實施TW-DRGs後醫療品質、醫療資源耗用與醫療費用相關性之研究-以中部地區某區域教學醫院脊椎融合手術為例

目的：以中央健保署公告第二階段DRG 3.4版支付制度導入後之費用為基準，藉由分析個案醫院健康保險申報資料費用探討病人特性(性別、年齡、BMI、合併症或併發症)、醫師特性(科別、年資、手術量)、疾病特性(入院來源、診斷數量、處置數量)及醫療品質(術後感染、住院天數、出院14日內再返院)對於脊椎融合手術(DRG496、497及498)醫療資源耗用情形與健保給付(TW-DRGs)費用之差異情況，並提出改善建議方案，作為研究個案醫院因應TW-DRGs制度之參考。方法：本研究採次級資料回溯性(retrospective)研究法。以個案醫院2016-2018三年之「住院醫療費用清單明細檔暨申報費用檔」排除健保署公告不適用個案後，符合DRG496、DRG497及DRG498案件共計954筆及人力資源管理資料庫(醫師)個案共計15筆為研究對象，比較分析研究對象醫療資源耗用、醫療品質與醫療費用之情況。先以EXCEL進行資料建檔與整理後，再以SPSS 22.0統計軟體進行描述性統計以及卡方檢定、t檢定、ANOVA以及邏輯斯迴歸(Logistic regression)分析來比較各變項之間差異性與關聯性。結果：研究發現：1.病患性別(p＜0.05)、合併症或併發症(p＜0.01)、疾病處置數量(p＜0.001)與術後感染有顯著相關性。2.病患性別(p＜0.01)、年齡(p＜0.05)、合併症或併發症(p＜0.001)、醫師科別(p＜0.001)、年資(p＜0.001)、手術量(p＜0.001)、疾病診斷(p＜0.01)及處置數量(p＜0.01)與住院天數有顯著相關性。3.醫師手術量(p＜0.05)與病患出院14日內再住院有顯著相關性。4.年齡越大、BMI值越高、有合併症或併發症、疾病診斷及處置數量越多、住院天數越高者平均醫療費用越高。5.邏輯迴歸分析發現術後感染與藥費(p＜0.05)、注射技術費(p＜0.05)有顯著關聯性；住院天數與診療費(p＜0.001)、病房費(p＜0.001)、治療處置費(p＜0.01)、手術費(p＜0.01)、血液血漿費(p＜0.05)有顯著關聯性；出院14日內再住院與病房費(p＜0.05)、檢查費(p＜0.05)有顯著關聯性。結論：TW-DRGs制度的改變已衝擊醫院財務與經營型態。本研究的結果提供個案醫院找出溢酬或虧損之因素，建議應即時修正臨床路徑、建立醫師費制度(Proportional Physician Fee, PPF)與TW-DRGs給付費用差額連動機制、建立成本管控與經營管理目標等措施，才能維持經營績效。

關鍵字

脊椎融合手術；診斷關聯群；醫療品質；醫療資源；醫療費用

並列摘要

Objective: This study aims to explore expenses of medical resource utilization and differences of reimbursement of National Health Insurance (NHI) to spinal fusion surgeries (DRG coding 496, 497, and 498 respectively) after the second phase of DRG version 3.4 was implemented in a regional teaching hospital from central Taiwan. The analyzed factors included: 1) patient characteristics (gender, age, BMI, comorbidities or complications), 2) physician characteristics (department, years of experience, surgery cases), 3) disease characteristics (admission information, number of diagnoses, number of treatments), and 4) healthcare quality (post-operative infection, lengths of inpatient hospitalization, returning back to hospital within 14 days after being discharged). After resulting, we attempts to propose better strategies and improvement solutions in response to this newer version of TW-DRGs payment system for target hospital in this case study. Methods: This research employed a retrospective method by secondary data. After eliminating some inadequate or unsuitable cases, there were 954 patients were selected for analysis by payments of DRG496, DRG497 and DRG498 during 2016 to 2018 from "Inpatient Medical Expenses List Details and Reporting Fee" in this study. Besides, a total of 15 physicians were selected to discuss from human resource management data bank according to the target hospital. The analysis themes were then compared the selected data for medical resources consumption, healthcare quality, and healthcare expenses. Research data were first collected and analyzed by using Microsoft EXCEL. Then SPSS 22.0 was in turn employed to analyze descriptive statistics and inferential statistics, including chi-square test, t-test, ANOVA and logistic regression to compare differences and relevance among respective variables. Results: The results showed that there were: 1)significant correlations among postoperative infections and variables of patients gender (p＜0.05), comorbidities or complications (p＜0.01), and treatment numbers of disease (p＜0.01); 2) significant correlation among lengths of inpatient hospitalization and variables of patients gender (p＜0.01), age (p＜0.05), comorbidities or complications (p＜0.001), departments of physician (p＜0.001), experience years of physician (p＜0.001), surgical operation loading (p＜0.001), numbers of disease diagnoses (p＜0.01), and treatment numbers of disease (p＜0.01); 3) significant correlation between returning back to hospital within 14 days after being discharged and surgical operation loading (p＜0.05). 4) The older patients, higher BMI numbers, with comorbidities or complications, more diagnoses and treatment, longer lengths of inpatient hospitalization tend to cause higher average healthcare expenses. 5) By logistic regression analysis, there were significant correlation among postoperative infections, medication fee (p＜0.05), and injection technical fee (p＜0.05). Besides, there were significant correlation among lengths of inpatient hospitalization, diagnoses fee (p＜0.001), ward fee (p＜0.001), disease treatment fee (p＜0.01), surgery fee (p＜0.01), and blood plasma fee (p＜0.05). In addition, there were significant correlation among returning back to hospital within 14 days after being discharged, ward fee (p＜0.05), and inspection fee (p＜0.05). Conclusions: The implementation of newer version of TW-DRGs payment system had substantially impacted financial and operational strategies of hospitals. The study results disclosed many potential factors of impacting the financial issues in the target hospital. In order to maintain or even better to improve operational performance of the hospital, we proposed following suggestions which including clinical paths need to be revised immediately, a proportional physician fee (PPF) be established, and a connected function for paying the difference of TW-DRGs payment system be implemented, cost control and target operational management be implemented and etc.

並列關鍵字

Spinal Fusion Surgery ； Diagnosis Related Groups (DRGs) ； Quality of Care ； Medical Resource Utilization ； Healthcare Expenses

參考文獻

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