臺灣博碩士論文加值系統

　　本研究的目的在探討醫院行為和醫療結果的關係。醫療結果指標為心臟相關疾病住院病患出院後是否發生30天內死亡與再住院。資料主要來自國家衛生研究院發行之1998年至2008年健保資料庫，並依三個不同議題設定觀察期間。
首先，本研究探討總額預算支付制度的實施對治療密集度與醫療結果的影響。由於總額預算支付制度是一種回溯性的固定預算支付制度，醫療服務供給者的報酬原則上是依浮動點值計算給付。總額預算支付制度的實施讓醫院暴露在收入不確定的風險下，醫院有很強的誘因藉由增加服務量來維持目標收入。為避免其他因素的干擾，我們以2002年第3季西醫總額預算實施前後一年為研究期間，並以設定醫院固定效果的邏輯斯特迴歸模型進行實證分析，結果顯示：總額預算支付制度的實施雖然提高急性心肌梗塞病患的治療密集度，對醫療結果卻沒有顯著影響。
　　第二，為了探討病患的醫療結果是否與其就診時間有關，本研究以1998年至2007年間急性心肌梗塞病患為樣本，分析週末住院的醫療結果是否有別於平日。以醫院固定效果之最小平方迴歸模型所做的實證檢驗結果顯示：週末就診的病患確實容易出現較差的醫療結果，而且主要是發生在非醫學中心的醫院。週末效應的存在很可能與部分醫院在週末的救治人力不足，因而無法施行重要處置有關。
　　最後，本研究探討中大型醫院的成立是否能提昇當地的醫療服務品質。我們以嘉義醫療區域缺血性心臟病病患為研究對象，發現兩家新醫院的成立均有助於改善在地就醫病患的治療結果。而且新醫院成立帶來的品質提昇，很可能與生產力外溢效果有關，也就是面對新醫院成立的威脅時，既存醫院會以提昇自身服務品質來因應。建議衛生主管機關制定相關政策以鼓勵醫院在醫療資源不足區域設立。

This study aims to investigate the relationship between hospital behaviors and patients’ treatment outcome which is measured by 30-day mortality and readmission rates of heart disease patients. We conduct our research via empirical analyses using the 1998-2008 data extracted from the National Health Insurance database and focus on the following three topics.

First, we examine the effect of the enactment of the global budgets payment system on patients’ treatment intensity and outcome. Since the global budgets payment system is a retrospective payment system with a fixed budget, providers are paid on the basis of a floating point value scheme. Under the global budget, hospitals are threatened by income uncertainty and tend to provide more services to secure their target incomes. The results from xtlogit regression models show that the global budget increases the treatment intensity of AMI patients, but does not have any significant effect on patients’ treatment outcome.

Second, we evaluate whether there is a difference in treatment outcome between patients admitted into hospitals during weekdays and weekends. The empirical results of hospital fixed effects regression models show that the patients admitted during weekends do have a higher rate of adverse outcomes, especially for patients admitted into non-medical-centers. The evidence of weekend effects implies a lower staffing level and the absence of ancillary medical support during weekends for some hospitals.

Third and final, we study how an entry of a large hospital in Chiayi medical area improves the quality of care delivered to the local dwellers. Our empirical results display a significant decrease in mortality and readmission rate of IHD patients in Chiayi medical area after two new hospitals entered the market. Part of the improvement of the care quality might be attributable to the “spillover effect” of medical productivity, i.e., the incumbents respond the threat of new entry by providing better services and quality of care. Our findings might provide some policy implications for policy makers to encourage hospitals entry into the places with inadequate medical resources.

中文摘要 ………………………………………………………………… i
英文摘要 ………………………………………………………………… ii
誌謝 ………………………………………………………………… iii
目錄 ………………………………………………………………… iv
圖目錄 ………………………………………………………………… v
表目錄 ………………………………………………………………… vi
第一章　 緒論…………………………………………………………… 1
第二章 總額支付制度的實施對治療密集度與醫療結果的影響…… 4
第一節 前言…………………………………………………………… 4
第二節 台灣保險支付制度演進及醫療費用變化情形……………… 6
第三節 文獻回顧……………………………………………………… 10
第四節 實證模型設定與實證資料說明……………………………… 14
第五節 估計結果……………………………………………………… 20
第六節 結論…………………………………………………………… 23
第三章 重症病患週末就診的醫療結果……………………………… 27
第一節 前言…………………………………………………………… 27
第二節 相關的文獻回顧與評論……………………………………… 29
第三節 實證模型設定………………………………………………… 31
第四節 實證資料說明………………………………………………… 32
第五節 實證結果分析………………………………………………… 38
第六節 結論、政策意涵與研究限制………………………………… 45
第四章 新進醫院對醫療結果的影響………………………………… 51
第一節 前言…………………………………………………………… 51
第二節 相關的文獻回顧與評論……………………………………… 53
第三節 台灣新進醫院概況…………………………………………… 58
第四節 實證模型設定與實證資料說明……………………………… 67
第五節 實證結果……………………………………………………… 72
第六節 結論與研究限制……………………………………………… 84
第五章 結論…………………………………………………………… 90

第二章 總額支付制度的實施對治療密集度與醫療結果的影響
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第三章 重症病患週末就診的醫療結果
李麗惠、薛亞聖與楊長興（2006），「週末假日就醫與治療結果之相關探討」，台灣衛誌，2：25，107-114。
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第四章 新進醫院對醫療結果的影響
劉容華與江東亮（2001），「台灣小型醫院新設與歇業之影響」，臺灣公共衛生雜誌，20(1)， 27 -33。
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