小兒尿道下裂手術診斷關聯群實施前後之回溯性成本效益分析-以中部某醫學中心小兒外科為例

全民健康保險自1995年開辦後，一直都擁有極高的民眾滿意度，而1999年後則持續呈現虧損的狀態，中央健康保險局為消弭赤字達到收支平衡，推動各項「前瞻性支付制度（Prospective Payment System, PPS）」，藉由有效的管理監控機制，來降低醫療費用的成長。更參考美國的疾病診斷關聯群（Diagnosis Related Group, DRGs）支付制度，於2010年實施台灣的疾病診斷關聯群（Tw－DRGs）支付制度，期望以經濟學之手段來抑制醫療費用的成長並提高醫療照護品質。隸屬於MDC12男性生殖系統之疾病與疾患也於2014年7月1日正式納入Tw－DRGs給付制度，而兒童先天疾病尿道下裂也涵蓋於其中。因此本研究主要目的是探討Tw－DRGs實施後，對兒童先天性疾病尿道下裂因手術年齡、手術方式、合併症、麻醉方式及住院天數等不同條件下，醫療費用、健保申報費用及本疾病整體損益之影響。本研究結果顯示Tw－DRGs實施後，因支付點數的調整、相對權重（RW）、兒童加成等因素的介入，Tw－DRGs實施後醫療費用、申報費用都相較於實施前增加；疾病整體損益也由實施前的正收益2.2%增加至16.54%。但此為單一疾病之分析結果，無法拓及所有兒童先疾病之損益，且兒童先天疾病相較於成人其照護難度及醫療耗損都較高，期望主管機關對於未來將納入Tw－DRGs之兒童先天疾病項目，制定合理的給付標準，使更多優秀醫療人才願意投身於小兒外科照護，並正視小兒外科醫師人力不足及分佈不均之現況。

關鍵字

小兒外科；尿道下裂；作業成本分析法；台灣的疾病診斷關聯群（Tw－DRGs）

並列摘要

Since the National Health Insurance (NHI) of Taiwan has been implemented in 1995, it always provides a very high level of public satisfaction. However, the NHI has continued to show financial deficits each year after the year of 1999. The Central Health Insurance Bureau has implemented the "Prospective Payment System (PPS)", which is expected to eliminate the deficit by the effective management and monitoring mechanism. Referring to the reimbursement system of the DRGs in the United States, the Tw-DRGs payment system was implemented in 2010 in order to curb the growth of medical expenditures and improve the quality of medical care. Diseases with the MDC12 (Major Diagnosis Category) male reproductive systems are also included in the Tw-DRGs payment system on July 1, 2014, and children with congenital disease hypospadias were also included. This study aims to investigate the medical expenses, health insurance declaration costs and the disease under different conditions such as the age of surgery, surgical procedure, co-morbidities, method of anesthesia and hospitalization days of children with congenital diseases after the implementation of Tw-DRGs, and clarify the impact of overall cost. The results show that, the medical expenses and reporting fees of Tw-DRGs increases after the implementation of Tw-DRGs, compared with those before implementation due to the adjustment of payment rates, relative weight (RW), child surcharge and so on. The revenue also increases from 2.2% to 16.54%. However, this is the result of analysis of a single disease, and it is impossible to extend the profit and loss of all children's diseases. Besides, care for children with congenital diseases is more difficult than care for adults. It is expected that the authorities will establish reasonable payment standards in Tw-DRGs for children in the future, so that more outstanding medical personnel are willing to devote themselves to pediatric surgical care, moreover, facing up to the lack of manpower and uneven distribution of pediatric surgeons.