「全民健康保險B型肝炎帶原者及C型肝炎感染者醫療給付改善方案」之成效評估

The Impacts of the Pay-for-Performance Program for Chronic Hepatitis B and C Patients Under National Health Insurance in Taiwan

朱育增

肝炎 ； 論質計酬 ； hepatitis ； pay-for-performance

國立臺灣大學健康政策與管理研究所學位論文

2014年

博士

賴美淑

英文

研究背景與目的： 為提升醫療照護品質，愈來愈多國家健康照護系統採用論質計酬方案，然過去研究顯示論質計酬方案會有挑選病人的問題，對能否提升品質亦尚無定論，尤其缺乏論質計酬方案成本效益之實證研究。慢性病毒性肝炎一直是全世界及台灣重要的公共衛生問題。中央健保署於2010年推行「全民健康保險B型肝炎帶原者及C型肝炎感染者醫療給付改善方案」，增加醫療過程面指標給付的方式，鼓勵醫療提供者提升照護品質，藉由定期超音波篩檢與肝功能檢測，早期發現肝癌。目前針對此計畫進行之評估有限，因此本研究主要目的是探討影響病人加入方案的因素，論質計酬方案對過程面品質指標之影響，與進行論質計酬方案之經濟評估。 研究方法： 本研究使用2002~2011年健保申報檔。第一部分以廣義估計方程式，針對於有加入論質計酬方案院所就醫之40,978人加入方案與73,489人未加入方案者，分析影響病人加入方案之病人層次與醫療院所層次因素。第二部分則以準實驗研究設計，先分析全部符合論質計酬方案之病人，定義2010年加入試辦計畫之慢性肝炎病人39,894人為研究組，用傾向分數1:1配對出從未加入計畫之對照組，利用差異中之差異法及廣義估計方程式比較加入方案前後之慢性肝炎超音波與肝功能檢查過程指標之變化。再進一步分析於有加入論質計酬方案院所就醫之有參與方案與未參與方案之病人。第三部分則利用馬可夫模式，以健康醫療保險給付者觀點，評估慢性肝炎論質計酬方案之成本效性。 研究結果： 2010年符合慢性肝炎醫療給付改善方案者有257,654人。第一部分結果顯示共病分數愈高與併發腹水、食道靜脈曲張者，較不易被納入論質計酬方案。區域醫院、地區醫院及診所較醫學中心不易納入非酒精性肝硬化病人。第二部分結果之研究組超音波檢查完成率，顯著高於對照組。再進一步分析有加入論質計酬之院所病人，醫學中心未加入方案病人之超音波及肝功能檢查指標完成率亦顯著增加。診所在過程品質指標顯著增加超音波之完成率，肝功能檢測則未顯著改變。第三部分成本效性敏感度分析結果顯示，納入方案之肝硬化病人比例從0~100%，慢性B肝論質計酬方案之遞增成本效果比從NTD3,953,544元至NTD1,172,225元。慢性C肝之遞增成本效果比則從NTD2,904,536元至NTD 831,852元。 結論： 本研究發現B型肝炎帶原者及C型肝炎感染者醫療給付改善方案，仍有選擇疾病嚴重度較輕的病人加入方案的情形，區域醫院、地區醫院及診所較醫學中心不易納入非酒精性肝硬化病人，且診所僅顯著增加超音波之完成率，肝功能檢情形則未顯著改變。是否納入肝硬化之高危險群病人是次級預防介入是否具有成本效果的決定因素。建議政府應針對高危險群病人推動肝炎論質計酬方案。

Background： P4P is a payment scheme designed to enhance performance. It has become popular and implemented in more and more countries. However, the effects of the P4P are still controversial and worth exploring, and there is also a lack of economic analysis of the P4P program. Taiwan is a hyperendemic area of liver diseases, especially in chronic viral hepatitis B- (CHB) or C- (CHC) related hepatocellular carcinoma. Since year 2010, the Bureau of National Health Insurance initiated the pay-for-performance program for CHB and CHC patients. This program emphasize on the secondary prevention of HCC by the regular follow up with ultrasonography. Taiwan is the only country that using P4P to improve the secondary prevention of HCC around the world. However, there is limited research of the P4P program for chronic hepatitis B or C patients in Taiwan. Thus, the purpose of this retrospective using national datasets is (1). To assess the factors associated with patient enrollment and evaluate whether there is the problem of adverse selection; (2). To evaluate the effects of the pay-for-performance program; (3). To provide economic analysis of the pay-for-performance program. Methods： This is a retrospective cohort study. The data used in this analysis come from the national datasets. In part one, generalized linear model (GEE) was used to test whether patient inclusion in the pay-for-performance is associated to patient and provider institution characteristics. In part two, in order to control selection bias, and create participant and non- participant cohorts of similar clinical characteristics, propensity score were used to match participants with non-participants (1:1 match). Process quality indicators, completeness of ultrasonography or blood tests, were examined between participant and non- participant cohorts using difference in difference method and GEE models. In part three, evaluate the cost-effectiveness of the pay-for-performance program from the third party payer perspective. Computerized economic modeling techniques of Markov analytic models were established. Results： In 2010, 257,654 patients met the criterion of the P4P program, 40,978 P4P patients (P4P) and 73,489 patients not participate in the P4P program (non-P4P) from the hospitals that joined the P4P program. The results showed that patients with higher comorbidity index, ascites, and esophageal varices were less likely to be included in the P4P program. Regional hospitals, district hospitals and clinics were less likely to include patients with non-alcoholic liver cirrhosis than medical centers. For the completeness of ultrasonography, patients enrolled in the P4P program had better process quality than nonenrollees after controlling for confounding factors. After selecting patients from the hospitals that joined the P4P program, patients not enrolled in the P4P program improved more than nonenrollees in medical centers. Clinics significantly improved the completeness of ultrasonography; however, the completeness of blood tests was not significantly improved. One-way sensitivity analysis showed that if the percent of cirrhosis patients followed in the P4P program from 0~100%, the incremental cost-effectiveness ratio (ICER) would from NTD 3,953,544 to NTD 1,172,225 for CHB patients. For CHC patients, the ICER would from NTD2,904,536 to NTD 831,852. Conclusion： This study found the adverse selection during P4P program for CHB and CHC patient selection process. Regional hospitals, district hospitals and clinics were less likely to include patients with non-alcoholic liver cirrhosis than medical centers. Clinics significantly improved the completeness of ultrasonography; however, the completeness of blood tests was not significantly improved. The important factor of the cost-effectiveness analysis is the percent of cirrhosis patients followed in the P4P program. This P4P program should encourage or emphasize on the enrollment of high risk groups fist for the intention to early HCC detection.

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