「家庭醫師整合性照護計畫」對民眾越級就醫之影響

Impact of the “Family Doctors’ Integrated Care Initiative” on patients’ behavior in seeking care at higher level health care institutions

目標：民眾不經轉診，越級就醫在台灣是重要問題，中央健保局於2003年開始實施「家庭醫師整合性照護計畫」，簡稱家醫計畫，以提升基層照護的品質與持續性，並促進落實分級轉診制度，故本研究目的為探討家醫計畫對越級就醫的影響。方法：以事前事後控制組比較研究設計與差異中的差異法，以每半年皆有適合在基層就醫的疾病（A類疾病）就醫之病人為對象，以2007-2010初次加入家醫計畫者為實驗組，並以性別、年齡、重大傷病、共病症指數、收入與控制組1：1配對，探討加入家醫計畫者與未加入者在介入前後越級就醫的變化。結果：家醫計畫可以改善2007至2009年加入民眾的越級就醫情形，但加入時間越長，效果越差，且退出計畫後民眾越級就醫情形顯著上升。然而，計畫無法改善2010年加入者的越級就醫情形。結論：家醫計畫可短期降低民眾越級就醫情形，但此政策對慢性病患者及過去醫療花費較高的族群較無影響。

Objectives: Seeking care at higher level health care institutions than should be (up-graded healthcare) is an important issue in Taiwan; therefore, National Health Insurance (NHI) has implemented the “Family Doctors’ Integrated Care Initiative (FDICI)” since 2003 to enhance the quality and continuity of primary care and to enhance the referral system. The aim of this study was to evaluate the effect of the FDICI on patients’ behavior in seeking upgraded healthcare. Methods: The study used the pretest-posttest control group design and difference in differences method on patients who received medical care with a diagnosis which could be dealt with in primary care. The intervention group included patients who initially participated in FDICI between 2007 and 2010. This group was 1:1 matched with a control group of patients, who had never participated in FDICI during the same period, by gender, age, catastrophic illness or not, Charlson comorbidity index, and income. Results: The FDICI reduced the rate of patients seeking upgraded healthcare during 2007-9; yet, the effect decreased over time. Moreover, after people dropped FDICI, their rate increased. Besides, the FDICI showed no effect for people who initially joined in 2010. Conclusions: The FDICI can reduce the rate of patients seeking upgraded healthcare within a short period; however, the plan showed no effect on patients with chronic illnesses or those with high medical costs.