全民健康保險多重慢性病整合式照護試辦計畫之初步影響評估

The preliminary evaluation of the Integrated Care Program for Patients with Multiple Chronic Conditions under National Health Insurance in Taiwan

潘尹婷(Yin-Ting Pan)

指導教授 ： 鄭守夏

國立臺灣大學/公共衛生學院/健康政策與管理研究所/碩士(2014年)

https://doi.org/10.6342/NTU.2014.00181

摘要

目的：
　　近年來我國多重慢性病問題日益嚴重，但現行醫療照護系統及照護模式仍著重於急性醫療，多重慢性病患容易因缺乏整合性醫療照護而造成片斷式醫療，導致醫療品質下降、醫療費用上升、及惡化醫療結果。我國健保於2009年實施「醫院以病人為中心之門診整合照護計畫」，目的為整合醫院機構內的多重慢性病患醫療照護，本研究考量目前此試辦計畫為我國首個針對多重慢性病試行整合式照護，具有試驗性及先驅性的意義，故希望藉由探討多重慢性病整合照護計畫實施對多重慢性病患之影響，提供我國建構多重慢性病患適當整合照護系統之建議，以期有助於建構多重慢性病患適當之整合照護系統。

研究設計：
　　本研究資料取自中央健康保險局2008至2011年1月之醫療費用申報檔，屬於次級資料分析，研究設計為自然實驗研究法，以個案收案時間前一年為前測期(T1)、個案收案後第一年為後測期(T2)，以差異中差異的方法進行分析。
　　本研究以「符合研究計畫條件之多重慢性病患」為研究對象，其中多重慢性病患定義為罹患二種以上慢性病之病患(慢性病範圍為高血壓、糖尿病、心臟病、中風及慢性阻塞性肺炎等5項慢性病)。
　　樣本篩選方式是透過傾向分數配對，選取介入組10,000人、試辦院所對照組10,000人及非試辦院所對照組10,000人，比較這三組在試辦計畫實施前後對多重慢性病患的初步影響及分析相關因素。

結果：
1.門診利用：
　　在門診次數方面，以差異中差異分析法發現，介入組之門診次數在試辦計畫介入後，相對於試辦院所對照組低了3% (e^β=0.97)，且達統計上顯著差異(P<.0001)；相對於非試辦院所對照組低了17% (e^β=0.83)，且達統計上顯著差異(P<.0001)。
　　在照護連續性方面，以差異中差異分析法發現，介入組之照護連續性UPC分數在試辦計畫介入後，相對於試辦院所對照組高0.03且達統計上顯著差異(P<0.0001)；介入組之照護連續性在試辦計畫介入後，相對於非試辦院所對照組高0.07且達統計上顯著差異(P<0.0001)。
2.照護結果：本研究以每百人平均每年ACSC住院住診次數作探討，以差異中差異分析法發現，介入組、試辦院所對照組及非試辦院所對照組無顯著差異。
3.醫療費用：本研究以健保申報的總醫療費用作探討，差異中差異分析發現，介入組與試辦院所對照組無顯著差異；但介入組之總醫療費用在試辦計畫介入後，相對於非試辦院所對照組低且達統計上顯著差異(β=-0.1878，P<0.0001)。

結論：
　　研究成果顯示，整合式照護計畫實施後對多重慢性病患整體照護情形有顯著的正面影響，包括門診次數減少、照護連續性增加及醫療費用減少等，但因本研究期間僅為試辦計畫介入前後一年，未來需更長期及更進一步地完整評估方得以反映出計畫對多重慢性病患的影響。

關鍵字

多重慢性病 ； 整合式照護 ； 以病人為中心 ； 計畫評估 ； 全民健康保險

並列摘要

Objective：
　　In recent years, patients with multiple chronic conditions (MCCs) have increasingly become a problem with high prevalence and high cost. Patients with MCC face fragmented care and lack of coordination among various health care providers because the medical system is mainly focus on acute care. In 2009, The National Health Insurance Administration (NHIA) in Taiwan implemented “The Coordinated Program for Multiple Chronic Conditions” in order to intergrate the medical services to patients with MCCs. The purpose of this study is to analyse the preliminary effect of this program on healthcare utilization, outcome and expenses. Results of this study may be of value to the NHIA.

Design：
　　A before-after control group natural experimental design was used to assess the impact of the program. Patients with MCCs who joined the program were identified by the NHIA participant list as the intervention group. Patients with MCCs and who had never participated in this program were identified as the control group. According to their most frequently visiting hospitals, we selected two control groups by propensity score matching approach, one is the participating hospital control group and the other is the non-participating hospital control group. The three study groups consisted of 10,000 subjects respectively. Data for the analysis were obtained from the NHIA from 2008-2011. Difference in difference analysis was conucted to assess the program impact.

Results：
1.Healthcare Utilization：
(1)Using difference in difference analysis, we found that patients with MCC in the intervention group have fewer out-patient visits than subjects in the 2 control groups which reached a statistically significant level (P<.0001).
(2)Results from the difference in difference analysis showed that patients in the intervention group has higher continuity of care (UPCs) than patients in the 2 control groups with P<.0001.
2.Outcome of care: Using difference in difference analysis we found no significant differences in hospitalization for ambulatory care sensitive conditions among the patients in the intervention group and the two control groups.
3.Medical expenditure: Results from the difference in difference analysis indicated that there was no difference in healthcare expenses between patients in the intervention group and participating hospital control group; but patients in the intervention group consumed lower expenses than those in the non-participating hospital control groups with β=-0.1878，P<0.0001.

Conclusion：
　　Our preliminary results indicated that the Integrated Care Program reduced the numver of physician visits, increased the continuity of care and lowered the medical expenditure for participating patients. However, more comprehensive evaluation is needed to detect the long-term impact of the the integrated care program in the future.

並列關鍵字

multiple chronic conditions ； integrated care program ； coordinated care ； program evaluation ； national health insurance in Taiwan

參考文獻

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