醫院總額支付制度對門急診醫事檢驗價量之影響

The impacts of the global budget on the price and utilization of utpatient laboratory tests.

范耀文(Yao-Wen Fan)

指導教授 ： 廖宏恩

亞洲大學/健康學院/健康管理研究所/碩士(2005年)

摘要

本研究主要目的在探討醫院總額支付制度實施後對國人前十大檢驗檢查項目次數及金額之變化與醫事檢驗項目於西醫門急診部門的利用情形，以及評估醫院總額支付制度對於抑制潛在醫事檢驗浪費之程度，用以評估醫院總額支付制度的實施對於醫事檢驗部份之影響。
本研究利用國家衛生研究院「全民健康保險研究資料庫」，來比較民國89年7月至90年12月及91年7月至92年12月西醫門急診檢驗檢查次數及費用在醫院總額支付制度實施前後的變化情形。本文研究對象為在民國89年7月至90年12月及民國91年7月至92年12月期間，所有到健保特約類別為地區醫院(含)以上的醫療院所門急診進行血液、尿液之檢驗檢查病患及開立此類檢驗項目之醫師。
研究結果發現，醫院總額支付制度實施一年半後：一、西醫醫院門急診醫事檢驗總耗用金額顯著增加，前十大檢驗檢查項目在次數方面無明顯改變，若以金額作排名，則有較明顯的變動。二、平均每病患人次或平均每位醫師所利用(或所開立)之門急診檢驗檢查項目，次數及金額都有顯著增加；而由複迴歸模式顯示，各醫師平均開立檢驗檢查金額的增加與檢驗檢查的相對健保支付點數有顯著的正相關。三、雖然總檢驗檢查費用在醫院總額制度實施後有顯著的增加，但總檢驗檢查費用在各健保分局別、醫院權屬別及醫院層級別間的費用分佈，則與醫院總額實施前無明顯差異；以T檢定檢驗各分局別、醫院層級別及醫院權屬別在醫院總額支付制度實施前後是否有差別，結果顯示在平均每病患人次醫事檢驗使用量方面，只有區域醫院層級有受到醫院總額支付制度的影響，呈現顯著增加。在每病患人次使用檢驗金額上，結果顯示醫學中心及地區醫院會受到醫院總額支付制度的影響，呈現顯著增加，可推論醫院總額支付制度對於以醫院層級別在各分局的分布上，會造成影響；在醫師部份，則皆呈現不顯著的狀況，可說明平均每位醫師在開立次數或耗用金額上，並不會因為醫院總額制度的實施，而造成各分局別間，在醫院總額前後呈現不同之情形。四、對於重複檢驗檢查的金額，在醫院總額後仍然呈現增加情形，顯示在醫院總額制度實施後，重複檢驗檢查並無改善。
根據以上結果，建議衛生主管機關應持續追蹤監測醫院總額預算實施後，醫療細項費用變化情形並分析原因。對於醫療費用支付模式，在二代健保規劃中應要有更詳細之配套措施，加強宣導使醫界充分瞭解制度規則，並且建立健全的審查制度，以使醫事檢驗耗用在整體醫療分配當中更加合理。配套推行病歷交換資訊系統以及加強國人健保IC卡稽核之功能，以提升醫療服務的適當性及品質。

關鍵字

總額支付制度 ； 重複醫事檢驗檢查 ； 醫療資源耗用

並列摘要

The main purpose of this research paper is to study the vicissitude of the top 10 lists of medical laboratory tests in quantitative and monetary orders after implementing the Global Budget Scheme, to analyze the utilization patterns of laboratory tests in outpatient and emergency departments, and to observe the potential impact of the Global Budget Scheme on curbing unnecessary uses of laboratory tests.
This study employed the “National Health Insurance Research Database” provided by National Health Research Institutes (NHRI) to compare the quantitative and monetary changes of laboratory tests in outpatient and emergency departments before and after the implementation of the Global Budget Scheme. The data were collected are both from July to December of Year 2001 and Year 2002. The objects of this study are all patients who have the blood and urine examination and inspection either in the outpatient or emergency departments of District Hospitals and above levels, as well as the doctors who prescribed those orders in the same periods. The major findings are as follows.
(1)The total expenditure of laboratory tests has significantly increased one-and-half years after launching the Global Budget Scheme. The top 10 lists of laboratory tests changes frequently in monetary order but not in quantitative one.
(2)The average items and charges of laboratory tests per patient visit or per doctor’s prescription have significantly increased. The average charge of laboratory tests per doctor’s prescription is positively correlated with relative value of Fee Schedule.
(3)The total medical expenditures of laboratory tests have increased significantly after implementing the Global Budget Scheme, while the allocating structures of medical expenditures didn’t statistically changed either by geographic areas, hospital ownerships, or hospital levels. Furthermore, statistical inference ( T test ) showed the average volume of laboratory tests per patient visit increased significantly for Regional Hospitals after the implementation of the Global Budget Scheme, while the average charges of laboratory test per patient visit increased significantly for Medical Centers and District Hospitals. Thus, there are differences on the allocation of laboratory tests per patient visit in different hospital levels among BNHI branches. For the parts of doctors’ behavior, there are no statistical differences on the allocation of laboratory tests per doctor’s order in different hospital levels among BNHI branches.
(4)The expenditure for unnecessary use of laboratory tests was still keeping growing after the implementation of Global Budget Scheme.
To sum up, the author suggested the health department should continuously monitor and analyze the allocation of medical expenditures. As for the payment scheme of the medical fees, there should be more comprehensive and fain designs in future 2nd generation of NHI planning. Besides, a sound peer review process with better communications among stakeholders can facilitate reasonable allocation of laboratory tests. Finally, the study recommend a comprehensive electronic medical record exchange system with motivated reimbursement and a National Health Insurance IC Card with upgraded audit for enchanting the appropriateness and quality of health services.

並列關鍵字

Global Budget Scheme ； Unnecessary use of laboratory test ； Medical Resources Consumption

參考文獻

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