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研究生:范秀秀
研究生(外文):Hsiu-Hsiu Fan
論文名稱:醫療費用監控機制之研究-以DRG20904部分髖關節置換術為例
論文名稱(外文):A Study of Surveillance Mechanism of Medical Care Expenses– An Exemplified of DRG 20904 the Partial Hip Arthroplasty
指導教授:吳文祥吳文祥引用關係
指導教授(外文):Wen-Hsiang Wu
學位類別:碩士
校院名稱:元培科技大學
系所名稱:健康產業管理研究所
學門:商業及管理學門
學類:醫管學類
論文種類:學術論文
論文出版年:2013
畢業學年度:101
語文別:中文
論文頁數:76
中文關鍵詞:診斷關係群決策樹管制圖
外文關鍵詞:Taiwan Diagnosis Related GroupsDecision TreeControl chart
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台灣於2010年實施診斷關係群支付制度後,部分落入診斷關係群之疾病群組給付方式改採定額給付,這對醫院而言是個很大的衝擊,故對醫院而言如何有效的監控醫療費用是重要議題。另根據內政部及衛生署統計資料顯示人口老化影響造成國人使用關節手術的比率提高。因此以執行髖關節部分置換術為例,進行醫療費用監控,以協助醫療院所或健保局相關單位可利用最簡單方法來有效率監控醫療費用是否落於利潤區域、或是虧本區域。
本研究透過健保資料庫由全國篩選三間醫學中心與另外一家區域醫院作為個案醫院,並找出2008年與2010年符合部分髖關節置換術之個案,運用資料探勘中的決策樹找出隱藏費用的因子為年齡,因此以年齡分群後並去除離群值後各群平均數為目標值,運算繪製可以同時監測兩群之目標個別值管制圖。但考慮到目標個別值管制圖計算並不易且不易與健保費用規定配合,故利用預控圖上下規格之表現方式與健保給付上下限規定剛好吻合之特性,發展出可以同時監控兩群之標準化預控圖,方便醫院基層人員學習與判斷醫療費用盈虧。此外本文亦提出健保局可利用無母數修華特管制圖來簡單判定相同給付的醫療院所們醫療費用申報是否超過定額,醫療院所如果想更深入瞭解醫療費用盈虧狀況則可利用多層級修華特管制圖建構一套屬於自己的監控系統,或運用其他管制圖依其特性分別與醫學中心、區域醫院以及自己醫院進行費用監控。
The payment system of Diagnosis Related Groups (DRGs) has been implemented since 2010 in Taiwan. How to effectively monitor the medical expenses for DRGs constrained from the defined payment is an important impact to the hospital. According to the information from the Ministry of Internal and the Department of Health, the population aging results in the higher rate in surgical joint operation. Exemplified by partial hip arthroplasty, this study aims to help the hospitals and the Ministry of Health and Welfare to monitor the medical expenses and to establish a feasible method to observe the profit and deficit in Taiwan.
Cases of the partial hip arthroplasty in three medical centers from 2008 to 2010 from database of the Ministry of Health and Welfare are chosen for this study. Age has been decided as the potential parameter related to the expenses by exploration of the data. After the removal of the stray values, the ages are subdivided into subgroups and then the target of this study is the average age value of each subgroup. Therefore, the control chart can be determined and schemed to monitoring the profit and deficit simultaneously. Because of the difficulties of the calculation of the individual target and the coincidence with the regulation of the Ministry of Health and Welfare, this standardized pre-control chart well combines the upper and lower formats with the upper and lower limits defined by the Ministry of Health and Welfare and are feasible for staffs to learn and judge the profit and deficit. Furthermore, this study suggests that the Nonparametric Control Charts is available for the Ministry of Health and Welfare to decide whether the declared expenses are oversubscribed by different hospitals with the same payments. A customized system to monitor the details of the profit and deficit could be implemented by the Multiple Control Charts. Furthermore, the other control charts might be suitable to monitor the expenses depending on the characteristics of different medical centers, regional hospitals, or our own hospitals.
目錄 I
圖目錄 III
表目錄 IV
第一章 緒論 1
1.1 研究背景與動機 1
1.2 研究目的 3
1.3 研究流程 4
1.4 研究結構 6
第二章 文獻探討 7
2.1 診斷關係群支付制度探討 7
2.1.1診斷關係群之沿革與發展 7
2.1.2各國實施診斷關係群概況 10
2.1.3台灣實施診斷關係群之發展 14
2.1.4診斷關係群支付制度之衝擊與影響 16
2.1.5 疾病分類之簡介 17
2.2 部分髖關節置換術與治療方式 20
2.2.1髖關節的構造 20
2.2.2執行部分髖關節置換術的病因 20
2.2.3部分髖關節置換術治療方式 21
2.3 資料探勘研究探討 23
2.4 管制圖運用與相關研究 25
2.5 目標個別值移動全距管制圖 27
2.6 預控圖與管制圖之差異 28
2.6.1 傳統預控圖 29
2.6.2 兩階段預控圖 30
2.7無母數修瓦特管制圖 32
2.8多層級修華特管制圖 33
第三章 研究方法 34
3.1 研究限制 35
3.2 研究範圍與對象 35
3.3 個別值移動全距管制圖 36
3.4 決策樹分析 37
3.5目標個別值移動全距管制圖 38
3.6 兩階段預控圖 39
3.7 無母數修瓦特管制圖 40
3.8多層級修華特管制圖 41
第四章 研究結果 43
4.1個別值移動全距管制圖監控結果 43
4.2資料探勘之決策樹分析結果 44
4.3 個案醫院目標個別值移動全距管制圖 45
4.4 標準化預控圖監控之結果 51
4.5無母數管制圖 55
4.6多層級修華特管制圖監控之結果 58
第五章結論與建議 62
5.1建議 65


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二.中文部分
1. 內政部統計處:101年底人口結構分析,民國102年2月1日摘自http://www.moi.gov. tw/stat/news_content.aspx?sn=7121
2. 行政院衛生署台灣地區93年到101年醫療機構現況及醫院醫療服務量住院手術統計摘要表,民國102年2月1日摘自http://www.doh.gov.tw/ CHT2006/DM/DM2_2.aspx? now_fod_list_no=12500&; class_no=440&;level _ no=3
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4. 江雪萍,「預估TW-DRG支付制度實施後對醫院經營績效之影響-以某區域醫院為例」國立台灣大學公共衛生學院醫療機構管理研究所碩士論文,民國87年。
5. 李玉春,「全民健康保險支付制度:如何兼顧品質與費用控制」,千禧年健保政策及相
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,醫院,第24卷第4期,,民國80年,248-253頁。
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11. 陳怡秀,「自然生產論病例計酬對醫療資源耗用之影響- 以三家醫學中心為例」,台灣大學公共衛生研究所醫管組碩士論文,民國85年。
12. 張耕銘、黃榮臣「利用無母數EWMA管制圖監控製程平均數/位置參數與變異數/尺
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醫學,七卷,民國82年,726-735頁
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22. 鄭金英,「病歷品質對編碼品質DRGs與健保給付之影響-以某區域教學醫院為例」,中國醫藥大學醫務管理學研究所碩士論文,民國83年。
23. 賴憲堂,「全民健保下疾病分類編碼的品質」,中華衛誌,民國87年。
24. 韓揆,「診斷組合制在台推行問題(上)—DRGs支付精神,支付邏輯及侷限」, 醫務管理期刊,民國94年,1-19頁。
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26. 美國CMS網站(2013),List of diagnosis related groups (DRGS), FY2008 MS摘自民國102年7月http://www.cms.gov/ site-search/ search-results. html?q= HOW%   20MANY%20NEW%20DRG%20AND%20MDC,民國102年
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28. 財團法人長庚紀念醫院全球資訊網, 民國102年7月摘自衛教天地人工髖關節http://www.cgmh.org.tw/asproot/article/health_cntt.asp?artno=000152013,民國102年。
29. 臺大醫院骨科部侯勝茂醫師,民國102年7月摘自骨科部衛教資訊「股骨頭壞死」,http://www.ntuh.gov.tw/orth/education/DocLib/%E8%82%A1%E9%AA%A8%E9%A0%AD%E5%A3%9E%E6%AD%BB.aspx,民國102年。



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