(3.236.214.19) 您好!臺灣時間:2021/05/09 22:43
字體大小: 字級放大   字級縮小   預設字形  
回查詢結果

詳目顯示:::

我願授權國圖
: 
twitterline
研究生:張維君
論文名稱:健保論病例計酬對住院費用與醫療品質的影響-以某醫學中心以腹腔鏡全子宮切除術為例
論文名稱(外文):The Study of Admission Charges and Medical Quality Under the Case Payment System-A Case Study of Laparoscopic Assisted Vaginal Hysterectomy in a Medical Center
指導教授:林正介林正介引用關係蔡文正助理
學位類別:碩士
校院名稱:中國醫藥學院
系所名稱:醫務管理研究所
學門:商業及管理學門
學類:醫管學類
論文種類:學術論文
論文出版年:2001
畢業學年度:89
語文別:中文
中文關鍵詞:論病例計酬制臨床路徑醫療品質醫師經驗
外文關鍵詞:case paymentclinical pathwaymedical qualityexperience effect
相關次數:
  • 被引用被引用:14
  • 點閱點閱:449
  • 評分評分:系統版面圖檔系統版面圖檔系統版面圖檔系統版面圖檔系統版面圖檔
  • 下載下載:0
  • 收藏至我的研究室書目清單書目收藏:4
我國從民國八十四年三月一日開始實施全民健康保險制度,但是採論量計酬制(Fee For Service)的給付制度卻逐漸導致醫療費用的高漲。所以中央健保局開始多元支付制度改革,其中以疾病診斷關係群(DRGs)為基準的論病例計酬制(Case Payment),到九十年二月已實施五十一項,佔住院總支付額的12%。因應定額支付制度,把財務、成本和品質風險轉嫁到醫院和醫師的趨勢,院所管理者須有良好對策。
本研究採回溯性世代研究法,以某醫學中心婦產部門符合接受腹腔鏡全子宮切除術定義的病患為研究對象,其中屬論病例計酬120例及論量計酬40例,收集資料進行多變項複迴歸、羅吉斯複迴歸等分析,探討醫師專業經驗和臨床路徑實施的前後對於住院費用及醫療品質的影響。所得重要結果如下:
一、論病例計酬下,醫師專業經驗對住院費用和醫療品質的影響:
1.經複迴歸分析,控制其他自變項後,主刀3年以上醫師在總醫療費用和所有細項費用都達顯著意義的減少,表示較好的資源合理使用和內部成本控制。
2.同樣經複迴歸分析,控制其他自變項後,主刀3年以上的醫師在手術時間、麻醉時間、住院天數和出院後3個月內回診次數,都顯著優於資淺醫師。至於術後點滴超過2天、注射抗生素超過2天和發生併發症並無統計上差異;而死亡、輸血、出院後2週內再入院和開刀日延遲都沒有個案發生。
二、臨床路徑實施前後對住院費用及醫療品質的影響:
1.經複迴歸分析,控制其他自變項後,臨床路徑實施後,總醫費用和所有細項費用,在至少做好規定的基本診療項目後,都達顯著意義的減少。
2.同樣經複迴歸分析,控制其他自變項後,臨床路徑實施後,在住院天數、手術時間、麻醉時間和抗生素的使用量控制都達顯著意義的減少,至於死亡、輸血、出院後2週內再入院和開刀日延遲都沒有個案發生,而併發症有7例佔5.8﹪。
所以,在健保論病例計酬定額給付下,院所經營管理者在成本制約和品質的維護或提升的前提下,實施臨床路徑並且做好醫師專業訓練教育和經驗傳承,激勵資深醫師,強化成本和品質意識,是因應新的醫療趨勢良好的對策之一。
The National Health Insurance (NHI) program was launched on March 1, 1995. Our government thus implemented this new system of social welfare. Nevertheless, in the beginning the "Fee for Service" single medical payment system results in an increased demand for medical care since the health care providers are not required to share the responsibility of financing the system.
The Bureau of NHI has made many changes to the payment system. Establishment of the 51 items of Case Payment from Normal Spontaneous Delivery in May 1995 to Diagnosis Related Groups (DRGs) in February 2001 has been completed, and the total payments comprise 12% of all hospitalization payments.
Due to the new policy of the payment system, hospital managers must have a good counter plan for costs and quality or else the program will be difficult to maintain.
This study involved a sample of patients who underwent laparoscopic assisted vaginal hysterectomy (LAVH) in a medical center in central Taiwan. Among them, 120 patients were paid under the Case Payment system and 40 patients were paid under the "Fee For Service" system. The method is retrospective cohort study and multiple regression and logistic regression analysis are used. Do the experience level of doctors and the implementation of clinical pathway influence the admission charges and medical quality ? The results are as follows:
1.Under the case payment system, the experience effect on admission charges and medical quality were:
(1)Surgeons with over 3 years experience have lowered all fee items according to the results of multiple regression analysis after controlling for other independent variables. It implies good use of resources and internal cost control.
(2)Multiple regression analysis after the control of other independent variables indicated that surgeons with over 3 years experience were better than junior physicians in surgery time, anesthesia time, length of stay and the number of follow up exams within 3 months after discharge from the hospital.
(3)Statistical analysis revealed no significant difference in intravenous administration for more than 2 days after surgery, antibiotic administration for more than 2 days and the occurrence of complications. Death, blood transfusion, readmission within 2 weeks after discharge and delay of surgery day didn''t occur in this series.
2.The effect on admission charges and medical quality after the adoption of clinical pathway:
(1)After the adoption of clinical pathway, the total medical fees and each item fee were significantly reduced. Multiple regression analysis indicated that the fees were significantly reduced after controlling for other variables
(2)After the adoption of clinical pathway, length of stay, surgery time, anesthesia time and antibiotic use were significantly reduced.
(3)Death, blood transfusion, readmission within 2 weeks after discharge from the hospital and delay of surgery day didn''t occur and complications were only 7 cases in the 120 cases who were treated in the clinical pathway.
Under the quota payment system, promoting senior doctors, arranging continual training and education programs and implementing the clinical pathway are good policy for the hospital managers to do well in cost containment and medical quality maintenance.
第一章緒論1
第一節研究動機1
第二節研究目的3
第二章文獻探討4
第一節論病例計酬制4
第二節醫療品質7
第三節臨床路徑11
第四節ANDERSEN健康行為模式14
第五節醫師在品質和成本的角色19
第三章研究設計與方法21
第一節資料來源21
第二節研究架構22
第三節研究假設24
第四節研究變項與操作型定義25
第五節資料分析方法29
第六節研究流程32
第四章研究結果33
第一節研究樣本基本資料描述33
第二節醫師專業經驗在費用和品質的比較38
第三節醫師在臨床路徑前後在費用和品質的比較40
第四節以迴歸模式分析醫師專業經驗對費用和品質的影響43
第五節以迴歸模式分析臨床路徑實施前後對費用和品質的影 響45
第五章討論55
第六章結論及建議62
第一節結論62
第二節建議64
參考文獻66
【英文部份】
1.Andersen RM. Revisiting the Behaviral Model and Access to Medical Care:Does It
Matter?Journal of Health and Social Behavior,1995;36:1-10
2.Chang PL. et. al. Use of the Transuerthral Prostatectomy Clinical Path to Monitor
Health Outcome:The Journal of Urology,1997;157:177-183
3.Chang PL. et. al. Improvement of Medical Care Quality After Implementation of a Clinical Path Monitoring Program for Transuerthral Prostatectomy Patients:Eur Urol,1998;33:523-528
4.Chang PL. et. al. Does the Use of Clinical Paths Improve the Efficiency and Quality of Care under the Case Payment System for Inguinal Herniorrhaphy or Transurethral Prostatectomy:Chang Gung Med J,1999;22:400-408
5.Chang PL. et. al. Improvements in the Efficiency of Care after Implementing a Clinical-care Pathway for Transurethral Prostatectomy:Br J Urology,1998;81:394-397
6.Donabedian A. et. al. Quality,Cost and Health:An Integative Model: Medical Care,1982;20:915-992
7.Donabedian A. The Quality of Care,how can it be assessed?JAMA,1988;260:1743
8.Dewoody S. et. al. A System Approaches to Multidimentional Article Paths:Nursing Management,1994;25(11):47-51
9.Darrikhuma IM. Developament of a Renal Trasplant Clinical Pathway:One Haspital''s Journey:AACN Clinical Issues,1999;10(2):270-284
10.Gambone JC. et. al. The Impact of Quality Assurance Process of the Frequency and Confirmation Rate of Hysterectmy:Am J Obstet Gynecol,1990;163:545-548
11.Husbands JM. et. al. Clinical care pathways:Decreasing resource utlization in head and neck surgical patients:Otolaryngol Head Neck Surg,1999;121:755-759
12.Ikhena SE. et. al. The Effect of the Learning Curve on the Duration and Peri- operative complications of Laparoscopically Assisted Vaginal Hysterectmy:Acta Obstet Gynecol Scand,1999;78:632-635
13.JCAHO. An Introduction to Quality Improvement in Health Care,Chicago, JCAHO,1991
14.Kaplan RM. Behavior As the Control Outcome in Health Care:Am Psychol,1990;45:1211
15.Kelly CS. et. al. Improved Outcomes for Hospitalized Asthmatic Children using a Clinical Pathway:Ann Allergy Asthma Immuno,2000;84:509-516
16.Kucenic MJ, Meyers DG. Impact of a Clinical Pathway on the Care and Costs of Myocardial Infraction:The Jonrnal of Vascular Disease,2000;51(5):393-404
17.Loegering L. et. al. Measuring the Quality of Health Care:Clinical Obstetrics and Gynecology,1994;37(1):122-136
18.Liao SL. et. al. The Impact of a Clinical Pathway for Transurethral Resection of the Prostate on Costs and Clinical outcomes:J Formos Med Assoc,1998;97:345-350
19.Lauve RM, Martin LF. What Surgeons need to know to Help Patient Receive Quality Medical Care in Managed Care Settings:Am J Surg,1997;174:452-458
20.Manton KG. et. al. Use of Medicare Services Before and After Introduction of the Prospective Payment System:Health Services Research,1993;28(3):269-292
21.Paivi H-S,Sjoberg J. Evaluation and the Learning Curve of the First One Hundred Laparoscopic Hysterectmies:Acta Obstet Gynecol Scand,1995;74:638-641
22.Rubin HR. Can Patients Evaluate the Quality of Health Care?Medical Care Review,1990;47(3):267-326
23.Reiter RC. et. al. Routine Hysterectmy for Large Asymptomatic uterine Leiomymata:A reappraisal:Obstet Gynecol,1992;79:481
24.Reiter RC. et. al. Consumer Advocacy,Elective Surgery and the "Golden Era of Medicine" Obstet Gynecol,1989;74:815-817
25.Summitt RL. Laparoscopic-Assisted Vaginal Hysterectmy:A Review of Usefulness and Outcomes:Clinical Obstetrics and Gynecology,2000;43(3):584-593
26.Sanfilippo J. Looking Down the Prospectoscope:Obstetrics /Gynecology in the Year 2000 and Beyond:Clinical Obstetrics and Gynecology,1997;40(2):395-401
【中文部份】
1.中央健康保險局新聞稿:人工股(髖)關節置換術實施論病例計酬制度後的病人醫療利用與醫療費用申報。8月,2000
2.朱樹勳等人:臨床路徑---理論與實務。翰蘆圖書出版有限公司,2000;9-10
3.李玉春:健康保險支付制度。於楊志良主編,健康保險(三版),1998;72-117
4.李佳霙:探討中部五縣市民眾的健康狀況與醫療利用間的相關研究:SF-36健康量表的合適性。中國醫藥學院環境醫學研究所碩士論文,1997
5.李瑤琴:臨床路徑對資源耗用醫療品質與病例組合之效應研究---以某醫學中心之腹腔鏡膽囊切除術為例。中國醫藥學院醫務管理學研究所碩士論文,1999
6.林儀品:從腹腔鏡膽囊切除術探討術後醫療品質---以某醫學中心與某區域醫院為例。中國醫藥學院醫務管理學研究所碩士論文,1996
7.周思源:論病例計酬制度下醫師績效評估與醫師費模式之建構---以消化外科為例。中國醫藥學院醫務管理學研究所碩士論文,1999
8.郭守仁:醫療品質專題座談。民生報3月19日,2001
9.黃金山:健保論病例計酬實施前後醫療資源耗用之分析---以某區域醫院四項外科系論病例計酬為例。中國醫藥學院醫務管理學研究所碩士論文,1998
10.莊逸洲:前瞻性支付制度之醫療管理模式建立與實證。中國醫藥學院醫務管理學研究所碩士論文,1994
11.鄭乃木、謝明娟:醫務會計及財務管理,第十章單項醫療成本分析,1995 ; 244-267
12.賴憲堂:全民健康保險下疾病分類編碼品質與相關影響因素研究。國立台灣大學公共衛生研究所碩士論文,1996
13.蔡文正:醫療品質管理課堂講義。中國醫藥學院醫務管理學研究所,10月,2000
QRCODE
 
 
 
 
 
                                                                                                                                                                                                                                                                                                                                                                                                               
第一頁 上一頁 下一頁 最後一頁 top
系統版面圖檔 系統版面圖檔