台灣醫院醫療照護的經營績效研究

Abstract

民國84年開辦的健保顯著的提高國民平均壽命，是政府施政滿意度最高的項目，但也為醫療市場點燃強烈的競爭戰火。健保支出佔台灣醫療保健支出的48%至53%，也是醫療院所的主要收入來源，而台灣醫療機構的發展生態深受健保的給付制度影響，醫院因為成本不斷增加及營運利潤逐漸減少，因此醫院的家數持續減少，診所家數不斷增加。健保局為控制醫療支出而將總額給付業務分為六大業務組，各業務組管轄的範圍內因醫療院所集中度不同而導致競爭強度不同，對醫療院所的經營造成不同程度的影響；總額給付制度開辦後國內醫療體系開始整頓及整合，隸屬於集團體系的醫院家數約佔全國醫院總數的29%，其總病床數佔全國醫院總病床數達60%，所申報的健保點數佔全國40%。私立醫院因缺乏公家資源補助，在面臨競爭時更需要靈活的運用營運效率，才能維持永續經營。本研究動機在瞭解健保局控制醫療支出後醫療院所間的競爭勝負是否有跡可尋。研究目的在(1)比較健保實施後醫療市場變化與國際變化；(2)探討醫學中心、區域醫院、地區醫院的經營績效；(3)分析不同健保總額區域間的競爭差異；(4)比較公私立醫院經營績效的差異；(5) 研究公立醫院委外經營後之績效；以及(6)探討醫院整合後的績效。 本研究首先分析本國醫療服務市場與國際醫療市場成長情況，並使用健保公布在公開網站的資料庫，做民國93年至100年之間醫學中心、區域醫院、地區醫院三種不同醫院層級經營效率的比較。所探討的項目包含門診申報總點數、門診申報總件數、住診申報總點數、住診申報總件數4項醫院規模相關指數，以及包含病床周轉率、門診每件點數、住診每件點數、每床每月住診點數、每床每月門住診點數5項經營績效相關指數。並分析健保6個總額給付區的各業務組之集中度指標-赫爾芬達爾-赫希曼指數(Herfindahl-Hirschman Index， HHI)對經營績效的影響。 我們發現我國醫療市場成長率遠低於國際市場，而健保各醫療總額分區內醫院間的競爭強度不同。醫學中心的經營較區域醫院及地區醫院有效能，代表醫院規模的門診申報總點數、門診申報總件數、住診申報總點數、住診申報總件數在全國各分區的醫學中心均逐年增加。全國各分區每個門診病患的平均點數均逐年增加(p<0.001)，而台北分局的門診平均單價為全國各分區最低(p<0.001)，顯示台北地區的醫學中心使用藥物及各項檢查及耗材最精準，醫療浪費應該較少。各分區醫學中心的住診平均點數有統計上差異(p=0.021)，競爭最激烈的台北分局，每位病患平均住診點數幾乎是全國最低，而且逐年減少，顯示病人住院日數逐年縮短，且台北總額區的醫療資院使用最為經濟。全國6家公立醫學中心平均醫院規模比13家私立醫學中心醫院規模大，但全國私立醫學中心平均績效優於公立醫學中心；健保局台北業務組的公私立醫學中心間的差距較為明顯，但台北分局公立醫學中心的平均經營績效仍高於全國公立醫學中心；另外，台北分局私立醫學中心的平均規模小於全國私立醫學中心平均規模，但經營能力優良。相反的，中區分局公立醫學中心的經營績效優於私立醫學中心。我們也發現非國軍體系的公立醫院經營效率優於國軍醫院，且各業務組區域HHI越高，亦即醫院集中度越高，則區域內醫學中心的平均年成長率越低；而屬於HHI較低的區域中之公立醫學中心，其經營績效優於HHI較高區域中的公立醫學中心。另外，本研究亦發現私立區域醫院的經營優於公立區域醫院，而且署立及市立醫院委外經營績效優於衛生署及衛生局經營，因此我們確認私立醫療院所的經營較具效能；但是私立地區醫院的經營與公立地區醫院差異不大。而公立區域醫院整併後經營分析顯示公立區域醫院整併對象醫院為私立醫院者，其經營績效高於整併對象醫院為公立醫院者。由於健保醫療費用版塊正逐年由醫療院所移動至藥局，醫療院所經營必須經由規模經濟減少支出才能維持運轉，公立醫院整合時將經營權交給私立醫療院所較能發揮經營效能，而醫院經營的品牌效應在以醫學中心的營運模式較能發揮。

The revolution of health care provider system in Taiwan has been deeply impacted by the national health insurance payments system. Bureau of National Health Insurance (BNHI), institued in year 1995, ignited strong competition among hosptials fighting for the medical severice market. The number of hospitals declined gradually while the number of clinics increased over the past 17 years due to the increasing operation costs and decreasing profit. The BNHI centralizes the disbursement of health-care funds but divides its payment business into 6 large global budget units for the jurisdiction of global budget control. The intesitity of competition among health care providers in each global budget unit varies due to the difference in health care provider market share concentration in each area. Consequently, the competition exerted various impact intensities to the operation of health care providers. They thus began systematic integration to strive and hopefully to profit. Currently, several medical systems own 29% of hospitals and up to 60% of hospital beds nationwise. The medical resource they claimed sum up to 40% of total NHI expenditure. Private hosptials are not funded by goverment, they thus need flexible strategy and tactics for sustainable operation and/or growth. The intention of our study was to identify the clues underlying the victory and/or defeat in the competition war behind the BNHI’s budget control. The specific aims of our study were (1) to compare the change in Taiwan’s health care market vs. the international market growth；(2) to compare the operation efficienty among medical centers, regional hospitals, and district hospitals；(3) to investigate the difference in competition intensity among different global budget areas and the impact of competition intensity on hospital operation；(4) to compare the operation efficiency between public hospitals and private hospitals；(5) to investigate the operation efficiency of public hostpials commissioned to private vs. public hospitals；and (6) to investigate the operations efficiency of public hospitals after consolidation. In this study, we first evaluate our health care service market size in comparision to other countries and further investigate the health insurance database in year 2004 to 2011. We compare the difference in the operation efficiency among medical centers, region hospital and discrict hospitals. The Herfindahl–Hirschman Index (HHI) was calculated in each global budget unit as an indicator of the amount of competition among hospitals in the 6 global budet areas. We further analyze the relationship between the operation efficieny of medical centers and the HHI in each global budget unit. Hospital scale related variables and operation efficiency related variables were compared between private and public medical centers as well as among medical centers, regional hospitals and district hospitals. The 4 hospital scale related variables included total number of outpatient, total outpatient revenue claimed, total number of hospitalization, total hospitalization revenue claimed, while the 5 operation efficiency related variables were hospital bed turnover rate, revenue claimed per outpatient, revenue claimed per hospitalization, inpatient revenue per hospital bed per month, and total revenue per hospital bed per month. We disclosed that medical market growth rate in Taiwan was far below other international markets. The intensity of competition varied among different health insurance global budget units. Medical centers operated more efficiently than regional hospitals and district hospitals. All 4 indicators of hospital scale increased from year 2004 to 2011 in all 6 global budget areas. The revenue claimed per outpatient also increased in all 6 global budget units (p<0.001), among which medical centers in Taipei global buget area claimed for least (p<0.001). This indicated that medical centers in Taipei global budget area managed their patients most economically, and with least waste of medical resource. There was statistically significant difference in the revenue claimed per hospitalization (p=0.021), lowest in medical centers in Taipei global budget area. There was also a trend of decreasing revenue claimed per hospitalization from year 2004 to 2011 in all 6 global budget units, indicating a tendancy of shortening in the length of hospital stay by either implementation of clinical path and/or alteration in hopstial culture. The 6 public medical centers had an averaged larger scale than the 13 private medical centers, while the private medical centers operated more efficiently than the public medical centers. In addition, in spite that public medical centers in Taipei area outperformed the nationwise averaged pulblic medical centers; the difference between public and private medical centers was largest in Taiepei global budget unit. The private medical centers in Taipei global budget area averaged the smallest scale but opeated most efficiently nationwise. In contrast, the single public medical center in central Taiwan outperformed the private medical centers in the same area. We also found that non-military public hospitals operated more efficiently than the military hospitals. The higher was the regional HHI, i.e. the more concentrated hospital market share in the global budget area; the lower is the averaged compounded annual growth rate of the medical centers within the region. Public medical centres in the lower HHI region performed better than public medical centres in the higher HHI region. In addition, private regional hospitals operated more efficiently than public regional hospitals. This further confirms that private hospitals operated with relatively higher efficiency. Public regional hospitals operated by the Department of Health (DOH) and/or City goverments operated less efficiently than regional hospitals commissioned to private systems by the DOH and/or city government. However, there was no difference in performance between public district hospitals and private district hospitals. Public hospitals commissioned to private hospitals outperformed the public hospital alliance. Health care expenditure shifted from hospital and clinic sectors to pharmacy sector in the past 10 years. Hospitals would survive by reducing expenditure through economy of scale. When public hospitals consolidate, commission to private hospitals with good operation efficiency and medical centers with good brand value should be prioritized.