臺灣新生兒健康照護的再評估：醫療價值之觀點

Abstract

近年來，眾所皆知美國正面臨著眾多醫療照護系統改革議題的爭論，包括醫療重大改革可能造成的危險性、醫療成本上升的可能性、公立政府保險的負面角色與相對於私人醫療保險所提供的醫療照護、單一給付制度的優缺點、自由市場與調節市場彼此的價值等。哈佛大學的麥可波特與伊莉莎白泰斯兩位教授認為錯誤的醫療照護競爭是導致美國醫療健康照護系統混亂的重要因素。他們建議正確醫療照護競爭的改革是必須的，唯有朝向基於價值系統考量的醫療服務，方能使得醫療更為有效率、更好的預後、更低的醫療消耗成本，才是解決與改革美國醫療系統的正確途徑。 不同於美國醫療保險制度，台灣的醫療保險主要來自於從1995年開始實施的全民健保制度。從一個家庭經濟的觀點來看，對於需要照顧高危險群新生兒的家庭，全民健保確實改善與減輕了他們的財務負擔。然而，縱使有助於這些家庭經濟負擔的減輕，目前的全民健保及相關醫療制度，仍然面臨眾多來自於醫院、雇主、被保險人的多所抱怨與批評，全民健康保險系統的公平性與效率仍是值得關心的重要議題。 比起西方先進國家，台灣新生兒與嬰兒的死亡率仍然相對較高，即使擁有全國性的醫療保險，台灣新生兒與嬰兒死亡率仍存在區域性的明顯差異，因此，台灣的新生兒照護仍有進一步改善的空間，而也引發本研究擬採取麥可波特的醫療價值系統觀點，重新評估台灣新生兒的健康照護體系的動機，從而提出有效的改善建議。 根據可應用的醫療資訊，我們的研究顯示台灣新生兒的臨床照顧基本上運作得相當平順。依目前新生兒照顧的供應鏈系統顯示，我們的執行效率在周產期與新生兒期的連續性醫療照護表現得相當不錯。研究顯示照顧重度新生兒的專業人力資源在市區還算充分，但是對於郊區，尤其是台灣東部地區仍相當不足。來自於台灣早產兒基金會所支持的五家早產兒醫療訓練中心的年度報告，對於極低出生體重新生兒的預後評估提供了重要的資訊，但是，年度報告的正確性與僅源自於五家醫療訓練中心的醫療資訊在全國的應用性仍須待改善。 本研究進一步採用全民健保的百萬歸人檔，進行醫療支出與醫療價值的分析評估。類似西方先進國家，我們的研究顯示早產或低出生體重兒會消耗相當的醫療成本。經由全國性的醫療給付，我們的研究顯示位於不同地區新生兒期與嬰兒期的所有醫療成本耗費是類似的。我們同時考量新生兒照護的花費與醫療價值來計算不同地區的負面價值，也就是採用新生兒期與嬰兒期的每千人死亡率除以每十萬元新台幣醫療費用來計算醫療的“負面價值”，我們發現這個負面價值在台灣東部是最明顯的，其醫療可近性亦相對貧乏。因此，若能採取以醫療價值考量給付，或許有助於平衡醫療資源的投入，全面改善全國的新生兒照顧品質。儘管由於不完整的出生登錄與保險給付資料，使得本研究推論的效度產生限制，但此一初步結果應仍具參考價值。 由於全國性的醫療保險制度，我們也許擁有了單一醫療給付制度的優點，但是這個制度很有可能比不上能夠創造高醫療價值的私人保險給付制度。像這種獨占性的全國醫療保險制度，在效率與公平性值得進一步的改善。不管是在其基礎架構、財政、還有所有的應用資源都需要接受持續性的監測與再評估。

It is well known that United States is currently undergoing an important debate on the issues of health care reform. There is much rhetoric about the dangers of reform, the likelihood of rising costs, the negative role of government versus the private health provider in administering health care, the merits and weaknesses of a single-payer system, the value of free markets versus regulated markets, etc. Michael Porter and Elizabeth Teisberg suggested that the wrong kinds of competition have made a mess of the American health care system. They urged that redefining competition in health care be mandatory and shifting the delivery of services to the value based system with more efficiency, better outcomes, and lower prices can solve many of the health care problems in United States. Unlike the U.S. health insurance system, Taiwan's health insurance system, the National Health Insurance, which had been launched since 1995, had actually improved the financial burdens of the insured family in general, for the high risk newborn infants in particular. However, despite the improved burdens, this national-wide covered health insurance system has received numerous complaints and critics from various stakeholders, including the health providers, the employers, and the insured patients. Especially, we are facing rapidly rising health care costs. The true equity and the efficiency of the current health care system are therefore an important issue for further research which motivates the present research. Within the context of newborn infants, compared with the western developed countries, the neonatal mortality rate and the infant mortality rates in Taiwan remain high. Despite the nationwide health insurance, there exist regional discrepancy of neonatal mortality and infant mortality which deserves further attention and reappraisal. The present research attempts to make an initial effort to tackle this issue by applying Porter and Teisberg's value-based system approach to our existing neonatal health care practices and reimbursement policy. Our research first revealed that the neonatal health care in Taiwan is generally running smooth. The current supply chain of the neonatal care had demonstrated that we had a good clinical performance including the continued perinatal and neonatal health care. We also showed that the manpower of specialists for caring the high risk newborn infants may be sufficient in the urban area. However, there remains regional discrepancy of the manpower in rural area especially in eastern Taiwan. To evaluate the value of newborn infant care, we used the Longitudinal Health Insurance Database 2005 (LHID2005) retrieved from the National Health Insurance Database for further analyses. Like the western developed countries, the preterm birth and low birth weight infants in Taiwan had imposed an immense burden on the health care costs. We found that there is no significant difference in neonates’ health care expenditures across five different geographic areas during the neonatal and infantile period. We then performed a novel approach by measuring a negative value calculated as the mortality rate (‰) in per thousand divided by the total health care cost in per hundred thousand NT dollars spent. We found that the negative value was most prominent in the eastern area of Taiwan where the medical accessibility is comparatively difficult than other areas. Although the current data set may contain insufficient information which may limit research inference, this result would indicate the potential of applying value-based approach to directing sufficient medical resources to rural areas so that overall neonatal health care quality can be improved. Implications of research results and suggestions to the existing health care policy are also discussed.