論質計酬制度對糖尿病患門診醫療費用之可能影響評估

Assessing the Potential Effects of the Pay-by-quality System on Outpatient Expenses of Diabetic Patients

陳明君(Min-Jun Chen) ； 陳啟禎(Chi-Jeng Chen) ； 錢慶文(Ching-Wen Chien)

《醫務管理期刊》 4卷4期 (2003/12) Pp. 14-26

https://doi.org/10.6174/JHM2003.4(4).14

摘要

我國全民健保自84年3月開辦迄今，健保支出逐年的增加。面對醫療費用上漲的壓力，健保局開始進行一連串支付制度的重大改革，例如全面實施的總額預算制度。但是在健保支付制度改革中只有一種支付制度和傳統論「量」計酬制度的基本的精神不同，包含總額預算制度，那說是「論質計酬」制度。「論質計酬」的主要目的是鼓勵醫療院所彼此合作共同照護病患，使病患能夠在各層級醫療機構的合作中達到既有的品質又能節約醫療費用的支出，更能夠實施類似「家庭醫師」的車案管理制度。但是許多醫療管理學者專家都懷疑「論質計酬」支付制度是否真正能夠達到上述之目的。有鑑於此，本研究以健保局目前針對五種實施「論質計酬」疾病之－糖尿病為例，用過去的申報資料來評估探討到底糖尿病患的照護是由少數醫師和／或少數醫療院所來照護在醫療資源耗用管控上會有較佳的效果。
健保局某分局轄下76，724位糖尿病病人其民國八十九年全年因治療和糖尿病相關之門診費用資料，在以身分證字號歸戶後，依病患的說醫紀錄將病患分成四組，用ANOVA和逐步複迴歸來做更深入的分析。結果顯示：
1．糖尿病患由同一位醫師照護的人比由同一所醫療機構照護的比例要高。
2．無論病患是在一家醫院（醫療機構）或多家醫院看診，當對同一位糖尿病患照護之醫師人數增加時，其醫療費用也會增加。
3．病患的特質在某些組別的病患來說對於解釋醫療費用差異的能力太小，不太具有管理上的意義。但對淤有些組卻非常有管理上的意義，所以更進一步的研究其他足以影響醫療費用的因素是非常需要的。

關鍵字

論質計酬 ； 糖尿病 ； 家庭醫師

並列摘要

Since the implementation of the National Health Insurance (NHI) in 1995, rapid growing of the NHI expenditure has become a headache for the Bureau of the NHI (BNHI). To slow down the speed of this growing trend, the BNHI has begun a series of improvements in correcting existing reimbursement problems. Among them, the pay-by quality (PBQ) reimbursement is deviated from traditional fee-for-service(FFS) reimbursement system in rewarding more to integrated services delivered by different health care providers than single ones. However, many health care managers were skeptical to the consequences of the PBQ method. Therefore, this study aims at assessing PQB and its potential effects, in terms of health resource consumptions, on existing methods of delivering services to Diabetes Mellitus (DM) patients.
76,724 DM patients and their outpatient claim data in 2000 were collected and analyzed in this study. DM Patients were first divided into four different groups according to their utilization behaviors, then their outpatient expenses were aggregated and adjusted for ANOVA and stepwise multiple regression analysis. Results of the study indicate:
1. More DM patients were cared by the same physician, regardless of the same health care institutions, than by multiple physicians.
2. For the same DM patient group, as the number of physician treating a patient increased, health care expenses would increase.
3. Whether DM patients' characteristics were useful in explaining variations of their medical expenses depend upon their behaviors.
Therefore, the authors of the study conclude that the PBQ method may not be very effective for treating DM patients unless DM patients are divided into several similar risk-adjusted groups prior to implementation of the PBQ.

並列關鍵字

Pay-by-Quality ； DM ； Family Physician

參考文獻

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