臺灣博碩士論文加值系統

台灣地區於民國八十四年三月開始實施全民健康保險，第一年被保險人口就佔總人口比例的89.54%，以後逐年增加到約95%，健保局幾乎成為醫療提供者收入的單一付費者，而且是統一付費標準，因此健保的支付制度對醫療提供者的財務有非常大的影響和衝擊。
醫療費用不斷的上漲是全世界共通頭痛的問題，全民健保開辦之初，延續公、勞保時代的支付制度，採取回溯性的論量計酬(fee for service, FFS)的方式，這樣的支付制度缺乏節約的機制，當然造成醫療費用不斷的上漲，對全民健保的財務造成沈重的負擔。因此健保局試圖以論病例計酬制(case payment)的支付方式來扼制論量計酬制的不當消耗醫療資源。民國八十八年三月止，中央健保局總共對26種疾病50項目的處置實施論病例計酬。其中與惡性腫瘤有關的項目只有乳癌乳房部分切除併腋下淋巴結廓清術及乳房全部切除根治手術。
本研究以某公立地區醫院之乳癌乳房全部切除根治手術之病例，收集健保局於民國八十八年七月一日實施論病例計酬前後各100個病歷，共200病歷的住院電腦批價檔案作統計分析，探討論病例計酬對乳癌乳房全部切除手術之醫療資源耗用的情形。
研究結果之重要發現如下：
(一)醫師別與病人特質方面包括年齡及疾病嚴重度並不影響乳癌乳房全部切除根治手術住院期間醫療資源的耗用，而且實施前後年齡及疾病嚴重度並無顯著差異。
(二)在實施論病例計酬後住院日由平均15.75日降至11.42日減少4.33日，還是比健保局規定的8日高，因此醫院在減少住院日方面還有努力的空間，全部住院費用由平均74,500.81元降至49,684.51元降低24,816.3元，健保申報金額由69,500.13元降至46,163.71元降低23,336.42元，檢驗費由3,593.47元降至1,853.24元降低1,740.23元，藥品費由9,312.61元降至2,567.09元降低6,745.52元，手術費由14,818.91元降至9,652.40元降低5,166.51元，病房費由10,335.24元降至7,734.54元降低2,600.7元，自費金額由5,000.68元降至3499.11元減少1521.57元。似乎改善非常明顯，但是除了住院天數降低，減少病房費及藥品費降低有意義外，其餘都是因為有些手術及處置和檢查費移轉至門診所致，若只作乳房乳癌全部切除根治手術，沒有乳房腫瘤切片手術及化學抗癌藥物治療，則住院天數在論病例計酬實施前後並沒有顯著差異，分別為12.87天及11.42天，P=0.105。藥品費的降低主要是因為化學抗癌藥物的治療轉移至門診及注射抗生素減少所致，注射抗生素減少由9.58支降至4.18支減少43.6%，531元，但是口服抗生素並未減少。論病例計酬實施後，病人的自費金額沒有增加反而下降，但未達統計學上的顯著差異(P=0.057)。
(三)乳癌病患對醫療資源的耗用以化學抗癌藥物治療及末期病患併發症的處理遠比手術要多許多。乳癌的患者只要早期診斷早期治療，零期與第一期患者手術後再加上荷爾蒙及化學抗癌藥物的輔助治療可達90%以上的5年存活率而很少會因為轉移而增加醫療資源的耗用。但是台灣乳癌患者零期及第一期患者僅20%，遠比美國60%為低、第二期44%（美國20%）、第三期和第四期佔36%（美國20%），因此如何降低乳癌對醫療資源的耗用，最重要的是如何加強乳癌的篩檢以便早期診斷、早期治療，才能減少醫療資源的耗用及健保的財務負擔，而且確保婦女的健康。但是論病例計酬的實施將能夠在門診進行的檢查、檢驗、治療處置、手術及化學抗癌藥物治療轉移至門診，而減少不必要的住院天數，因而減少住院時院內感染的機會，這是正確的方向。值得肯定。

The Bureau of National Health Insurance program was launched on March 1st 1995 in Taiwan. The insurants were 89.54% of the population in the first year, then increased to 96.1% next year. The Bureau of National Health Insurance had became the only standard paymaster to the medical providers. It had a great influence and shock on them, too.
The raising medical fee was an annoy common problem all over the world. The Bureau of National Health Insurance adopted the system of payment by Civil and Labour Insurance which was lack of effective utilization under “Fee-for-Service”. So The Bureau of National Health Insurance couldn’t afford this financial problem, and tried to use the Case Payment instead of “Fee-for-Service”, to prevent wasting medical resources. Up to date of March, 1999, The Bureau of National Health Insurance had applied Case Payment to 50 items of 26 diseases. Among them, there were only Partial Mastectomy with Dissection of Axillary Lymphatics and Modified Radical Mastectomy related to Malignant tumor.
This research was based on cases of Modified Radical Mastectomy of Breast Cancer in a public district hospital, it showed 200 patients from the computer files of admitted patients, 100 patients paid under Fee-for Service and 100 patients paid under Case Payment after the implementation of BNHI on July 1st, 1999. The study analysed that the effects of Case Payment on health resources utilization of Modified Radical Mastectomy for Breast Cancer.
Results of this research are as follows:
(1) There was no significant difference between doctors and patients’ characters, ages and diseases, and no big influence on health resources utilization after the implementation of Case Payment on the case of Modified Radical Mastectomy.
(2) After the implementation of Case Payment, the length of stay was reduced by 4.33 days from 15.75 days to 11.42 days, but it was still 8 days higher than the limitation of The Bureau of National Health Insurance. Therefore, this public district hospital still needed to work hard on reducing the length of stay. The length of stay expenditure was reduced by 24,816.3 NTdollars from 74,500.81 NTdollars to 49,684.51 NTdollars , the charges from The BNHI was reduced by 23,336.42 NTdollars from 69,500.13 NTdollars to 46,163.71 NTdollars , the laboratory examination expenditure was reduced by 1,740.23 NTdollars from 3,593.47 NTdollars to 1,853.24 NTdollars , medication expenditure was reduced by 6,745.52 NTdollars from 9,312.61 NTdollars to 2,567.09 NTdollars , operation expenditure was reduced by 5,166.51 NTdollars from 14,818.91 NTdollars to 9,652.40 NTdollars , the length of stay expenditure was reduced by 2,600.7 NTdollars from 10,335.24 NTdollars to 7,734.54 NTdollars and the out-of-pocket payment was reduced by 1,521.57 NTdollars from 5,000.68 NTdollars to 3,499.11 NTdollars. It seemed that had improved apparently, such as the decrease of length of stay expenditure, maternal stay expenditure and medication expenditure, except for operation expenditure and exam. Expenditure had been shifted to outpatient care prior to admission. There was no significant difference between the implementation of Case Payment and the length of stay without Breast Tumor Biopsy and Chemotherapy. The length of stay was reduced by 0.105 day from 12.87 days to 11.42 days, medication expenditure decreased by Chemotherapy and injection antibiotic shifting to clinic. Injection antibiotic was reduced by 43.6%, 531 NTdollars from 9.58 injection to 4.18 injection, but except for oral antibiotic. It still had not achieved the significant difference on statistics after the implementation of Case Payment, and for patients’ out-of-pocket payment didn’t raise but decrease.
(3) The health resources utilization on Breast Cancer patients by Chemotherapy and complications of terminal stage had charged much more than operation expenditure. If the breast cancer patients could get early diagnosis and early treatment, 90% of patients of Stage 0 and Stage 1 would survive more than 5 years with hormone and Chemotherapy after operation. But Stage 0 and Stage 1 breast cancer patients were 20% in Taiwan which was much lower than 60% in U.S.A. The Stage 2 of breast cancer patients were 44% in Taiwan (20% in U.S.A.) The Stage 3 and Stage 4 breast cancer patients were 36% in Taiwan. (20% in U.S.A.) How to decrease the health resources utilization? The most important thing is that how to get the early diagnosis and treatment on breast cancer patients, in order to reduce health resources utilization and to solve The Bureau of National Health Insurance’s financial problem, to promote women’s healthy. The implementation of Case Payment had reduced the length of stay and infection in the hospital. It had transferred successfully some laboratory exam, treatment, operation and chemotherapy to out patients department. It was worthy of affirmation.

摘 要………………………………………………………………………… Ⅰ
英文摘要………………………………………………………………………Ⅳ
誌 謝………………………………………………………………………… Ⅷ
目錄……………………………………………………………………………Ⅸ
表目錄………………………………………………………………………ⅩⅠ
圖目錄………………………………………………………………………ⅩⅡ
第一章 緒 論 ……………………………………………………………… 1
第一節 研究背景與動機……………………………………… 1
第二節 研究目的……………………………………………… 4
第三節 研究的重要性………………………………………… 5
第四節 名詞界定……………………………………………… 7
第二章 文獻探討 ………………………………………………………… 14
第一節 支付制度與醫療資源耗用關係………………………14
第二節 影響住院日及醫療費用的相關因素…………………18
第三節 乳癌疾病的探討………………………………………23
第三章 研究材料與方法 ………………………………………………… 30
第一節 研究架構………………………………………………30
第二節 研究問題與假設………………………………………31
第三節 研究對象………………………………………………32
第四節 研究變項及操作型定義………………………………33
第五節 資料處理與分析………………………………………34
第四章 研究結果 …………………………………………………………37
第一節 描述性統計 …………………………………………38
第二節 不同支付制度與醫療資源耗用之分佈比較…………55
第三節 影響住院日、醫療費用及各項費用之複迴歸分析…72
第五章 討 論……………………………………………………………… 80
第一節 結果討論………………………………………………80
第二節 研究限制………………………………………………87
第六章 結論與建議 ……………………………………………………… 88
第一節 結 論 …………………………………………………88
第二節 建 議 …………………………………………………91
參考文獻 …………………………………………………………………… 94
附 錄…………………………………………………………………………104

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