臺灣博碩士論文加值系統

不同權屬別醫院之經濟行為研究
摘 要
目的：財產權理論認為私有醫院追求利潤最大化，將使私有醫院比財團法人醫院或公立醫院更具經營效率，可以減少醫療費用支出。然而，國外相關研究的結論卻相當不一致。本論文運用台灣全民健保資料，克服美國醫療體制繁複與資料取得等限制，實證分析不同權屬別醫院間醫療費用、診療與用藥密度、與獲取藥價差利潤等經濟行為之差異，並分析不同支付制度之影響。
方法：選取台灣地區於2002年1月至3月，全國地區教學醫院層級以上（含）醫院，六種常見主診斷（糖尿病、中風、肺炎、氣喘、剖腹產、闌尾切除）出院病人進行不同權屬別醫院之診療與用藥密度分析，並抽出同時期17,798名患者進行自付費用與醫療品質問卷調查，分析各項醫療費用之差異。藥價差初探之資料則來自2000年與2001年健保資料庫，門診與住院之「醫療費用清單」與「醫令清單」，分析2001年4月藥價基準調整前後，同成份不同廠商之使用量變化以探究藥價利潤的影響。
結果：研究期間全國六種主診斷之出院病人共計45,625人次。出院病人調查之問卷份數共6,725份，回收率為46.7%。經複迴歸及Logistic迴歸控制相關變項後，發現論病例計酬類主診斷，私有醫院明顯收取最高的民眾自付費用，即使是扣除掉病房差價後亦然。論量計酬類疾病中，公立醫院之自付費用、自付醫療費用、與醫療總費用最低，住院天數也較長。
私有醫院會因應不同支付制度調整其診療密度。對論病例計酬類主診斷，私有醫院之診療種類、數量、診療費用都比其它權屬別醫院低；然而，論量計酬類主診斷，私有醫院傾向使用較多的診療種類、診療數量與診療費用。用藥方面，私有醫院並未明顯因應不同支付制度而調整藥品費用，論病例計酬類診斷，財團法人醫院之用藥種類、費用、單價、與進口藥使用率皆較低；論量計酬類診斷，財團法人醫院之藥品費用仍然最低，但進口藥使用比率最高。
私有醫院是否傾向於追求藥品價差的最大利潤？本論文發現藥品使用量明顯與健保支付藥價之降價幅度相關，Logistic迴歸模式亦發現私有醫院比另二種權屬別醫院，明顯因應調價幅度改變其同成分藥品之使用量。且在調價之後，明顯停用被調降價格較多的廠牌，並以調降少的廠牌取代。
結論：在我國全民健保制度下，私有醫院藉由增加自付費用，改變診療密度，變更同成份藥品廠牌等行為，追求利潤最大化的企圖較其它權屬別醫院明顯，政府是否需介入監控，有待進一步研究。

Ownership and Hospital Behaviors
Abstract
Objectives: According to property rights theory, we assume that for-profit hospitals pursue profit-maximization, and they are likely to be more efficient than those of not-for-profits or public hospitals. Therefore, medical services offered by for-profit hospitals could be less expensive. However, findings from previous studies were not conclusive, which may due to the complicated insurance and payment system, and relatively limited data in the Unite States. Under Taiwan’s National Health Insurance (NHI), hospital behavior agrees with the assumption of property rights theory. This study took the advantage and analyzed hospital behaviors such as medical fees, diagnosis and medication frequencies, and changing medication among hospital with different ownership, while various payment systems were also considered.
Methods: Inpatient claim data filed in the period from January to March 2002 at all hospitals across the nation qualified as regional teaching hospitals and above were used; patients with six common principal diagnoses (i.e. diabetes, stroke, pneumonia, asthma, cesarean section, and appendectomy) were randomly selected. We distributed a structured questionnaire on medical fees and perceived quality to 17,798 selected patients. In order to study the switching medication behavior, another NHI database containing claim data of outpatient and inpatient in 2000 and 2001 were employed to examine the effect of fee schedule change in April 2001.
Results: A total of 6,725 questionnaires for discharged patients were successfully completed with a respond rate of 46.7%. Results from regression analyses, showed that for-profit hospitals charged significantly higher out-of pocket, even adjusting for the price difference in ward types. For those diagnoses reimbursed by fee-for-service (FFS) system, public hospitals had the lowest claim expense, out-of-pocket, and total medical expense, and had longer average length of stay.
We also found that for-profit hospitals adjusted their medical practice to best-fit different payment systems. For those diagnoses with fixed payments, their diagnosis and treatment items, quantity of orders, and medical fees are in general lower than their counterparts. For those diseases paid by FFS, for-profit hospitals used more diagnostic and treatment items, quantity of orders, and had higher claimed fees. However, concerning the medications, for-profit hospitals did not adjust medication usage to cope with different payment system.
Interestingly, price-related switch-medication behavior was found in the study. Results from logistic regression model, showed that for-profit hospitals significantly changed the quantities of medication of different brands according to their price changes. For-profit hospitals obviously discontinued the use of those brands with bigger reduction rate in the NHI payment scheme, and shifted to other brands with smaller reduction. This finding revealed the possibility that for-profit hospitals might maximize their income through medication kickbacks.
Conclusion: Under the National Health Insurance System, the tendency of for-profit hospitals pursuing maximized profit through charging higher out-of-pocket, changing frequencies of diagnostic and treatment orders according to payment methods, and switching medication brands based on drug profit more obviously than their counterparts. The need for government to monitor hospital behavior deserves further investigation.

目 次
第一章 緒論-------------------------------------------------------------------------------- 1
第一節 研究緣起--------------------------------------------------------------------- 1
第二節 研究目的--------------------------------------------------------------------- 7
第二章 文獻探討-------------------------------------------------------------------------- 9
第一節 醫院權屬別之定義-------------------------------------------------------- 9
第二節 國際間醫院權屬別分佈情況------------------------------------------- 14
第三節 醫院行為經濟理論-------------------------------------------------------- 16
第四節 美國醫院權屬別之歷史沿革------------------------------------------- 20
第五節 醫院權屬別與價格行為表現------------------------------------------- 31
第六節 診察與處置內容----------------------------------------------------------- 39
第七節 收取藥價差行為----------------------------------------------------------- 43
第三章 研究方法------------------------------------------------------------------------- 45
第一節 資料來源---------------------------------------------------------------------- 45
第二節 變項測量---------------------------------------------------------------------- 48
第三節 研究架構---------------------------------------------------------------------- 54
子題一 醫院權屬別與醫療價格之研究-------------------------------------- 53
子題二 醫院權屬別與診療密度及用藥密度分析------------------------ 56
子題三 醫院權屬別與藥價差之研究---------------------------------------- 58
第四章 結果------------------------------------------------------------------------------ 60
子題一 醫院權屬別與醫療費用----------------------------------------------- 61
子題二 醫院權屬別與診療密度及用藥密度分析------------------------- 65
子題三 醫院權屬別與藥價差--------------------------------------------------- 68
第五章 討論------------------------------------------------------------------------------- 76
子題一 醫院權屬別與醫療費用之討論-------------------------------------- 76
子題二 醫院權屬別與診療密度及用藥密度之討論---------------------- 80
子題三 醫院權屬別與藥價差之討論----------------------------------------- 83
第六章 結論與建議--------------------------------------------------------------------- 85
第一節 研究限制------------------------------------------------------------------- 85
第二節 政策建議------------------------------------------------------------------- 83
第三節 結論------------------------------------------------------------------------- 85
參考文獻--------------------------------------------------------------------------------------- 88

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