總額支付制度實施前後，醫療市場競爭對醫師診療行為的影響

Initial Impacts of the Global Budget Scheme on the Effect of Market Competition upon physician's behavior

趙崇翎(Chang-Ling Chao)

指導教授 ： 楊志良

亞洲大學/健康學院/健康管理研究所/碩士(2004年)

摘要

民國八十四年三月全民健康保險實施，保障全民醫療服務的獲得，增進了就醫的可近性，且隨著中大型的醫院紛紛設立，醫療產業間的競爭趨於白熱化。而在有限的醫療資源下，健保的支付制度以論量計酬為主，在醫療提供者缺乏節約的誘因之下，常藉以量制價的策略，利用醫療資訊的不對稱，提供病患不必要的醫療服務，產生醫師供給誘發病患需求的情況，而使得醫療費用支出節節高升。而在全民健保規劃之初，為控制醫療費用於合理的成長範圍內，即著手研擬總額支付制度，且在民國九十一年七月實施醫院的總額支付制度。換言之，健保醫療資源分配責任已從全民健保局移交給醫療提供者，而在總額下價量互動的情況，希望藉由醫療團體間同儕制約，減少不必要的醫療浪費，使醫療資源做最有效的利用。本研究利用全民健保資料庫，欲探討總額支付制度實施前後，醫療市場競爭程度與醫師診療行為間的關係，以賀芬達指標來分析醫療市場競爭程度，以平均每位醫師申報的醫療資源來分析醫師診療行為，研究期間為民國八十七年一月至民國九十二年十二月，以衛生署民國七十九年七月「建立醫療網第二期計畫」中所劃分的醫療次區域為醫療市場服務範圍進行探討。本研究結果顯示，在總額支付制度實施之前，醫療市場競爭程度愈高的地區，其平均每位醫師的診療行為會愈多，有供給誘導需求的情況發生；而在總額支付制度實施之後，醫療市場競爭程度並不會影響醫師診療行為，顯示並無供給誘導需求的情況。而在比較總額實施前後的醫療市場競爭程度對醫師診療行為的關係中發現，總額支付制度實施前後對醫師診療行為，但醫療市場競爭程度對醫師診療行為的影響力不高，且影響方向不定。另外本研究亦發現，醫療次區域的都市化程度與每位醫師服務的人口數均會影響醫師的診療行為。

關鍵字

總額支付制度 ； 醫療市場競爭程度 ； 賀芬達指數 ； 醫師診療行為 ； 供給誘導需求

並列摘要

With the implementation of the National Health Insurance (NHI) in 1995, medical services to the all citizens are guaranteed and it improves the availability of medical treatments. As the middle- and large-scale hospitals established, the competition in the medical industry is getting incandescing. Under the limited medical resources, the payment system in NHI is calculated by quantity, which causes medical service providers to provide unnecessary medical services using the unbalanced medical information between the medical service providers and the patients. To be more specific, physicians might induce the patients to require more medical treatments and results in the rising of the medical expense. In the planning phase of NHI, the Global Budget System was begun drafted in order to control the medical expense growing up in a reasonable range, and it was put into practice in each hospital in July 2002. In other words, the responsibility of distributing medical resource under NHI has been transferred from the Bureau of National Health Insurance (BNHI) to medical service providers. It is anticipated that under the Global Budget System, the unnecessary wastes in medical resources is reduced and the medical resources are utilized in the most effective way with the aid of supervision between medical organizations. This research probes into the relation between medical market competition and physician’s behavior before and after the Global Budget System was put into practice, and uses the Herfindahl index to analyze the degree of market competition in medical industry. Physician’s behaviors are analyzed by the average medical resources reported by each physician surveyed from January 1998 to December 2003 and investigated in the medical industry delimited by medical sub-region in the objective of the Medical Care Network Project implemented by the Department of Health, Executive Yuan, Taiwan, R.O.C. in July 1990. The results of the research show that the average behaviors of each physician are much more in the area of high market competition and the situation of physicians inducing patients to require more medical treatment is found before the Global Budget System was put into practice. But after the Global Budget System was carried out, the degree of market competition doesn’t affect physician’s behaviors, which demonstrates there is no supplier-induced demand situation. When comparing the relation between market competition and physician’s behaviors before and after the Global Budget System was carried out, we observe that the influence of the market competition to the physician’s behaviors is not significant, and the aspects of the influence are not fixed. In addition, this research shows that both the urbanization in the medical sub-region and the number of patients treated by each physician affect the physician’s behaviors.

並列關鍵字

Global Budget ； Market Competition ； Herfindahl Index ； Physician's Behavior ； Supplier-Induced Demand

參考文獻

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