台灣牙科醫療服務資源耗用相對值(RBRVS)模式之建立及其適合性評估

Abstract

目標：嘗試參考美國RBRVS方法，修正後建構台灣牙科的RBRVS模式，並且探討所建構模式的適合性。 方法：先以隨機抽樣方法自全國牙醫師中抽出360位，進行德菲法問卷調查具有代表性醫療服務之牙醫師工作量、臨床操作時間值，並由4家樣本診所取得藥衛材成本，再透過專家小組主觀判斷外推至未調查之醫療服務，共獲得三種相對值。接續調查牙科診所成本結構、牙醫師全聯會提供牙科各項醫療服務之服務量、並取得健保局之支付標準，將三個不同基準的相對值轉化為相同基準，發展評估牙科醫療服務資源耗用相對值模式。再由(1)專家小組評價 (2)以某醫學中心牙科ABC成本作為效標之相關性分析 (3)探討本研究79項醫療服務對牙科全科的涵蓋性 (4)探討和健保支付標準之相關性與解釋力 (5)探討本研究結果如何轉化為支付標準，共五個構面來檢討本研究模式之適合性。 結果：根據本研究所獲得牙科79項醫療服務之牙醫師工作量相對值、牙醫師臨床操作時間值、藥衛材成本相對值，以及牙科診所成本結構，發展出牙科醫療服務的資源耗用相對值。檢討該模式的適合性方面，專家小組對資源耗用相對值之評價相關係數高、與ABC成本相關性高、79項對牙科全科的涵蓋性高、與支付標準之相關性與解釋力雖高但仍有差距、以及可轉化為資源耗用支付標準，顯示本研究所建立台灣牙科的RBRVS模式具適合性。 結論：(1)利用專家小組、德菲法、及外推三種技巧，本研究獲得牙科79項醫療服務之牙醫師工作量、時間值、藥衛材成本相對值。牙科藥衛材成本研究適宜以專家小組訂出內容後，以少數樣本進行估算。牙科診所之成本結構大致為醫師費佔50%、藥衛材成本佔15%、其它執業成本佔35%。本研究模式適宜探討牙科醫療服務資源耗用相對值。 (2)健保版支付標準大致可代表牙科執業資源耗用的相對性。(3)本研究建立之相對值可轉化為資源耗用支付標準，提供健保修訂支付標準參考。

Objectives: The objectives of this dissertation is trying to construct a dentistry RBRVS model in Taiwan based on the American Resource-Based Relative Value Scale (RBRVS) method and to examine the appropriateness of our model. Methods: A group of 360 dentists were randomly selected from the national roster of dentists and were asked to participate in the Delphi Technique to estimate dentists’ workload relative value units (RVUs) and procedural time for representing services. We also examined the drugs and materials costs for these services from 4 sample dentistry clinics. We then asked the Technical Consulting Group (TCG) to estimate the dentists’ workload RVUs, procedural time, and drugs and materials costs RVUs for un-surveyed services. By combining the dentistry clinic cost structure investigated with the National Health Insurance (NHI) dental payment schedule and services volume, we adjusted these three kinds of RVUs into a common scale and set up the D-RBRVS for 79 dental services. The appropriateness of our model was evaluated by the following 5 methods: 1) evaluating by the TCG experts, 2) exploring the association between D-RBRVS and the dental ABC cost in a medical center, 3) examining the coverage of the 79 services of our studies to the whole dental services, 4) analyzing the correlation and explanation power of D-RBRVS to the NHI dentistry payment schedule, 5) studying the adjustment of the payment standards in our D-RBRVS base. Results: Three RVUs for dentist's workload, procedural time, and drugs and materials costs for 79 services and the cost structure of the dentistry clinic were constructed. By using the model of this study, the RBRVS for 79 dental services were established according to these results. In terms of the appropriateness of this model, the views of the TCG and the ABC cost in a medical center were significantly associated with our D-RBRVS. The high coverage, relativity, and explanation power of 79 services to the NHI payment schedule also show the appropriateness of the model. Finally, the converting of the D-RBRVS into a payment schedule supports that the Taiwan dentistry RBRVS model is appropriate. Conclusions: 1) By using of TCG, Delphi method, and extrapolation techniques to study the RBRVS of dental service, we have set up a local dentist’s workload RVUs, the procedural time, and the drugs and materials costs RVUs for 79 dental services. It is better to establish the list of drugs and materials used for each service by a TCG and to investigate the specific costs required through the cooperation of dentistry clinics. It is nearly 50% for dentist’s fee, 15% for drug and material cost, and 35% for other practice cost of the dentistry clinic cost structure in Taiwan. The research model is appropriate to study the resource consumes RVUs of the dentistry services. 2) The current NHI dental fee schedule fairly well matched with the D-RBRVS of our study. 3) The D-RBRVS can be converted into a payment scheme to provide an amendment reference of NHI payment standards.