牙醫總額支付制度實施後醫療資源分布合理性探討

The Research of Reasonableness on the Distribution of Health Resources After Dental Global Budget System

洪慶鐘(Hung Ching-Chung)

指導教授 ： 吳凱勳 ； 藍守仁

亞洲大學/健康學院/健康產業管理學系健康管理組/碩士(2004年)

摘要

牙醫總額支付制度由民國87年實施至今，已經過了6個年頭；其間牙醫資源分配是否更趨合理，尤其是醫事人力的配置、各分局轄區內的城鄉差距等課題，都是本研究所欲探討的。本研究分析自86年1月至91年12月的牙醫申報資料，以供給面資源分布合理性探討為主軸，探究總額實施後各項牙醫醫療資源指標分布的變動情形。
本研究主要著眼在牙醫供給方面資源配置的公平性，因此分析的目標是以各鄉鎮牙醫師數、當地所申報的金額、門診人數、就診次數為主要研究資料，使用相對均等概念的 Lorenz 曲線及 Gini 係數作為衡量醫療資源分布均勻程度的指標，並且搭配t-檢定及f-檢定進行統計分析檢定，同時提出以下兩點研究假說：
假說一：牙醫總額支付制度實施後，牙醫醫療資源分布更為均勻。
假說二：牙醫總額支付制度實施後，牙醫醫療資源利用更為適當。
根據研究結果，得知在牙醫總額支付制度實施後，4項代表牙醫醫療資源分布均勻與否的指標，除了每位牙醫師申報健保點數外，其餘都無顯著的改善，因此判定假說一並不成立；另一方面，5項代表牙醫醫療資源利用適當與否的指標，雖然每一保險對象使用牙醫就診次數及牙醫門診病人使用健保點數上並無統計上顯著結果，但另外3項指標則有明顯的改善，因此判定假說二是成立的。
根據上述研究結果，本研究提出幾點建議，僅供各界參考：
一、現階段改進措施：
(一)為求牙醫師人力分布均衡，需限定規範牙醫師執業地點。
(二)加強醫療資源不足地區支援牙醫師人力或巡迴醫療。
(三)力行地區總額分配，真正符合「錢跟人走」的精神，及消除「有保險無醫療」的缺失：
(四)有效改善民眾的就醫可近性，促進牙醫擴展門診服務對象，適度限制點值＞1的區間。
(五)加強異常管理，節制費用支出，穩定點值，合理分配資源。
(六)牙醫師人力資訊透明化，有益於牙醫師擇地執業。
二、未來努力改進目標：
(一)試辦牙醫論人計酬制度。
(二)培育總額管理相關人才。
(三)建議全聯會建存“保險對象檔”，俾利了解新增病患確實人數。

關鍵字

牙醫 ； 總額支付制度 ； 資源分布 ； 資源利用 ； 勞倫茲曲線 ； 吉尼指數

並列摘要

Dental global budget system in Taiwan has been operated for six years since 1998 and many things are still under evaluating. My research is aim at finding out whether the distribution of dental health resources is reasonable. Also, I put more attention to the distribution of medical resources and the inequality between cities and counties under Nation Health Insurance’s six divisions. The data of this research comes from dental health insurance and the duration analyzed is form January 1997 to December 2002. By analyzing the reasonableness of providers’ distribution of dental medical resource, I try to discover the change in the distribution indexes after dental global budget system has been taken into effort.
The analysis is focused on the equality of providers’ distribution in dental medical resource and therefore, the goal indexes will be the number of registered dentists, the amount of expenditures, the number of outpatients, and the number of patients seeing the dentist. Lorenz curve and Gini coefficient are used to analyze the degree of inequality in health resources distribution and t-test and f-test are used in the process of statistic. Here, I offer two hypotheses:
Hypothesis 1: The distribution of dental medical resources is
more equableafter dental global budget system has been operated.
Hypothesis 2: The utilization of dental medical resources is more reasonable after dental global budget system has been operated.
The results of this research show that 4 indexes for the equability in the distribution of dental medical resources are not significant besides the total amount of expenditures applied by each dentist in each year after dental global budget system has been operated. Thus hypothesis 1 is not established. On the other hand, 5 indexes for the reasonable utilization of dental medical resources are significant besides the number of insured patients seeing the dentist in each year and the amount of each outpatient spending on seeing the dentist each time after dental global budge system has been operated. Thus, hypothesis 2 is not established either.
Accounting to this result, I also offer some suggestions for policy makers in the government while determining the decision of distribution as resource providers. Toward current operating system, the suggesting approaches of improvement will be aim at below dimensions:
a.Regulate service places of dentists in order to balance the dentists spread.
b.Enhance the supportable dental manpower or strengthen Integrated Delivery System for areas with lower dental resource distribution.
c.Enhance the supportable dental manpower or strengthen
Integrated Delivery System for areas with lower dental resource distribution.
d.Allocate the budget for divisions of Nation Health Insurance in order to fit the meaning of “money to people” and eliminate the inefficiency of “having insurance but no service”.
e.Improve the accessibility of the public, promote the dental service for more target patients, and regulate the division with value＞1.
f.Transparent the information of dentists human capital so that dentists can choose where to practice.
With no doubt, there are still more expectations in the long-term progress. My suggestion is focused on two aspects－test the dental capitation and develop the professional manager and administrator for the global budget system.

並列關鍵字

dentist ； global budget system ； the distribution of resources ； the utilization of resources ； Lorenz curve ； Gini coefficient

參考文獻

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