全民健保部分給付制度下塗藥血管支架價格影響因素分析

Abstract

中央健康保險局自2006年12月起實施塗藥血管支架部分給付制度，即同意以傳統血管支架給付點數支付塗藥血管支架，差額部分由民眾負擔，同時要求醫療院所應公開塗藥血管支架收費標準相關資訊，此舉正式開啓醫療院所在健保支付制度體制內，得以自由定價向病人收取醫療給付差額費用。從各醫院公布塗藥血管支架的病人自付價格發現，即便相同品牌的塗藥血管支架在不同院所間價格卻不相同，究竟是什麼因素造成差異，迄今仍未有相關文獻探討。因此，本研究之目的在探討全民健康保險部分給付制度下，醫療院所間塗藥血管支架價格差異之影響因素。 本研究利用次級資料進行研究，以中央健康保險局網站公布之2006年12月至2008年12月各醫院各品牌第1筆進入醫療市場的塗藥血管支架自付價格，串聯全民健保住診申報資料、病床及醫事機構等相關資料，以廣義估計方程式(Generalized Estimating Equation ,GEE)進行分析。本研究將從市場競爭情形、產品價值、醫院規模、醫院採用塗藥血管支架之時機四個面向進行分析。市場競爭情形係以賀芬達指數衡量市場集中情形，以及同一醫院塗藥血管支架的品牌數來評估。產品價值分為產品品牌及產品創新程度二種分類方式加以分析，研究期間可供評估的產品品牌包括禧福第1代、禧福第2代、塔克斯第1代、塔克斯第2代、奧爾第1代、美敦力第1代及美敦力第2代等七種品牌；而創新程度係依上開品牌之材質，分為材質較薄且較具延展性的鈷鎳合金材質之高度創新組及不銹鋼材質之低度創新組二組進行分析。醫院採用塗藥血管支架之時機係指該品牌塗藥血管支架，在醫療市場中，醫院採用的先後順序。優先採用者為「先採用院所」，後採用者為「跟隨者」。 本研究期間，共有73家醫院，291筆資料採用塗藥血管支架。研究結果發現，以賀芬達指數衡量的市場競爭程度，所有醫療區皆屬低度競爭地區。在控制其他變項後，賀芬達指數高低、院內品牌數、產品創新程度與價格的關係並不顯著。但以產品品牌來看，各品牌皆達統計上顯著差異，禧福第2代相較於參考組禧福第1代，平均價格最高（β=2,575，p=0.0306）；其他品牌不論第1代或第2代皆較禧福第1代來得低，而各品牌的第2代皆較該品牌的第1代來得高，各品牌平均價格依序為塔克斯第2代（β=-3,526，p=0.0035）、美敦力第2代（β=-4,199，p=0.0092）、美敦力第1代（β=-6,265，p<0.0001）、奧爾第1代產品（β=-7,123，p=0.0002），塔克斯第1代最低（β=-13,136，p<0.0001）。醫院規模方面，病床數大於500床的醫院，其平均價格較低（β分別為-3231與-3,601，p為0.0203及0.0110）。另該醫院該品牌塗藥血管支架，為醫療市場上先採用的院所，平均自付價格較高（β分別為7,639與7,800，p<0.0001），且達統計上顯著差異。 本研究主要發現，塗藥血管支架的產品品牌、醫院規模、醫院採用塗藥血管支架時機會影響塗藥血管支架之自付價格。當醫院達一定規模、後採用院所（跟隨者）塗藥血管支架的平均自付價格較低。市場競爭情形則無顯著影響。 塗藥血管支架市場大都屬低度競爭，市場集中度較高，主管單位應監控是否有價格壟斷情形。對於高科技醫療器材，建議可成立具公信力單位，進行成本效益分析。另有關塗藥血管支架部分給付制度的實施，是否有供給誘發需求的情形，亦值得相關單位注意。

Background：“Balanced billing”, an exceptional regulation allowing contracted healthcare providers to extra charge beneficiaries for drug-eluting stents for coronary heart disease, was adopted under the reimbursement payment mechanism of National Health Insurance (NHI) of Taiwan in December 2006. The different pricing of drug-eluting stents among providers became an issue of concern. However, empirical research on such phenomenon is not yet reported. Objective：Therefore, the aim of this thesis is to explore the factors contributing to the price difference of drug-eluting stents among contracted hospitals of NHI program. Methods：Secondary data was compiled by retrieving hospitals’ initial pricing information on drug-eluting stents of all brand names on the market during the period between 2006 and 2008. These data was further linked with records in claim files and provider files of NHI database. Four primary influencing factors were indentified: market competition, product value, scale of hospital, and pioneer timing of introducing drug-eluting stents by individual hospital. In total, there are 291 drug-eluting stents for pricing among 73 hospitals. Descriptive statistic analysis and Generalized Estimating Equation (GEE) were applied to examine the relationship between pricing and related factors. Results：Herfindahl-Hirschman Index (HHI) shows that market competition of drug-eluting stents was mild in medical catchment areas. After controlling for other factors, we found statistically significant relationship between pricing and brand related variables, scale of hospital and pioneer timing of introducing stent product. However, HHI, number of brands carried by hospital, or the innovation in drug-eluting stents were not significant factors. Prices of Cypher’s second- generation sirolimus-eluting stent (Cypher Ⅱ) was higher than those of the first-generation (Cypher I). The average price of CypherⅡwas the highest among all (B=2575, p=0.0306); and the prices of all others were lower than those of Cypher I. All the prices of second-generation products were higher than those of the first-generation. The average price was lower in hospitals with scale greater than 500 beds (β:-3231,-3,601; p:0.0203, 0.0110). In addition, the out-of-pocket charge was higher in hospitals which are first to introduce drug-eluting stents to their patients (β:7639,7800，p<0.0001). Conclusion：The extra amount of fee charged by hospitals to patients for drug-eluting stents are influenced by the brand of the stents, scale of hospital and pioneer timing of introducing stent product by hospital. The market concentration of drug-eluting stents was high and competition, mild. This study found no evidence of the effect of market competition on the different pricing of drug-eluting stents. It is recommended that the authority should monitor the possibility of monopoly pricing and whether or not balance billing facilitates hospital-induced demand. Finally, we suggest that government should establish a neutral agency to evaluate cost-effectiveness of hi-tech medical products.