醫療道德風險 - - - 全民健保DRG制度的探討

Moral Hazard of Medical Insurance --- A Study at DRG Payment System of National Health Insurance

周振銘(CHENG-MING CHOU)

指導教授 ： 林文昌

國立中正大學/管理學院/財務金融學系/碩士(2016年)

摘要

台灣的健保制度舉世聞名。在1995年3月開始實施之初期，醫療給付與行政支出小於實收保險費，收支尚可平衡；然而在1998年首度出現財務缺口之後，健保財務就日益惡化，造成了健保的財務危機，一直持續到今日。為了控制醫療支出的成本，健保署在民國99年1月1日施行了第一階段的DRG（診斷關連群）給付制度；以定額給付的論件計酬，取代無限額的論量計酬。實施DRG的目標是迫使醫院改善醫療效率，重視醫療品質，避免併發症，從而減少醫療花費，達到全民皆贏的目標。然而，醫療工作的內容極其複雜，在施行DRG定額給付之後，是否真如預期，達到減少醫療花費的效果；或是因為實施定額給付，醫院為了降低成本而衍生了醫療問題，目前並沒有相關的科學研究報告。
本研究系以全民健保資料庫為基礎，收集98年度與99、100年度的骨科病人住院健保資料，年度比較共兩項：99年度對照98年度；100年度對照98年度。應變數據為三項：住院天數、住院花費、與14日內再入院。以全國、醫學中心、區域醫院、與地區醫院，比較99年1月1日實施DRG之前後，已實施DRG項目的變化，與未實施DRG項目的變化，兩者的差異有無統計學上的意義。在總共168912個案的住院數據分析後顯示，在全國的總住院數據上，99年度對照98年度，實施DRG在減少的住院天數，顯著的大於未實施DRG減少的住院天數；在醫療花費上則是沒有顯著的差異；而14日再入院也沒有顯著的差異。100年度對照98年度，實施DRG在減少的住院天數顯著的大於未實施DRG減少的住院天數；實施DRG減少的醫療花費，也顯著的大於未實施DRG減少的醫療花費；而14日再入院則沒有顯著的差異。針對全國的數據，本研究再細分醫院層級為醫學中心、區域醫院、與地區醫院，對於各層級醫院的數據結果，本研究亦會予以報告與討論。
本研究的結論：整體而言，實施DRG定額給付有助於降低病人住院天數，減少醫療花費，而且不會增加14日再入院的比例。

關鍵字

醫療花費 ； 住院天數 ； 診斷關連群 ； DRG ； 14日再入院

並列摘要

The system of National Health Insurance in Taiwan is worldwide renowned. In March 1995, the medical payment with administration fee became lower than the insurance premium and still the budget remained balanced. However, after the deficit first appearing in 1998, the finance of NHI deteriorated and finally turned into a crisis. To date, the financial crisis still persisted. In order to curb medical payments, NHI enacted the first stage DRG payment system, which pays medical expenses on a piece basis rather than on a service basis as before. The aim of DRG payment is stimulating hospitals to increase medical efficiency , improve service quality , avoid medical complication and reduce medical costs. Conceptually, it is beneficial to all stakeholders, including NHI , hospitals and patients. Nevertheless, medical care is a complex practice. Hence, whether DRG system can lower medical expenses, or it will give rise to greater medical malpractice problems when service providers control costs is still not verified. To date, there is no related studies concerning this issue. This study attempts to answer this question based on the data base created by NHI. The data in 2009, 2010 and 2011 are collected, in which the 2010 and 2011 (after implementing DRG) data are used to compare with the 2009 (before implementing DRG). Three variables are used to measure medical performance, days of stay, medical expense and re-admission rate within 14 days. The effect of implementing DRG on medical saving is further examined by dividing service providers into medical center, metropolitan hospital and regional hospital. This study test if there are cost differences before and after DRG implementation for DRG groups and non-DRG groups. The results show that, among the whole nation of 169812 admission cases , the reduction of days-of-stay between 2009 and 2010 for the DRG group is significantly greater than that for the non-DRG group. However, the difference of medical expense between 2009 and 2010 is insignificant for DRG and non-DRG groups. The change of the re-admission rate within 14 days is also insignificant. For the medical saving in 2011, the reduction of days-of-stay for the DRG groups is significantly larger than the non-DRG groups. The medical expense reduction for the DRG groups. is also significantly greater than the non-DRG groups The difference of re-admission rate within 14 days is insignificant between groups.
The differencing tests are also performed by various degrees of providers. This study concludes that the implementation of DRG payment system can significantly reduce the day-of-stay and medical expenses while it does not reduce the re-admission rate within 14 days.

並列關鍵字

medical expense ； days of stay ； diagnosis related group ； DRG ； re-admission rate within 14 days

參考文獻

4、李冬蜂、吳肖琪（2004），論病例計酬實施前後冠狀動脈繞道手

5、陳婉茗、吳肖琪（2005），模擬DRGs實施對我國醫院的財務衝擊，

6、張佳琪、黃文鴻（2001），健保支付制度對全髖及全膝關節置換手術醫療利用情形之影響，台

7、劉偉文，Tw-DRGs導入前後醫院經營績效評估 – 以某國軍醫院骨科為例寶建醫護與管理雜誌

12、簡麗年、吳肖琪（2003），論病例計酬實施前後全股（髖）關節置換術病患出院後30日內的