台灣診斷關聯群實施、市場競爭程度與醫療資源耗用及照護品質之相關性探討-以心導管、經皮心臟血管手術、冠狀動脈繞道手術為例

Abstract

根據經濟合作發展組織統計資料指出全球醫療保健支出不斷上漲，即使是在台灣也不例外。台灣在尚未有全民健康保險前，社會保險就已面臨費用上漲問題，全民健康保險自1995年3月1日實施後亦然，為解決費用上漲問題，中央健康保險署不斷研擬相關政策，包含保險費收取費率、支付制度改革等。台灣於2010年1月1日起台灣診斷關聯群（Tw-DRGs）第一階段正式實施，其實施之目的為降低醫療資源耗用與增進照護品質，分攤各醫療院所財務風險。過去許多研究曾針對台灣診斷關聯群（Tw-DRGs）之效益進行評估，但其結果不一致，且並無觀察市場結構與結果之關係。因此，本研究以2007-2011年間曾執行心導管、經皮心臟血管手術、冠狀動脈手術區域醫院等級以上醫院為研究對象，將探討台灣診斷關聯群（Tw-DRGs）實施對醫療資源耗用與照護品質效果，另外還針對市場競爭程度與資源耗用及照護品質關係進行探討。 根據上述研究背景與動機，本研究之目的有二：（一）探討台灣診斷關聯群（Tw-DRGs）實施對醫療資源耗用與照護品質之影響；（二）探討台灣診斷關聯群（Tw-DRGs）實施下市場競爭程度對醫療資源耗用、照護品質之關聯性。 本研究資料來源為國家衛生研究院所發行之全民健康保險研究資料庫-2005年承保抽樣歸人檔，研究期間為2006-2012年，並選取2007-2011年間曾執行心導管、經皮心臟血管手術、冠狀動脈手術區域醫院等級以上醫院，計算其各年醫療資源耗用（平均住院天數與平均醫療費用）與照護品質（出院後30日內再住院率與出院後30日內死亡率），並以SAS 9.3進行資料處理與統計分析，統計分析方法包含描述性統計、多變量變異數分析與多階層迴歸分析-成長模型。 利用多階層迴歸分析-成長模型進行研究假說驗證，結果顯示在控制醫院特質後，台灣診斷關聯群（Tw-DRGs）實施後平均住院天數逐年減少6.3%，平均醫療費用是實施逐年減少6%，風險校正前出院後30日內再住院率逐年增加0.8605%，風險校正後出院後30日內再住院率逐年增加13.43%，至於市場競爭程度與醫療資源耗用及照護品質無顯著相關，綜合上述結果，台灣診斷關聯群實施對有助於減少醫療資源耗用，照護品質無太大差異，市場競爭程度與醫療資源耗用與照護品質無太大關係。本研究認為台灣診斷關聯群（Tw-DRGs）品質監控措施可能失靈，衛生主管機關應加強品質監控與改善。

According to Organization for Economic Co-operation and Development (OECD) report, healthcare expenditure increasing globally, Taiwan is included. Before universal health insurance implementation, the insurer was eager to solve the issues of the increasing healthcare expenses. However, the issue had not be solved as National Health Insurance implement on March 1, 1995. To terminate the rate increasing, National Insurance Administration adapted several strategies, including elevating the premium rate and payment system reform. In order to decrease medical resource utilization, to improve quality, and decreasing the financial risk, Tw-DRGs implemented in Taiwan on January 1, 2010. Even though several studies has evaluated the efficacy of Tw-DRGs, the studies conclusion is inconsistent, simultaneously, those did not assess the association between market structure and outcomes. Thus, this study aimed to assess the impact of Tw-DRGs implementation on medical resource utilization and quality, the association of market competition on medical resource utilization and quality under Tw-DRGs for cardiac cath, Percutaneous Transluminal Coronary Angioplasty (PTCA), Coronary Artery Bypass Graft (CABG) surgery conducting in medical centers and residential hospitals from2007 to 2011. This study aimed to assess the impact of Tw-DRGs implementation on medical resource utilization and quality, the association of market competition on medical resource utilization and quality under Tw-DRGs. This study used National Health Insurance Research Database (NHIRD) of Taiwan from 2006 to 2012. The data included cardiac cath, Percutaneous Transluminal Coronary Angioplasty (PTCA), Coronary Artery Bypass Graft (CABG) surgery conducting in medical centers and residential hospitals from2007 to 2011. The indicators of medical resource utilization included length of stay and medical cost, and the indicators quality 30- day readmission rate, 30-day post-discharge mortality rate. Using SAS 9.3 software, statistical analysis included description, multi-variant analysis, and Hierarchical linear growth model. Under Hierarchical linear growth model, as considering hospital characteristics Tw-DRGs caused length of stay decreasing 6.3% per year, average cost reducing 6% per year, 30- day readmission rate before calibration increasing 0.8605% per year, and 30- day readmission rate after calibration growing 13.43% per year. As evaluating the impact of market competition on hospital medical resource utilization and quality under Tw-DRGs, the market competitions had not correlation with medical resource utilization and quality. As the results, Tw-DRGs had positive impact on hospital medical resource utilization, elsewise, Tw-DRGs had a little negative effect on quality. In addition, there was no significant association to medical resource utilization and quality. This study indicated quality assessment system of Tw-DRGs might failure. Therefore, the health policy authorities might improve quality through adapting appropriate intervention approach.