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研究生:王主科
研究生(外文):Jou-Kou Wang
論文名稱:兒童心臟醫療工作的資源基礎相對值之研究
論文名稱(外文):A Study of Resource Based Relative Value for Pediatric Cardiology
指導教授:葉疏葉疏引用關係
學位類別:碩士
校院名稱:國立臺灣大學
系所名稱:會計學研究所
學門:商業及管理學門
學類:會計學類
論文種類:學術論文
論文出版年:2004
畢業學年度:92
語文別:中文
論文頁數:56
中文關鍵詞:兒童心臟醫療資源基礎相對值作業基礎成本制
外文關鍵詞:pediatric cardiologyresource-based relative value scaleactivity-based costing
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健保局已開始研議診療項目的資源基礎相對值(RBRVS),日後將相對值轉換的金額作為給付標準,診療項目的相對值=醫師工作投入之相對值+執業耗用成本之相對值+醫療執業保險之相對值。本研究的目的在於探討兒童心臟醫療工作的資源基礎相對值應如何訂定,與成人心臟醫療的給付比較,加成應該是多少? 以兒童的心導管檢查及攝影的診療項目來作研究,探討:
一、新生兒至成年不同年齡層,不同病情複雜程度在兒童與成人耗用時間之差異。
二、以作業基礎成本制進行心導管檢查及攝影之成本分析,比較不同年齡層、病情複雜或單純對耗用成本之影響,並與健保局公佈第二版相對值的給付差異。
三、以問卷方式調查國內的小兒心臟科醫師,二十一種常用的診療項目,不同年齡病人所耗用時間、投入精力及加成的看法、對健保相對值之建議。
得到如下的結果:
一、病童年齡愈輕,尤其是6個月以下的嬰兒其檢查耗用時間愈長,若病情複雜所耗時間會愈多。

二、以作業基礎成本制算出的成本以0.5歲以下且病情複雜,耗用成本最高,給付金額與耗用成本的比值也在40%以下。
三、問卷調查的結果普遍認為1.兒童加成項目應擴大2.加成額度不足3.相對值與耗用醫師時間應等比率增加4.健保的相對值對兒童加成不足以及缺少精確計算耗用成本,且沒有考量醫療執業保險的支出。

由客觀的測定不同年齡層病人心導管耗用時間,以及作業基礎成本制分析,並以問卷調查結果佐證,兒童心臟醫療耗用的成本比成人高出許多,給付明顯不足,複雜性心臟病成本比簡單性心臟病成本高,若導入相對值時應考慮年齡與疾病複雜程度給予一個修正值。
The national insurance bureau is developing resource based relative value scale (RBRVS) as a reimbursement system for medical service in Taiwan. The relative value scale (RVS) is calculated as following: RVS = RVUw+RVUPE+ RVUmalp. Then RVS is converted to amount of money by a conversion factor. The purpose of this study aims to compare the pediatric cardiology work relative value to those of adult cardiology. The procedure time of cardiac catheterization and angiography in children and infants were measured in patients admitted to this hospital. The costs of the above procedures were also calculated using activity-based costing (ABC). The reimbursement for the above procedure from the national insurance bureau was used to compared the costs of the procedure in patients with different ages and different complexity. Questionnares regarding the procedure time and relative value scale in 21 current procedure terminologies in children were surveyed among pediatric cardiologists. The results of the studies showed the mean procedure time of cardiac catheterization and angiography in infants were significantly longer than that in older children and adults. The more complexity of the heart disease, the longer procedure time will be. The cost of the procedure incurred is inversely related to mean age of the patients and is positively related to complexity of heart disease. The ratio of reimbursement to cost is far below 40%, if the diagnosis is complex heart disease. The results of guestionnare are similar to this study and could be used to support the results of the current study. All participants agreed that the relative value for pediatric cardiology work is significantly higher than those of abult cardiology. The RBRVS which will be implemented in Taiwan should be carefully reevaluated since there is no malpractice insurance RVS and the reimbursements for pediatric cardiology are far below the costs. Therefore, it is concluded that age and complexity in diagnosis should be used as a modifier in the calculation of RVS, particulary a younger age is frequently associated with more difficulties in procedures. The costs estimated with ABC are significantly higher than reimbursements.
第一章 緒 論 1
第一節 研究動機與背景 1
第二節 研究目的 2
第三節 論文架構 2

第二章 文獻及歷史回顧 4
第一節 兒童相關醫療相對於成人醫療成本與給付差異 4
第二節 兒童相關醫療之現狀 5
第三節 RBRVS之發展過程 7

第三章 研究方法 10
第一節 依據作業基礎成本制,分析作業流程 11
第二節 調查心導管檢查及攝影在不同年齡層耗費時間 12
第三節 分析心臟檢查及治療的給付之是否合理 13
第四節 以問卷調查方式,瞭解該科別醫生主觀認定之
資源耗用情形 14








第四章 分析及回函結果 16
第一節 依據作業基礎成本制分析作業流程 16

第二節 心導管檢查及攝影在不同年齡層耗費時間與
RBRVS給付的計算 22
第三節 估計心臟檢查及治療的給付之合理加成比率 28
第四節 以問卷調查方式,瞭解該該科別醫生主觀認定之
資源耗用情形 33

第五章 研究結果與建議 38
第一節 研究結果彙總 38
第二節 研究限制 41
第三節 心得與建議 42
第四節 再探RBRVS的給付制度 45
參考書目 48
附錄 50
1.楊志良、陳琇玲、徐慧娟等:探討三種支付標準相對值方法美國RBRVS、健保局模式、台大台中模式之比較。台灣醫界2002;45:504-509
2.楊志良、陳琇玲、徐慧娟等:對健保局研訂醫療費用支付標準相對值(RBRVS)之分析與建議。台灣醫界2004;47:46-51
3.楊志良、陳琇玲、溫信財等:牙科處置耗用相對值表之探討。台灣衛誌2001; 20 : 475-484
4.張北葉:小兒科相對值之研究中華民國醫療精算學會 「以資源為基礎之相對點值合理性探討」2003
5.Hsiao WC,Braun P,Yntema D, et al:Estimating physicians’work for a resource-based relative-value (special report). N Engl J Med 1988; 319: 835-841
6.Hsiao WC, Yntema DB,Braun P, et al :Measurement and analysis of intraservice work. JAMA 1988 ; 260: 2361-2370
7.Hsiao WC,Braun P,Becker ER,et al:Resource-based relative values. An overview. JAMA 1988;260:2347-2353
8.American Academy of Pediatrics. Issue in the application of the resource-based relative value scale system to pediatrics: a subject review. Pediatrics 1998;102: 996-998
9.Grimaldi PL. Medicare fees for physician service are resource-based.J of Health Care Finance 2002;28:88-104
10.Melzer SM, Molteni RA, Marcuse EK, Rivara FP: Characteristics and financial performance of a pediatric faculty inpatient attending service : a resource-based relative value scale analysis. Pediatrics 2001; 108:79-84
11.Baker JJ, Boyd GF.:Activity-based costing in the operating room at Valley View Hospital. J Health care Finance 1997; 24 :1-9
12.Garson A.Jr, Wolk MJ.,Morrin SB, Gold W., Dickstein M, Dobson, A.:Resource based relative value scale for children-comparison of pediatric and adult cardiology work values. Cardiol Young 1995;5:210-216
13.Nisenbaum HL, Birnbuam BA,Myers MM, Grossman, RI, Gefter, WBB, Langlotz, CP. The costs of CT procedures in an academic radiology department determined by an activity-based costing(ABC) method. J of Comput Assist Tomogr 2000;24:813-823
14.Morehouse, DL, Elmore, JR, Franklin, DP, Youkey JR.Phisician work effort and reimbursement for ruptured abdominal aortic aneurysms. Am J of Surgery 1997;174:136-139
15.Zwolak Robert M.:Resource-based relative value scale(RBRVS), coding, and medicare reimbursement. Seminars in Vascular Surgery 1997;2:119-127
16.Laurila J, Suramo I, Brommels M, ToLppanen EM, et al. Activity-based costing in radiology:application in a pediatric radiological unit. Acta Radiologica 2000;41:189-195
17.Player S. Activity-based analyses to better decision making. Health Financ Manage. 1998;52:66-70
18.Glass KP, Anderson JR. Relative value units and cost analysis, part 3 of 4. J of Medical Practice Management.2002;18:66-70
19.Berlin MF. Evaluation of activity-based costing versus resource-based relative value costing. J Med Pract Management 2004; 19:219-227
20.Ross TK. Analyzing health care operation using ABC.J Health Care Finanace.2004;30:1-20
21.Harris-Shapiro J, Greenstein MS. RBRVS-1999 update. J Health Care Finance 1999;26 :48-52
22.Gallagher PE,Klemp T, Smith SL. Medicare RBRVS: The physicians’guide.2001 5th ed, Chicago.
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