全民健保新制部分負擔對民眾就醫層級選擇之影響

Abstract

民國94年7月15日健保局再次調漲部分負擔，為落實轉診制度以推動本土化的家庭醫師制度，若是不經由醫師轉診而逕行至地區醫院、區域醫院及醫學中心看病者，調漲30~150元不等的門診部分負擔費用。本研究即是針對此次部份負擔調漲，探討新制部份負擔對民眾就醫層級選擇之影響，並以吳肖琪、李玉春(2004)所發展出之分級醫療指標，作為評估此次部份負擔調漲影響之指標。 本研究以全民健保申報資料與民眾問卷調查資料進行分析。研究結果發現，在門診各層級院所疾病分級醫療指標之迴歸模型中，在控制相關病人與醫院特質後發現，醫學中心與區域醫院在新制部份負擔實施之後，A類疾病(在基層及地區醫院就醫為主之疾病)比例均有顯著減少，可見醫學中心、區域醫院由於部分負擔調漲較多，有達到減少大醫院輕病比例之效果。 在民眾就醫層級選擇之改變方面，新制部分負擔實施之後，雖有抑制民眾到醫院就醫的選擇，使小部分病人前往診所看病，但政策實施成效似乎不如預期；其中對於健康狀況較佳之年輕人、及家庭收入較低無法負荷部分負擔調漲之族群影響較大。而在民眾就醫層級偏好方面則發現，本次部份負擔調漲，在區域級以上醫院調漲幅度較大，使得民眾對大醫院偏好之比例下降。 政府欲控制健保醫療費用之成長，除應考量到實施成效之外，更應了解哪些族群對於部分負擔調漲較為敏感，以避免降低某些族群之醫療可近性。

On July 15, 2005, the Bureau of National Health Insurance raised the co-payment requirement for physician visit to promote the referral system and family doctor system. Patients seeking for medical service in district hospital, regional hospital and medical center were charged higher co-payment for 30~150 NTD. The purpose of this study was to examine the impact of NHI co-payment increase on patients’ choice among various levels of hospitals. The data source of this study included the National Health Insurance Research Database and a national survey. The results revealed that: after controlling for related patient and hospital characteristics, the percentage of A-type diseases (mainly treated in clinic and district hospital) had significant decreased in medical center and regional hospital after the new co-payment program. The higher co-payment amount had limited patients’ visits to medical center and regional hospital for miner conditions. In terms of choosing hospitals, the new co-payment program reduced the use of hospital out patient visits and forced some patients to community clinics for medical service; however the impact was not as obvious as expected. Young and low-income persons were more likely to be affected by the co-payment increase. The percentage of “big-hospital preference” were decreased by the new co-payment program among the general public. When controlling health care expenditure, the government should also pay attention to the impact of increased co-payment to the accessibility and utilization of health care services by those disadvantaged persons who are sensitive to the price changes.