臺灣博碩士論文加值系統

近年來我國的剖腹產比率雖略有下降仍維持在32%至34%之間，居高不下。剖腹產率高漲已是世界性的趨勢和待解的難題。健保局陸續在各個分局實施「全民健康保險週產期前瞻性支付制度」試辦計畫。健保局希望由支付制度著手，將現行論量計酬、論病例計酬改為論人計酬之前瞻性支付制度以期達到整合性醫療照護的目的及降低剖腹產率。本研究的主要目的如下（1）了解剖腹產率是否因導入論人計酬支付方式而下降（2）分析醫師行為在論人計酬下和論病例計酬下是否有所差異。（3）論人計酬可能出現的選擇病人情形有無發生。資料蒐集方式為向國民健康局申請新生兒出生通報檔。蒐集資料範圍包括高雄市、高雄縣、屏東縣和澎湖縣之生產資料。蒐集時間自民國九十一年四月一日至民國九十二年十二月三十一日。參加試辦者之剖腹產率有明顯的減少剖腹產率由39.6%降為37.9%。醫師工作型態改變最大的是星期六的前胎剖腹產指數明顯減少。星期六前胎剖腹再次剖腹產的部分於2002年指數是112.0，這項指數在2003年降為101.6。規避風險選擇病人等現象在本次試辦計畫中並未出現•參加試辦者嘗試陰道產的意願提高了，包括剖腹產後陰道產比率提升及初次剖腹產的比率由28.11%減少為26.43% 。試辦計畫有顯著提升醫療品質之效果。

The cesarean delivery rate of Taiwan area remains high between 32% and 34% in the recent years. The escalating cesarean rates have become a global trend and an urgent issue to be solved. Several divisions of the Bureau of National Health Insurance implement the prospective perinatal prepayment project for the purpose of health care improvement and diminution of high cesarean rate in the year 2003. The project shifts the payment system from original case payment to capitation reimbursement. The aims of the study were (1) to find out whether the cesarean rate would decrease or not after the implementation of the experimental capitation project (2) to realize the difference of obstetrician’ behavior under the capitation and case payment systems (3) to observe whether the case selection phenomenon of capitation payment system develop in the experimental project or not. Data collection was from the Bureau of National Health by means of birth certificate notification. The sample were confined to Kaohsiung City, Kaohsiung County, Pintong County and Penhu County within the period from Apr. 1 2002 to Dec. 31 2003. The participants had lower cesarean rate in year 2003 than that of the year 2002. One of major change of obstetrician’ behavior was the repeat cesarean delivery index markedly decreased during the experimental period. The case selection phenomenon, which could happen in the capitation payment system, did not appear in this study. The participants had more willing to try vaginal delivery than those did not participate, including higher rate of vaginal delivery after previous cesarean and lower rate of primary cesarean. The researcher fined out that the experimental project did improve health care quality of delivery.

目 錄
第一章 緒論
第一節 研究背景與動機……………………………………… 1
第二節 研究目的……………………………………………… 7
第三節 研究重要性…………………………………………… 8
第二章 文獻評論
第一節 醫療支付制度………………………………………… 10
第二節 週產期照護品質指標………………………………… 19
第三節 剖腹產率……………………………………………… 22
第四節 醫師行為……………………………………………… 30
第五節 高屏地區「全民健康保險週產期前瞻性支付制度」試 辦計畫 ……………………………………………… 34
第三章 研究方法
第一節 研究架構……………………………………………… 40
第二節 研究變項定義與名詞解釋…………………………… 43
第三節 研究假設……………………………………………… 47
第四節 研究對象與樣本選擇………………………………… 48
第五節 資料分析與統計方法………………………………… 50
第四章 研究結果
第一節 醫療院所與樣本生產資料描述……………………… 52
第二節 剖腹產率……………………………………………… 56
第三節 各週日剖腹產相對指數……………………………… 64
第四節 早產兒及低体重兒…………………………………… 69
第五節 嘗試陰道產意願……………………………………… 71
第六節 選擇病人病例組合 …………………………………… 77
第五章 討論
第一節 費用………………………………………………… 84
第二節 剖腹產率……………………………………………… 86
第三節 性別、國籍與剖腹產率……………………………… 90
第四節 醫師工作型態………………………………………… 92
第五節 疾病組合……………………………………………… 94
第六節 早產兒、低体重兒與極低体重兒…………………… 96
第七節 研究限制………………………………………………… 97
第六章 結論與建議
第一節 結論…………………………………………………… 98
第二節 建議…………………………………………………… 101
參考文獻
中文部分 …………………………………………………… 103
英文部分 …………………………………………………… 105
附錄A…………………………………………………………… 112
附錄B …………………………………………………………… 117
附錄C …………………………………………………………… 118
表目錄
表1-1 中央健康保險局高屏分局週產期孕產婦全程照護紀錄表… 6
表2-1 現行論病例計酬孕產婦產前檢查之給付時程及服務項目… 20
表2-2 全民健保產前檢查利用率…………………………………… 21
表4-1 參加與未參加試辦院所與樣本生產資料描述……………… 53
表4-2 參加與未參加試辦院所依醫院層級與樣本生產案件統計… 54
表4-3 參加與未參加試辦院所依縣市別與樣本生產數…………… 55
表4-4 參加試辦計畫前後剖腹產率與全國剖腹產率對照表……… 56
表4-5 未參加試辦計畫院所層級別剖腹產率與全國剖腹產
率對照表…………………………………………………… 57
表4-6 參加試辦計畫院所縣市別剖腹產率……………………… 58
表4-7 未參加試辦計畫院所縣市別剖腹產率…………………… 59
表4-8 嬰兒性別與出生体重剖腹產之關係統計表……………… 62
表4-9 產婦國籍別與出生体重剖腹產之關係統計……………… 63
表4-10 2003年參加組各週日依生產方式之生產發生指數…… 64
表4-11 2002年參加組與美國各週日之活產平均數及依生產方
式之生產發生指數 ……………………………………… 65
表4-12 2003年未參加試辦之院所各週日之活產平均數及依生
產方式之生產發生指數 …………………………………… 66
表 4-13 2002年未參加試辦之院所各週日之活產平均數及依生
產方式之生產發生指數 …………………………………… 67
表4-14 參加試辦組早產兒及低体重兒率…………………………… 70
表4-15 參加試辦計畫組剖腹產後陰道產率……………………… 72
表4-16 未參加試辦組剖腹產後陰道產率………………………… 72
表4-17 參加試辦計畫組再次剖腹產率…………………………… 73
表4-18 未加試辦計畫組再次剖腹產率………………………… 74
表4-19 參加試辦計畫組初次剖腹產率………………………… 75
表4-20 未參加試辦計畫組初次剖腹產率……………………… 75
表4-21 參加試辦院所前置胎盤發生率………………………… 78
表4-22 未參加試辦院所前置胎盤發生率……………………… 78
表4-23 參加試辦院所懷孕合併高血壓發生率………………… 79
表4-24 未參加試辦計畫院所懷孕合併高血壓發生率………… 79
表4-25 參加試辦計畫院所胎位不正發生率…………………… 80
表4-26 未參加試辦計畫院所胎位不正發生率………………… 81
表4-27 參加試辦計畫院所妊娠糖尿病發生率………………… 82
表4-28 未參加試辦計畫院所妊娠糖尿病發生率……………… 82
表5-1 參加試辦計畫生產費用對照表………………………… 85
圖目錄
圖1-1台灣地區近年剖腹產率……………………………………… 2
圖1-2世界各國之剖腹產率………………………………………… 2
圖1-3美國近年之剖腹產率………………………………………… 4
圖2-1台灣地區嬰兒出生數………………………………………… 22
圖2-2總剖腹產率、初次剖腹產率及前胎剖腹產後陰
道產率………………………………………………………… 27
圖2-3高屏地區週產期醫療體系服務流程………………………… 37
圖3-1研究架構……………………………………………………… 39
圖3-2研究流程……………………………………………………… 40
圖4-1參加試辦計畫組剖腹率月線圖……………………………… 58
圖4-2 未參加試辦計畫組剖腹率月線圖…………………………… 58

參考文獻
丁芳（1995）。耐糖不良與妊娠糖尿病孕婦與新生兒週產期併發症之研究。國立陽明醫學大學，未出版碩士論文
古智愷（2002）醫師與醫院管理者對剖腹產管理指標認知、態度與行為之研究。未出版碩士論文
江東亮 (2000)。談全民健保制度下的三個矛盾。全民健康保險，第11期，4-5頁。
李玉春 (1996)。健康保險支付制度。健康保險，楊志良(編)，巨流圖書公司， 67-110頁
李隆生 （2000）全民健保改制－HMO 是答案嗎？ 醫院 3（6），33－39
健保局北區分局（2003）北區分局週產期前瞻性支付制度試辦計畫之監測指標
健保局高屏分局（2003）高屏分局週產期前瞻性支付計畫
莊世杰 （2002）論病例計酬對醫師診療行為之影響－以某區域教學醫院鼻中隔鼻道成形術為例。義守大學管理科學研究所，未出版碩士論文
莊逸洲、黃崇哲(2000)。組織經營。經營理念，第一版(18-46頁)。台北：華杏。
郭信智 楊志良（1994）。醫師目標收入理論之試證。中華公共衛生雜誌13:2 149-155頁
陳先煒（2003）週產期前瞻性支付制度”試辦計劃對孕產婦醫療照護品質與醫師行為之影響。長庚大學醫務管理研究所，未出版碩士論文。
楊志良(1998)。健康保險： 健康保險，楊志良(編)，第三版，台北: 巨流圖書。6-19頁
楊昱琦（2001）。醫院服務支付制度對住院醫療費用之影響。逢甲大學保險學系未出版碩士論文
雷文玫 （2001）美國老年國民健康保險「健康維護組織」法制改革之研究－尋繹對於我國全民健康保險法制改革之啟示。中原財經法學 7：107－158頁
劉見祥 (1999)。全民健保支付之趨勢。醫院，第32卷，第6期，15-20頁
衛生署 （2002）。衛生署/相關資料/婦女相關統計
衛生署（2002）。衛生署/相關統計/生命統計/91/05.XLS
衛生署（2002）全民健康保險孕婦產前檢查申報報案件
衛生署（2002）統計資料/衛生統計年報/91/2衛生指標/表10.xls
鄭丞傑（2000）婦產科醫師與助產士的分與合 醫望雜誌30卷, 88－91 頁
賴美淑 (2000)。讓全民健保的明天更美好。全民健康保險。第11期1頁
韓揆（1997）。公共衛生學：醫院的功能組織與管理，陳拱北預防醫學基金會編，修訂二版，台北：巨流圖書，254－258 頁
羅紀瓊 (1998)。健康保險：健康保險財務制度，楊志良(編)，第三版。台北: 巨流圖書。40-48頁
Reference:
Bailey, J.E., Van, Brunt, D. L. Mirvis, D. M.,（1999） Academic Managed Care Organization and Adverse Selection Under Medicaid Managed Care in Tennessee. JAMA, 282: 1067－1075
Baumol, W.J. （1988）Monograph: Price Controls for Medical Services and the Medical Needs of the Nation’s Elderly. Chicago; American Medical Association. Connecticut medicine Aug; 52 (8), 485－94
Berwick, D.M. （1996）Payment by Capitation and the Quality of Care. N ENGL J MED, 335; 1227－1231
Carey, T.S., Weis, K, Homer, C. （1990） Prepaid versus traditional Medicaid plans: effects on preventive health care. J Clin Epidemiol;43:1213-20
Carey, T.S., Weis, K.（1990） Diagnostic testing and return visits for acute problems in prepaid, case-managed Medicaid plans compared with fee-for-service. Arch Intern Med;150:2369-72.
Carey, T.S.., Weis, K. Homer, C. （1991）Prepaid Versus Traditional Medicaid Plan: Lack of Effect on Pregnancy Outcomes and Prenatal Care. Health Serv Res 26: 165－81
Carla, F.（2003）. Caesarean section rates skyrocket in Brazil. The lancet.362, 628
Carlisle, DM, Siu, AL, Keeler, EB, （1992） HMO vs fee-for-service care of older persons with acute myocardial infarction. Am J Public Health;82:1626-30
Clement, D.G., Retchin S.M., Brown, R.S., Stegall M.H.,（1994） Access and outcomes of elderly patients enrolled in managed care. JAMA;271:1487-92. JAMA;272:276
Cunningham, F.G. （2001）Williams Obstetrics. The McGraw-Hill Companies, Inc.
Danel, I, Johnson, C., Berg, C., Flowers, L., Atrash, H.（1997） Length of maternal hospital stay for uncomplicated deliveries, 1988-1995: the impact of maternal and hospital characteristics. Matern Child Health J;1:237－42
Feldman, R., Sloan, F. （1988）Competition among Physician, revisited? Journal of Health Politics, Policy and Law 13: 2, 239－261
Fetus and Newborn Committee.（1996） Policy statement: early discharge and length of stay for term birth: a joint policy statement by the Canadian Paediatric Society and the Society of Obstetricians and Gynaecologists of Canada. Journal of the Society of Obstetricians and Gynaecologists of Canada;18:1281－5
Flamm, B.L., Goings, J.R., Yunbao, L.（1994） Elective repeat cesarean delivery versus trial of labor: A prospective multicenter study. Obstet Gynecol; 83:927－932
Flamm, B.L., Geiger, A.M. （1997）Vaginal birth after cesarean delivery: An admission scoring system. Obstet Gynecol, 90: 907－912
Freund, D.A., Rossiter, L.F., Fox, P.D., .（1989） Evaluation of the Medicaid Competition Demonstrations. Health Care Financ Rev;11(2):81- 97
Glazener, C.M.A., Abdalla, M, Stroud P., Naji, S., Templeton A, Russell I.T.（1995） Postnatal maternal morbidity: extent, causes, prevention and treatment. Br J Obstet Gynaecol;102:282-7.
Goldenberg, R.L., Rouse, D.J. （1998）Prevention of premature birth. New England Journal of Medicine. 339(5):313-20
Government Printing Office （1993） General Accounting Office. Medicaid: states turn to managed care to improve access and control costs. Washington, D.C. GAO/HRD-93-46.
Government Printing Office（1988）General Accounting Office. Medicare: physician incentive payments by prepaid health plans could lower quality of care. Washington, D.C.GAO/HRD-89-29
Government Printing Office（1996）. General Accounting Office. Medicare HMOs: rapid enrollment growth concentrated in selected states. Washington, D.C GAO/HEHS-96-63.
Greenfield, S., Rogers, W., Mangotich, M., Carney, M.F., Tarlov, A.R.（1995） Outcomes of patients with hypertension and non-insulin-dependent diabetes mellitus treated by different systems and specialties: results from the Medical Outcomes Study. JAMA;274:1436-44
Grimes, D.A.（1994） The morbidity and mortality of pregnancy: still risky business. Am J Obstet Gynecol;170:1489－94.
Hall, M.H., Carr-Hill, R. (1982) Impact of sex ratio on onset and management of labour. BMJ 285:401-3
Harlow, BL., Frigoletto, F.D., Cramer, D.W., Evans, J.K., Bain, R.P., Ewigman, B. McNellis, D. ( 1995) Epidemiologic predictors of cesarean section in nulliparous patients at low risk. Routine Antenatal Diagnostic Imaging with Ultrasound Study. American Journal of Obstetrics & Gynecology 172(1 Pt 1):156-62
Health Care Financing Administration. (1996）1996b. Medicare and Medicaid statistical supplement,. Pub. No. 03386. Baltimore, MD: Department of Health and Human Services.
Health Insurance Institute (1969) Modern health insurance New York.
Hillman, A.L., Pauly, M.V., Kerstein, J.J.（1989） How do financial incentives affect physicians'' clinical decisions and the financial performance of health maintenance organizations? N Engl J Med;321:86－92
Hillman, A.L., Pauly, M.V., Kerstein, J.J.（1989） Prepaid versus traditional Medicaid plans: lack of effect on pregnancy outcomes and prenatal care. Health Serv Res;26:165－81
Hohlen, M.M., Manheim, L.M., Fleming, G.V. （1990） Access to office-based physicians under capitation reimbursement and Medicaid case management: findings from the Children''s Medicaid Program. Med Care;28:59-68.
Hsiao, W.C.（1995）Medical savings accounts: Lessons from Singapore. Health Affairs 14, (2): 260-266
Hsieh, C.C., Hsieh, T.T., Soong, Y.K.（1990）Prevalence of cesarean section in Chang Gung Memorial Hospital, 1984-1989. Changgeng Yi Xue Za Zhi. 13(4):282-9.
King, H.（1998）Epidemiology of glucose intolerance and gestational diabetes in women of childbearing age. Diabetes Care. 21 Suppl 2:B9-13
Ko, Y.L., Wu, Y.C., Chang, P.C. (2002) Physical and social predictors for pre-term and low birth weight infants in Taiwan. JNR, 10:83-9
Koch, A.L.（1993） Financing health services. In Introduction to Health Services. 4th eds. S.J. Williams and P. R. Torrens, 299－331. Albany, NY: Delmar Publishers.
Krieger, J., Connell, F., Logerfo, J. （1992）Medicaid Prenatal Care: A Comparison of Use and Outcomes in Fee-for Service and Managed Care. Am J Public Health. 82: 185－90
Leaf, A. （1984）The doctor’s dilemma and society’s too. N Engl J Med 310: 718－21
Leape, L.L., Park, R.E., Solomon, D.H. （1990）Does inappropriate use explain small-area variations in the use of health care services? JAMA 263:669－72
Leung, A.S., Leung, E.K., Paul, R.H.（1993） Uterine rupture after previous cesarean delivery: Maternal and fetal consequences. Am Obstet Gynecol;169:945-950
Liu, S., Heaman, M. K., Michael, S. D., Kitaw, W. S., Wu, M. S.（2002 ）Length of hospital stay, obstetric conditions at childbirth, and maternal readmission: A population-based cohort study. American Journal of Obstetrics and Gynecology 187(3) 681－687
Lurie, N., Christianson, J., Finch, M., Moscovice, I.（1994） The effects of capitation on health and functional status of the Medicaid elderly: a randomized trial. Ann Intern Med;120:506-11
Lydon-Rochelle, M, Holt, V.L., Martin, D.P., Easterling ,T.R.（2000）Association between method of delivery and maternal rehospitalization. JAMA;283:2411－6.
Malkin, J.D. （2001） Not As much As You Think: Toward a True Estimate of the Difference in Direct Medical Costs Between Vaginal and Cesarean Deliveries. British Journal of Obstetrics and Gynecology; 108（2）, 149－157
McClellan, M.,D. Kessler. (1999) A global analysis of technological change in health care: The case of heart attacks. Health Affairs 18 (3): 250-257
McMahon, M.J. （1998）Vaginal birth after cesarean. Clinical Obstetrics & Gynecology, 41（2）; 369－381
Meikle, S.F., Lyons, E., Hulac, P., Orleans, M.（1998）Rehospitalizations and outpatient contacts of mothers and neonates after hospital discharge after vaginal delivery. Am J Obstet Gynecol;179:166－71.
Miller, R.H., Luft, H.S. （1980）Managed care plan performance since: a literature analysis. JAMA 1994;271:1512－9
Ming, T.S. （2001）The Long-Term of Medicaid Managed Care on Obstetric Care in Three California Counties. Health Serv Res August.
Morita, N., Matsushima, N., Ogata, N., Saeki, K., Ishibashi, M., Komukai, H., Matsuda, R., Kurumatani, N. （2002） Nationwide description of live Japanese births by day of the week, hour, and location. Journal of epidemiology 12 (4), 330－5
Morrisey, M.A., Alexander, J., Burns, L.R. （1999）The effect of managed care on physician and clinical integration. Med Care 37: 350－361
Murray, J.P., Greenfield, S., Kaplan, S.H., Yano, E.M. （1992）Ambulatory testing for capitation and fee-for-service patients in the same practice setting: relationship to outcomes. Med Care;30:252－61
Nadler, E.S., Sims, S., Tyrance, P.H. （1999）Does a year make a difference? Changes in physician satisfaction and perception in an increasingly capitated enviroment. Am J Med 107: 38－44
National Vital Statistic Reports,（2001） Births: Final Data for 1999; Volume 49, Number 1 April
National Vital Statistic Reports,（2003） Births: Preliminary Data for 2002 . Volume 51, Number 11
National Vital Statistic Reports,（2003） Births: Preliminary Data for 2002 . Volume 51, Number 2
Oleske, D.M., Linn, E.S., Nachman, K.L., Marde, M.S., Thompson L.D.（1998）Cesarean and VBAC Delivery Rates in Medicaid Managed Care, Medicaid Fee-for-Service, and Private Managed Care BIRTH 25:2 .125－127
Oleske, D.M., Branca, M.L., Schmidt, J.B. （1998）A Comparison of Capitated and Fee-for-Service Medicaid Reimbursement Methods on Pregnancy Outcome. Health Serv Res, 33, 55－73
Phelan, J.P.（1996） VBAC: Time to reconsider? OBG Management; 11:62-68
Ransom, S.B. (1996) The Effect of Capital and Fee-For-Service Remuneration on Physician Decision Making in Gynecology? Obstetric Gynecology 87-5, 707－710
Ray, W.A., Gigante, J., Mitchel, E.F.（1998）Perinatal Outcomes Following Implementation of TennCare. JAMA, 279; 314－315
Retchin, S.M., Brow, B.（1990） The quality of ambulatory care in Medicare health maintenance organizations. Am J Public Health;80:411－5
Retchin, S.M., Brown, B.（1991） Elderly patients with congestive heart failure under prepaid care. Am J Med; 90:236－42
Retchin, S.M., Brown, B.（1990） Management of colorectal cancer in Medicare health maintenance organizations. J Gen Intern Med; 5:110-4
Retchin, S.M., Clement, D.G., Rossiter, L.F., Brown, B., Brown, R., Nelson, L.（1992） How the elderly fare in HMOs: outcomes from the Medicare Competition Demonstrations. Health Serv Res; 27:651－69
Rice, T.H., Labelle, R.J. （1989）. Do physicians induce demand for medical services? Journal of Health Policies, Policy and Law 14, no. 3: 587－600
Rose, VL.（1999）ACOG urges a cautious approach to vaginal birth after cesarean delivery. American Family Physician 60(4): 1245－6
Schlenker, R.E. （1986）. Case mix reimbursement for nursing homes. Journal of Health Politics. Policy and Law 11, no. 3: 445
Scott, J.R.（1991） Mandatory trial of labor after cesarean delivery: An alternative viewpoint. Obstet Gynecol;77:811－814
Shortell, S.M., Gillies, R.R., Anderson, A.D. （1994）New world of managed care: Creating organized delivery system. Health Aff 13: 46－64
Somers,A.R., Somers, H.M. (1977). Health and health care: Policies in perspective. Germantown, MD: Aspen Systems.
Sussman, A.J., Barbieri, R., Brennan, T. A. （2000） Global Capitation at a Women’s Health Referral Center: The Challenge of Patient Selection, Clinical Commentary. 96: 1018－1022
Thilo, E.H., Townsend, S.F., Merenstein, G.B.（1998）The history of policy and practice related to the perinatal hospital stay. Clin Perinatol;2:257－70
Tsai, Y.W., Hu, T.W.（2002）National Health Insurance, Physician Financial Incentives, and Primary Cesarean Deliveries in Taiwan . American Journal of Public Health, Vol. 92, Issue 9, 1514－1519
US department of health and Human Services,（2000） Public health service. Healthy People 2010: Objectives for Improving Health. Washington, DC: Author,
Ward, R.A. （1987）HMO Satisfaction and Understanding Among Recent Medicare Enrollees. Journal of Health and Social Behavior 28: 401－402
Wen, S.W., Liu, S., Marcoux, S., Fowler, D.（1998）Trends and variations in length of hospital stay for childbirth in Canada. CMAJ;158:875－80.
Williams, S.J.（1995）. Essentials of services. Albany NY: Delmar Publishers.
World health organization （1985） Appropriate technology for birth. Lancet:2,436－437