家庭醫師整合照護計畫 之醫療利用探討-以高屏地區為例

Medical Utilization of Family Physicians' Comprehensive Health Care Program- Kao-Ping Areas as Example

王悅萍(Yueh-Ping Wang)

指導教授 ： 張永源

高雄醫學大學/健康科學院/醫務管理學研究所碩士在職專班/碩士(2008年)

摘要

目的：
2003年嚴重急性呼吸道症候群(SARS)以迅速的方式在全球擴散，亦對台灣造成重大的威脅，在SARS期間因病人求醫行為太過自由造成隔離困難及醫療知識缺乏，引起台灣人民的恐慌與不安，中央健康保險局於民國92年3月10 日公告「全民健康保險家庭醫師整合性照護試辦計畫草案」已實施多年，希望透過本研究瞭解高屏地區家庭醫師計畫實施情形，研究目的為：
一、 瞭解參加家庭醫師整合性照護試辦計畫之民眾92至95年固定就醫狀況。
二、 探討參加家庭醫師整合性照護試辦計畫之民眾，固定就醫率在性別、年齡層及地區別是否有差異。
三、 分析參加家庭醫師整合照護計畫民眾與未參加家庭醫師整合性照護試辦計畫民眾前後醫療利用之差異。
方法：
本研究為類實驗設計（quasi-experimental designs），採回溯性、縱貫面之健保局次級資料分析，瞭解家庭醫師試辦計畫實施參加及未參加民眾之前後醫療利用差異之研究設計。研究對象為93及94年加入同一家診所之家庭醫師計畫民眾共3,360人與未參加家庭醫師計畫之民眾之固定就醫率、平均就診次數、急診利用率、住院利用次數及醫療花費，其在未加入家庭醫師計畫之前一年（92年）及加入家庭醫師計畫之後三年（93、94、95年）醫療利用之差異等，以SPSS12.0 for Windows 套裝軟體進行研究分析。
結果：
一、參加家醫計畫固定就醫分析
1、高雄市、高雄縣及屏東縣三縣市參加家庭醫師計畫的診所、醫師及民眾有逐年增加但占西醫診所比率以高雄縣最高也僅為29.62%。
2、參加家醫計畫之民眾92-95年門診（西醫）固定就醫率為92年固定就醫率高於其他三年，且以94年為最低。
二、家醫組與非家醫組醫療利用前後比較
1、92-95年前後的門診（西醫）平均就醫次數呈現顯著交互作用（P值0.0001），家醫組為有逐年減少（除95年），而非家醫組為有逐年增加，表示有無參加家醫群其92-95年其門診（西醫）平均就醫次數增減幅度不相同。
2、92-95年前後的住診平均就醫次數呈現顯著交互作用（P值0.036），表示有無參加家醫群其92-95年其住診平均就醫次數增加幅度不相同，為家醫組增加幅度較非家醫組為少。
3、有參加家醫群與未參加家醫群與92-95年前後的急診平均費用呈現顯著交互作用（P值0.023），家醫組與非家醫組92-95年急診平均費用皆有增加，但增加幅度為非家醫組高於家醫組其增加幅度不相同，為家醫組增加幅度較非家醫組為多。
建議：
一、對民眾：
落實有並先前往家醫診所就醫，提高其固定就醫率，較能獲得連續、完整的醫療照護。
二、對醫療機構：
家庭醫師計畫已試辦5年，95年西醫診所加入情形僅為29.62%，建議應鼓勵更多的西醫診所參加，讓民眾獲得連續、完整的照護。
三、對政府機關：
經統計顯示民眾固定就醫情形並未因為參加家庭醫師計畫後有逐年增加，是否應採論人計酬之支付方式，較能符合家庭醫師計畫之健康管理精神或應加強評估家庭醫師計畫之目的達成情形。

關鍵字

家庭醫師整合性照護試辦計畫 ； 醫療利用 ； 固定就醫率

並列摘要

Background：
In 2003, Severe Acute Respiratory Syndrome （SARS）rapidly outbroke through the whole world and also caused major threat to Taiwan. Due to no limitation of the patient’s behavior in visiting doctor, the outcome which inducing isolation difficult, combining lack of medical knowledge, caused public panic in Taiwan. The Bureau of National Health Insurance announced a draft of “Family Physicians' Comprehensive Health Care Program of National health”,which had been put into practice for several years. This study was aimed to investigate the results of this program.
Objective：
The purposes of this study included:
1. Look into the people’s single doctor visiting behavior who attended in the“Family Physicians' Comprehensive Health Care Program” during 2003 to 2006.
2. Investigation if any difference in the single doctor visiting rate in the people who attended in the “Family Physicians' Comprehensive Health Care Program” between gender, age, and regions.
3. Analysis the utilization of medical care services before and after people attended the “Family Physicians' Comprehensive Health Care Program”compared to the unattended others.
Methods:
This study was a quasi-experimental design, with retrospective analysis of the data gathered from the Bureau of National Health Insurance, which were used to investigate the utilization of medical care services between attended and unattended people. The subjects included 3,360 persons visiting in the same clinic between 2004 and 2005. The independent variables included the rate of visiting the same doctor, the average times of doctor seeing, utilization of emergency and admission, and cost of hospitalization. The dependent variable was the difference of medical utilization one year before attended the program and three years (2004, 2005, and 2006) after that. All data were analyzed by SPSS12.0 for Windows.
Results:
1、Analysis of single doctor visiting
（1）There were increasing numbers of family doctors, clinics and people attended to this program in the Kaohsiung city and county, and Pingtung county. Though increasing year by year, the highest rate was only 29.62% in Kaohsiung county.
（2）The single doctor visiting rate of people attended the program was highest in 2003 and lowest in 2005.
2、Comparison of the medical utilization before and after the program between groups of having single family doctor and no family doctor,we found that
（1）There were significant different between the frequencies of visiting doctor (p=0.0001) between 2003 to 2006. The group having family doctor was decreasing (except 2006), but increasing in the other group. The results meant that the change of frequencies in visiting doctor were different between the two groups.
（2）The average times of admission had significant difference between the two groups (p=0.036) between 2003 to 2006.The increasing rate of admission was different between the two groups and the attended group was less increasing than the other one.
（3）There was difference between the two groups in the average cost of emergency department (p=0.023). The cost was increasing in both groups between 2003 to 2006. But the attended group was increasing more than the other.
Suggestion:
1、For public:
To receiving continuous and integrated medical care, visiting single family doctor should be instilled.
2、For the health providers:
The program had already functioned for five years. To ensure the public get the continuous and integrated medical care, more clinics should be encouraged to attend this program.
3、For government:
The findings revealed that the single family doctor visiting rate was not increasing in the people attending the program. The capitation payment system should be considered to full fill the idea of family doctor providing health care, or this program should be inspected more detail in its performance.

並列關鍵字

Family Physicians' Comprehensive Health Care Program ； medical utilization ； single doctor visiting rate

參考文獻

一、中文部份

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2. 朱慧凡(2000)。台灣榮民住院利用之分析研究。國立陽明大學公共衛生研究所碩士論文，未出版，台北。

3. 李孟智(2003)。家庭醫學與全民健保醫業管理。台北：合記。

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