- 學位論文
西醫診所在總額預算浮動點值下的經濟行為
ECONOMIC BEHAVIOR OF MEDICAL CLINICS UNDER GLOBAL BUDGET FLOATING POINT SYSTEM
摘要
我國自全民健保實施以來，醫療費用增加快速，健保的財政負擔日益沈重。為因應醫療費用的快速成長，全民健保自民國87年起陸續開始實施總額預算制度。總額預算實施後，一方面健保所支付的醫療費用成長，立即受到了控制，但是另一方面在總額預算制度下，浮動點值的降低卻也造成醫界抗議。然而經過一段時間後，卻又觀察到浮動點值開始逐漸上升，其中的變化值得探討分析。 本研究分別從理論模型與實證資料分析的角度切入，對於西醫診所在總額預算浮動點值下的行為進行分析。理論模型以診所所得最大化為原則設計，探討總額預算下診所所得最大化的條件。實證資料分析則是根據93~95年的健保資料庫，進行敘述性分析、Panel Data的迴歸分析，研究影響西醫診所浮動點值變動的因素。 從理論模型得到的結論是:所得最大化的條件為其他診所申報的診察費與診療費點數必須合計為零，因此單一診所實際上無法透過正當手段達成所得最大化。但這個結果也指出總額預算下將存在醫師同儕團體的壓力，使得診所行為受到影響。此外，在單一診所無法達成所得極大化的情況下，則進一步地推導出各診所如果達成均分總額預算額度的協議，此協議的均衡將呈現不穩定的狀態。根據現行支付規範，診所破壞協議的動機十分充足，因此勢必會出現競逐總額預算支付的結果。 實證分析所得到的結論為:迴歸分析首先確認了浮動點值先降後升的原因，主要是受平均申報件數及診所家數的影響。其中，平均申報件數的增減更是造成浮動點值變動的主要原因。關於平均申報件數在94年第1季開始出現的減少現象，研究中也進一步確認了兩個主因。首先，從敘述性分析中發現，在94年第1季之後，平均診察費點數上升，這代表診所每日看診件數下降; 再者，從部份分局的西醫基層診所委員會明文規定中發現，各分局委員會具體規定了每個月份的「合理門診日數」，這也使得每月的看診日數下降。隨著平均看診件數下降，浮動點值得以上升，但是同時也會損害民眾的就醫可近性。此外，根據各分局平均申報件數接近與增減變動幾乎同步的情況發現，同儕團體是彼此存在具體影響力。而「中區分局」、「高屏分局」採用簡表申報比例較低且平均申報件數略低的情況，也說明了診所在總額預算制度之下，皆儘可能因應環境不同來追求所得的極大化。
並列摘要
After the implementation of National Health Insurance (NHI), the total medical expenditure increased rapidly, the financial burden became a serious problem for the operation of NHI. In order to control the growth of medical expenditure, NHI started to employ the global budget payment system. Under the global budget, the payment was retrospective, the final payment received was calculated by the value of floating point. After the execution of global budget system, the value of floating point continuously dropped in the medical clinic sector. However, the value started to rise back since Q4 of 2005. As there is no major change in the global budget system and the overall medical environment, there must be other change occurred. The aim of this study is to explore the behavior of medical clinics when facing the global budget payment system and try to figure the causes of value variation. In this paper, we employ both the theoretical model and empirical data analysis. In the hypothesis of theoretical model, the medical clinic was assumed to pursue the maximum of income under the global budget floating point system. In the empirical section, the data was drawn from the National Health Insurance database and covered the application data of 2004, 2005 and 2006. Since the floating point system works on the quarterly and NHI branch basis, panel data regression was applied to this study. The descriptive statistics analysis was also utilized to see if there is any area difference and specific trend in the macro environment. The major findings of the theoretical analysis include: (1) the condition of income maximizing for individual clinic was not practically feasible because it need other clinics to stop their operations. (2) If the clinics achieve the agreement of sharing the budget evenly, there still exists the incentive for clinics to violate the agreement and make their own income higher. Thus, the value of floating points will decrease in this circumstance. (3) The value of floating point was also found to have a positive relationship with the motivation of increasing the points applied by clinics. Higher value encourange higher motivation of increasing application. In the empirical analysis section, we ascertained the value variation of floating point was significantly influenced by application case quantity and the number of medical clinics. Further, the phenomenon of value rising back mainly resulted from the decrease of application cases. The decrease of application cases was due to the reduced practice day in a month and smaller patient number a day. The above finding was supported by the official document of the medical clinic association and clearly revealed the influence of peer group. In the descriptive statistics, the area difference of application behavior was found to support the hypothesis of income maximizing in the theoretical model analysis.