臺灣博碩士論文加值系統

論文摘要
目前全民健保已就28項手術實施論病例計酬制，預計於88年底再度擴大實施項目，目前國內並無明顯證據足以支持此項制度能有效地控制醫療費用上漲，同時醫院管理者有必要在論病計酬即將擴大實施的此時，先行瞭解論病例計酬所帶來的影響並評估醫院所採行的措施是否有效，對醫院管理而言確有其必要性。
本研究以痔瘡切除手術為實驗組(實施論病計酬)，與痔瘡切除手術相近之肛門廔管切開或切除術為對照組比較(實施論量計酬)，研究論病例計酬實施之後，對單一手術醫療資源使用之影響，及探討類似手術不同支付制度下醫療資源使用的改變，最後探討論病例計酬實施對不同院區之影響。
本研究之資料來源為長庚醫院基隆、林口、高雄三院區，於民國85年10月至民國87年9月，痔瘡切除實施論病例計酬之前後各一年為研究時間，研究樣本共7925人。
本研究之結果如下：
一、 支付制度的改變對醫療資源使用之影響
實驗組平均住院日均明顯縮短，同時非手術類之費用也顯著下降，顯示論病計酬的實施，對於醫療資源使用可能具有顯著的影響效果。
二、 單一手術論病計酬與類似手術論量計酬之醫療資源使用
透過對照比較之後可發現，實驗組與對照組平均住院日皆為顯著下降；平均住院總費用方面，支付制度的改變並無法影響痔瘡切除住院總費用，實施論病例計酬，對於降低平均住院日與住院總費用可能沒有成效。
三、論病計酬實施對不同院區資源使用之影響
透過迴歸分析，實驗組與對照組相比較之後，可發現論病例計酬實施後，可能只有林口院區平均住院日下降的原因與高雄院區平均住院總費用下降的原因是來自於支付制度的改變；論病例計酬的實施對各院區而言，並不一定會有成效，但本研究認為論病例計酬的實施，可能也對於其他手術產生擴散效果。
本研究結果可供醫院管理者作為參考，瞭解論病例計酬對醫院醫療資源使用之影響，同時提供醫院管理者重新考量論病例計酬之實施，對於院內其他無實施論病例計酬之項目可能產生之影響。

Abstract
Increasing medical expenditure has become a global trend. According to the experience of other nations with national health insurance, a well-designed payment system is one way to contain the rapidly growth of health care expenditure .
To prevent escalating health care expenditures after the implementation of National Health Insurance (NHI), Taiwan Breau of National Health Insurance adopted case payment for some surgical in stead of fee-for-services, and in the hope to eventually into a prospective payment system (PPS), based on the Taiwan-version of DRGs (Diagnose Related Group). The NHI applies case payment to 28 surgical procedures. To date, emprical studies on effects of case payment in Taiwan are quite limited. Therefore, the purpose of this study is to analyze the effects of case payment and to examine whether the hospital respond to case payment effectively.
Though there are 28 major procedures paid under case payment, we examine only the case of hemorrhoidectomy. We included anal fistulectomy and fistulotmy as comparison group, which are similar procedure but still subject to fee-for-services payment. We assess the effects of csae payment by comparing the resources utilized for hemorrhoidectomy before and after case payment. We further compare the change in resource utilization between similar procedures under different payment system. Finally, we investigate the effects of case payment across different hospitals.
Data are obtained from Chang Gang Memorial Hospital at Kee-Lung, Lin-Kou, and Kaohsiung. Samples are selected from claims data for those who had relevant surgery codes between October 1996 and September 1998. The total number of patients is 7925.
Important findings are as follows:
1). Effects of case payment on health care utilization:
After controlling age、sex、severity and hospitals , length of stay for the experimental group is significantly shorter after case payment , so are the cost of non-surgical claims. It indicates that incentives embodied in case payment to shorten the length of stay may be effective.
2). Comparison of resource utilization for procedures under different payment system:
After case payment system, length of stay of all groups are significantly shorter. Claims for the comparison group is also significantly lower. The implementation of case payment seems not affect the health care utilization.
3). Health care utilization across different hospitals:
Decrease in length of stay in Lin-Kou and reduction in claims in Kaohsiung may be due to case payment. The effects of case payment on three hospitals seem to vary by procedures. One explanation may be spill-over effects to procedures not included in the case payment.

第一章緒論1
第一節 研究背景與動機1
第二節 研究目的3
第二章文獻探討5
第一節 論病例計酬介紹5
第二節 研究疾病介紹10
一、疾病介紹11
二、手術介紹13
第三節 支付制度對醫療資源使用之影響：14
一、支付制度對住院日之影響15
二、支付制度對醫療資源使用之影響20
第四節 論病例計酬下之管理方法23
第三章研究方法26
第一節 研究假設26
第二節 研究架構27
第三節 資料來源28
一、研究醫院29
二、研究樣本29
第四節 研究變數30
一、自變項30
二、依變項30
第五節 分析方法32
一、描述性分析32
二、單變項分析32
第四章資料分析37
第一節 樣本基本資料37
一、樣本分佈情形37
二、樣本之性別及年齡分佈37
三、痔瘡切除術實施論病例計酬前各院區樣本分布情形38
四、痔瘡切除術實施實施論病例計酬後各院區樣本分布情形38
第二節 不同支付制度對醫療資源使用之影響38
一、住院日分析39
二、住院費用分析39
第三節 院區別醫療資源使用情形41
一、住院日分析41
二、費用分析方面43
第四節 各細項費用之多變項迴歸分析46
一、住院日分析方面47
二、各項醫療費用方面48
第五節 院區別醫療資源使用之迴歸分析51
一、住院日方面51
二、各細項費用方面52
第五章綜合討論55
一、論病例計酬實施對住院日之影響55
二、論病例計酬對住院總費用之影響57
三、論病例計酬對細項費用之影響58
四、論病例計酬對費用結構之影響59
五、論病例計酬對院區之影響60
六、論病例計酬實施後對手術費之影響62
七、論病例計酬實施後對麻醉費之影響64
第六章結論與建議65
第一節 結論65
一、支付制度的改變對醫療資源使用之影響65
二、單一手術論病例計酬與類似手術論量計酬之醫療資源使用65
三、論病例計酬實施對不同院區資源使用之影響66
第二節 建議66
第三節、研究限制67

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