- 學位論文
未參與卓越計畫之醫院對門住診費用比例之影響：以中區分局為例
The Effect on Expenditure between Outpatient Services and Hospitalization for non-enrolled Center of Excellence：Examples of Bureau of National Insurance the Central Region Branch
摘要
本研究旨在探討未參與卓越計畫之醫院對門住診費用比例之影響。以民國93 年7 月1 日健保卓越計畫實施為區隔，使用93 年中區分局1 家醫學中心、5 家區域醫院、61 家地區醫院，共67 家未參加卓越計畫醫院之資料進行統計分析。本研究之主要實證發現： 1、 各層級醫院在健保卓越計畫實施後之門住診點數比例並無明顯差異，變化幅度在2%以下，地區醫院則在實施前後皆維持一樣的比率，表示各層級醫院並未以內部管控措施來調配門住診比例，顯示未參與卓越計畫之醫院，並未因目標比率之訂定而改變其原有之醫療行為，亦即未以內部管控措施來調配門住診比例。 2、中區唯一一家未參加卓越計畫之醫學中心，雖然其門診件數及門診點數在卓越計畫之後均有下降的趨勢，但其住診件數及住診點數在卓越計畫之後，均呈上升的趨勢，比率皆在5%以上，顯示醫院欲由內部管控之措施來調整門住診比例之意圖；區域醫院及地區醫院雖有門住診費用比例之壓力，但更因要搶食被卓越計畫切割之後之總額大餅，而不得不有衝量之行為產生。值得注意的是，未參與卓越計畫醫院增加的部分，是不是因參與醫院之門診限量而迫使病人轉移，如此有沒有造成拒絕民眾就醫的情形？有沒有影響民眾的就醫權利？這些都是衛生主管當局應審慎探究的地方。 3、 門診藥費除醫學中心有下降以外，其餘區域醫院及地區醫院在實施卓越計畫後，其平均門診藥費均呈上升的趨勢，比率分別是高達21%及27%。區域醫院增加的門診點數中有50%是藥費，地區醫院增加的門診點數中有49%是藥費，顯示未參與卓越計畫醫 院對於藥品似乎無較嚴格之管控措施，有因藥費是固定點值且有藥價差之利潤，醫院會有不吝開立藥物以獲取利益之嫌。 4、 在卓越計畫實施後，除醫學中心住診手術點數維持不變外，其餘各層級醫院之門住診手術點數及件數，均呈上升的趨勢，亦無明顯的門診手術轉移至住院手術之情形，應注意的是，在門住診手術點數、件數皆增加的情況之下，增加的部分是因病人遭到參加 卓越計畫醫院因已屆額度上限而拒收，因而轉求助於未參加之醫院，抑或是醫院本身為求衝量，而產生之供給誘發需求現象(SID)，亦即誘導病人施予不必要之手術，這是值得衛生主管當局更深一層探討的地方。
並列摘要
The purpose of this study is to explore the influence on the ratio of inpatient and outpatient expenses for the hospitals that do not participate in the “Center of Excellence Plan”. Based on the health insurance excellent plan implemented as from July 1, 2004 for comparison, the data of 1 branch medical center in central area, 5 regional hospitals, and 61 district hospitals for a total of 67 hospitals that do not participate in the Center of Excellence plan were targeted for statistic analyses. Following are the major positivist findings of this study: 1. There was no significant variance at the ratio of outpatient and inpatient points at various levels of hospitals after the implementation of the health insurance Center of Excellence plan. The variation level was within 2%. For regional hospitals, the ratio remained the same during the pre and after the implementation. It represents that all levels of hospitals do not adjust their ratio of outpatient and inpatient service with internal control measures. It also illustrates that those hospitals that do not participate in the Center of Excellence plan do not change their medical behavior even though the institution of the goal ratio. In other words, they do not use internal control measure to adjust the ratio of outpatient and inpatient service. 2. For the only medical center that does not join the Center of Excellence plan in central area, although its outpatient cases and points showed decline after the Center of Excellence plan, its inpatient cases and points were presented with rising trend, and the ratio was over 5%. It illustrates hospital’s intention to adjust its ratio of outpatient and inpatient service through internal control measures. Even though there is pressure for regional and district hospitals for the ratio of inpatient and outpatient expenses, in order to grab a piece of pie generated from the Center of Excellence plan, they can not help taking measures. One thing worth noting is that whether the limitation of outpatient service for the Center of Excellence plan participating hospitals forces some patients to transfer to the non-participating hospitals resulting in the addition to the non-participating hospitals? If this is the case, are there any patients being rejected for medical treatments? Whether the public medical care rights are affected? All of them are the issue that the health competent authorities shall deliberately explore. 3. Except for the medical center where the medicine expenses for outpatient service has dropped off, the average medicine expenses for outpatient service at regional and district hospitals have actually shown an upward trend after the implementation of the Center of Excellence plan, and the increase rate is 21% and 27% respectively for regional and district hospitals. Among the increased outpatient points, 50% of them are medicine expenses at the regional hospitals whereas 49% at the district hospitals. It indicates that those hospitals that do not join the Center of Excellence plan are less likely to give strict control over medicines. Since fixed points are used for the medicine cost and the hospitals can get some benefit from the medicine price difference, it is quite possible that hospitals may profligately prescribe medicines trying to get some profits. 4. Following the implementation of the Center of Excellence plan, other than the medical center where the points of inpatient operations remain the same, the outpatient and inpatient operation points as well as cases in other various levels of hospitals all show upward trend, and there is also no significant change on the transfer from outpatient operations to inpatient operations. However, it is noticeable that while both outpatient operation points and cases are on the rise, whether the increased points and cases at the non-participating hospitals are resulted from the transfer of the patients who are rejected by the Center of Excellence plan participating hospitals due to patient quota being full, or whether it is the supply inducing demand (SID) phenomena initiated by the hospitals. It means to induce patients to take unnecessary operations. It is also an issue required in-depth investigation by the health competent authorities.