全民健保制度下醫院處方集對結腸直腸癌用藥可近性之影響探討

Abstract

結腸直腸癌為我國常見癌症之一，近年來新型抗癌藥物陸續問市，價格普遍而言較其他傳統化學治療藥物來得高；然而醫院處方集反映了病患就醫時能夠獲得的藥品治療，對於不同醫院考量財務預算及經營管理之下，提供之藥品不盡相同，可能在病患用藥可近性上產生差異。本研究蒐集醫院治療結腸直腸癌之化療相關藥品內容，以了解結腸直腸癌化療藥品實際供應概況與醫院特質的相關性。並藉由轉移性結腸直腸癌患者化療紀錄以描述實際標靶藥物費用與利用之情形。

本研究分為二個研究主題，主題一為結腸直腸癌化療藥品差異調查，採用自行設計之自填結構式問卷於民國98年6月17日至8月15日間對中央健康保險局特約之區域級以上且收治結腸直腸癌病患之醫院，採郵寄問卷方式進行普查，回收率為90.5％，有效樣本為85份，應用卡方檢定與羅吉斯迴歸，探討結腸直腸癌化療藥品實際供應概況及醫院納為處方集常備品項之考量與醫院特質的相關性；主題二為結腸直腸癌化療相關藥物費用分析，為一回溯性研究，採病歷回顧方式進行，針對北部某醫學中心於民國95年1月1日至12月31日期間內新確診為轉移性結腸直腸癌且接受標靶治療的病患，至民國97年12月31日為止之化療相關藥物的耗用情況與藥品費用加以分析。

本研究結果顯示，相較於傳統化療藥物而言，醫院對於具創新性且價格較高之標靶藥物如bevacizumab與cetuximab，沒有供應或另設有院內使用規範的比例較高，就標靶藥物供應情形而言，在醫院的層級別、癌症治療規模﹙即平均每日化療處方箋張數及腫瘤專科設立情形﹚達到統計上的顯著差異。醫院對於健保給付的cetuxiamb之供應不及於民眾須自費使用的bevacizumab，尤其以東部地區格外明顯。醫院認為藥品的療效與安全性等臨床面向考量是將癌症治療藥物列為常備品項最重要的考量依據，但是醫學中心相較於區域醫院而言，較重視藥品造成醫院財務上的影響且達到統計上的顯著差異。然而當健保新增標靶藥物給付品項如cetuximab以後，健保涵蓋了傳統化療費用的比例達到百分之百，對於標靶藥物費用則有六成三為健保支付，雖然減緩了就醫障礙，但是仍有不少病患被拒於健保之外必須承受巨額的藥品負擔。

因此民眾對於標靶藥物的低可獲得性與低可負擔性之下，產生民眾用藥可近性之障礙。此現象值得衛生政策決策者思考相關政策時應加以特別重視，以避免民眾在追求健康權力上的不平等，維護健保秉持的社會正義，落實健保基本目標。

Background: Colorectal cancer is one of the cancers commonly seen in Taiwan. In recent years, innovative drug against cancer have been successively launched to market with higher prices compared to those traditional chemical therapies in general, for example, monoclonal antibodies which are excluded from National Health Insurance(NHI) or under strict utilization management approaches. Therefore, hospital formulary indicates available drug therapy for patients, and different hospitals may offer different drugs to the patients with similar diseases, based on hospitals’ financial considerations on budget and management. The aim of this study is to examine relativity between practical formulary coverage of chemotherapy against colorectal cancer and characteristics of different hospitals associated with Taiwan’s National Health Insurance, by means of chemotherapy records from the metastatic colorectal cancer patients who receives target therapy, to explain the real expenditure and usage of cancer drugs.

Study design: (1) Nationally representative, cross-sectional analysis of the 2009 Survey for regional hospitals & medical centers in Taiwan. (2) Retrospective chart review of metastatic colorectal cancer cases in a particular medical center during the period from 2006 through 2008.

Methods: The data have been collected by the questionnaires survey. There are 95 questionnaires delivered and 86 valid ones. Descriptive statistics, Chi-square test and Logistic Regression were applied to examine the relativity between formulary coverage of colorectal cancer drugs and hospital characteristics (ownership, levels, locations and chemotherapy group scales). In addition, chart review has been utilized to analyze the drug expenditure among the colorectal cancer patients treated with target therapy in a medical center in northern Taiwan.

Results: A higher proportion of hospitals do not supply, or they utilize under strict utilization management approaches, with innovative and high-priced target drugs such as bevacizumab and cetuximab, compared with traditional chemotherapy. Hospital levels and chemotherapy group scales (i.e. daily average number of chemotherapy prescription and existence of oncology institution) also make statistically significant differences in molecular target drug supply. Hospital supply cetuximab, which was covered by NHI, less than bevacizumab self-paid, particularly in the eastern Taiwan. This study also shows efficacy and safety of drugs are the most important considerations when hospitals select cancer drugs and include into the formulary. It shows statistically significant difference that medical centers make much of financial consideration. Though NHI covers all the cancer drug expenditure of traditional chemotherapy after cetuximab has been included, there is only 63% of the target drug expenditure that is paid by NHI. Still, there are quite a few patients refused by health insurance and thus need to face enormous cost burdens.

Conclusions: This study shows low availability and low affordability of target drugs have become barriers against access to cancer drugs for the common people. Health policy makers should take the implications and consistency of formulary coverage for cancer treatments into consideration when making decisions.