臺灣博碩士論文加值系統

目的：探討台灣精神醫療市場競爭及其他因素，對精神病患精神醫療利用、品質與對精神醫療機構產出表現之影響。
方法：利用民國90年身份證加密之全民健保精神科門住診申報資料，以ICD-9-CM主診斷介於290-319之精神病患為對象。市場區域以縣市為單位。市場競爭程度採用賀芬達指標，分別以門診人次、費用，急慢性住院費用及住院日計算之。
結果：在精神病患檔部分，市場競爭程度愈高，每人次門診費用愈低、每人次急性住院費用較高、每人次急性住院日較短、發生急性住院14、30日再住院情形較高、對慢性住院費用的影響不顯著、且每人次慢性住院日高於中度市場競爭地區、慢性住院14、30日再住院情形低於中度競爭市場。在醫院權屬別方面，私立醫院門診費用、急慢性再住院情形較公立醫院高，急性住院費用、急慢性住院日較公立醫院低。醫院屬性方面，一般/綜合醫院精神科門診費用、急性住院費用較精神專科（教學）醫院高，急性再住院情形、慢性住院日較精神專科（教學）醫院低。
在機構檔部分，市場競爭程度愈高，每日門診人次低（p>0.05）、平均門診費用愈低、平均急性住院費用較低度競爭市場少（p>0.05）、平均急性住院日較長（p>0.05）、急性住院14、30日再住院率較高，對慢性住院費用、住院日、14、30日再住院率無統計上顯著影響。其他醫院特性方面，醫院層級愈高，醫院每日門診人次愈高。公立醫院之平均醫療費用較私立醫院高。
建議：由於低度競爭門診市場之每日門診人次及醫療費用較高，因此建議衛生署、健保局，避免低競爭程度之門診市場有壟斷的情形；急性住院照護高度競爭市場較低度競爭市場有較高之14、30日再住院率，且急性住院患者於私立醫院、精神專科醫院就醫，雖費用較低但再住院情形較高，建議政府應注意高度競爭急性住院照護市場的品質監控，降低再住院率，以減少醫療支出。在高度競爭環境下，精神醫療供給者應密切注意品質，以建立優勢。

Purpose: To investigate the effects of psychiatric market competition and other factors on the patients’ medical utilization, quality of care and hospitals’
performance in Taiwan.
Methods: The claimed data with scrambled ID of the outpatients and inpatients of psychiatry in 2001 was from the National Health Insurance database. The primary diagnosis code numbers of ICD-9-CM were between 290 and 319. The market area of psychiatric service was based on city or county. The Herfindahl-Hirschman Indexes were based on the amount of outpatient, the outpatient fee, inpatient fee and the length of stay. These indexes were used for the representation of the degree of the competitive
psychiatric market.
Results: In the patients’ profile, the outpatient fee was lower, acute inpatient length of stay was shorter, acute inpatient fee and 14 & 30 days readmission were higher (p<0.05) in the area of highly competitive psychiatric market. The chronic inpatient fee was not associated with the degree of the competitive psychiatric market (p>0.05). The chronic inpatients in the high competitive psychiatric market were with longer length of stays and lower 14 & 30 days readmission than those who lived in the middle competitive psychiatric market area (p<0.05). On the ownership of hospitals, the outpatient fee and 14 & 30 days readmission of private hospitals were higher than the public hospitals (p<0.05). The acute inpatient fee and length of stay of private hospitals were lower than the public hospitals (p<0.05). The outpatient and acute inpatient fee of general hospitals with psychiatric section were higher than the psychiatric hospitals, but with lower acute inpatient readmission and length of stay of
chronic inpatients (p<0.05).
□In the hospital profile, the daily amount of outpatient (p>0.05), outpatient fee (p<0.05), and acute inpatient fee (p>0.05) in the areas of high competitive psychiatric market were lower than the areas of low competitive psychiatric market. The length of stay (p>0.05) and readmission rate (p<0.05) of acute inpatient were higher in the areas of high competitive psychiatric market than the areas of low competitive psychiatric market, but not for the chronic inpatients (p>0.05). The daily amount of outpatient of medical centers were higher than regional and district hospitals (p<0.05). The average medical fee of
private hospitals was lower than the public hospitals (p<0.05).
Suggestion: Because of the high number of outpatients and higher medical fee in the areas of low-competitive psychiatric market, the Department of Health and the Bureau of National Health Insurance should set up policy to avoid monopolization. The government should also pay attention to the quality of care in order to reduce the readmission rate especially for the hospitals in the areas of highly competitive psychiatric market. The better quality of care should be the guarantee for the hospitals in the competitive psychiatric market.

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