醫療行為及醫療資源應用之研究- 署立宜蘭醫院的個案研究

Medical Behavior and Medical Resource Application Research - A Case study of I-Lan Hospital, Department of Health, the Executive Yuan.

劉祖德(Tsu-Te Liu)

指導教授 ： 柯承恩

國立臺灣大學/管理學院/會計與管理決策組/碩士(2008年)

https://doi.org/10.6342/NTU.2008.03229

摘要

全民健康保險自84年3月開辦實施之後，負責照顧全體國民的健康。隨著人口高齡化產生的醫療費用的急遽上升，及經濟情況不如預期，造成結構面的失衡，使得健保制度在財務上面臨極大的挑戰。在台灣的醫療體系中分為四個層級：醫院中心、區域醫院、地區醫院及基層診所，台灣醫院的總數是不斷減少，到目前西醫醫院總只剩500家左右，但醫學中心的規模及床數卻不斷的擴大，而相對的西醫基層診所數則不斷上升，到96年約有9200家，這代表了兩極化的走向，身處中間層級的醫院應該如何因應，來面對外在的變化，可能要先由目前的經營情形，以及就醫民眾的醫療行為及醫療資源的使用情形來加以分析，來強化自己的競爭力。
本研究以區域醫院一年(民國95年1月1日至民國95年12月31日的期間)內的所有就醫民眾的資料加以分析，分為門診、住院及急診三個區塊加以分析，透過年齡別、性別、疾病別、醫療資源(經費)的使用等方面加以解析。
結果發現由門診就醫最多的是大於等於65歲以上的老人，佔就醫總人次的44%，平均全年門診就醫的次數為9.9次，遠大於平均值的5.3次。住院的部份也是大於等於65歲以上的老人最多，佔住院總人次的35.86%，65歲以上的老人的全年平均住院次數為1.55次，略高過其他族群(平均為1.41次)。急診就醫情形最多的族群是25-44 歲，佔就醫總人次的24.94%，其次才是大於等於65歲以上的老人，佔就醫總人次的22.72%。本院不論門診、住院及急診的主要來源有將近90%左右都是來自蘭陽溪以北的地區。門診疾病總數最多的是中老年人常見的慢性病，如骨關節病及相關病患，慢性腎衰竭、結膜相關的疾病、糖尿病、自發性高血壓等居多。住院部份則以呼吸系統、循環系統、骨骼肌肉系統、神經系統及消化系統之疾病件數最多。這些分布情形與健保局的統計資料是相似的。
費用的部份：門診的費用，其中大於等於65歲以上的老人使用最多，佔總費用的46.15%。大於等於65歲以上的老人平均全年門診就醫的次數為9.9次，遠大於平均值的5.3次，而每次門診費用平均是1,568元，為平均值 (1033.5)的1.52倍。在門診的費用別方面，隨著年齡上升，總費用的增加部份以藥費的成長最多。65歲以上的老人的住院總費用，也超過所有族群的住院費用，佔所有住院經費的51.85%。65歲以上的老人的全年平均住院次數為1.55次，略高過其他族群(平均為1.41次)，而且每次平均住院費用為68,015，也比全部的平均費用47,044來的多。急診部份的費用，則未隨著年齡的增加有明顯的增加，其中25-44歲的族群使用最多，佔總費用的36.71%，全年每人的平均急診費用，也是25-44歲的族群花費最多，65歲以上的老年人口雖然的每年平均急診次數為1.75次，遠超過其他族群，但全年每人的平均急診費用卻不是最高。在性別上的區分上並沒有明顯的差異，發現不論性別，隨著年齡上升，門診及住院的經費使用上急速上升，尤其在65歲以上的族群更明顯。急診的費用，男女性在醫療經費的使用上差距不大。
由醫院的經營角度來看，門診的部份，應加強宜蘭市以外的民眾的吸引力，尤其是65歲以上的老年族群，並應盡速補齊目前缺乏的科別，配合適當的公關宣傳，加強各科的吸引力及競爭力。如果醫院沒有總額的限制，應該吸引更多慢性腎衰竭病人來醫院進行血液透析，來增加盈收。住院的部份，目前對65歲以上老人住院的需求未能滿足，也表示有許多的病人根本就不在本院就醫住院，改善的方式是增加科別，增加空間來容納更多的床位及設備。急診部份：急診佔有率不錯，維持目前的水準。
本研究也印證了65歲以上的老人族群在門住診的就醫次數較多，每次的就醫費用也較高，可能是老人慢性疾病較多，使用的醫療費用也較多。這個現象一方面反應了這個族群需要投入較多的資源來照顧他們，滿足其醫療需求，另一方面如何有效整合老人的醫療需求，減少醫療的費用，是相當重要的關鍵，應該增加經費加強維持老年族群的健康，不要落入失能的情形而需要他人照顧，將可以節省醫療支出。

關鍵字

醫療資源利用 ； 醫療費用 ； 醫院經營 ； 醫療行為 ； 老人

並列摘要

National health insurance was started since 1995 March and it was responsible for all national's health. Medical expenditure rises tremendously because the old age people (more than 65 years ago) increasing in percentage. The medical care system in Taiwan was divided into four levels: medical center, regional hospital, local hospital and clinic. In recent years, the total number of hospitals is decreasing and the number of clinics is increasing. However, the scale of medical center is enlarged, and the total hospital bed per medical center is increasing.
As a staff in the middle level of medical care system, we try to find a way to face the facts. We start to analyze data from daily medical operation. From the patients who came to our hospital for seeking health care, we try to find out the medical behavior and usage of medical resources within these people.
This research is based on a region hospital data at I-Lan County. We analyzed one whole year data (from 2006/1/1 to 2006/12/31). We divided these patients into three category: from outpatient clinics, inpatient and from emergency room. We analyzed these data through the difference of age, sex, disease and medical expense.
We found 44% of outpatients were elder than 65 years old persons. These people came to policlinic about 9.9 times per year and more than the average in all outpatients (5.3 times/year). Near 35.86% of inpatients were also elder than 65 years old. The average frequency of hospitalization in one year is 1.55 for elder patients (more than 65 years ago) and beyond the average of all inpatients (1.41 times/year). Peoples who are more frequent came to emergency room for help are age between 25 years old to 44 years ago. The majority (about 90%) of our patients came from the northern parts of the Lan-Yang River of I-Lan County. The most frequent disease encountered at outpatient clinics were chronic disease such as degenerative arthropathy, chronic renal failure, retinal disease, DM, and hypertension. The most inpatients werer admitted due to respiratory system diseases, circulatory system diseases, skeleton-muscular diseases, nervous systems diseases, and digestive systems diseases. It is similar result to DOH annual statistical reports. About forty-six percent of outpatient medial expense was used for the elder people who are older than 65 years old. The average fee for outpatient in every visiting of elder patients is more than average (NT 1,568 v.s. 1033.5). It had similar result in inpatient expense for elder people.
This study proved the aged people need more medial care. It is possible that elder people had more co-morbidity. They need more medical resource to help them to maintain their health. On the contrary, integration of medical care for these patients and try to find a way to reduce the medical expense in this patient group are important.

並列關鍵字

medical service utilization ； medical expense ； hospital management ； medical behavior ； the elderly.

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