資訊不對稱與就醫選擇──以醫事人員暨親屬就三種手術之選擇為例

Abstract

緒論：由於全民健保的開辦與台灣地狹人稠且交通便利，金錢成本與地理可近性不再是民眾獲取高品質醫療服務的重大障礙，因而，資訊不對稱所造成的就醫選擇障礙便成為當前極重要的政策課題。 文獻回顧：國內外文獻指出，資訊不對稱使得民眾期待獲得醫療品質指標，文獻並證實提供者服務量與照護結果具有正相關，此外，文獻亦實證知情消費者有著差異性醫療利用模式。然而，過去資訊不對稱的研究較少著墨於知情消費者是否運用其資訊優勢選擇具有較佳醫療品質指標的服務提供者。 研究材料與方法：本研究為以全民健保資料庫1998年至2006年九年間的PTCA、CABG與TKR三個手術之個案所進行的次級資料分析與橫斷性研究，並採用住院醫療費用醫令清單明細檔中之醫令代碼定義手術個案。 研究結果：1. 在PTCA手術，知情消費者選擇高服務量「醫院」的勝算比為1.079 (p=0.364)，在CABG手術此勝算比為1.373(p=0.0442)，而在TKR手術此勝算比為1.458(p=0.0194)；2. 在PTCA手術，知情消費者選擇選擇高服務量「醫師」的勝算比為1.023(p=0.7704)，在CABG手術此勝算比為1.320(p=0.0719)，而在TKR手術此勝算比為1.222(p=0.1780)。 討論：本研究發現，知情消費者確實會選擇具有較高服務量的醫院而非高服務量醫師，此或因此三手術均屬較常規之手術因而醫院團隊整體經驗對於照護結果的影響較大。三個手術的比較研究也顯示，手術緊急度愈高的手術，病患就醫選擇受到極大的時間上與地理上限制，知情消費者選擇高服務量醫院的勝算比愈小，反之，手術醫急度愈低的手術則知情消費者選擇高服務量醫院的勝算比愈大。 結論與政策建議：知情消費者確會選擇高服務量手術醫院，而提供者服務量與醫療品質的正相關又已經實證研究肯認，可見，知情消費者的差異性就醫選擇值得加以研究並將之納入制訂醫療品質評鑑指標項目時的重要參考。

Introduction: Because of the establishment of National Health Insurance and the high population density and convenient communications, out-of-pocket payment and geographical accessibility are no longer major obstacles for the public to gain high-quality medical service in Taiwan. Therefore, the obstacle resulting from information asymmetry becomes a very important policy issue today. Literature Review: International and local references both indicate: 1. Because of information asymmetry, the public is eager to obtain convenience medical quality indicators; 2. The volume-outcome effect has been well-established; 3. Informed consumers do have different patterns of their consumption of medical service. However, studies on information asymmetry rarely focus on the provider selection behavior of informed consumers. Methods and Subjects: This study is a secondary and cross-sectional study based on cases of PTCA, CABG, and TKR surgeries of NHI database between 1998 and 2006. This study uses the “o_code” of the “DO” dataset to define surgical cases. Result: 1. In PTCA, the odds ratio (OR) for informed consumers to choose high-volume hospitals is 1.079 (p=0.364). In CABG, the OR is 1.373 (p=0.0442). In TKR, the OR is 1.458 (p=0.0194). 2. In PTCA, the OR for informed consumers to choose high-volume surgeons is 1.023 (p=0.7704). In CABG the OR is 1.320 (p=0.0719). In TKR, the OR is 1.222 (p=0.1780). Discussion: Comparative study between 3 surgeries reveals that informed consumers do have higher possibility to choose high-volume hospitals but not high-volume surgeons, probably because the three surgeries are relatively routine surgeries and thus the experience of the hospital staffs as a whole plays a more important role in the determination of surgical outcomes. This study also reveals that in surgeries with higher urgency, informed consumers are less likely to choose high-volume hospitals due to temporal and geographical limitations. On the contrary, in surgeries with lower urgency, informed consumers have higher OR to choose high-volume hospitals. Conclusion and Policy Implication: Informed consumers do choose high-volume hospitals given volume-outcome effect well-established. Therefore, the different provider-selection pattern of informed consumers is worth researching and might be important in designing medical quality indicators.