全民健康保險氣喘醫療給付改善方案長期影響評估

Long-term evaluation of asthma disease management and pay-for-performance program under National Health Insurance in Taiwan

方俞尹(Yu-Yin Fang)

指導教授 ： 鄭守夏

國立臺灣大學/公共衛生學院/衛生政策與管理研究所/碩士(2009年)

https://doi.org/10.6342/NTU.2009.00758

摘要

目的：
氣喘為全球最常見的慢性病之一，Global Initiative for Asthma（GINA）指出目前全球約有三億人口患有氣喘，預估到了2025年會額外增加約10億人。臺灣地區氣喘盛行率在這三十年間也正大幅上升中，顯示氣喘之高盛行率與嚴重性，也代表了氣喘防治的重要性日漸上升。中央健康保險局於2001年11月開始推動「全民健康保險氣喘醫療給付改善方案試辦計劃」，結合了「論質計酬」與「疾病管理」的概念出發，希望提升照護品質及增進病患自我照護的能力，長期來看有助於醫療費用的降低。本研究即探討「全民健康保險氣喘醫療給付改善方案試辦計畫」介入後的影響，以長期分析與全國性的角度來檢視此計畫結果面的品質，即以醫療資源的使用來當作指標，期能以實證分析結果提供醫療相關單位此氣喘疾病管理計畫之資訊與建議。

方法：
資料取自於中央健康保險局2002年至2006年的全國醫療申報檔，屬於次級資料分析。研究設計為準實驗設計，以加入氣喘醫療給付改善方案者為實驗組母體，未加入方案者為對照組母體，再以傾向分數方法（propensity score method）挑選出最終分析樣本，實驗組為714人，對照組為2142人。實驗組選取加入前一年及加入後三年、對照組則選取2003年至2006年之醫療利用資料，並以差異中之差異法（difference in difference）與複迴歸方法比較兩組醫療利用之差異。

結果：
實驗組在四年的觀察期間門診次數與費用在後測第一年有上升趨勢，其後第二年與第三年皆是下降。急診次數（四年共下降0.13次）與住院次數（四年共下降0.08次），即急性醫療利用方面隨著介入的時間增加是呈現下降的趨勢且兩者在後測的三年和前測相比皆有達到顯著差異。對照組之急診次數（四年共下降0.08次）與住院次數（四年共下降0.05次）之下降幅度都不若實驗組來的多。

在控制實驗組與對照組的前測差異後，實驗組在試辦計畫介入後第一年門診次數比實施前較對照組多2.89次，後測第二年為1.89次，後測第三年為1.57次，差異有縮小趨勢。同樣趨勢也反映在門診費用上（8880元、3602元、2402.3元）。在急性醫療利用方面，急診次數在控制實驗組與對照組的前測差異後，實驗組在試辦計畫介入後第一年急診次數比實施前較對照組少0.02次，後測第二年為少0.06次，後測第三年為少0.05次。住院次數在控制實驗組與對照組的前測差異後，實驗組在試辦計畫介入後第一年住院次數比實施前較對照組少0.02次，後測第二年為少0.02次，後測第三年為少0.03次。由急診次數和住院次數兩組差異中之差異得知在試辦計畫介入後實驗組比對照組較介入前在急性醫療資源的使用上並未明顯減少。在急診費用（5.47、-43.53、-32.03）、住院費用後測兩年（-84.5、-374.93）與住院日數（-0.11、-0.20、-0.11）方面是顯示實驗組使用較低的醫療資源。

探究影響氣喘醫療資源利用的因素，本研究發現實驗組在試辦計畫實施後比實施前之門診次數與費用都比對照組來的多，但有逐年下降的趨勢，且後測三年與前測相比均有達到統計上顯著水準。在急性醫療利用方面，急診次數與費用、住院次數、費用與住院日數皆是年代為主要之影響因素，以所有進行分析的實驗組與對照組來看，後測的三年都比前測來的低且都有達到顯著。與差異中差異的結果我們可知，氣喘醫療給付改善方案的介入實驗組比對照組並未明顯減少急診與住院次數，即使變化方向與本研究的假說相同，但未達統計上顯著差異。

結論：
由長期結果發現實驗組與對照組門診次數的差異有縮小趨勢。在急性醫療利用方面，氣喘試辦計畫的介入實驗組比對照組較介入前雖有較少急診與住院次數，但未明顯減少且未達顯著差異。從此計畫2001年開辦到2008年第五版的方案裡皆尚無針對任何品質表現提供獎勵措施，本研究建議可以對急性醫療利用提出實際獎勵措施，及加強執行面的稽查或檢舉方式，確保疾病管理照護的項目能確實落實，以有效降低急診與住院利用。建議未來可進行成本效果與效益分析與更為精準的評估疾病嚴重度。

關鍵字

氣喘 ； 醫療利用 ； 疾病管理 ； 論質計酬 ； 品質

並列摘要

Objectives:
Asthma is one of the most common chronic diseases in the world. Global Initiative for Asthma (GINA) indicates that there is approximately thirty billion asthma patients in the whole world, and it will increase additionally one hundred billion in 2025. Likewise, the incidence of asthma in Taiwan has rapidly increasing in the past three decades. These facts show the high prevalence and seriousness of asthma and also signify the growing importance of preventing and treating asthma. The Bureau of the National Health Insurance (BNHI) implemented ’The Pay for Performance Program for Asthma’ in 2001, combining ’pay for performance ’ and ‘disease management’ mechanism. The program is to improve the quality of care and empower the patients to take care of themselves, which may reduce the medical expenditure in the long run. The main purpose of this study is to analyze the long-term effect of the ‘The Pay for Performance Program for Asthma’ on medical utilization and expenses. This study hypothesizes that the new payment program may reduce patient’s emergency visit or hospitalization.

Methods:
In this study, we used BNHI claim data during 2002 to 2006 and employed a quasi-experimental design. Asthma patients who were enrolled into the program were identified as the population of the experimental group, and those who had never been enrolled in this program were defined as the population of the control group. Then we use propensity score method to select our study groups from the populations. Finally, there were 714 patients who were enrolled into the program in 2003 being selected into the experimental group, and 2142 patients in the control group. The healthcare utilization data were identified for every patient a year before and 3 years after the enrollment for the experimental group, while the observation period were 2003 to 2006 for the control group. The data were analyzed by difference-in-difference method and multiple regression models to compare the difference of healthcare utilization between two groups.

Results:
During the four years, patients in the experimental group had a higher number of physician visit than that of the control group with a dramatic increase in the first year after enrollment and then declined gradually. For the patients in the experimental group, the number of ER visits decreased 0.13 visits and the number of hospitalization decreased 0.08 admissions within the four years, which were significantly greater than the figures for the patients in the control group with 0.08 and 0.05 respectively.

The difference-in-difference analysis showed that, after controlling for the baseline patient characteristics in the model, the net differences of the number of physician visit were 2.89, 1.89 and 1.57 respectively between the two groups in the three years. The patients in the experimental group had fewer ER visits than the control group with net differences of 0.02, 0.06 and 0.05 respectively. The numbers of hospital admission were also lower in the experimental group with net differences of 0.02, 0.02 and 0.03 respectively. According to the result, we found that the pay-for-performance program had decreased the ER visit and admission for asthma; however differences were not statistically significant.

Conclusions:
According to the long-term observation, the pay-for-performance program had increased patient’s physician visit for asthma. We also found that the difference in the numbers of physician visits for asthma between the intervention and control groups had been lessened gradually in the successive years. Patients in the experiment group had fewer emergency visits or inpatient admissions than the control group after the intervention, but the differences were not statistically significant. Further study can focus on cost-effectiveness analysis and cost-benefit analysis for the pay-for-performance program with more appropriate measures for care outcome.

並列關鍵字

asthma ； healthcare utilization ； disease management ； pay-for-performance ； quality of care

參考文獻

行政院衛生署(2000)。氣喘診療指引。臺北市：行政院衛生署。

李待弟(2007)。全民健康保險糖尿病醫療給付改善方案初步影響評估。臺灣大學衛生政策與管理研究所碩士論文，未出版，臺北市。

吳時捷(2003)。實施門診合理量對區域級以上醫院門診利用與費用的影響。臺灣大學醫療機構管理研究所碩士論文，未出版，臺北市。

吳家興、林瑞雄、謝貴雄、邱文達、陳麗美、邱淑媞等人(1998)。臺灣北部國中學生氣喘盛行率調查。中華公共衛生雜誌 ，17，214-225。

徐世達(2008) 。氣喘病的致病機轉。2008年8月14日，取自