中西醫療替代互補關係之研究---以肌肉骨骼系統損傷為例

Abstract

研究背景：每個人一生中總會經驗過扭傷腳踝或肩頸背痛而有醫療的需求。目前國內缺乏關於肌肉骨骼系統損傷醫療利用情形的研究。過去多篇文獻驗證中、西醫之關係，但結論不一致，且多數為問卷調查，非採用自然試驗方法。本研究利用健保局在民國88年8月引入中西醫復健療程造成的”價格變動”，創造出自然試驗的契機，以交叉價格彈性驗證中西醫復健療程之替代互補關係。目的：1.探討影響肌肉骨骼系統損傷患者選擇中、西醫療利用型態(只用西醫、只用中醫與中西合用)的因素。2.驗證中、西醫復健療程(傷科、針灸與物理治療)間是否存在替代互補關係。方法：肌肉骨骼系統損傷醫療利用型態研究，是利用健保資料庫2007年一百萬人抽樣歸人檔，以multinomial logistic regression分析不同醫療利用型態人口特質的差異。中、西醫復健療程之替代互補驗證利用健保資料庫1998~1999年一百萬抽樣歸人檔共5組20萬人，採panel data自然實驗設計研究，並以一階差分模型進行統計分析。結果：1.醫療利用型態只用西醫占61%，只用中醫21%，中西合用占18%。比起65歲以上只用西醫者，年紀越小越容易只用中醫；但25~64歲比較容易中西合用。比起男性只用西醫，女性比較容易只求診中醫與中西合用。有慢性病比起只用西醫者，不較不會只用中醫，但是比較會中西合用。重大傷病者比起只用西醫，比較不會只用中醫或中西合用。比起需部分負擔者只用西醫，不需部分負擔者較容易只求診中醫或中西合用。比起每萬人口中醫師數低者只用西醫，每萬人口中醫師數越高，越容易只用中醫或中西合用。2. 價格彈性物理治療為-0.16，傷科為-0.20，針灸療程數量對物理治療價格的交叉價格彈性在控制每萬人口復健專科醫師數與每萬人口中醫師數後為0.043，即物理治療價格上漲10%，針灸使用量增加0.4%；針灸療程數量對傷科價格的交叉價格彈性在控制每萬人口中醫師數後為0.092，即傷科價格上漲10%，針灸使用量增加0.92%。討論：影響民眾因肌肉骨骼系統損傷就醫，只用中醫與中西合用的因素包括年紀較輕、女性、慢性病、不需部分負擔與當地中醫師資源的多者。本研究估算的價格彈性在國內外計算醫療服務的價格彈性值(-0.17~-0.22)內。交叉價格彈性結果，推翻兩者為互補關係的研究假說。本研究在區分出肌肉骨骼損傷疾病後，得到的彈性係數(0.02)雖然較李氏(-0.005)稍大，但是依然遠小於0.1而可視為無彈性，傾向解釋兩者間為獨立商品。依然沒有發現中西醫療間有替代互補關係的證據。

Background: Everybody in the life must have the experience of ankle sprain or back pain and have the need to seek the medicine help. There had far been relatively little research into the area of the medical utilization pattern of musculoskeletal damage Several researches investigated the relationship between Chinese and Western medicine, but the conclusion were not in concert and the data collect through interview by questionnaire, not through natural experiment. The study used price difference of Chinese and Western medicine rehabilitation treatment program since in August, 1999 when the NHI copayment policy was to take effect to estimate the cross-price elasticity to examine the relationship of Chinese and Western medicine rehabilitation treatment programs. Purpose: 1.Investigate the factor that influence the medical utilization pattern (Western medicine only, Chinese medicine only and both) between Chinese and West medicine.2.Examine if the Chinese and West rehabilitation programs (traumatiology manipulative therapy, acupuncture and physical therapy) existed the substitute and complementary relationship. Method: 1. Used 2007 data one set of the longitudinal health insurance database (LHID2005) , and multinomial logistic regression was introduced. 2. Used 5 set data of 1998~1999 of the LHID2005 with natural experiment study design, and first-difference statistical method is introduced. Result: Among the musculoskeletal damage medical utilization, 61% used Western medicine only,21% used Chinese medicine only and 18% used both. The younger tended to use Chinese medicine only and the 25~64 y/o tended to use both then the people older then 65y/o who used Western medicine only., Female tended to use Chinese medicine only or both then Male who used Western medicine only. No copayments were needed people tended to use Chinese medicine only or use both then the people who needed. 2. The price elasticity of physical therapy was -0.16, traumatiology manipulative therapy is -0.20. The cross-price of acupuncture to physical therapy price was 0.043, controlling the rehabilitation and Chinese doctors per ten thousand people. The cross-price of acupuncture to traumatiology manipulative therapy was 0.092, controlling Chinese doctors per ten thousand people. Conclusion: The factor influence people used Chinese medicine or both was the younger, female, no copayment needed and with more sufficient Chinese medicine manpower resources. The price elasticity estimated in the study was in the range of the medical price elasticity estimated by other researches. The result of the cross-price elasticity demolished the hypothesis. There was still no substitute or complementary relationship found between the Chinese and West medicine even we separate the disease type.