預估Tw-DRG支付制度實施後對醫院經營績效之影響-以某區域醫院為例

Projecting the impact of Tw-DRG payment system on hospital performance：using a regional hospital as an example

江雪萍(Shueh-Ping Chiang)

指導教授 ： 楊銘欽

國立臺灣大學/公共衛生學院/醫療機構管理研究所/碩士(2008年)

https://doi.org/10.6342/NTU.2008.01439

摘要

目的：本研究希望了解TW-DRG支付制度的實施對醫院經營績效之影響，因此本研究之主要目的為：1、瞭解在DRG支付制度下，不同MDC之差額佔定額比率。2、探討不同科別之差額佔定額比率有否差異。3、探討在相同DRG下主要影響差額佔定額比率的因素。
方法：以某公立區域教學醫院為研究對象，採次級資料研究法，擷取其96年度住院申報資料樣本數計12406筆，以健保公告之第三版Tw-DRGs支付制度原則並以第四階段全面導入之費用基準，模擬每一住院案件之實際醫療點數與實際核付點數所產生的差額佔定額比率，驗證本研究之假說。
結果：Tw-DRGs支付制度的導入對醫院的財務衝擊可以運用差額佔定額比率的量化指標衡量影響程度。研究結果驗證：1、在不同的MDC疾病型態其差額佔定額比率的影響程度不一，且因總費用佔率、服務量的比重不同相對影響財務風險比重。2、在治療相同DRG病人時因臨床專科別、年資而影響臨床治療的決策，致差額佔定額比率的影響程度不一且不一定在屬於該疾病型態的專科醫師在治療上有絕對溢酬的正向效益，但是年資相對有正向效益。3、住院天數為影響各科財務風險主要因素，且差額佔定額的比率皆為負值即為虧損，顯示較不利醫院的財務。4、當「住院天數」超過平均住院天數，其醫療費用的溢酬機率相對較低，因此，每個DRG在支付標準規定的幾何平均住院天數就是最好的溢酬、虧損的指標。
結論：整體而言，支付制度的改變影響醫院的財務衝擊及經營型態已可預見，而本研究的發現，正可提供醫院管理透過量化的客觀衡量方法能將醫療服務的損失程度予以估計比較，找出可能溢酬與損失的因素，尤其是對醫院本身服務對象的特性、疾病型態、醫療專長等都必須列為重要的風險因素，適時因應變化，掌握均衡原則調整經營發展方向，才能維持經營績效。

關鍵字

Tw-DRG支付制度 ； 差額佔定額比率 ； 風險衡量 ； 經營績效

並列摘要

Purposes:
The study attempted to reveal the impact of Taiwan-Diagnosis-Related Groups ( TW-DRG ) payment system on the performance of hospital administpredetermined payment. Its aims are: (1) to comprehend the ratios of difference to predetermined payment by different MDC under DRG payment system, (2) to show the variance of ratios of difference to predetermined payment among various specialists, and (3) to explore major factors influencing the ratio of difference to predetermined payment under an identical DRG.
Methods:
The study was a secondary retrospective data analysis.The subject was one public regional teaching hospital in northeasten Taiwan. Hospitalization data of total 12406 cases filed to the Bureau of National Health Insurance (BNHI) in 2007 was collected . This study calculated the ratio of the difference, between actual medical expense and DRG predetermined payemt and caculates the ratio of the difference to DRG predetermined payment by formula of TW-DRG payment system, the 3rd edition, and implemented at the 4th phase. The results were used to test our hypotheses.
Results:
The ratio of difference to predetermined payment could be a quantitative indicator and could be applied to evaluate the influence of hospital finance by implementing TW-DRG payment system. The study revealed several results as follow: (1) The influence of different MDC on the ratio of difference to predetermined payment varied to some extent, the proportion of financial risks were also depended on the proportion of service and the rate of total payment. (2) The influence of specialty and seniority on the ratio of difference to predetermined payment also varied, The specialist of a disease didn’t always gain positive benefit, while the seniority did. (3) The length of stay was the major factor of financial risk. the negative ratio of difference to predetermined payment indicated loss and disadvantage of hospital finance. (4) TheALOS was a good indicator for loss or surpluss of hospital finance.
Conclusions:
Overall, the alteration of payment system will be sure to influence the hospital finance and hospital management. The study helps hospital managers to evaluate the loss of medical service and to find the factors influence finalcial surpluss or loss. It cannot be overemphasized that maintaining the performance of hospital administration should depend on closely monitoring the risk factors including characteristics of patients, disease patterns, and medical expertise, and appropriate reaction and adjustment in time.

並列關鍵字

Tw-DRG payment system ； the ratio of difference to predetermined payment ； risk measurement ； hospital performance

參考文獻

中央健康保險局(2006)；總額支付制度意涵。

韓揆(2005)；診斷組合在台推行問題(上)-DRGs之支付精神、支付邏輯及侷限。醫務管理，6(1)；1-17。

陳婉茗、吳肖琪（2005）；模擬DRGs實施對我國醫院的財務衝擊。台灣衛誌；24；306-313

饒鈴瑜（2005）；以TW-DRGs分類探討全民健保住院日、疾病嚴重度及醫療費用之相關性，健康管理研究所碩士論文，54-56

洪瀅琇(2006)；DRG支付制度下住院醫療服務之財務風險分析-決策支援系統之應用。長榮大學健康科學學院醫務管理學系碩士論文。