健保支付標準與醫師執業耗用資源對牙科服務量之影響

The Effects of BNHI Payment Rates and Resource-input on the Changes of Dental Service Volume

陳琇玲(Hsiu-Ling Chen) ； 溫信財(Hsyien-Chia Wen) ； 楊志良(Chih-Liang Yaung) ； 黃文駿(Wen Jiun Huang) ； 黃意婷(I-Ting Huang) ； 徐慧娟(Hui-Chuan Hsu)

《台灣公共衛生雜誌》 21卷1期 (2002/02) Pp. 17-26

https://doi.org/10.6288/TJPH2002-21-01-03

摘要

目標：文獻顯示醫師行為會受到支付制度所形成的經濟誘因影響，本研究以牙科為研究對象，嘗試了解牙醫師在執業耗用資源考量下，支付標準改變與服務數量之間的關係。方法：以牙科79項主要處置87年與88年下半年同期服務量均超過1,000次之13項調高支付標準的處置與44項未調價處置為研究對象，並引用其他研究之醫師執業耗用資源的成本資料，分析調價與未調價處置之服務量及總點數差異情況，同時探討牙醫師在執業耗用資源考量下，點數調整對醫師行為的影響。結果：（1）由Pearson's相關係數得知調整點數與服務量增減數、調整點數與該處置較前一年度增加之總支付點數、調價佔醫師成本之比率與服務量增減數之相關不顯著。而服務量變動比率分別與點數調整比率、醫師實得收入調整比率、調價佔醫師成本之比率均呈顯著相關，以及該處置總支付點數較前一年度增加比率與點數調整比率均呈顯著相關。（2）排除有相互替代性的「銀粉充填」及「樹脂充填」單、雙面各二項後，支付標準調價11項與未調價42項處置服務量增加之項目分別為10項（10：11=91%）及18項（18：42=43%）。調價處置成長率均超過平均成長率5.47%；而未調價處置中只有11項（26%）超過平均成長率。調高支付標準處置之總服務量增加5%，而未調價處置增加1%；支付標準調價處置和「數量」有關的因素所導致的「總點數差異率」為5%，大於支付標準未調價處置之2%。結論：（1）支付標準調整點數和服務量增減相關性不顯著，但是點數調整幅度（百分比）越高，牙醫師服務量增加幅度（百分比）越高。（2）排除有替代性處置外，牙醫師比較會對支付標準調高之處置增加服務量以及提高所得。

關鍵字

支付標準 ； 耗用資源 ； 牙醫師 ； 服務量 ； 醫師行為

並列摘要

Objectives: There is considerable evidence indicating that physicians’ behavior may be affected by economic incentives in the payment system. We investigated the relationship between price-adjusted and volume-increased under the consideration of resource-consumed in the dental practice. Methods: We evaluated 79 major dental procedures that were performed more than 1,000 times in the second half of both 1998 and 1999. The reimbursement for 13 of these procedures (designated price-adjusted procedures, PAP) was adjusted upward in 1999, while it remained the same for 44 procedures (designated price unadjusted procedures, UAP). Using resource-input data from other research, we analyzed differences in service volume and total payment between PAP and UAP and the effects these had on dentists’ behavior. Results: (1) Pearson’s coefficients showed no significant correlation was found between price-adjusted and volume-increased, between price-adjusted and total payment-increased, and between the ratio of price-adjusted to the cost of physician work and the volume-increased. However, there was a significant correlation between the volume-increased rate and the price-adjusted rate, between the volume-increased rate and the physicians’ real-income-adjusted rate, between the volume-increased rate and the ratio of price-adjusted to the cost of physician work, and between the price-adjusted rate and the total payment-increased rate (p＜0.05). (2) After excluding four procedures (2 each from PAP and UAP) which can be replaced by each other and whose change in volume was significantly affected by patient demand, we found the volume of 10 PAP (91%) increased in 1999, compared with 18 UAP (43%), All of the PAP had a higher payment-increased rate than the average, but only 11 UAP (26%) did. The total volume of PAP increased by 5% and of UAP by 1 %. The corresponding increases in total payment were 5% and 2% due to the factor of “quantity”. Conclusions: (1) Price-adjusted and volume-increased were not significantly correlated, but the price-adjusted rate and volume-increased rate were significantly correlated. (2) Excluding procedures replaceable by each other and influenced by patient demand, dentists increased the volume of PAP more than UAP, presumably to increase their revenue.

並列關鍵字

physician behavior ； payment scheme ； resource-input ； dentist ； service volume

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