醫院卓越計畫介入後醫院之價量變動分析-以參加卓越計畫之地區醫院為例

Analysis on the variations of price and volume of health care under the implementation of “Hospital Excellence payment program” by Taiwan’s Bureau of National Health Insurance

蔡永裕(Yung -Yu Tsai)

指導教授 ： 江宏哲

共同指導教授 ： 李金德(King-Teh Lee)

高雄醫學大學/健康科學院/醫務管理學研究所碩士在職專班/碩士(2007年)

摘要

研究目的：隨著健保的推行， 逐漸普及至全民的結果，大幅提昇了民眾醫療的可近性，也減低了民眾就醫時的財務負擔，所以，醫療費用的快速膨脹是可以預見的。健保局推動“醫院卓越計畫”試圖利用賦予醫療提供者更多的自主性，以緩和醫療費用的成長，同時避免影響民眾的就醫可盡興與公平性。本研究，從預算分配的觀點，討論參加的地區醫院，在政策介入前後，醫療費用的配置有何改變。從價與量的醫療服務指標，觀察卓越計劃介入前後地區醫院的群體應變效應，希望本研究能作為衛生署或健保局在未來醫院總額支付制度研修時有一個政策參考。
研究方法：我們以九十三年參加醫院卓越計畫之地區醫院為研究對象，探討個別醫院參加醫院卓越計畫前與參加醫院卓越計畫後醫療提供行為之變化，以九十三年申報資料為判斷基準，針對卓越計劃介入前後之醫療服務行為(價與量之改變)比較，分析對象醫院之各項費用之變化趨勢以了解對象醫院價與量之間之相關操作。
研究結果： 49床以下醫院參加醫院卓越計畫者，政策介入後，門診與住院申報件數與金額與政策介入前均呈現明顯負成長(門診-6%V.S.-8.6%，住院-2.4% V.S.-1.8%)，50-99床醫院參加卓越計畫者，於政策介入後，門診與住院均與49床以下者相似呈現負成長(門診-7.9%V.S.-6.7%，住院-2.3% V.S.-3.5%)，100床以上醫院，住院金額的成長較為明顯(2.8%)。在門診服務量與價格的影響方面，參加的醫院不論規模大小，平均每日看診人次均呈現負成長(49床以下-7.3%，50-99床-9.2 %，100床以上-8.6%)，價格於藥費呈現負成長(49床以下-9.9%，50-99床-3.8 %，100床以上-9.8%)，檢驗檢查費呈正成長等(49床以下0.1%，50-99床5.3 %，100床以上6.5%)。
討論與建議：本研究有如下幾個結論：1. 透過醫院卓越計畫的執行有助於我國全民健保總額支付制度的落實2. 參加卓越計畫醫院門診服務量逐年遞減3. 門診服務單價在計畫介入後均逐年上升。總額支付制度雖然可以平衡民眾醫療需求無法消化的困境，但是很快的當各醫院熟悉遊戲規則之後問題仍然會浮現，所以本研究建議政策介入與醫療機構是否應有結構化的合約規範。在一個制度推動之前需要像先進國家給個三到五年的緩衝期並逐步的加強宣導，使得醫療業者及民眾能夠逐漸適應醫療制度之變化。

關鍵字

總額支付制度 ； 醫院卓越計

並列摘要

Purpose: We aim to explore the variation of prices and volumes of healthcare provided by district hospitals in Taiwan under the implementation of “Hospital Excellence Payment Program (HEPP)” by Bureau of National Health Insurance (BNHI) at year 2003. We hope to show the group effects of behavioral changes before and after the implementation of new payment system (hospital global budget) and provide the insight for references of decision makers in the Bureau and Ministry of Health.
Methods: All of the district hospitals that had joined to the HEPP during the year 2003 were selected as study group. We extracted the BNHI claimed data of district hospitals from 2002 to 2005. Changes of prices and volumes of inpatient and outpatient services during study period were analyzed. Data of the second and third quarters (Q2 and Q3) of 2003 were excluded because of SARS attack during these months. Hence, only Q3 and Q4 of 2002, Q1 and Q4 of 2003, and Q1 of 2004 were taken as period before implementation of HEPP. And from the Q2 to the Q4 of 2004 were defined as period of after implementation. Paired t test and regression model of GEE were used to analyze the changes of healthcare providing behaviors among these district hospitals.
Results: There were 149 out of 362 (41.2%) district hospitals that joined the HEPP. The percentages of health care expenditures claimed by these hospitals were 44.3% among all district hospitals. However, the budgets that were really reallocated to the 44.3% of district hospitals were 47.3% of total budget for all district hospitals. The growth rate changes of outpatient volumes and expenditures of healthcare before and after HEPP were obviously declined in hospitals of beds fewer than 50, beds of 50-99, and beds of greater and equal than 100. As for the growth rate of inpatients service volumes, there were no obvious changes. According to the analyses of GEE model, the trends of averaged cost per outpatient were increased when taken the Q4 of 2002 as a base line to compare with Q4 of 2003 and 2004. In the GEE model of averaged cost per outpatient service, the time trend, averaged cost of drug per visit, and averaged cost of ancillary service per visit were the 3 major influencing factors. On the other hand, the results of the GEE analyses showed that the time trend and the averaged length of stay were the 2 major influencing factors.
Conclusions: Under the implementation of the new hospital global budget payment, hospitals that had joined the HEPP were finally reimbursed more money for healthcare that provided during Q2 to Q4 of 2004. Healthcare providing behaviors of hospitals in the HEPP showed that the volumes of outpatient and inpatient services were under constrained. However, the prices of outpatient and inpatient services of them were increased year by year. Further study on the waiting list and satisfaction of services from patient side has to be done for the references of decision making of policy evaluation.

並列關鍵字

Global budget ； Hospital Excellence Payment Program

參考文獻

英文部分

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