美國住院與急性後期照護之包裹式支付制度

Bundled payments for inpatient and post-acute care services in the United States

美國老人健康保險（Medicare）在住院與急性後期照護（post-acute care，PAC）服務皆採前瞻性支付制度，但此種設計沒有提供兩者協調整合之誘因，且醫療照護支出仍持續上漲，CMS（Centers for Medicare and Medicaid Services）遂於2013年實行全國性包裹式支付（bundled payment）試驗計畫，將住院與PAC包裹於同一筆定額支付，以促使醫院與PAC單位進行跨單位合作，改善移轉流程及照護品質，並降低照護成本。台灣自全民健保開辦以來，積極進行支付制度改革，雖然自2010年起實施Tw-DRGs（Taiwan Diagnosis Related Groups）支付制度，但遲未全面推動，且未在社區提供PAC服務，加上病人不願意出院，導致醫院以超長住院或再住院形式提供住院病人PAC；隨著人口快速高齡化，勢必對照護體系與健保財務造成重大衝擊。建議政府應盡快全面實施Tw-DRGs，並搭配合理之居家及社區化PAC制度及品質監控，使個案在家中或社區接受照護，以最佳價值（best value）之地點提供有效率的服務，在支付面則宜參考美國包裹式支付，將住院服務與PAC合併考慮支付。

In the US, Medicare adopted prospective payment systems for inpatient and post-acute care (PAC) services, but there were not enough incentives to facilitate coordination of these two services and the Medicare expenditures continued to increase. Thus, the Centers for Medicare and Medicaid Services (CMS) implemented a nationwide bundled payment program in 2013, which combined the payment of inpatient and PAC services to promote coordination and cooperation between hospitals and PAC units, improve the referral procedure and quality of care, and lower healthcare costs. Taiwan has continued to reform its payment system. In 2010, Taiwan Diagnosis Related Groups (Tw-DRGs) were implemented, but have not been completely instituted. We did not provide PAC services in communities, and patients were not willing to be discharged from hospitals; these were the main reasons that patients acquired PAC services through prolonged hospital stays or readmissions. With an aging population, this will have a great impact on the healthcare system and National Health Insurance expenditures. It is suggested that the government should comprehensively enforce Tw-DRGs with an appropriate PAC system with the best value as soon as possible. Additionally, PAC services should be provided at home or in communities in an efficient way. The payment system can be referred to the US bundled payment, which includes inpatient and PAC services with proper quality surveillance.