of providing patients with the most suitable care by medical teams and of utilizing medical resources more efficiently. Unfortunately, only seven hospitals have participated in the program since it was launched. In the meantime, no long-term analyses but only annual reports have been conducted regarding the effectiveness of this program.

Objectives: This study aims to discuss the differences in short- and mid-term utilization of medical resources as well as care results between patients who participate in the pay-for-performance program for breast cancer and who do not, and to conduct a cost-effectiveness analysis.

Research Method: Based on Aday’s behavioral healthcare model, this study was designed to be a quasi-experimental research. The experimental group included patients who had participated in the pay-for-performance program for breast cancer while the control group included patients who had not. For the research data, 13 sets of panel claims data in 2005 were extracted from the National Health Insurance Research Database established by the National Health Research Institute. Breast cancer patients who were diagnosed of it for the first time and received treatments at regional hospitals or medical centers, and whose entire treatments were covered by one single payment program were recruited as the research subjects, resulting in 109 patients in the experimental group and 413 patients in the control group. Statistic methods such as a t-test, chi-square test, multiple regression analysis, survival analysis, Cox regression analysis and a cost-effectiveness analysis were adopted.

Research Results:
1.In terms of using medical resources, most utilization of medical resources of breast cancer patients occurred in the first year after diagnosis. The t-test and Chi-square test of a single year show that, in the first year, patients who had participated in the pay-for-performance program for breast cancer had more operations, a higher total cost for examinations and a higher cost for follow-up checks than patients who had not participated in the program. In the second year, program participants contributed to fewer outpatient visits and a lower cost for other treatments than patients outside of the program. In the third year, the total cost for examinations of patients in the program was lower than the non-participants while no other difference was found on the utilization of other medical resources.
2.Considering the total medical expense, when other variables were controlled, the total costs of outpatient visits, of hospitalization, and of the entire medical service for patients who participated in the program were all higher than the non-participants in the first and the third year.
3.In terms of care results, although breast cancer patients who participated in the pay-for-performance program showed a lower recurrence rate and mortality, as well as a later recurrence and death than patients outside of the program, all differences were not significant. The result did not change after other variables were controlled.
4.As no significant difference was found on the effectiveness of care results by the cost-effectiveness analysis, a cost-minimization analysis was conducted instead. Breast cancer patients participating in the pay-for-performance program contributed to a higher total medical expense than patients not participating in the program.

Conclusion: Breast cancer patients participating in the pay-for-performance program contributed to higher short- (the first year) and mid-term (three years) costs of total outpatient visits, of total hospitalization and of total medical services than patients not participating in the program. In terms of the effectiveness of preventing recurrence and death, no significant difference was found between the two groups. As a result, the cost-effectiveness analysis shows that the pay-for-performance program for breast cancer is not better than the traditional payment method.

並列關鍵字

pay-for-performance program ； breast cancer

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