- 期刊
論病例計酬制實施對喉直達鏡顯微手術治療良性喉部病變之影響：以某醫學中心為例
Impact of the Case Payment System on the practice of Laryngo-Microsurgery in Treating Benign Laryngeal Lesion:an Experience from a Medical Center
摘要
目的 為應付醫療費用不斷上漲的問題，保險人常改變支付制度來控制醫療資源的支出，實施論病例計酬支付制度是其中一種方式。本研究係以喉直達鏡顯微手術(laryngo-microsurgery：LMS)為對象，探討論病例計酬支付制度的實施對LMS手術治療良性喉部病變執行層面的各種影響。 方法 本文收集自1998年3月至2000年3月間於某私立財團法人醫學中心耳鼻喉科住院接受LMS手術治療良性喉部病變之病患，共收入225例患者資料，其中論量計酬組102例、論病例計酬組123例。本研究探討論病例計酬支付制度實施前後病患之醫療資源的耗用、醫療費用支出及手術結果的變化。以unpaired t test及卡方檢定(chi-squared)進行統計分析。術後3個月及術後6個月門診費用以無母數方法(Mann-Whitney U Test)進行比較分析。 結果 我們發現在LMS論量計酬與論病例計酬兩組的比較中，醫療提供者的行為只有些許改變。平均住院天數沒有變化均為2.8天；而總醫療費用在論病例計酬組減少了4%，惟在統計上並無意義；醫師逆選擇(adverse patient selection)行為並不存在；研究也沒有證據顯示醫院試圖將醫療費用轉嫁至門診中。手術預後(包括再入院、再手術、併發症、延長住院及術後門診次數)均沒有明顯的差異。 結論 在正常營運的醫學中心中，論病例計酬支付制度的實施對於LMS手術治療良性喉部病變並不能進一步的提升其效率，醫療費用小量的下降，在統計上並無顯著意義。然而效率只是醫療品質的一部份，尤其對於惡性腫瘤接受LMS手術治療或診斷的病患，病人預後狀況之變異性較大，支付制度改變對於病患主客觀預後的影響仍待長時間、多層次的觀察。
並列摘要
Objectives. The aim of the case payment system is to contain healthcare expenditures. The objective of this study was to investigate the impact of the case payment system on the practice of laryngo-microsurgery in treating benign laryngeal lesion. Methods. We enrolled a total of 225 patients with benign laryngeal lesion who had undergone larngo-microsurgery at a tertiary referral medical center from Macrh 1998 to March 2000. Surgical outcomes, medical resource utilization and healthcare costs were compared between groups of patients who received laryngo-microsurgery under the fee-for-service system (102 patients) and those who received the surgery under the case payment system (123 patients). Analyses were conducted by the t test and chi-square test. Results. The surgical outcomes were indistinguishable between the two groups. We found that provider behavior was only slightly modified. The average length of stay remained unchanged (2.8 days). The total up-front admission cost was reduced by 4%. There was no adverse selection effect and no evidence to show that the provider had attempted to shift hospital charges to outpatient service. Conclusions. The case payment system dose not enhance the efficiency of laryngo- microsurgery. The reduction in cost was not statistically significant. The impact of the case payment system on the quality of care for patients with laryngeal malignancy will require longer and mulit-dimensional observation.