台灣地區論人計酬試辦計畫之評估——以醫院忠誠病人模式為例

Evaluation of the capitation payment pilot program in Taiwan - using the hospital’s loyal patient model as an example

目標：本文以健保署2012年開始試辦的論人計酬支付制度中的醫院忠誠病人模式為基礎，嘗試探討三家試辦醫院是否達到了促進民眾健康、減少醫療浪費的目標。方法：採用差異中的差異（Difference-in-Differences）模型分析試辦醫院與對應醫院忠誠病人2010年7月至2013年6月全民健保門、住診利用與費用；且以傾向分數配對（Propensity Score Matching）模型篩選對應醫院的忠誠病人。醫院的忠誠病人為試辦前一年在該院門診就診次數達該病人門診就診次數的一半以上。結果：試辦計畫對所有試辦醫院之門診利用皆有顯著減少的成效；然而由於試辦醫院A與C之住院費用顯著提升，以致總醫療費用在試辦醫院A與B沒有顯著變化，但在試辦醫院C則呈顯著增加。結論：目前論人計酬試辦計畫僅僅觀察試辦醫院的忠誠病人在試辦前後的醫療費用，並據以衡量試辦計畫成效的作法，因同期間另有影響醫療費用的總體因素存在，以致試辦前後醫療費用的差異並非僅由試辦計畫所造成。在試辦計畫的成效指標中，適度納入總體因素的考量，應是當行的修正。

Objectives: The aim of this study was to determine if the capitation payment pilot program beginning in 2012 reached its designed target of promoting patient health and reducing medical waste. Methods: We employed the Difference-in-Differences model to study the healthcare expenditures by National Health Insurance in the study group (pilot hospital’s loyal patients) and the control group (corresponding hospital’s loyal patients), for the periods from July 1, 2010 to December 31, 2011 and January 1, 2012 to June 30, 2013. The Propensity Score Matching method was used to select the final control group. A hospital’s loyal patient was defined as one who made more than half of his/her outpatient visits in that particular hospital. Results: Patients’ outpatient visits in all three pilot hospitals were significantly reduced, while the inpatient expenditures were significantly increased in hospitals A and C. This resulted in significantly higher total healthcare expenditures in hospital C but not in hospitals A and B. Conclusions: The current tool for the evaluation of the capitation payment pilot program is patients’ healthcare expenditures before and after the pilot program. However, since there were other influential factors in existence during the same time period, the expenditure difference observed was not affected solely by the pilot program. Taking those external factors into evaluation consideration is a must.