臺灣博碩士論文加值系統

雖然台灣從1995 年開始實施全民健保制度，減輕了民眾在使用醫療資源上的財務負擔，但是位於偏遠山區或是離島的居民卻仍然空有保險，而無處看病，導致醫療可近性存在城鄉差距。因此，健保署也逐步實施偏鄉醫療計畫以改善偏遠地區醫療資源不足的問題，其中於民國88 年起實施的「全民健康保險山地離島地區醫療給付效益提昇計畫」（Integrated Delivery System, IDS），藉由導入偏鄉外的醫療資源與整合當地醫療院所與山地離島鄉衛生所，改善偏鄉地區整體健保醫療服務品質。本研究使用1996 至2006 年健保資料庫中，偏鄉地區病患資料，利用差異中差異分析法，估計參與計畫之鄉鎮在IDS 計畫實施前後兩年可預防住院的變化。實證結果發現位於台灣西半部地區的IDS 計畫之鄉鎮，在IDS 計畫實施之後有顯著的降低可預防住院的發生，而對於住院醫療費用也有節制的效果存在。然而，位於台灣東半部地區的IDS 計畫之鄉鎮，在IDS 計畫實施之後反而有增加可預防住院發生的趨勢，而可預防住院醫療費用也有提高的現象，隱含當地可能存在未獲滿足的醫療需求（unmet medical need），而在經過醫療介入之後，當地醫療資源的增加正好滿足了當地病患的醫療照護需求量。

Despite the fact that Taiwan has implemented National Health Insurance (NHI) at 1995, there's still some people who live in rural areas have obstacles to access medical
care. In order to improve the accessibility of medical care, the Department of the Health and Welfare successively implemented the integrated delivery system (IDS for short) programs which appoint local hospitals to regularly offer ambulatory care to the residents living in different remote areas since 1999.
This research selects patients reside in rural areas and its neighbor townships from 1996-2006 National Health Insurance Database and uses difference-in-difference
technique to evaluate the IDS policy effect on preventable hospitalization. We found that rural townships in the west of Taiwan have lower rate of preventable hospitalization as well as the hospitalization expenditures after the implementation of the IDS plan. By contrast, the rural townships in the east of Taiwan have the opposed effects, that is the
IDS program will increase the rate of preventable hospitalization and its expenditures. This may imply that the IDS may substitute inpatient care for ambulatory care for the residents in remote township in the east.

中文摘要 ··························································································· I
ABSTRACT ······················································································ II
誌謝 ······························································································· III
目錄 ······························································································· IV
圖目錄 ····························································································· V
表目錄 ···························································································· VI
第一章 緒論 ······················································································ 1
第一節 研究背景與動機 ···································································· 1
第二節 研究目的 ············································································· 5
第二章 文獻回顧 ················································································ 7
第一節 可預防住院 ·········································································· 7
第二節 醫療資源分佈 ······································································· 8
第三節 偏鄉醫療政策 ······································································· 9
第四節 醫療體系變化 ····································································· 11
第三章 研究方法 ·············································································· 14
第一節 差異中差異分析法（DIFFERENCE-IN-DIFFERENCE METHOD） ············ 14
第四章 資料來源與變數說明 ······························································· 18
第一節 資料來源與建構 ··································································· 18
第二節 變數說明與敘述統計 ····························································· 22
第五章 實證結果分析 ········································································ 32
第一節 可預防住院機率 ··································································· 32
第二節 住院醫療費用 ······································································ 48
第六章 結論 ···················································································· 52
第一節 結論與建議 ········································································· 52
第二節 研究限制 ············································································ 54
參考文獻 ························································································· 56
附錄一 ···························································································· 59

一、中文文獻
1. 吳佳蓁（2008），全民健康保險第五類被保險人醫療利用之探討，亞洲大學健康管理研究所碩士論文。
2. 吳依凡（2004），「醫療資源可近性對個人醫療利用的影響－台灣地區的實證研究」，國立中央大學產業經濟研究所碩士論文。
3. 洪維河（2001），台灣住診市場分析，台灣大學公共衛生政策與管理研究所博士論文。
4. 洪維河、江東亮、張睿詒（2004），「市場結構與組織特性對醫院營運效率之影響」，管理學報，22卷2期，191-203
5. 張雅雯（2002），「醫療利用可近性－台灣老人之實證研究」，國立中央大學產業經濟研究所碩士論文。
6. 陳文意（2016），遠距健康照護對可預防住院與醫療利用之影響，台灣公共衛生雜誌 ，35卷5期，524-541。
7. 陳宗梧（2009），「偏遠地區民眾之醫療照顧政策成效分析」，國立政治大學研究所碩士論文。
8. 陳珮青（2002），「醫療資源分佈與民眾跨區就醫之探討－以四種診斷住院病人為例」，國立臺灣大學衛生政策與管理研究所碩士論文。
9. 游素蘭（2001），「影響臺灣地區醫療資源分布之因素」，國立臺北大學財政學系碩士論文。
10. 楊貴蘭（2004），「探討山地鄉實施醫療給付效益提升計畫對民眾醫療服務利用影響與可近性之成效─以屏東縣牡丹鄉為例」，國立臺灣大學醫療機構管理研究所碩士論文。
11. 劉容華、江東亮（2001），「台灣小型醫院新設與歇業之影響」，台灣公共衛生雜誌，20卷1期，27-33。
12. 蔡淑真（2003），低收入戶全民健康保險資源耗用分析，國防醫學院公共衛生學研究所碩士論文。
13. 鄭鴻藝（2005），「急重症整合性醫療服務（IDS）成效評估」，高雄醫學大學公共衛生學研究所碩士論文。
14. 謝琇蓮、江東亮（1994），「臺灣地區醫院歇業及新設之決定因素」，中華公共衛生雜誌，13卷6期，453-458。
15. 鍾翰其（2000），「不同支援模式對澎湖離島地區醫療服務可近性與醫療利用之影響」，高雄醫學大學公共衛生學研究所碩士論文。
16. 全民健保20週年叢書系列-綠色奇蹟（全民健保山地離島醫療服務紀實）

二、英文文獻
1. Aday, L. A. and Andersen, R. M. (1974), “A Framework for the Study of Access to Medical Care,” Health Services Research, Vol. 9, 208-220.
2. Agency for Healthcare Research and Quality (2007). Guide to Prevention Quality Indicators: Hospital Admission for Ambulatory Care Sensitive Conditions (Version 3.1).
3. Agency for Healthcare Research and Quality. Prevention Quality Indicators Technical Specifications Updates - Version 6.0 (ICD-9), October 2016
4. Billings, J., Anderson, G. M., & Newman, L. S. (1996). Recent findings on preventable hospitalizations. Health Affairs (Project Hope), 15 (3), 239-249.
5. Billings, J., Zeitel, L., Lukomnik, J., Carey, T. S., Blank, A. E., & Newman, L. (1993). Impact of socioeconomic status on hospital use in New York City. Health Affairs (Project Hope), 12 (1), 162-173.
6. Capps C., Dranove D., Lindrooth RC. (2010). Hospital closure and economic efficiency. J. Health Econ., 29 (2010), 87-109
7. Cheng, S.H. and Chiang, T.L. (1997). The effect of universal health insurance on health care utilization in Taiwan: results from a natural health experiment, The Journal of the American Medical Association, Volume 278 (2), 89-93.
8. Ciliberto, Frederico and Richard Lindrooth, “Exit from the Hospital Industry,” Economic Inquiry 45 (2007), 71–81.
9. Frech, H.E., Mobley, L.R., (2000). Efficiency, growth, and concentration: an empirical analysis of hospital markets. Economic Inquiry 38, 369-384.
10. Hill C1, Zurakowski D, Bennet J, Walker-White R, Osman JL, Quarles A, Oriol N. (2012) Knowledgeable Neighbors: a mobile clinic model for disease prevention and screening in underserved communities. Am J Public Health, 102 (3), 406–410.
11. Hill CF., Powers BW., Jain SH., Bennet J., Vavasis A., Oriol NE. (2014). Mobile health clinics in the era of reform. Am J Manag Care, 20 (3), 261-264.
12. Hjortsberg, Catharina (2003). Why do the sick not utilize health care? The case of Zambia, Health Economics, Volume 12 (9), 755-770.
13. Lindrooth RC., Lo Sasso AT., Bazzoli GJ. (2003). The effect of urban hospital closure on markets. J Health Econ. 691-712.
14. MacStravic R.S. (1995). Patient loyalty to physicians: attitudes and behavior. Journal of Hospital Marketing, 10 (1), 51-61.
15. Menec, V. H., Sirski, M., Attawar, D., & Katz, A. (2006). Does continuity of care with a family physician reduce hospitalizations among older adults? J Health Serv Res Policy, 11 (4), 196-201.
16. Oriol NE1, Cote PJ, Vavasis AP, Bennet J, Delorenzo D, Blanc P, Kohane I. (2009). Calculating the return on investment of mobile healthcare. BMC Med. 7 (1), 27.
17. Weissman, J. S., Gatsonis, C., & Epstein, A. M. (1992). Rates of avoidable hospitalization by insurance status in massachusetts and maryland. JAMA: The Journal of the American Medical Association, 268 (17), 2388-2394.