Ｔ質子治療中心營運可行性推估

Evaluation of Operation of Proton Therapy Center

廖漢文(Hon-Man Liu)

指導教授 ： 湯明哲

國立臺灣大學/管理學院/國際企業管理組/碩士(2010年)

https://doi.org/10.6342/NTU.2010.03287

摘要

癌症在近年來已成為台灣最重要的疾病及人死亡原因之首。隨著科技進步許多新穎的癌症治療方式及藥物不斷的發明及採用。但放射線治療仍為主要治療癌症的方式之一。傳統放射線治療最大缺點是會傷及正常組織及不能全部能量加褚癌病灶上。所以治療上會發生不少後遺症或容易復發。基本上，質子治療針對傳統放射線治療的上述兩大缺點具有其特別優勢。但由於質子治療系統造價昂貴，相關配備及硬體設置也較傳統放射線治療成本增加很多，所以台灣遲遲未有質子治療的成立。
在未來二至三年內，台灣會有兩個質子治療中心相繼成立。本研究主要針對Ｔ質子治療中心的特性(硬體由外界捐贈)，公家機構營運，以及沒有前例可循的情況下，作出各種不同的分析推算。
文中首先針對質子治療的歷史，質子治療的物理與生物基礎及目前全球質子治療的現況作簡單扼要的介紹。然後依文獻報告了解目前質子治療的適應症，以作為研究中討論的參考。
雖以Ｔ質子治療中心乃以捐贈為主，但是由於涉及日後營運維護成本，所以在成本分析中仍要計算儀器及建築成本等。文中依國外資料參考推估建造一個有5個治療房(含3 gantry+2 fixed beam)的質子治療中心建置總成立約為台幣五十億。而營運成本方面，最主要討論人事成本，公用事務成本，設備管理維護與服務成本，設備與工程整修費用折舊，作業及行政管理費用的成本，以一般計算方式。Ｔ質子治療中心在第三年以後要自行負擔設備管理維護費用，所以成本會突然高漲。此外，其中最重要是指出所謂fraction的成本概念，主要原因是美國，和歐洲目前針對質子治療的支付都是以fraction為給付單位。質子治療隨著不同方法和疾病有不同的治療量及方式，每個病患接受的fraction數目，可以從1個到40個或以上，而每個fraction的照野次數及方式也不一定相同。
所以依文獻說明假定以平均每位病人接受25fraction為整體質子治療的數量。研究中也指出影響fraction的單位成最主要的因素分別為工作時間，start-up與turn-down time，up-time的百分比及名目治療時間(正式治療時使用質子的時間加上每fraction前準備時間)，研究中針對上述因素作出敏感分析。
針對未來質子治療收入部份，研究中也以fraction為單位，參考目前台灣，美國，日本，瑞士的傳統放射線，立體定位放射線治療與質子治療的給付情況，作出合理的推算，未來合理的質子治療給付為每fraction，合台幣20,928。以上針對前面所得結果，推算Ｔ質子治療中心的營運財務情況。爾後，就治療費用人員營運成熟度，及每年工作時數作出不同敏感分析，針對淨現值與內部報酬率作出試算。
結果顯示其中影響最大是每年工作時數(名目治療時間)，對淨現值與內部報酬率，從每週上班六天，工作十六小時變成每週上班五天，工作十二小時兩值均有60~70%的影響，而以名目治療時間分析發現，工作人員營運成熟度影響較小約為3~5%，治療費用如從每fraction台幣20,000元降為15,000元時，淨現值也會有7%的變動，而內部報酬率變動較小。
最後討論其他對質子治療中心營運可能影響因素。
就全國病人數目而言，目前依質子治療的適應症Ｔ質子治療中心未來是有很大發展空間，但必需配合工作時數，相關人力與人才培育，使早日有達到完全營運狀況。此外，要靠智慧型的排程及人員成熟度來減輕病人複雜度對營運的影響。建議提出聘僱相關重要人力是重要的一環。研究中也指出semi-fixed cost在放射線治療以及質子治療同屬重要，日後經營也必然要多作考量。也討論到外在影響如Open system，政府政策，Ｃ醫院的定價策略，捐贈單位的長期補助與否等。最後提出國際醫療的可行性。

關鍵字

質子治療 ； 癌症 ； 成本 ； 收入 ； 營運 ； 損益兩平 ； 非經濟因素

並列摘要

Recently, cancer has become one of most important diseases and also the first leading cause of death in Taiwan. Though there are many newly developed medication and implementation of many innovative treatments, radiotherapy still play an important role in cancer treatment. Damage to normal tissue and cannot put all the energy into the lesions are the major disadvantages of conventional radiotherapy. These make radiotherapy can cause sequelae and recurrence occasionally. Proton therapy has the advantage over conventional radiotherapy to avoid the damage of normal tissue during the treatment and put almost all the energy to the designed lesion location. However, it is very expensive to build an integrate proton treatment system and cost of each proton treatment is much higher than the conventional radiotherapy.
In the next few years, two proton treatment centers will start to operate. In this research, we try to analysis the operation of T proton treatment center which is characterized by the aspect of public center donated by private funds, run by government owned university, and without local reference.
In the first part of this study, the history of proton treatment, its physical and biological basis in treatment of cancer, the current status of proton therapy in the world, and the indication of proton treatment were briefly reviewed.
A private fund donated all the major hardware to the T proton treatment center, but this fix cost was closely related to operation cost in the future, so the construction cost and equipment cost was also calculated according to references. All the calculation will be set upon a presumption that the T proton treatment center will have 3 gantries and 2 fixed beam treatment rooms and costs about NT$ 5,000,000,000 (construction cost + equipment cost). In the terms of operation cost, we discussed the personnel cost, cost of utilization, cost of management and maintenance, deprivation, cost of operation and administration according to the traditional way in T hospital. Three years after the installation, the total operation cost will be rising suddenly due to cost of management and maintenance.
Most of all, the cost of fraction in treatment is the key factor. In the USA and Europe, the unit of reimbursement in proton treatment is “fraction”. In different disease and different location, the use of proton therapy will be different. This means the number of fraction of each treatment in different patient will be not the same. One patient may receive one fraction (stereotactic radiosurgery) to more than 40 fractions in one course of proton treatment. Even, the number of portal is different in each fraction also.
In this study, the assumption is a total of 25 fractions will be averagely delivered to every patient. The important factors that impact the fraction are working hours, start-up and turn-down time, nominal treatment time(time for preparation and using proton beam in each fraction). The sensitivity analysis was done for these factors too. Working hours is the key factor effect the cost of fraction.
Regarding to revenue, fraction is also the unit of income. With reference to the data from USA, Japan, and Swiss and the ratio of payment to stereotactic radiosurgery and proton treatment in these 3 countries, the reimbursement of each fraction can be predict to be NT$20,928. With all these results, we can evaluate the operational financials in NTU proton treatment center. Sensitivity analysis of net present value and IRR with the variants such as maturity of person performance, nominal treatment time, and working hours were also performed.
Working hours and nominal treatment time are the two key factors to net present value and IRR. If the schedule is working 6 days a week and 16 hours a day, that will be a remarkable increase in both values as compare to a schedule of working 5 days a week and 12 hours a day. The percentile of change is about 3%-5% in the variant of maturity of person performance, and it is about 7% change in NPV but minimum in IRR if the reimbursement decreased from NT$20,000 to NT$15,000.
The study found that the new cancer patient that can be the candidates using proton therapy is far more than the capacity of the 2 new proton treatment centers in Taiwan. If T proton treatment center can provide enough working hours for treatment, accelerate the maturity of staffs, the fully operation of whole system can be foreseen in a short time. However, this also acquires intelligent scheduling to relief the problem of patient-mixed. Early appointment of key leading person such as director and medical physicists is also important. The concept of semi-fixed cost is important in conventional radiotherapy as well as proton treatment center. Other factors such as open system, governmental policy, the pricing of C hospital, the support from private funds are also discussed. Finally, the possibility of international medicine is also mentioned briefly.

並列關鍵字

Proton treatment ； cancer ； cost ； revenue ； operation ； break-even point

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