診斷關聯制度實施對醫療行為之衝擊－以某區域醫院為例

The Impact of Medical Behavior When Implementing the DRG System－A Empirical Study of Region Hospital

龍威任(Wei-Ren Long)

指導教授 ： 林利萱

元智大學/管理學院/管理碩士在職專班/碩士(2011年)

摘要

由於中央健康保險局的醫療支出持續成長，從民國87年開始健保收入入不付出，因此陸續推動各項支付制度，如:醫院卓越計畫、限定門住診申報比率、醫療總額支付制、醫院自主管理方案、醫院個別總額制、論病例計酬支付制等制度，其目的是為了降低醫療費用成長。以論病例計酬支付制來說，自87年開始實施至98年共實施49項住院定額給付病例，在實施的過程中，各醫院均推行臨床路徑以定型化治療模式，規範病例治療天數、檢查項目、放射次數等，以合乎論病例計酬支付制規定，目的為節省醫療費用，創造醫院盈餘。從99年1月1日開始將論病例計酬支付支付(Case Payment : CP )制改為疾病診斷關聯群(Diagnosis Related Groups :DRGs)制申報。本研究探討98年論病例計酬支付制支付制度及99年疾病診斷關聯群制，針對相同疾病發生但在上述兩種不同給付制度下，撿視醫療資源耗用(包括住院天數，檢查費用，放射線診療費用)之增減變化情形，探討醫師是否會由論病例計酬支付制改變為診斷關聯群計酬制,因而改變倫理醫療行成為求利益導向的醫療行為。
研究結果顯示，整體來說實施DRGs制比CP制在(1)醫療利益額增加；(2)住院天數降低，(3)檢查費降低均有顯著差異。其次篩選前十項最多的病例實證中，發現DRGs制相較於CP制在（1）醫療利益額增加；（2）住院天數減少；（3）檢查費減少、（4）放射線診療費減少均有顯著差異。再將資料分別依四大科別區分，發現DRGs制比CP制在（1）骨科；檢查費及放射線診療費減少有顯著差異，在（2）外科醫療利益額增加，檢查費及放射線診療費減少有顯著差異，在（3）心臟內科放射線費降低有顯著差異，而在（4）婦產科選定各項費用指標則均無顯著差異 。再以十五位主治醫師來分析，多數主治醫師在DRGs制比CP制在其住院天數、放射線診療費、檢查費均有降低，但醫療利益額並無顯著差異。可見DRGs制的實施是可以有效降低醫療資源耗用。可推測主治醫師會因支付制度改變而改變醫療治療方針，但是醫療利益額增與檢查費、放射線診療費及住院天數減少並無統計相關性，因此推斷醫師不會以追求利益為導向的醫療而是遵照制度精神以醫療倫理為主的醫療。

關鍵字

全民健保 ； 支付制度 ； 論病例計酬支付 ； 診斷關聯群 ； 區域醫院

並列摘要

As the medical expenses of the Bureau of National Health Insurance had been growing continuously, the health care revenue began to hardly make ends meet from 1998.Consequently, each payment system has been launched one after another, such as: hospital excellence program, defined outpatient and inpatient reporting rate, total-amount payment system of medical care, hospital self-management program, hospital total individual system, case payment system and other systems in an attempt to reduce the growing health care costs. At the perspective of case payment system。The hospitalization fixed payment with 49 items of patients had been implemented from 1998 to 2009. On the process, every hospital launched clinical pathways in a fixed treatment model, regulating the standard of the number of days, check items, and radiation frequency for treatment so as the case payment system may be in line with the regulations. It aims to save medical costs, and create hospital surplus. From January 1, 2010, Case Payment (CP) system will initially be changed to Diagnosis Related Groups: (DRGs) to declare. In this study, Case Payment (CP) system in 2009 and Diagnosis Related Groups: (DRGs) in 2010 are to be explored. In view of similar diseases but in two different payment systems, we examine the medical resource utilization (including hospitalization days, examination fees, radiation treatment costs) to see their varied growths and reductions. We also explore to find out whether doctors will change their medical practices because of the payment system changed from Case Payment (CP) system to Diagnosis Related Groups: (DRGs), and further exploration is conducted to see the relationship between such a change and interest orientation.
The findings of the study show that in general, in comparison with CP system, the implementation of DRGs (1) is more in terms of increasing amount of medical benefits; (2) the number of days of hospitalization is reduced; (3) the examination fee reduction is significant in difference. Followed by screening of the top ten most empirical cases, we found that in comparison with CP system, DRGs (1) is more in terms of increasing amount of medical benefits; (2) the number of days of hospitalization is reduced; (3) the examination fee is reduced; (4) radiation treatment costs are remarkably reduced
Then the data were distinguished in four major categories, we found that in comparison with CP system, GPGs (1) in orthopedic; examination fees and radiation treatment fees are remarkably reduced (2) there are remarkably on the increase in terms of surgical medical benefit and examination fees and radiation treatment fees are remarkably on the decrease; (3) in Cardiology, radiation fees are remarkably reduced, and (4) in obstetrics and gynecology, selected fees for each item are not remarkably different. And then, as fifteen physicians are to be analyzed, compared with CP system, for the majority of physician in DRGs, the hospital stay, radiation treatment fees, examination fees are lower, but there was no significant difference for medical benefit amount. It is seen that the implementation of GRGs can be efficiently reduced in terms of medical resource utilization. It can be assumed that Physician may change the treatment policies because of payment system, but amount of increase in medical benefits and decrease in examination fees, radiation treatment fees and days of hospitalization are not statistically correlated. It therefore infers that physicians may not seek to interest-oriented medical care, but to follow the medical ethics-based care.

並列關鍵字

Bureau of National Health Insurance Medical ，Payment System ，Case Payment System，Diagnosis Related Groups，Regional Hospitals

參考文獻

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