醫院總額支付制度實施前後對固定醫院就醫病患醫療利用比較之研究

To compare the differences of healthcare utilization before and after hospital global budget payment system for patients seeking for the same healthcare organization

陳素珊(Su-Shan Chen)

指導教授 ： 葉玲玲

亞洲大學/健康學院/健康管理研究所/碩士(2006年)

摘要

我國全民健康保險自2002年7月開始實施醫院總額支付制度，醫院自主管理、醫院卓越計畫等類似個別醫院總額政策也陸續推行，這些政策是否會使得至醫院看病的患者轉移至基層診所就醫是值得探討的。大部分醫院總額的相關研究多半是整體性的分析或以醫院為分析單位進行探討，鮮少有針對同一群病患來探討其在支付制度實施前後醫療利用的變化情形。因此，本研究將針對在醫院總額支付制度實施前只去醫院就醫的病患進行分析，探討其在醫院總額實施後就醫層級動向以及醫療利用的變化情形。
本研究以1999年至2004年國家衛生研究院之全民健康保險資料庫承保抽樣歸人檔進行研究分析，研究對象為在醫院總額實施前二年2000年7月至2002年6月期間在接受一般西醫醫療服務（扣除牙醫、中醫）時只在醫院就醫之病患，共4,043位。將2000年7月至2004年6月之研究時間劃分每半年為一期進行比較分析，共分八期。
研究結果顯示，在病患就醫層級動向方面，醫院總額實施後會前往基層診所就醫的病患比率逐漸增加，病患之基層診所各項醫療利用亦呈現增加趨勢。在住診醫療服務方面，研究對象在醫院總額實施前之住診醫療利用變化不大，在醫院總額實施後成長的幅度增加許多。在醫院部門門診醫療服務方面，研究對象在醫院總額實施後，除醫院部門門診就醫次數呈現減少趨勢之外，醫院部門門診醫療服務點數、醫院部門門診給藥天數、醫院部門門診用藥點數皆呈現增加的趨勢。此外，研究對象在醫院總額實施後的醫院部門門診就醫次數雖較實施前減少，但加上基層診所門診就醫次數後，總門診就醫次數則是增加的，顯示醫院總額實施後病患整體的就醫次數並未減少。
從研究結果可以發現，醫院總額實施後病患就醫層級有從醫院轉移至基層診所之傾向，需注意是否有急、重症病患遭到醫院排擠而轉至基層診所就醫；醫院逐漸增加住院醫療服務，可能是受到門住診預算比率分配的影響；病患之醫院部門門診就醫次數減少，醫院部門門診醫療服務點數增加，顯示醫院對病患每次就醫的照護強度增加、亦或是單純的申報點數增加所致。整體而言，研究對象在醫院總額實施後門診或住診的醫療利用是增加的，總醫療服務點數在總額實施後的成長幅度更勝於實施前許多，顯示醫院總額實施後研究對象的醫療利用仍持續增加，值得政府相關單位以及醫療提供者多加注意。

關鍵字

醫院總額支付制度 ； 醫療利用

並列摘要

In July 2002, Bureau of National Health Insurance (BNHI) implemented hospital global budget payment system, and successively pursued the self-management and excellent project for hospitals like hospital-based global budget. It was worth to study if the implementation of these policies would make the patients who used to visit hospitals visit the clinics or not. Most studies about hospital global budget payment system were overall analysis or took the hospital as a unit of study to analysis, and it was rarely just to treat a chort to compare the differences of healthcare utilization before and after the implementation of hospital global budget payment system. Therefore, this study will focus on the patients who always sought for the hospitals before hospital global budget payment system, and to compare the differences of the patients seeking for the level of medical institutes and healthcare utilization of the patients before and after hospital global budget payment system.
This study applied secondary data analysis to representative NHI enrollees sample files between 1999 and 2004 provided by the National Research Institute. The sample were the patients who only visited the hospital during the two years before the implementation of hospital global budget payment system (not included the dental services and Chinese medicine services). It contained 4043 subjects in this study. The period of observation was from July 2000 to June 2004, and it was divided into 8 terms by 6 months.
These results show that the proportion of the patients who sought for the clinics and the healthcare utilization in clinics increased after hospital global budget payment system. About healthcare utilization of inpatients, the healthcare utilization of inpatients didn’t change too much before hospital global budget payment system, but after hospital global budget payment system the rate of growth in healthcare utilization of inpatients increased rapidly. About healthcare utilization of outpatients in hospitals, except the trend of the number of ambulatory visits in hospitals, the trend of the claimed points of outpatients, the days of prescriptions, the claimed points of drugs of outpatients were increased. The number of ambulatory visits in hospitals decreased after Hospital Global Budget Payment System, but the number of ambulatory visits (included the number of ambulatory visits in clinic) increased.
In conclusion, the patients who always sought for the hospitals before hospital global budget payment system had the tendency to go to the clinics after hospital global budget payment system, but we had to attend that if there were serious ill patients who were rejected from hospitals going to the clinics. The hospitals increased the medical services of inpatients, and it might due to the distribution of rate of the budget for outpatient services and inpatient services. The number of ambulatory visits of outpatients in hospitals decreased and the claimed points of outpatients in hospitals increased shows that the hospitals supplied more density of medical services for the patients or just claimed more points of medical services. In sum, the healthcare utilization of both outpatients and inpatients increased, and the rate of growth of total claimed points after hospital global budget payment system was more than before. It shows that the healthcare utilization of patients was still increasing, and it was worth for the government and the medical service providers to pay attention to this situation.

並列關鍵字

hospital global budget payment system ； healthcare utilization

參考文獻

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