台灣全民健保實施論病例計酬支付制度之有效性分析

Abstract

中文摘要 本研究分析全民健保資料庫，針對成人鼻中膈鼻道成形術（Septomeatoplastry，SMP）及成人喉直達鏡手術(Laryngo-microsurgery，LMS) 探討「論病例計酬制度」對健保給付制度之影響。其中，鼻中膈鼻道成形術之研究對象為1998年至2000年接受接受鼻中膈鼻道成形術手術之病患，共6,046例。我國健保局自1999年3月開始實施鼻中膈鼻道成形術論病例計酬制，本研究分析「論量計酬」(2,101人)及「論病例計酬」(3,945人)兩種不同支付制度下病患特質、醫療費用、醫療資源耗用以及醫療品質四大層面的差異。研究結果顯示「論病例計酬」實施後病人有從區域醫院向醫學中心流動的傾向，且在延長住院與在入院上之比例有顯著降低(p<0.05)，故有醫師或醫療院對病患逆選擇的現象；醫療資源耗用方面，論病例計酬組其平均住院天數比論量計酬組顯著地減少0.6天(p<0.001)；醫療費用方面，因住院日數降低不到1日，平均申請費用上住院費用明顯降低，而門診費用明顯上升。「論病例計酬」制度實施後平均住院日數減少，住院效率有所提升，而影響醫療品質最重要因素為「醫院服務量多寡」、「醫師服務量多寡」、「有其他系統合併症」。 在成人喉直達鏡手術之研究對象為1998-2000年間，因良性喉部病變而接受成人喉直達鏡手術(Laryngo-microsurgery)治療之病患，共2,946例。研究進行「論量計酬」( 1,320人)及「論病例計酬」 ( 1,626人)兩種不同支付制度下喉直達鏡手術病患特質、醫療資源耗用、醫療費用、及醫療品質的差異。研究結果顯示「論病例計酬」實施後病人有從地區醫院向區域醫院流動的傾向，在醫療資源耗用方面，「論病例計酬組」平均住院天數比「論量計酬組」顯著減少(p<0.05)；在醫療費用方面，平均申請費用上，住院費用明顯降低，而門診費用明顯上升；醫療品質相關指標值在兩組間並無顯著差異(p>0.05)。本文發現在實施「論病例計酬」制後，有其他系統合併症病人之比例亦有顯著降低(p<0.05)，故有醫師或醫療院對病患逆選擇的現象；「論病例計酬」制度實施後平均住院日數顯著減少，但醫院平均總申報醫療費用沒有顯著降低；而影響醫療品質最重要因素為系統性合併症、年齡、醫療提供者的服務量，而不是支付制度。 總括兩種耳鼻喉科手術所得之研究結論為：論病計酬制度的實施對手術結果與品質影響並不顯著；對醫療資源耗用量的影響為住院平均天數顯著降低；對總醫療費用之影響為：在實施論病計酬制後，住院費用受到抑制，但醫師或醫療院所卻將費用轉嫁至門診費用；在門診費用時間數列趨勢分析上，發現在實施論病計酬制初期，醫師與醫療院所因不熟悉健保局之規定，故在兩、三月內所申報之門診費用有顯著受到抑制，但一旦資訊擴散效果產生，其費用之增加則回到原有趨勢上；另在論病計酬制實施後，控制變因中有其他系統合併症病人之比例有顯著降低而產生醫師對病患逆選擇之現象；在病患於不同層級醫療院所的流動上，鼻中膈鼻道成形術之病人發生從區域醫院向醫學中心流動的傾向，成人喉直達鏡手術則發生病人從地區醫院向區域醫院流動的傾向，此說明在論病計酬制實施後較基層之醫療院所會將有其他系統合併症病人轉介至較高層之醫療院所，由於鼻中膈鼻道成形術住院給付較成人喉直達鏡手術高，醫學中心較易接受給付較高之病症病患，故鼻中膈鼻道成形術之病人朝向醫學中心流動的傾向更為顯著，此亦使改變支付是否可有效降低醫療費用支出之效果頗令人質疑。 在本研究發現無論是鼻中膈鼻道成形術或喉直達鏡手術都發現門診醫療之申請費用有顯著上升，此顯示醫師或醫療院所會將住院的費用轉嫁至門診等方式向中央健保局申報以增加營業收益之假設獲得證明，此說明政府在實施政策時，如未清楚考慮其政策之完整性及可行性時，往往會造成政策有效性之質疑。

關鍵字：全民健康保險、論病例計酬制、論量計酬制、鼻中膈鼻道成形術、成人喉直達鏡手術、資訊不對稱、逆選擇

ABSTRACT Analyzing the 6,259,342 items of insurance claim data from the Taiwan’s National Health Insurance Database in the period from April 1, 1998 to July 31, 2000, this research compared the impacts of the Case Payment Scheme (CPS) and the Fee For Service (FFS) scheme on total insurance payments and quality of healthcare services. The operations of the adult septomeatoplasty (SMP) and the adult laryngo-microsurgery (LMS) were used as targets for in-depth study. A total of 6,046 patients who underwent SMP during the period from April 1998 to March 2000 were identified (2,101 cases under FFS; 3,945 cases under CPS). There was an increase of SMP operations in medical centers and 0.6 day shorten in the average length of hospitalization days after the implementation of CPS. However, the healthcare expenses of outpatients increased significantly which out weighted the savings from inpatient cares. A total of 2,946 patients who underwent LMS during the period from July 1998 to July 2000 were identified (1,320 cases under FFS; 1,626 cases under CPS). The research findings were consistent with the SMP operation after the transition from FFS to CPS. The analyses results indicate less systemic comorbidities were identified in the case payment group. The average length of stay was significantly shortened (p<0.05). The total claimed of hospitalization decreased significantly and of outpatient increased significantly. There is no clear evidence to show there was any change in the quality of care (p>0.05). The implementation of case payment system proved to be effective to enhance efficiency of the practice of adult LMS by reducing length of stay. There was significant adverse patient selection manipulation by the providers. We find age, systemic comorbidities, provider service volume, rather than payment system, are significant factor of healthcare quality. The research conclusions are: (1) There is significant effect for operations of the adult septomeatoplasty and insignificant for laryngo-microsurgery in medical quality after the transition from FFS to CPS; (2) The average length of stay was significantly shortened; (3) The total claimed of hospitalization decreased significantly and of outpatient increased significantly in these two disease cases; (4) The total claimed of outpatient decreased jump between one to three months after the transition from FFS to CPS and then return to the original trend; (5) We find the phenomenon of adverse selection and the analyses results indicate less systemic comorbidities were identified in the case payment group. This research find the doctors and hospitals would transfer the expense from hospitalization to outpatient after the transition from FFS to CPS. This result will not decrease the medical expense for Taiwan’s national health insurance.

Key words: Health Insurance, Case Payment, Fee For Service, Septomeatoplasty, Laryngo-microsurgery, Information Asymmetry, Adverse selection