診斷關係群前瞻性支付制度對醫療品質影響之探討

Exploring the Effects of Diagnosis--Related Groups Based Prospective Payment System on Quality of Care

中央健康保險局繼實施醫院總額支付制度後，計畫自民國九十四年起， 全面施行住院論病例計酬支付制度。當民眾就醫的可近性獲得滿足後，即開 始要求高品質的醫療服務，因此有必要探討診斷關條群前瞻性支付制度對醫 療品質的影響。前瞻性支付制度的目的是以財務誘因促使醫療服務提供者提 供合乎成本效益的醫療服務，同時提昇醫療機構的服務效率。由於此制度賦 予醫療服務提供者必須分擔財務風險，國外的實證研究顯示診斷關條群為基 礎的前瞻性支付制度可能造成的醫療品質負面影響有：病人過早出院或病情 未穩定即出院、將住院病人轉為門診診療，導致門診執行高風險處置及檢查 的機會增加、為了節省醫院的成本，導致住院病人轉移至成本較低的護理照 護機構、導致併發症出現的機會增加，即愈早出院，病情愈嚴重，所謂 “quicker and sicker' discharge 、疾病診斷編碼出現取巧的不當行為（ coding creep） 、疾病嚴重度高的病人有被推趕（patient dumping） 的現象及可能增加 醫療糾紛的發生情形。而目前台灣對於論病例計酬醫療品質監控系統，只有 中央健保局所訂定的數個指標，實有必要擬定相關配套措施，以確保未來全 面實施住院論病例計酬支付制度時的醫療品質。

The Bureau of Health Insurance (BNHI) initiated a case payment system based on diagnosis-related groups (DRGs) in 1995 to contain the profound increment of medical expenditures induced by fee-for-service reimbursement. After introduction of hospital global budget in 2002, BNHI plans to implement the prospective payment system (PPS) to all inpatient services in 2004. The purpose of this article is to discuss the effects of DRGs-based PPS on quality of care. Evidence- based study revealed that the impacts of DRGs/PPS were premature patient discharge or unstable discharge, increased opportunities of performing the high-risk medical procedures at out-patient services, cost-shifting to long-term care, quicker and sicker discharge, DRGs coding creep, patient dumping, and medico-legal litigation. However, there were only several quality indicators monitored by BNHI under the case payment system. It is suggested that mandatory necessity of more quality indicators is very important to prevent the impacts of DRGs/PPS on quality of care after implementation of case payment system to all inpatient services in the near future.