研究背景: 台灣版住院診斷關聯群(Tw-DRGs)的精神,除了基本診療費用外,同一組DRG在不同層級醫院的支付點數是相同的,但「同病同酬」的觀念完全忽略醫院性質不同對醫療費用或資源消耗產生的影響,以及同一組DRG支付點數的盈虧程度亦有所不同;即同一組DRG中,較嚴重的病人仍集中在較高層級的醫院,而此差異並非僅有基本診療費用的差異而已。以往已實施的論病例計酬項目中多為外科手術性診療項目,極少是內科系的疾病項目;而肺炎在臨床醫學、公共衛生和醫務管理上均有相當重大的意義。 研究目的: 以病人特性(個體)與醫院特性(群體)兩部份,探討同一組DRG病人的性別、年齡、就醫科別、合併症或併發症、入住加護病房、手術處置,以及醫院的權屬別、特約類別、教學性質、評鑑類別、地區別,對於住院天數與醫療費用,以及超出幾何平均住院天數與支付定額是否有顯著影響,以藉此建立更公平的支付方式。 研究方法: 自國家衛生研究院所發行健保資料庫(2009)取得“單純性肺炎及胸(肋)膜炎(DRG089-DRG09102)”為研究樣本共8,099筆,採用SPSS 19版與HLM 6.04執行統計分析與檢定步驟,除了描述性統計外,亦利用單因子變異數分析、獨立t檢定、卡方及階層線性模式(HLM)進行推論性統計分析。 研究結果: HLM分析結果顯示住院天數方面,年齡0至17歲高於18歲以上,且與性別、就醫科別、合併症或併發症、手術處置及入住加護病房有顯著相關。醫療費用方面,年齡0至17歲高於18歲以上;醫學中心高於區域醫院和地區醫院;且與就醫科別、合併症或併發症、手術處置及入住加護病房有顯著相關。超出幾何平均住院天數方面,年齡0至17歲高於18歲以上;且與就醫科別、手術處置、入住加護病房及醫院權屬別有顯著相關。超出支付定額方面,年齡0至17歲高於18歲以上;醫學中心高於區域醫院和地區醫院;且與就醫科別、合併症或併發症、手術處置、入住加護病房及地區別有顯著相關。 研究結論: (一)本研究發現該DRG以18歲為年齡切分點並不適切,並有修改之必要,為了避免醫院傾向收治年齡較輕之成人病患,因而排擠65歲以上老人之需要,建議健保局應將年齡區分為三組。(二)醫學中心的病患大多疾病嚴重度較高,應考慮各層級醫院間病人嚴重度的差異,並給付更合理的支付加成。(三)醫院特性變項因素對於住院天數和醫療費用之影響力明顯較小,未來研究應朝向發掘影響住院天數與醫療費用的醫院特性群體層次變項。
Background: In Tw-DRGs, the same reimbursement fee is given in different levels of hospitals among a selected DRG group except the basic fee such as physician fee or ward fee. However, “the same disease pay the same money” ignore that the healthcare expenditure and resource utilization are dramatic different among hospitals and the surplus or deficit of payment is also different in a selected DRG group. Most high severity patients gathered in the higher level hospitals. The difference of healthcare expenditure is more than basic payment fee. The implemented case payment items were tended to surgical cases, less cases of internal medicine were inclusive. Pneumonia had a important place in clinical medicine, public health, and healthcare administration. Objective: This study used individual level(patient characteristics) and group level (hospital characteristics) simultaneously to identify the association with length of stay and reimbursement in a selected DRG. The patient characteristics included gender, age, clinical specialty, complication/comorbidity, ICU admission, and surgery procedures. The hospital characteristics included ownership, contract type, teaching type, accreditation category, and area location. Methods: We adopt a set of a selected DRG from National Health Insurance Research Database, and 8,099 case of simple pneumonia and pleurisy (DRG089- DRG09102) were selected finally. Descriptive statistics, ANOVA, t- test, χ2 test and HLM were used to identify the association of patient (individual level) and hospital (group level) to length of stay and reimbursement. Results: (1)The length of stay(LOS) was significantly different from gender, clinical specialty, CC(complication/comorbidity), surgery and ICU. The length of stay in the 0-17 years old was higher than over 18 years old. (2)The reimbursement was significantly different from clinical specialty, CC, surgery and ICU. The reimbursement in the 0-17 years old was higher than over 18 years old, and medical centers was higher than that regional and distinct hospitals. (3)Excess of LOS’s geometric mean was significantly different from clinical specialty, surgery, ICU and hospital ownership. Excess of LOS’s geometric mean in the 0-17 years old was higher than over 18 years old. (4)Excess of fixed payment amount was significantly different from clinical specialty, CC, surgery, ICU, and hospital distinguish. Excess of fixed payment amount in the 0-17 years old was higher than over 18 years old, and medical centers was higher than that regional and distinct hospitals. Conclusion: (1) This study was found that the inappropriate discrimination of age in this selected DRG resulted in the tendency toward admiting younger adult patients in hospitals. The age discrimination would be divided into three age groups to protect the resoures utilization of elder patients. (2)Mostly patients has higher disease severity in medical centers, it is should be considered that the differences in severity of patients among all levels of hospitals and let them pay more reasonable cost-plus. (3)Hospital characteristics was significantly smaller than patient characteristics in the influence of LOS and reimbursement, it should be explore more possible factors of hospital characteristics in the future.
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