實施Tw -DRGs支付制度前後對醫療服務利用的影響 —以中耳炎手術為例

Abstract

背景：尋求抑制醫療費用上漲的方法，已成為世界各國健保制度改革的共同趨勢，臺灣健保支付制度經歷多次改革，中央健康保險署自2010年1月1日起實施全民健康保險住院診斷關聯群（Taiwanese Diagnosis Related Groups，簡稱Tw-DRGs）支付制度，目前臺灣在診斷關聯群制度之實施對於中耳炎手術之相關研究則闕如，且第一年實施之Tw-DRGs項目是由原論病例計酬項目重新編碼而成，又論病例計酬制度已實施多年，有一定的成效及控管方式，醫院已有相當之因應經驗，因此為了更深入了解Tw-DRGs支付制度對醫療利用所造成的影響，本研究選擇以原非論病例計酬項目的中耳炎手術患者為研究主體。 目的：本研究目的探討Tw-DRGs支付制度實施前後對於中耳炎手術之醫療資源利用、醫療費用與醫療品質之影響 方法：本研究使用2009年與2012年全民健保資料庫，以接受中耳炎手術病人為研究對象，自變項為Tw-DRGs政策實施前後，控制變項分為病人特質及醫院特質，依變項分別探討醫療利用、醫療費用與醫療品質。本研究使用T檢定、卡方檢定、變異數分析、廣義線性迴歸(Generalized linear model)以及多元羅吉斯迴歸(Multiple logistic regression analysis)進行分析。 結果： Tw-DRGs制度實施後會減少醫療資源耗用以及醫療費用，總住院醫療費用下降約30%，各項醫療費用以手術費減少了4901.8元為最多，藥費減少了1980.8元次之，住院天數由3.83日下降至3.02日，比制度實施前下降約26%，可見住院流程管控確實有所成效，而醫療費用的降低也代表政策介入會影響醫療院所之行為，促使醫療院所去整合醫療資源的利用，本研究結果發現Tw-DRGs制度實施後並沒有增加中耳炎病患門診資源利用，且醫療品質亦沒有下降的情況。

Backgroud：To reduce rising health care costs, Taiwan has implemented a DRG-based prospective payment system in the beginning of 2010. Few studies examined the impact of DRG-based payment systems on otitis media surgery. Objectives: The objective of this study was to analyze the impact of DRG-based payment systems on medical care utilization, medical care expenditure and medical care quality while payment system changed from the previous to TW-DRGs—using otitis media surgery as an example. Methods: This study selected those who received otitis media surgery in 2009 or 2012 from “2010 sampling cohort database of 1,000,000 insureds” of National Health Insurance Research Database (NHIRD). Outcome variables were medical care utilization, medical care expenditure, and medical care quality.With SAS 9.4 software, this study tested the hypotheses by t test, chi-square test, analysis of variance, generalized linear model and multiple logistic regression analysis. Results: Both medical care utilization and medical care expenditure reduced due to the implementation of Tw-DRGs. The average health expenditure decreased 30%, the average length of stay reduced from 3.83 to 3.02. As a result, hospitals will adjust the behavior according to the standard of payments. Besides, there were no differences in outpatient service.Medical care quality did not have significant difference after implementing TW-DRGs system.