探討醫療機構特性與病人選用不同差額人工水晶體之相關性

Abstract

研究背景：我國的高價植入性醫療特殊材料除健保全額給付品項，針對材質精進或增加附加功能的品項適用自付差額制，人工水晶體為其中適用較早且用量最大者。過往研究可見不同都市化地區與不同層級醫療機構的自付差額使用佔率存在顯著差異。若能了解病人選用不同自付額的人工水晶體與醫療機構之關係，則可進一步探討此制度潛在的機構財務誘因或病人可負擔性。 研究目的：藉由次級資料分析以了解醫療機構特性與病人選用不同差額人工水晶體之相關性，並檢視當醫師轉換至不同特性的機構執業時，病人選用與機構特性的相關是否改變，以期增進對自付差額制度實務運作的認識。 研究方法：本研究為橫斷性研究，資料來源為全民健保資料庫，以2016年至2019年首次於門診接受水晶體置換的病人為研究對象，以階層式羅吉斯迴歸模型進行分析，探討在控制病人人口學特性、社經特性、共病狀態與醫師特性後，醫療機構特性對病人選用不同差額類別的人工水晶體之影響。 研究結果：就醫機構層級越高、所在地所得程度越低，病人選用中、高差額人工水晶體的傾向越低，權屬別則未達統計顯著意義。當醫師至不同層級的機構執業時，醫院較診所病人選用中差額相對低差額類別的可能較高（醫學中心OR=0.620、區域醫院OR=0.657、地區醫院OR=0.776），選用高差額相對低差額類別的可能亦然（醫學中心OR=0.178、區域醫院OR=0.282、地區醫院OR=0.369）。 結論：本研究發現就醫機構層級、所在地所得程度與病人選用不同差額人工水晶體存在相關性。因此建議政府強化公開各家院所在各種功能類別的使用率與價格資訊，讓民眾就醫時增加對特材需自付差額的敏感度，則可視自身經濟能力，就治療的期待與醫師進行更務實的討論。

Background: A large number of medical implants are fully covered by the national health insurance in Taiwan ; however, advanced medical implants that are made from better materials or boast additional functions fall into a balanced-billing system, among which intraocular lens (IOL) are the most common. Previous studies have shown that there are significant differences in the use of balance-billed medical devices in different urbanized areas and different accreditation levels of healthcare providers. The financial incentives that healthcare providers potentially face and the affordability for patients in choosing appropriate implants can be further explored by understanding the association between providers' characteristics and patient choice on IOL with different co-payments. Objective: Through secondary data analysis, this research aimed to explore whether the relationship between patient choice and providers' characteristics changed depending on the accreditation level of the institution in which physicians practiced. A better understanding of this relationship provides new insights into how a balanced-billing system works in practice. Methods: The data sources used in this study were from the National Health Insurance Research Database (NHIRD) and included patients who first underwent outpatient cataract surgery between 2016 and 2019. The hierarchical logistic regression model was used to examine the effects of the characteristics of physicians and providers on patients' selection of IOL with different co-payments after controlling for patient age, sex, socioeconomic status, and comorbidities. Results: The higher the accreditation level and the lower the area income level of the provider were, the lower the likelihood of patients choosing IOLs with medium and high co-payments. The ownership of the provider was not significant. When physicians switched to different accreditation levels of practice, patients at medical centers (OR=0.620), metropolitan hospitals (OR=0.657), and community hospitals (OR=0.776) had a higher likelihood of choosing medium versus low co-payment items; similarly, patients at medical centers (OR=0.178), metropolitan hospitals (OR=0.282), and community hospitals (OR=0.369) were also more likely to choose high versus low co-payment items. Conclusions: Patients' choice on IOLs with medium and high co-payments was associated with a higher accreditation level and lower area income level of a provider. As the co-payment of the IOL increased, the patients' preference for IOL varied more between hospitals and clinics. Therefore, policies for improving the accessibility and affordability of appropriate IOL for patients should take into account the information already available to the public, such as utilization and price comparisons among providers.