探討山地鄉實施「醫療給付效益提升計畫」對民眾醫療服務利用影響與可近性之成效—以屏東縣牡丹鄉為例

The influence on the medical utilization and the improvement of accessibility of the implementation of Integrated Delivery System in rural-mountain areas--A case study of Mwudan Siang, a mountain aboriginal village in southern Taiwan

楊貴蘭(Kuei-Lan Yang)

指導教授 ： 楊銘欽

國立臺灣大學/公共衛生學院/醫療機構管理研究所/碩士(2004年)

https://doi.org/10.6342/NTU.2004.10344

摘要

為增進山地離島偏遠地區就醫可近性，健保局自1999年起陸續推動「山地離島醫療給付效益提昇計畫」，期能達到「平等就醫」和照顧「弱勢團體」的目的。本研究以設籍牡丹鄉5015位民眾為研究對象，利用健保局2001年7月至2003年6月申報資料進行次級資料分析。研究目的：1.分析「全民健康保險山地離島醫療給付效益提昇計畫」實施前、後民眾醫療利用情形。2.探討影響鄉內、外醫療利用之相關因素。

研究結果：1.鄉內門診使用率：由20.3％顯著上升至28.4％(p<0.001)。2.每人門診平均費用：鄉內由648.1元顯著下降至611.0元(p<0.001)，鄉外由862.2元上升至889.1元。3.就醫疾病別分佈：鄉內、外疾病別就醫人次百分比顯著改變，尤其以全鄉門診就醫人次最高的上呼吸道感染疾病，由過去鄉外佔90.4％顯著下降至72.2％，但是下背痛、挫傷、眼科、皮膚則鄉外就醫仍高。4.住院人次與費用則呈現上升情形，但可預防性住院下降達統計上意義。5.預防保健在成人健診與子宮頸抹片檢查鄉內服務人次顯著增加，兒童健診則呈現下降趨勢。6.影響是否使用門診因素之對數迴歸分析，整體而言「傾向因素」，女性、年齡大於65歲、不識字、有偶者；「能用因素」中居住村莊為：石門村與投保類別第三類；「需要因素」中有罹患慢性病與重大疾病者使用門診的機會較高。7.多變項分析，鄉內門診使用次數方面，整體而言「傾向因素」，女性、年齡大於65歲、小學、無偶者；「能用因素」中居住村莊為石門村、高士村與投保類別第三類；「需要因素」中有罹患慢性病者鄉內門診就醫次數較高。

研究結果得知IDS的確有助提升居民就醫可近性，未來應配合推動慢性病疾病管理及加強預防保健與衛教指導，以提升健康照護的品質。

關鍵字

全民健康保險山地離島醫療給付效益提昇計畫 ； 可近性 ； 原住民 ； 醫療利用

並列摘要

In order to improve accessibility of medical and health services at remote mountain areas, the Bureau of National Health Insurance (NHI) has implemented Integrated Delivery Systems (IDS) in all the mountain village since 1999. The purposes of the research were to evaluate the effectiveness of the IDS implemented in Mwudan Siang, during the period of July, 2001 to June, 2003. We wanted to see the first, whether the policy has influences on the residents’ medical-seeking behaviors and what are the major parts of it；and the 2nd ,what and which characters of these residents might influence on their medical-seeking decision ,preference in or outside the village.

This study used the insurance database provided by the Bureau of NHI. A total of 5,015 residents of Mwudan Siang were included in the study. The study results show: 1). The rate of out-patient utilization inside the village increased significantly from 20.3% to 28.4% after the IDS was implemented (p<0.0001); 2). The average medical cost of outpatient inside the village decreased significantly from NT$ 648.1 to NT$611.0 after IDS (p<0.0001), 3).Rates of visit due to acute upper respiratory, arthritis, skin disease, low back pain, eyes disease, gastroenteritis, gout, and Diabetes mellitus were all significantly increased inside the village after IDS (p<0.001); 4).Admission rate increased significantly (p<0.0001) but avoidable hospitalization conditions decreased significantly after IDS (p<0.001 ); 5). Utilization rate of adult preventive health service and cervical cancer screening increased significantly inside the village after IDS (p<0.001); 6).The factors affecting out-patient utilization were analyzed with multiple logistic regression. The results revealed the following significant factors : predisposing factors (female, age>65, married), enabling factors (living in Si-menh village, the category III insurance), and need factors (chronic disease patients); 7.) The factors affecting inside the village out-patient utilization were analyzed with multiple regression model, the results show that some factors favored inside-village out-patient utilization: predisposing factors (female, age>65, elementary school education, the singles), enabling factors: (living in Si-menh and Kau-sih villages, the category III insurance) and need factors: (chronic disease patients).

In general, the IDS program successfully increased the accessibility of medical care of the villagers. According to the study results, we suggest the authority should establish the system to manage chronic disease, and reinforce the service and education in disease prevention to improve the quality of medical care and health status in the aboriginal mountain area.

並列關鍵字

Integrated Delivery System ； Accessibility ； Aboriginal ； medical utilization

參考文獻

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