區域醫院面對全民健保住院診斷關聯群（Tw-DRGs） 支付制度的因應策略：北部某區域醫院為例

Regional hospitals' tactical strategy in response to the new payment system - Tw-DRGs （Taiwan Diagnostic Related Groups）

賈蔚(Wey Chia)

指導教授 ： 郭瑞祥

國立臺灣大學/管理學院/商學組/碩士(2016年)

https://doi.org/10.6342/NTU201601660

摘要

台灣全民健康保險雖於民國84年3月匆促上路，但二十餘年來不僅在國內創造了不可能的任務–納保率超過九成，民眾整體滿意度超過八成，而且醫療支出含公衛預算僅占了GDP的6.1%，真可謂締造了另一項的台灣奇蹟。然而在這台灣奇蹟的背後，不少問題逐漸浮現，其中尤以不斷出現的財務危機和急重症醫療人力的短缺為最。
中央健康保險署為有效控制支出的不斷上升，多管齊下，由原先的抽樣審查核刪制度，到民國87年牙醫門診總額支付開始，繼以89年，90年及91年擴及中醫門診、西醫基層及醫院總額支付制度的擴大實施，雖然達到抑制醫療費用快速增加的目的，但也對醫療生態造成一些影響，地區醫院快速萎縮，醫療機構愈朝向大型財團醫院及基層診所兩極化發展。
民國99年起，另一項財務控制之措施開始分階段實施-住院診斷關聯群（DRGs： Diagnosis Related Groups）。中央健康保險署原規劃將住院病人分五年五階段分批導入DRGs支付制度，第一二階段推行時雖然也遭遇到醫界反彈，認為既然已經實施了總額支付制度，不應再推行DRGs支付制度，但因第一二階段實施項目以外科手術及婦產科生產案件為主，實施阻力不大，尚稱得上順利執行。但接下來全面實施的第三四五階段，則屬於內科系疾病；內科系疾病變數甚多，且老年人，同時罹患多重疾病者佔多數，醫院若無良好的醫療服務流程，嚴格的醫療品質管理，將會面臨極大的挑戰，輕者營運壓力增加，嚴重者亦可能會步入地區醫院的後塵，面臨轉型或倒閉的可能。美國保險機構於實施DRGs支付制度後，全國病床數亦隨之減少。
他山之石，可以攻錯；區域醫院雖無如醫學中心的採購議價能力，經營成本較高，面對即將而來的挑戰，必須先行重複的財務模擬試算，找出脆弱點，針對可能改善的環節重新檢視，依住院三階段（1）確定診斷期-排程改善，（2）治療期-加強診療病程說明、降低併發症、資訊輔助，（3）出院準備期-個案管理師的提早介入，制定新的流程，提升醫療效率，化危機為轉機，創造醫病雙贏。

關鍵字

全民健保 ； 住院診斷關聯群 ； 區域醫院

並列摘要

National health Insurance was instituted in 1995 in Taiwan. Over the last two decades, it had accomplished an impossible mission- over ninety percent of Taiwan’s population were enrolled, more than eighty percent overall general public satisfaction, and health expenditure including public health budget were merely 6.1% of the gross domestic product (GDP). It was indeed a Taiwan miracle. However, many problems had emerged; among these were financial crisis, and shortages of manpower in emergency and critical care medicine.
National health insurance administration introduced several tactics for effective cost containment in the face of escalating health expenditure. These included sampling review for payment subtractions and global budget system. The global budget payment system was initially applicable to dental clinics in 1998, and then expanded to traditional Chinese medicine clinics in 2000, followed by primary care providers in 2001, and finally to hospitals in 2002. Though it restrained the rapid increase in medical expenditure, there were wider influences on the whole infrastructure of health care systems. There was a rapid shrinkage of local hospitals, with expansion of the two extreme ends of healthcare providers, namely large enterprise founded hospitals and primary care clinics.
In 2010, another strategy to control financial expenditure was implemented stage by stage- inpatient Diagnosis Related Groups (DRGs). National health insurance administration’s original plan was to carry out inpatient DRGs payment system in five stages over five years. During implement of the first one and two stages, resistance came from medical professions who voiced that under the then ongoing global budget payment system, it was unreasonable to implement DRGs. But because these first two stages were carried out on mainly surgical and obstetric specialties, the resistance was relatively smaller. However, subsequent implementation of stages three, four and five includes internal medicine, which involves more complicated diseases with many variables. In particular, a majority of elderly people suffer from concurrent multiple disorders. Hospitals would face immense challenges ahead if there is no work flow procedure in place for effective delivery of medical service, and a stringent health quality management. The difficulties might include funding pressure to closure of hospitals in more serious cases. Looking at the United States of America, the number of hospital beds nationwide had dropped significantly following its implementation of DRGs
As regional hospitals do not have better buyer bargaining ability compared to large medical centers and their hospital running costs are high, the need for financial simulation to find out their weaknesses is paramount. A strategy to strengthen these weak areas may include the following three stages of inpatient care: (1) Confirm diagnosis- improve on scheduling of arrangement for investigations. (2) Treatment period- reinforce on provision of explanation and information on treatment plan, and reduce complications. (3) Discharge preparation stage- early intervention from case management nurse specialist, formulate standard operation procedure flow chart, and raise medical effectiveness.

並列關鍵字

Tw-DRGs ； National Health Insurance ； Regional Hospital

參考文獻

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