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研究生:阮子凌
研究生(外文):Juan, Tzu-Ling
論文名稱:以行為風險模式評估健保部分負擔政策對持續性氣喘病患使用有效醫療服務之影響
論文名稱(外文):A Study Applying Behavioral Hazard Model to Evaluate the Effects of the NHI Cost-Sharing Policy on the Use of Effective Care of Patients with Persistent Asthma
指導教授:李玉春李玉春引用關係
指導教授(外文):Lee, Yue-Chune
口試委員:鄭守夏連賢明楊銘欽吳肖琪李玉春
口試委員(外文):Cheng, Shou-HsiaLien, Hsien-MingYang, Ming-ChinWu, Shiao-ChiLee, Yue-Chune
口試日期:2022-1-17
學位類別:博士
校院名稱:國立陽明交通大學
系所名稱:衛生福利研究所
學門:醫藥衛生學門
學類:公共衛生學類
論文種類:學術論文
論文出版年:2022
畢業學年度:110
語文別:中文
論文頁數:140
中文關鍵詞:行為風險模式部分負擔有效醫療服務氣喘健保申報資料
外文關鍵詞:Behavioral Hazard ModelCost-sharingEffective careAsthmaClaims data
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針對我國部分負擔政策之評估,過去的研究多著重於探討部分負擔對保險對象就醫利用與費用之影響,研究結果也與國外一致,都發現部分負擔可以降低醫療利用及費用,但不論國內外研究,多是在「道德風險模式」的理論基礎下進行,無法解釋民眾面對就醫實際價格的增加,可能選擇不利用或減少有效(高價值)的服務,而這些服務通常可以帶來較佳的健康結果,這議題也常是政府提出部分負擔調漲方案時,會被外界質疑將影響弱勢群體如慢性病人的就醫權益,近年來,有學者提出「行為風險模式」來解釋此種行為,以及後續可能的健康風險,目前國內尚無研究運用此種模式探討我國部分負擔政策調整是否會影響病人使用高價值(有效)的服務,因此引起本研究的關注。
持續性氣喘病人必須定期就醫與服藥,才能緩解氣喘症狀,美國國家品質確保委員會發展一套有效醫療指標,作為監控管理或照護組織之依據,其中針對氣喘提出持續用藥服務(MMA )以及氣喘藥物比例(AMR)兩項指標,可以做為本研究有效醫療服務之測量,藉以探討部分負擔政策改革對於持續性氣喘病人使用有效醫療服務之影響。
本研究以2005年的政策調整進行短中長期政策效應之探討,運用行為風險模式理論,以及Andersen之健康服務利用行為模式為理論架構,藉類實驗設計的事前事後控制組比較研究設計,對照組選擇未受部分負擔影響的基層院所就醫之病患,進行DID分析,並藉傾向分數配對(PSM)控制選擇偏差,介入前之觀測時間採2004年7月至2005年6月。介入後之短、中、長期觀察時間則為政策實施後一年、三年及五年,並以GEE分析差異中差異法的政策效應。
本研究發現有以下兩點:
一、增加門診部分負擔對於持續性氣喘病人有效醫療服務會有減少利用的短期、中期及長期影響。
二、可印證Baicker行為風險模式,增加部分負擔對持續性氣喘病人可能造成行為風險,因而影響其健康。

根據上述研究發現提出以下建議:
一、對政策的建議
1.部分負擔改革政策之設計應審慎,避免影響慢性病人有效醫療服務之使用,提升健康風險。
2.政府應制定保護慢性病群體的策略,由於慢性病患多數需長期依賴藥物治療,老年患者多有一項以上之慢性疾病,除了慢性病連續處方箋之免收藥品部分負擔外,並無其他減免,可考量比照住院部分負擔年度上限採用門診部分負擔定率收取加上年度上限制或訂定所得相關的門診部分負擔上限。
3.建議政府在調整部分負擔政策時,若對慢性病人有影響,應定期監測慢性病之醫療服務之下降服務情形,避免政策影響特定疾病患者有效醫療服務之利用。
二、對未來研究的建議
1.建議後續研究者可選擇其他慢性病及其有效醫療服務,驗證行為風險模式是否可推論到所有慢性病。
2.建議後續研究者針對2017年的政策調整對於有效醫療服務利用之影響情形。
3.可進一步探討門診有效醫療服務利用的降低,是否影響健康,如是否導致後續急診或住院利用增加。
Over the past several decades, many studies based on standard moral hazard models, have confirmed that under the price effect, increasing the cost contribution of patient reduces the inappropriate as well as the appropriate utilization of healthcare resources. In other words, it is very likely that cost-sharing measures prevent patients from seeking necessary care. Researchers have reported that cost-sharing measures may compromise the health of susceptible individuals, increase expenditures for hospitalizations and emergency department services, and reduce the utilization of essential drugs, particularly among people with chronic diseases. It appears that the conventional moral hazard model is insufficient to explain the underuse of effective care. The behavioral hazard model provides a sounder theoretical basis for the underuse of high-value care based on the supposition that patients undervalue the benefits of the treatment. This study wanted to determine whether 2005 reforms to the NHI cost-sharing policy led to a reduction in the utilization of effective care by patients with persistent asthma (i.e., mediation of behavioral hazard).
A quasi-experimental retrospective observational study based on a pretest-posttest non-randomized control group design using the difference-in-differences methods for the analysis of nationwide claims data. The Longitudinal Health Insurance Database of Taiwan was used to compare changes in effective care following drastic reforms to copayment policy in 2005. Propensity score matching (PSM) was used to select the intervention group and control group. HEDIS medication management for people with asthma (MMA) and asthma mediation ratio (AMR) measure was used to identify patients with persistent asthma and instances of effective care. Generalized estimating equations (GEEs) were used to compare between-group differences.
Reforms to NHI cost-sharing policy were significantly correlated with a reduction in the utilization of effective care by patients with persistent asthma over the short-, medium- and long-term. These results also provide evidence supporting the tenets of the behavioral hazard model.
中文摘要 i
英文摘要 iii
目錄 iv
圖目錄 vi
表目錄 vii
第一章 緒論 1
第一節 研究背景與動機 1
第二節 研究目的與研究問題 4
第三節 研究重要性 4
第四節 重要名詞解釋 5
第二章 文獻探討 6
第一節 部分負擔理論、行為風險模式與部分負擔方法 6
第二節 健康服務利用理論 15
第三節 我國健保部分負擔制度 20
第四節 有效醫療服務之定義 27
第五節 以行政申報資料定義持續性氣喘及其疾病嚴重度 34
第六節 部分負擔對醫療服務利用之實證研究 40
第三章 研究方法 56
第一節 研究設計 56
第二節 研究架構 59
第三節 研究假說 61
第四節 研究對象及樣本 61
第五節 資料來源 62
第六節 研究變項定義與測量 64
第七節 研究資料處理流程 68
第八節 統計分析 71
第四章 研究結果 73
第一節 描述性結果 73
第二節 雙變項分析 76
第三節 GEE政策效應分析 86
第五章 討論 109
第一節 研究理論的驗證 109
第二節 研究方法的討論 110
第三節 研究結果的討論 113
第四節 研究限制 116
第六章 結論與建議 117
第一節 結論 117
第二節 建議 117
參考文獻 118
附錄1、HEDIS 127
附錄2、氣喘用藥 134
附錄3、氣喘疾病嚴重度指標 138
附錄4、健保投保單位屬性分類表 139
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