總額支付制度下醫院加入自主管理前、後與非自主管理之門診手術利用率及醫療費用比較---以中區分局為例

Comparison of utilization of ambulatory surgery and medical fee between pre- and post-self management and non-self management hospitals under the system of Global budget - Central branch of National Health Insurance in Taiwan as an example

隋志華(Chih-Hua Sui)

指導教授 ： 楊志良

亞洲大學/健康學院/健康管理研究所/碩士(2006年)

摘要

全民健保自民國84年開辦以來，由最初的論量計酬制至91年的總額支付制度，無非是希望在合理的制度下降低醫療資源耗用，93年更推行醫院自主管理，即醫院個別總額。健保局為鼓勵醫院加入自主管理及監測品質，規劃出四大類分級審查排除項目及20項品質指標値。門診手術為排除項目中的一類，亦是第6項品質指標，是屬正項指標，比率越高代表品質越佳；門診手術的點數不計入個別醫院總額，但仍在全國總額底下價量互動。此研究是針對中區健保分局內醫院對於門診手術（案件分類為03）利用率所做的探討。研究目的是希望能得知：醫院加入自主管理前、後及非自主管理，其門診手術利用率之差異性和醫療費用間之相關性。
研究結果顯示：醫院的經濟行為及管理制度與醫院的權屬別及層級別有密切的相關性，會影響醫療的行為及結果。就門診手術總件數及總費用而言，各層級的醫院及不同的權屬別皆有增加的趨勢。在2004年醫院加入自主管理後，公立及私立醫院在門診手術指標上，皆有明顯增加，可能和公立醫院的政策與宗旨有關；而私立醫院則較重視財務績效，某項醫療服務項目支付高，則會傾向執行該項服務。層級別中以區域醫院增加最明顯，可能本身較具營利傾向，能快速反應市場的需求，改變服務的內容及項目。

關鍵字

總額支付制度 ； 自主管理 ； 門診手術

並列摘要

Since the beginning of National Health Insurance in 1995,the payment system had been changed from the initial paid-by-services to the paid-by-budgets in 2002, for the hope that the medical expense can be deduced under a reasonable system. After 2004, the system was changed to the hospital self-managements, i.e., individual hospital budgets. The National Health Insurance encourages the hospitals to participate in this self-management and quality monitoring systems, which designed four major classified inspection exclusion items and twenty items of quality control scores. Ambulatory surgery is one of the exclusion items and the sixth quality indicator. It is a positive indicator, the higher in the ratio the more excellent in the quality. Ambulatory surgery score is excluded from the hospital budget, but still under the regulation of the national global budget.
This study is aimed at the central branch of National Health Insurance, exploring the utility rates of ambulatory surgery (file class 03) in the hospitals. The object is intend to find out: the differences of utility rates and its relation to the medical fee between the hospitals of pre- and post- self-management and the non-self-management hospitals.
The study shows: As to the total number and fee of ambulatory surgery, there are all have a tendency of increase at various levels and belongs of hospitals. Since 2004, the indicators of ambulatory surgery all shows obvious increase either in the public and private hospitals in all of the self- management hospitals. It may be related to the policy and aim in the public hospitals. But the private hospitals pay more attention to the financial effects.
If the paid is higher in some medical services, they will shift to that services. The regional hospital shows the most obvious difference in the hospital level. Probably, the regional hospital itself is more profit tendency and can rapid response to the market requirements, then changes the content and item of services. The hospital economic behavior and management system are closely related to the hospital belongs and levels and it can influence the medical behaviors and outcomes.

並列關鍵字

global budget system ； self-management ； ambulatory surgery

參考文獻

4.余秀芳（2003）：台灣地區病人重複住院之分析。國立台灣大學衛生政策與管理研究所碩士論文，台北。

11.楊志良（1994）：勞保門診醫療費用支付制度對醫療提供者診療行為之影響。

2.McCorkle L.P.,1966.Utilization of Facilities of a University Hospital：Length of Inpatient Stay in Various Hospital Department,Health Service Research;1:91-114.

3.Rice T.H.,1983.”The Impact of Changing Medicare Reimbursement Rates on Physician Induced Demand”,Medical Care,21(8),803-815,August 1983.

4.Robinson,J.C.,Luft,H.S.,1985.”The Impact of Hospital Market Structure on Patient Volume,Average Length of Stay,and the Cost of Care”,Journal of Health Economics,4(4),333-356.