應用全民健保資料庫探討Tw-DRGs支付制度分類項目適用性

全民健康保險開辦經過20多年，醫療費用支出從1995年開辦時的2,200億元，至2017年已達6,600億元，成長3倍，對健保財務已帶來沉重負擔，是推動健保改革重要的任務。應用全民健保資料庫之住院醫療費用點數去辨別化回溯性資料，瞭解膝關節置換術之住院醫療費用項目分佈、比較全膝關節置換術與部分膝關節置換術之醫療費用、探討運作已10年之膝關節置換術DRG20905項目，拆項分為DRG20905全膝關節或DRG20909部分膝關節置換術之適用性，作為Tw-DRGs項目修訂重點評估。研究資料取自健保資料庫2018年住院醫療費用進行次級資料回溯性分析。本研究樣本以DRG申報膝關節置換術之病人，比較全膝關節置換術和部分膝關節置換術1年的資料。分析單位以Tw-DRGs住院申報案件之集合資料，主要目的在分析DRG項目拆分後，在全膝和部分膝關節置換術的醫療費用差異。以SPSS 25進行描述性分析住院申報膝關節置換術的案件特質，及隨時間推移在DRG 20905拆分全膝和部分膝關節置換術醫療費用上的變化。以SPSS 25進行推論性分析：檢定住院DRG 20905拆分全膝和部分膝關節置換術在17項費用分佈及占率的改變。膝關節置換術病人在實際住院天數之性別及年齡無顯著差異。以T檢定分析，全膝與部分膝關節置換術分組後之實際醫療費用及損益有顯著差異。膝關節置換分組在實際醫療費用中，特殊材料費、手術費、檢查費、治療處置費、血液血漿費有顯著差異。部分膝組案件之各項醫療費用皆小於全膝組案件平均費用，以特殊材料費及手術費有非常顯著差異，特殊材料費(48.74%)及手術費(26.72%)二項費用合計占健保總醫療費用75%，可列為該項DRG拆分首要管理項目。同一個DRG項目有兩種手術方法，在健保給付上的差異，支付政策可能影響醫療行為，考量Tw-DRGs實施屬重大支付制度變革，徵詢專科醫學會意見，審慎評估全面導入Tw-DRGs的發展，共創三贏。

關鍵字

Tw-DRGs支付制度；全膝關節置換術；部分膝關節置換術

並列摘要

The National Health Insurance Administration (NHI) is planning to fully introduce the General Rules for Taiwan Diagnosis Related Groups (Tw-DRGs) Payment Policy Version 4.0 with the addendum of suspended items. The Tw-DRGs Payment Policy is an “equal compensation for the same disease” policy, dividing in-patients into different groups based on the diagnoses and surgical conditions. After more than 20 years of the establishment of the National Health Insurance Administration, medical expenses have tripled from 220 billion yuan when it was launched in 1995 to 660 billion yuan in 2017, which has brought a heavy burden on health insurance finance and is an important task for promoting health insurance reform. The Application of National Health Insurance database of medical cost. Take the Partial Knee Replacement as an example, the DRG code is 20909 and the NHI payment is approximately NT$115,000 if the hospital decides to perform the novel approach. However, if the hospital performs traditional TKR, the NHI payment is approximately NT$135,000, DRG code is 20905. Although the final outcomes between the two approaches are the same, the NHI payments are significantly different. In expenses item material, surgery, examination, treatment and blood plasma, which showed significant differences. Given that the NHI payments between these two surgical approaches are markedly distinct, which may lead to different medical behavior, it is required to introduce a thorough review system for the Tw-DRGs payment policy. Moreover, DRG case manager can be an effective strategy to promote the appropriate use of health service resources. The Tw-DRGs policy shall be in line with the development of novel technology. Health Insurance, doctor and patient, become win-win situation.