健康照護系統中潛在浪費的衡量與國際比較

Measurements of Potential Waste and It’s International Comparisons in Health Care System

醫療支出隨著人口老化和醫療科技進步攀升，降低浪費能減輕超額支出衍生不良後果，本文提出衡量浪費的概念，並進行國際比較。將浪費區分行政浪費、運營浪費和臨床浪費三種類型，根據經濟合作暨發展組織（OECD）健康資料以及我國衛生統計，擷取1995～2008年醫療資源利用和配置指標，如國家醫療保健支出（NHE）占GDP比例及每人年NHE，每人門診次，急性照護住院天數，每千人CT、MRI檢查，每萬人CT、MRI台數，每萬人病床數及醫師數，以及健康表現如平均餘命、嬰兒死亡率等指標，間接評估八個會員國和台灣健康照護潛在浪費。行政浪費是超額行政開銷，NHE花費在行政管理之百分比，台灣2002年2.32％降至2008年1.51％，1995～20002年加拿大2.6％、德5.6％，美國高達7.3％，顯見多元付費者系統的交易成本較高。營運浪費指特定流程的無效率，如重複診療、昂貴儀器利用過高；台灣每人門診15次、日本14次，高於歐美，平均住院日台灣（6～7）低於日（19～33）、韓（10～11），與歐美相近； CT、MRI使用率德國最低（約40, 14次），美國是加（103,31次）2～3倍；日本投入CT、MRI最充沛，美、韓次之，台灣也不遜於加、荷、英；每萬人口病床數日本108床居首，歐美呈下降、台韓有上升趨勢；每萬人口醫師數亞洲國家趨近美、加。臨床浪費是產生不利健康或低價值的產出，美國其NHE/GDP 16％最高，但平均餘命77歲最低，日（8％）、瑞典（9％）其平均餘命超過81歲，台灣78歲且NHE/GDP僅約6％，英國8.5％，德、加、荷約10.5％，其健康指標皆優於美國。多數國家至少有一領域表現良好，台灣整體表現不遜於受參評國家。然而，行政支出無法直接轉換量化浪費，藉由資訊科技精實營運流程的投資成本高，醫療本身不確定性難以明確估計臨床浪費，加上病患、付費者和醫療提供者間利益取捨，降低照護系統浪費仍存在諸多挑戰。

The rising rapidly spending in health care as the aging population and advanced medical technology has undesirable consequences that could be alleviated through waste reduction. We propose a framework to measure waste and of international comparisons. We measure health care waste as administrative, operational, and clinical waste. The data collected from statistical reports of the Organization for Economic Cooperation and Development (OECD), and the Department of Health in Taiwan. Based on indicators of health care resources supply and utility, such as national health expenditure (NHE) per capita and NHE as a percentage of gross domestic product (GDP), beds (physicians) per million population, CT (MRI) exams per 1000 population, CT (MRI) units per million population, doctor consultations (DC) per capita, average length of stay (LOS) for acute care, as well as indicators of health performance, i.e. life expectancy at birth, infant mortality rate, focusing on eight OECD countries during 1995~2008 to discuss examples of potential waste. Administrative waste is the excess administrative overhead that stems from the complexity of the multi-payer and provider systems, and operational waste refers to specific inefficient service processes. Clinical waste is waste created by medical uncertainties that encourage the production of low-value services. International comparisons can highlight differences among countries in levels of administrative spending and show inefficiency of resource allocation or utilities. Our results show that most countries had at least one area in which it performed the best. Taiwan's health system performance is not inferior to eight countries. The Unite State overall performance lags behind other industrialized countries in terms of healthy lives and efficiency. Various efforts to reducing waste in health care have encountered challenges, such as the high costs of initial investment in medical information technology, and trade-offs among patients’, payers’ and providers’ interests.