健保部分負擔實施對某醫學中心急診利用之影響

Abstract

研究背景與目的： 關於急診部分負擔對於急診醫療利用的研究較少，且急診壅塞是醫療供給需求不平衡的狀況下產生，也就是病患所需要的醫療資源遠超過醫療院所所能供給，而急診輕症壅塞在許多研究發現上會影響急診醫療品質，也會造成醫療資源的浪費，並壓縮到真正需要急診醫療照護之民眾就醫權益。因此本研究想深入去探討2017年部分負擔針對急診部分負擔調升三到五級檢傷分類費用，是否真的能減少醫學中心的急診利用，能否有效減少非緊急之急診醫療利用。對臺大醫院急診人次概況作分析。研究部分負擔介入前後是否會因為病人是忠誠病人或頻繁急診醫療利用者，急診醫療利用前後有差異。 瞭解2017年部分負擔實施對於急診利用人次是否有隨部分負擔調升有所改變，並針對來診人次做社會人口學變項做統計分析，以釐清臺大醫院急診族群特質，清楚瞭解現行政策執行對臺大醫院急診之成效，以提供院方參考。而影響政府相關健保政策，也做更深入的個案分析，瞭解部分負擔是否對於忠誠病人及頻繁急診醫療利用者個案至急診就醫有所影響。若能有此次部分負擔對醫療利用相關研究結果，則可以對政府在健保政策上有所助益，也能給予後續實施健保部分負擔改革上有新的想法及調整；更重新評估急診壅塞的解決方法，以利病患就醫時有良好的醫療品質。 研究方法： 運用臺大醫院醫療整合資料庫做回溯性研究，研究對象就診人次107,343人次，進行歸人整理合計79,280人，依照其急診就診次數大於等於四次以上，作為頻繁急診醫療利用者之定義。而門診就診次數大於三次以上，作為忠誠病人之定義，將研究對象分為實驗組與對照組，並透過傾向分數加權，增加實驗組與對照組之可比性，以差異中的差異法觀察了解兩組別急診醫療利用變化，瞭解部分負擔介入的實際影響。 研究結果： 研究資料顯示總計79,280人之樣本數，女性較男性多，佔51.6%；平均年齡42.1歲；低收入戶為979人，佔1.2%；免部分負擔者為18,960人，佔23.9%；曾經轉診5,869人，佔研究族群的7.4%；來急診時曾被檢為一到二級檢傷分類有4,343人，佔5.5%；介入前後急診醫療利用次數分別為1.35和0.36，配對後頻繁急診利用者2,583人；忠誠病人為27,455人。在多變量分析結果中顯示部分負擔介入對整體急診醫療利用造成負向之影響，且因身分不同，有影響程度之差別。而在控制相關變項後下，頻繁急診醫療利用者相對於非頻繁急診醫療利用者，其急診醫療利用下降更為明顯；非忠誠病人相對於忠誠病人，其急診醫療利用下降更為明顯。 結論： 本研究發現部分負擔介入對於急診醫療利用呈現負向影響，控制其他變項介入對於頻繁急診醫療利用者有顯著影響，且對於忠誠病人有顯著影響。對頻繁急診醫療利用者和非忠誠病人之負向影響更劇烈，在現有變項特性外，仍有未知之影響因素，因頻繁急診醫療利用者此群族人數比例相對小，但使用急診醫療資源卻是大忠，了解頻繁急診醫療利用者個體根本問題，是未來能努力前進之新策略。而忠誠病人也會是急診就醫的常客，也需要了解其的態度與行為，才可以有效解決急診壅塞的問題。

Background: There are few studies on the copayment of emergency medical treatment utilization, and emergency overcrowding is caused by the imbalance of medical supply and demand. Many studies have found that it will affect the quality of emergency medical care, cause a waste of medical resources, and reduce the chance of people who really need emergency medical care. Therefore, we would like to conduct an in-depth study on whether the copayment increase in 2017 for the emergency department to increase the triage fee of three to five levels can really reduce the emergency use of medical centers. An analysis of the emergency visits in National Taiwan University Hospital. To examine whether there are differences in emergency care utilization before and after copayment intervention because of loyal patients or frequent emergency department users. The purpose is to understand whether the number of emergency visits has changed with the copayment increase in 2017, and to conduct statistical analysis of socio-demographic variables on the number of visits to clarify the characteristics of emergency department groups in National Taiwan University Hospital. As for the impact of relevant government health insurance policies, we also conducted a more in-depth case analysis to understand whether copayment has an impact on the cases of loyal patients and frequent emergency medical users who seek emergency medical treatment. If the results of this study on copayment on medical utilization are available, it can be helpful to the government in health insurance policies, and can also provide new ideas and adjustments for the subsequent implementation of copayment reform on health insurance; it can also re-evaluate emergency overcrowding. Solutions to help patients receive good medical quality when seeking medical treatment. Method: This study is based on the emergency department visit of a medical center in northern Taiwan, National Taiwan University hospital. 79,280 people and 107,343 visits of them were the data observed. The definition of frequent emergency department user is the number of visit above 4 times in one year. The definition of patient-loyalty is the number of visit above 3 times in one year. To increase the comparability between the experimental group and the control group through propensity score matching. Difference-in-difference method (DID) is used to observe the emergency department utilization change of the two groups in different state. Results: The sample size of 79,280. There were more women than men, accounting for 51.6%; the average age was 42.1 years old; there were 979 people from low-income, accounting for 1.2%; those who were exempted from copayment there were 18,960 people, accounting for 23.9%; 5869 people had been referred, accounting for 7.4% of the study population; 4,343 people had been diagnosed with first to second level injury classification when coming to the emergency room, accounting for 5.5%; the number of emergency medical utilizations before and after intervention were respectively are 1.35 and 0.36. After propensity score matching, there were 2,583 frequent emergency department users; there were 27,455 loyal patients. The multivariate analysis results show that copayment intervention has a negative impact on overall emergency medical utilization, and the degree of impact varies depending on the status. After controlling for relevant variables, frequent emergency medical users have a more obvious decrease in emergency medical utilization than in frequent emergency department users; non-loyal patients have a more obvious decrease in emergency medical utilization than loyal patients. Conclusions: This study show that copayment intervention has a negative impact on emergency medical utilization. Controlling other variables, intervention has a significant impact on frequent emergency department users and loyal patients. The negative impact on frequent emergency department users and non-loyal patients is even more severe. In addition to the characteristics of the existing variables, there are still unknown influencing factors. The proportion of frequent emergency medical users is relatively small, but the number of emergency medical visits are a lot. Resources are the key, and understanding the individual fundamental problems of frequent emergency department users is a new strategy for moving forward in the future. Loyal patients will also be frequent visitors to emergency departments, and it is necessary to understand their attitudes and behaviors in order to effectively solve the emergency overcrowding.