分析全民健保資料庫以探討喉直達鏡手術治療喉部良性病變論病例計酬制實施之影響評估

The Impacts of Case Payment System on the Practice of Laryngo-Microsurgery in Treating Benign Laryngeal Lesion--National Healthcare Insurance Database Analysis

本研究利用全民健保資料庫來探討“論病例計酬'制度的實施對成人喉 直達鏡手術在病患特質、醫療費用、醫療資源使用以及醫療品質等各種層面 的影響。研究對象為1998-2000 年間，因良性喉部病變而接受成人甘侯直達鏡手 術（Laryngo-microsurgery ）治療，共2 ， 946 例。研究進行“論量計酬' （1 ,320 人）及“論病例計酬' （1 ， 626 人）兩種不同支付制度下喉直達鏡手術病患特 質、醫療資源耗用、醫療費用及醫療品質的差異探討。研究結果顯示醫療資 源耗用方面， “論病例計酬組'平均住院天數比“論量計酬組'顯著減少 （p<0.05） ；在醫療費用方面，藥費、手術費、病房費用都降低，但在醫院層 級間皆無差異；醫療品質相關指標值在兩組間並無顯著差異（p>0.05 ）。我們 發現在“論病例計酬'制度下有顯著病患逆選擇的現象；平均住院日數顯著 減少，但醫院平均總申報醫療費用沒有顯著降低；而影響醫療品質最重要因 素為系統性合併症、年齡、醫療提供者的服務量，而不是支付制度。

Using National Healthcare Insurance Database, we investigated the impacts of case payment system on patients selection, medical resources utilization, medical expenses, and healthcare quality for adult laryngomicrosurgery (LMS). A total of 2,946 adult patients with benign laryngeal lesions who underwent LMS during the period from 1998 to 2000 were identified. Surgical outcomes, medical resource utilization, and healthcare expenses were compared between groups of patients who were operated before (1,320 patients) and after (1,626 patients) the implementation of LMS case payment system. Our analyses results indicate less systemic comorbidities were identified in the case payment group. The average length of stay was significantly shortened (p<0.05). The total claimed amount remained unchanged (p>0.05) among different hospital level, despite of significant reductions in claimed medication fee, operation fee, and ward fee following the implementation of case payment system. There is no clear evidence to show there was any change in the quality of care (p>0.05). The implementation of case payment system proved to be effective to enhance efficiency of the practice of adult LMS by reducing length of stay. There was significant adverse patient selection manipulation by the providers.