臺灣博碩士論文加值系統

動機：近期女性健康議題在健康照護或預防保健皆受到世界各國所重視，而臺灣女性癌症中乳癌死亡率自民國八十八年起已超越子宮頸癌僅次於肺癌、肝癌、結腸直腸癌位居第四位。中央健保局在民國九十年十月推出「論質計酬」制度，以五大疾病為重點，包括子宮頸癌、肺結核、糖尿病、氣喘與乳癌，希望透過新支付方式，提供良好誘因以導引醫療品質的提昇及內部成本的控制。但此目標能否達成，仍須實務證明。

目的：探討乳癌試辦計劃能否提高醫療品質，節省醫療費用，同時對影響乳癌試辦計劃之醫療費用高低和成效的因素做進一步的分析與探討。

研究方法：以實驗組（參與乳癌試辦計劃之醫學中心）與對照組（未參與乳癌試辦計劃之醫學中心）比較方式，分析乳癌試辦計劃前一年（2001年）與承接計劃後第二年（2003年）之醫療耗用（就醫特性及重要醫療處置-化學、放射治療及手術治療等）及成效（死亡率）。資料來源為南區健保局的健保費用申報資料，在試辦計畫前樣本數為1,105人，在試辦計劃後為1,222人。

研究發現：在就醫特性方面，參與乳癌試辦計劃前後實驗組之門診次數減少（t=15.15，p=0.000），同時在門診相關醫療費用及總醫療費用有減少的現象，對照組在年度方面門診及住院就醫次數皆未改變。在重要醫療處置部分實驗組偏好放射治療（t=-8.536，p=0.000）而對照組則偏好化學治療（t=-4.206，p=0.000）。在醫療費用方面，實驗組化學治療費用明顯高於對照組（t=5.172，p=0.000），而放射治療費用則明顯低於對照組（t=-20.67，p=0.000）；在死亡率部分兩組無明顯差異。

結論：以參與乳癌試辦計劃前後實驗組確實會因乳癌試辦計劃的實施而減少門診次數及化學治療次數，但在費用部分卻無下降現象；實驗組在參與乳癌試辦計劃後，除放射治療費用低於對照組外，其他費用未因乳癌試辦計劃實施而有差異；在死亡率部分兩組無明顯差異。另一方面，實驗組實際醫療費用與向健保局申請之醫療費用亦無明顯差異。
實驗組之乳癌病患平均就醫日數多於試辦計劃前及多於對照組之乳癌病患平均就醫日數，造成醫療費用偏高原因之一，或許就醫日數多代表病患疾病嚴重度高，相對醫療耗用增加，因資料來源無法得知乳癌期別，需日後進一步探討。

Background: Women’s health issues, whether related to medical care or prevention, have attracted great attention all over the world. In Taiwan, the mortality rate of breast cancer has been higher than cervical cancer since 1999, and ranks the fourth in women cancer mortalities, next to lung cancer, liver cancer, and colon or rectum cancer. The Bureau of National Health Insurance has implemented a Payment-For-Performance pilot project for the care of cervical cancer, pulmonary tuberculosis, diabetes, asthma and breast cancer since October 2001. .

Purpose: The author holds an assumption of the Payment-for-performance System enhances the quality of medical treatment and the control over cost management in institutions. The research question of this study is if the tentative project of breast cancer can enhance the quality and reduce the cost of medical treatment? Meanwhile, this study also investigates and analyses the cost and the effect of medical treatment in this tentative project of breast cancer.

Method: A comparison between an experimental group (a medical center involved in this tentative project of breast cancer) and a control group (a medical center not involved in this tentative project of breast cancer) is conducted by analyses of the cost of medical treatment(characteristics of using medical treatment and important items of medical treatment, such as chemical, radiological, and surgical treatment) and the effect (death rate) in the former year (the year of 2001) and the next year (the year of 2003) of this tentative project being conducted.

Result:From the perspective of the characteristics of using medical treatment, the number of outpatient visits decreases（t=15.15，p=0.000）and the cost does decrease in the experimental groups. At the same time, the control group remains the same in the numbers of either outpatient or inpatient visits. From the perspective of important items of medical treatment, the experimental group prefers radiological treatment（t=-8.536，p=0.000）and the control group prefers chemical treatment（t=-8.536，p=0.000）. From the perspective of the cost of medical treatment, the experimental group spends more in chemical treatment（t=5.172，p=0.000）, and less in radiological treatment（t=-20.67，p=0.000）than the control group does. Two groups do not reveal any difference of the death rate.

Conclusion: The experimental group reveals a decrease of the number of outpatient visits and chemical treatment, but does not reveal a decrease in the cost of medical treatment when comparing before and after participating in this tentative project of breast cancer. The experimental group reveals less cost in the radiological treatment and remains the same in other types of medical treatment when compared to the control group. Also, these two groups show no differences in death rate. Also, it reveals no significant differences between these two groups in terms of the real cost of patients’ medical treatment and the fee application of medical treatment from the Bureau of National Health Insurance.
Breast cancer patients in the experimental group have a higher average of day number for seeking medical treatment before the conduction of this tentative project and than the patients’ in the control group. This may cause a higher cost of medical treatment. A higher average of day number in seeking medical treatment may indicate more severity of patients and more cost in medical treatment. The information about the phases of patients’ breast cancer should be investigated in future studies.

第一章 前言 ..............................................1
第一節 研究背景 .................................................1
第二節 研究目的 .................................................5
第二章 文獻探討 ..........................................6
第一節 乳癌病患診斷與治療 .......................................6
第二節 論質計酬 .................................................7
第三節 經濟醫療評估方法 .........................................9
第四節 乳癌篩檢與治療的醫療經濟分析 ............................11
第三章 研究材料和方法 ....................................14
第一節 研究架構與設計 ..........................................14
第二節 研究假說 ................................................15
第三節 研究對象及資料來源 ......................................15
第四節 變項定義 ................................................18
第五節 資料統計分析方法 ........................................20
第四章 研究結果 ..........................................25
第一節 研究對象的基本特性 ......................................25
第二節 試辦醫院在乳癌試辦計劃前後之醫療處置和費用變化 ..........36
第三節 試辦計劃實施後試辦醫院與非試辦醫院之醫療處置和費用變化...44
第五章 討論 ..............................................57
第一節 乳癌試辦計劃對醫療品質的影響 ............................57
第二節 乳癌試辦計劃對醫療處置類別的影響 ........................59
第三節 乳癌試辦計劃對醫療費用的影響 ............................62
第四節 乳癌試辦計劃對成本效性的影響 ............................62
第五節 疾病嚴重度的影響.........................................63
第六節 研究限制 ................................................64
第六章 結論與建議 .......................................65
第一節 結論 ....................................................65
第二節 對未來研究者建議 ........................................66
參考文獻 ................................................67

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