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  • 學位論文

實施門診合理量對區域級以上醫院門診利用與費用的影響

The Impacts of Regressive Physician Payment Policy on the Utilization and Expenses of Ambulatory Care for Medical Center and Regional Hospitals in Taiwan

指導教授 : 薛亞聖

摘要


健保局90年1月1日實施醫院門診合理量政策,希望藉由調整診察費的方式,達成抑制門診量的快速成長,並期待能夠給予門診病患更多診察時間,以提升門診醫療品質,因此,本研究目的在於探討健保局90年1月1日實施門診合理量對於區域級以上醫院門診利用與費用之影響,並瞭解醫院因應之方式。 本研究為一自然試驗,觀察區域級以上醫院實施門診合理量前後三年之時間,為排除外在環境之影響,採用實驗與對照組方式進行研究,將實施門診合理量之區域級以上醫院為實驗組,沒有實施門診合理量之地區教學醫院為對照組。本研究使用次級資料進行分析,運用健保資料庫88年至90年「門診處方及治療明細檔」及衛生署88年至90年「醫療機構現況檔」進行探討,以差異中之差異法與迴歸分析方法進行統計分析。 本研究主要結果如下: 1.實施門診合理量後,區域級以上醫院之門診量為持續增加的情形;經迴歸分析與對照組相較後,呈現無顯著差異,代表門診合理量政策並無法抑制門診量的成長。 2.實施門診合理量後,區域級以上醫院之診察費為持續增加的情形,但成長幅度明顯變緩慢;經迴歸分析與對照組相較後,呈現顯著之差異,代表門診合理量政策達到抑制診察費的成長。 3.實施門診合理量後,區域級以上醫院之診療與材料費以及藥劑費為持續增加的情形;經迴歸分析與對照組相較後,呈現無顯著差異,代表門診合理量政策並沒有產生費用轉移之情形。 4.實施門診合理量後,區域級以上醫院之總門診費為持續增加的情形;經迴歸分析與對照組相較後,呈現無顯著差異,代表門診合理量政策並沒有抑制總門診費用。 5.實施門診合理量後,區域級以上醫院之病床數為持續增加的情形,成長程度較為緩慢。 6.實施門診合理量後,區域級以上醫院之醫師數為持續增加的情形,成長程度較為緩慢,經迴歸分析與對照組相較後,呈現無顯著差異,代表門診合理量政策並沒有明顯增加醫師數以因應門診合理量。 整體而言,本研究發現區域級以上之醫院針對門診合理量政策之因應方式為持續增加門診量,儘管超過門診合理人次診察費降至120點,但由於對超過部份並未就停止支付診察費,再加上門診量增加可帶動檢驗檢查與藥劑費之其他門診收入,且下一年度門診合理人次亦可增加,導致門診合理量政策無法達成預期之目的。 因此,本研究建議,(1)應修正門診合理量公式,針對個別醫院給予適當成長空間,避免預期效應產生及醫院刻意增加門診量,(2)鼓勵多開慢性處方箋與持續調整急診與住院支付標準,以正確誘導醫院執行主要密集性照護之工作,減緩門診量成長快速之情形。

並列摘要


Regressive Physician Payment Policy has been put into practice since 1st,January 2001.The policy aimed at decreasing the growth rate of ambulatory care patients and increasing the time doctors can give outpatients by decreasing the number of patients. The purpose of this research was to understand the impacts of Regressive Physician Payment Policy on the utilization and expenses of ambulatory care for medical center and regional hospitals in Taiwan. This study was a natural experiment. It observed three years before and after the introduction of the Regressive Physician Payment Policy for medical center and regional hospitals. It was a case-control study in order to eliminate the effects of confounding factors. The study group was the Medical Center which executed Regressive Physician Payment Policy. The control group was the Regional Hospitals which did not executed Regressive Physician Payment Policy. This study used claimed data of Nation Health Insurance and Department of Health from1999 to 2001 for analysis. The “difference-in-difference” methodology and polynomial regression were used for statistic analysis. The following are the results of this study: 1. After Regressive Physician Payment Policy was put into practice ,the number of patients of medical center and regional hospitals still increase. There’s no significance between the study group and the control group by polynomial regression. Regressive Physician Payment Policy did not decrease growth rate of ambulatory care patients. 2. After Regressive Physician Payment Policy was put into practice, medical center and regional hospitals diagnosis fee still increase. But the growth of rate was slow. There’s significance between the study group and the control group by polynomial regression. Regressive Physician Payment Policy decrease the growth rate of diagnosis fee. 3. After Regressive Physician Payment Policy was put into practice, medical center and regional hospitals treatment fee and drug fee were still increase. There’s no significance between the study group and the control group by polynomial regression. Hospitals did not make up the loss of diagnosis fee by increasing treatment fee and drug fee. 4. After Regressive Physician Payment Policy was put into practice, medical center and regional hospitals total ambulatory care expenditure were still increase. There’s no significance between the study group and the control group by polynomial regression. Regressive Physician Payment Policy did not decrease total ambulatory care expenditure. 5. After Regressive Physician Payment Policy was put into practice, medical center and regional hospitals still increased hospital beds. The growth rate was slow. 6. After Regressive Physician Payment Policy was put into practice, medical center and regional hospitals still increased physicians. There’s no significance between the study group and the control group by polynomial regression. Hospitals did not increase physicians under Regressive Physician Payment Policy. This study found that medical center and regional hospitals still increased ambulatory care patients under Regressive Physician Payment Policy. Because the increase ambulatory care patients can bring treatment fee ,drug fee as well as the increasing the definition of reasonable loads for outpatients; therefore, even if the diagnosis fee will be decreased to 120 points when the reasonable loads for outpatients go beyond, hospitals still increased ambulatory care patients. Regressive Physician Payment Policy can not attain its goal. This study suggested that: (1) To avoid “Expectation Effects” and to increase ambulatory care patients, current formula should be changed so that it can be used by each hospital to set up the reasonable growth. (2) In order to encourage hospital to take care of serious patients, and to decrease the growth rate of ambulatory care patients, longer duration of medicine for chronic diseases should be encouraged and paid unit of emergency cases and hospitalization should be adjusted.

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