臺灣博碩士論文加值系統

醫療照護是普世價值，亦是人類基本需求，建構良好醫療體系以達到高品質、高可近性及合理費用支出之目標則深受健康保險支付制度之影響，而各種支付制度導入之目的在促進醫療品質提昇、增加醫療服務效率及降低醫療費用支出。台灣自1995年實施全民健康保險，克服就醫障礙，達成了高納保率及高滿意度的成就，中央健康保險局亦在2010年推動前瞻性支付制度-診斷關聯群，以期降低醫療費用快速成長及促進醫療品質的提升。然而醫院針對診斷關聯群實施之經營策略主要以機構層面(Institutional Level)、管理層面(Management Level)、技術層面(Technical Level)三個層面訂定因應策略，並以醫療系統整合、醫療資源整合、經營績效提昇、醫療品質控制、住院醫療費用轉移、病歷記錄改變、專業人員培訓及醫療資訊系統建立等八個子構面進行策略因應規劃。
本研究為橫斷性研究法(Cross-Sectional Study)，於診斷關聯群支付制度實施前後採分層立意取樣方式針對樣本醫院相關臨床科別醫師與管理者進行結構式問卷調查，收集台灣66家醫院，有效問卷329份進行資料分析。研究架構以醫院特性為自變項，醫院實施之經營策略及經營績效指標為依變項，已實施診斷關聯群支付制度之西醫一般醫院科別與未實施診斷關聯群支付制度之精神科專科醫院進行比較，探討台灣健保導入診斷關聯群支付制度前後，醫療提供者經營策略及其影響程度。
結果顯示已實施診斷關聯群支付制度之西醫一般醫院與未實施診斷關聯群支付制度之精神科專科醫院在實施診斷關聯群支付制度前後經營策略因應程度呈現統計上顯著差異，其中西醫一般醫院在實施前後三個主要層面呈現明顯之因應策略程度的改變，而精神科專科醫院僅在技術層面呈現統計上顯著差異。績效評估指標差異分析，西醫一般醫院在費用指標、財務指標、可近性指標在統計上並無顯著差異，但在成長指標中全院住院醫療費用成長率呈現統計上顯著差異，在品質指標中實施診斷關聯群支付制度後出院病患合併症/併發症比率呈現統計上顯著差異。不同層級醫院、不同健保分區及不同床位數醫院在診斷關聯群支付制度實施前後並無顯著差異，不同權屬別醫院及不同開院歷史醫院於技術層面呈現統計上顯著差異。
迴歸分析結果顯示實施診斷關聯群制度後，醫院特性對於績效指標預測模式，在全院編制內員工總人數、平均每月出院人次、平均每人次住院醫療費用呈現統計上顯著差異。另在全院住院醫療費用成長率、全院編制內員工總人數、平均每月出院人次、全院佔床率、平均每人次住院醫療費用、平均每人日住院醫療費用、DRG住院病患費用基準值、DRG住院病患件數佔全院費用比率、門診手術人次、出院後30日內死亡率、全院病患違背醫囑出院(AAD)比率、出院病患合併症/併發症(C/C)比率及住院病患滿意度有高解釋力(R2值>0.5)。以因應策略預測各項績效評估指標之結果顯示實施診斷關聯群DRG支付制度後在住院病患疾病嚴重度(CMI值)、平均每人次住院天數及住院病患轉診比率呈現統計上顯著差異。另在住院病患疾病嚴重度(CMI值) 、平均每人次住院天數、住院病患轉診比率有高解釋力(R2值>0.5)。以實施診斷關聯群DRG支付制度前後差異比較顯示在全院住院醫療費用成長率、全院編制內員工總人數、平均每人次住院醫療費用、住院病患疾病嚴重度(CMI值)、平均每人次住院天數及住院病患轉診比率呈現統計上顯著差異。另在全院住院醫療費用成長率、住院病患疾病嚴重度(CMI值)、平均每人次住院天數及住院病患轉診比率有高解釋力(R2值>0.5)。
本研究主題主要在探討台灣健康保險導入前瞻性支付制度診斷關聯群(DRGs)所造成對醫療提供者之衝擊影響及其相關因素分析，相關結果將提供未來台灣健康保險全面導入前瞻性支付制度之參考，並做為醫療提供者經營策略因應之建議。

Healthcare is a general value and basic need for human beings. The implementation of the prospective payment system is an essential factor to reach the goal of high quality, high accessibility and reasonable medical costs of a good healthcare system, which aims on improving the quality, increasing the effectiveness and cutting the medical expenditure. In 1995, Taiwan implemented National Health Care Insurance System that it accomplished a high-insured rate and high satisfaction, and for which, the Bureau of National Health Insurance(NHI) intended to promote prospective payment system - Diagnosis Related Groups (DRGs) to increase medical quality and smooth the rapid growing of medical costs. Nevertheless, hospital’s strategies of DRGs comprise management level, technical level, and institutional level, and is composed by system integration, resource integration, performance increase, quality control, cost shift, medical documentation change, professional training and health information system establish.
This study uses cross-sectional analysis and stratified purposively sampling method. Structured questionnaire was sent to clinical physicians and managers from 66 hospitals in Taiwan, and 329 questionnaires were valid. Hospital’s characteristic was independent variable, hospital management strategies and performance indicators were dependent variables relatively. This study try to analyze the differences between DRGs implemented hospitals and non DRGs implemented hospitals to see the impact on hospital strategies in Taiwan.
The results show there is a significant difference of hospital management strategy before and after DRGs implemente in DRGs and non DRGs implemented hospitals, where as there are significant differences on three levels of DRGs implemented hospitals but only technical level in non DRGs implemented hospitals. In performance evaluation indicator difference analysis, there were no significant differences on cost , financial and accessibility indicators but the increasing rate of whole hospitalization expenses on growth indicators. Moreover, the result shows there is a significant difference of complication and comorbidity rate on quality indicators for discharged patients. There were no significant differences on different ranks, health insurance divisions, and bed number of hospitals. However, the study found that there are significant differences on technical level between different hospital relegations and between different hospital backgrounds.
Results in regression analysis shows there are significant differences between hospital characteristics and performance indicator prediction model on hospital employees, monthly average discharges, and the average cost of hospitalization per person. It also expresses high correlation (R2>0.5) on hospitalization expenses growing rate, hospital employees, monthly average discharges, occupation rate, average cost of hospitalization per person, average cost of hospitalization per day per person, the base rate of DRG, the expenses ratio of hospitalization number, outpatient surgery visits, 30-day death rate after discharge, discharge against advice rate, discharged patient complication and comorbidity rate, and hospitalized patient satisfaction.As for the coping strategies to performance evaluation indicators, the results show that there are significant differences on inpatient disease severity, average length of stay , and inpatients referral rates after the DRGs was implemented. It also expresses high correlation(R2>0.5) on these three variables as well.
To investigate the differences of DRGs implementation, the study found that there are significant differences on hospitalization expenses growing rate, hospital employees, average cost of hospitalization per person per time, inpatient disease severity, average length of stay , and inpatients referral rates. It also expresses high correlation(R2>0.5) on hospitalization expenses growing rate, inpatient disease severity, average length of stay and inpatients referral rates.
This study mainly investigate the impacts on introduce of DRGs prospective payment system of Taiwan healthcare insurance to healthcare providers and analyze its’ related factors. Results will be provided as a reference to the comprehensive PPS and to the healthcare providers.
Key words: payment system, Prospective Payment System, Diagnosis Related Groups, patient classification system, case mix index

致謝 I
中文摘要 II
英文摘要 IV
目錄 VI
表目錄 X
圖目錄 XII
壹、緒論 1
1.1 背景及重要性 1
1.2 研究目的 5
1.2.1研究動機 5
1.2.2研究目的 6
1.3 研究流程與內容 7
1.4 研究範圍與限制 9
1.5 重要名詞定義 11
貳、文獻探討 14
2.1 診斷關聯群介紹 15
2.2 世界各國實施診斷關聯群經驗探討 20
2.3 世界各國實施診斷關聯群支付制度對醫院之影響與因應策略 27
2.4 台灣版診斷關聯群支付制度簡介與對醫院之影響及因應策略 50
2.5 世界各國診斷關聯群支付制度審查制度建立探討 57
叁、研究方法 66
3.1 理論模式與研究架構 66
3.2 研究設計 69
3.2.1前驅研究 69
3.2.2問卷設計 69
3.2.3研究設計 77
3.3 資料分析與統計方法 80
3.3.1資料分析程序 80
3.3.2 資料蒐集 83
3.3.3研究對象權益保護 84
3.4 信度與效度 86
3.4.1 信度分析 86
3.4.2 效度分析 87
3.4.3 路徑分析 88
肆、資料統計分析結果 91
4.1 描述性統計分析 91
4.2 推論性統計分析 (Inferential Statistics) 94
4.2.1 T檢定 94
4.2.2變異數分析 98
4.2.3複迴歸分析 101
伍、結論 105
5.1 結論與討論 105
5.1.1 信效度分析 105
5.1.2 一般西醫醫院與精神科醫院結果討論 106
5.1.3 一般西醫醫院績效評估指標結果討論 107
5.1.4 一般西醫醫院之醫院特性對經營策略結果討論 108
5.1.5 一般西醫醫院之醫院特性與經營策略對績效評估指標結果討論 109
5.2 研究貢獻及建議 112
陸、參考文獻
6.1 中文文獻
6.2 英文文獻 115
115
121
柒、附錄 134
7.1 診斷關聯群基本架構 134
7.2問卷內容專家審查及建議結果 136
7.3 問卷 145

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